Navigating Challenges in the Endovascular Treatment of Asymptomatic Aortoiliac Aneurysms: A 10-Year Comparative Analysis

BACKGROUND

Treating an abdominal aortoiliac aneurysm (AAIA) with endovascular methods can be challenging when the internal iliac artery (IIA) is involved. Embolizing the IIA and extending the limb to the external iliac artery (IIAE + EE) to prevent a type 2 endoleak may lead to pelvic ischemic complications. To avoid these complications, strategies that preserve the IIA, such as the bell-bottom technique (BBT) and the iliac branch device (IBD), have been proposed. This study aims to compare the outcomes of these three endovascular approaches for AAIA.

METHODS

Between January 2010 and December 2019, 174 patients with asymptomatic AAIA were enrolled in this retrospective analysis. They were divided into two groups: 81 patients underwent non-IIAE procedures, and 93 patients underwent IIAE procedures. The iliac limb study group consisted of 106 limbs treated with the BBT, 113 limbs treated with the IIAE + EE, and 32 limbs treated with the IBD. The primary outcomes included the 30-day mortality rate and intraoperative limb complications. The secondary outcomes included postoperative pelvic ischemia, freedom from reintervention, and the overall 10-year survival rate.

RESULTS

There was no significant difference in the perioperative mortality rate between the non-IIAE group (0%) and the IIAE group (2.1%), p = 0.500. The intraoperative limb complications did not differ significantly between the BBT limbs (7.5%), the IIAE + EE limbs (3.5%), and the IBD limbs (3.1%) groups, p = 0.349. The incidence of buttock claudication was significantly greater in the bilateral IIAE + EE group compared to the unilateral IIAE + EE and non-IIAE groups (25%, 11%, and 2.5%, p-value < 0.004), and was similar to the incidence of buttock rest pain with skin necrosis (15%, 0%, and 0%, p < 0.001). During the 10-year follow-up, the BBT limbs group had a significantly lower rate of iliac limb reintervention free time than the IIAE + EE limbs and the IBD limbs groups (88.7%, 98.2%, and 93.8%, p = 0.016). There was no significant difference in the overall 10-year survival rate between the non-IIAE and IIAE groups (51.4% vs. 55.9%, p = 0.703).

CONCLUSIONS

The early and late mortality rates were similar between the non-IIAE and IIAE groups. Preserving the IIA is recommended to avoid pelvic ischemic complications. Considering the higher rate of reintervention in the BBT group, the IBD strategy may be preferred for AAIA.

The quality and quantity media-cultured mononuclear cell transplantation is safe and effective in ischemic hindlimb mouse model

Objective

This study was conducted to investigate in vitro proangiogenic and anti-inflammatory phenotypes and functions and the in vivo efficacy and safety of quality and quantity (QQ) media-cultured mononuclear cells (MNCs) compared with standard cultured MNCs from the peripheral blood of patients with chronic limb-threatening ischemia (CLTI) with atherosclerotic risk factors.

Methods

Peripheral blood MNCs (PBMNCs) from patients with CLTI were cultured in QQ culture media or standard culture media. Phenotypic analysis of progenitor cells (CD34+CD133+), M2 macrophages (CD206+), and inactivated T regulatory cells (CD4+CD25+CD127+), colony-forming assay, and tube formation assay of QQ media-cultured MNCs (QQMNCs) and PBMNCs, were conducted. Intramuscular transplantation of QQMNCs or PBMNCs was performed in the ischemic hindlimb model. The clinical appearance of ischemic limbs was observed, and blood flow in ischemic limbs was measured using a laser Doppler perfusion imager. Outcomes were compared between the QQMNC and PBMNC groups.

Results

Twenty patients with CLTI were included. The mean percentages of CD34+ cells, CD133+ cells, CD34+CD133+ progenitor cells, CD206+ cells, colony-forming cells, and tube formation were significantly higher in the QQMNCs. The mean percentage of CD4+CD25+CD127+ cells was significantly lower in QQMNC. The colony-forming unit count and Dil-acetylated low-density lipoprotein uptake were significantly greater in QQMNCs. The clinical appearance of post-QQMNC-injected limbs was less severe than the appearance of post-PBMNC-injected limbs. Limb perfusion was significantly better in the QQMNCs.

Conclusions

Proangiogenic and anti-inflammatory phenotypes of MNCs cultured in QQ culture media were reproducible. Intramuscular QQMNC transplantation was safe and resulted in better reperfusion of ischemic hindlimbs compared with PBMNCs.

Prevalence and predictors of combined >50% iliocaval venous obstruction and superficial venous reflux in chronic venous insufficiency patients with healed or active venous leg ulcer

OBJECTIVE

The aim of the present study was to investigate the prevalence and predictors of combined >50% iliocaval venous obstruction (ICVO) and superficial venous reflux (SVR) in patients with chronic venous insufficiency (CVI) with a healed (C5) or an active (C6) venous leg ulcer (VLU).

METHODS

We conducted a retrospective review of prospectively collected data from patients with CVI with CEAP (Clinical, Etiology, Anatomy, Pathophysiology) class C5 (healed ulcer) or C6 (active ulcer) with SVR who had been treated at our institution from February 2017 to January 2018. The demographic, clinical, and surgical data and duplex ultrasound and computed tomography venography findings were collected. We used OsiriX MD, version 2.9, software (Pixmeo SARL, Bernex, Switzerland) to measure the vein diameter via multiplanar reconstruction. The prevalence of combined >50% ICVO and SVR was evaluated, and univariate and multivariate analyses were performed to identify the independent predictors of >50% ICVO in patients with CVI and SVR.

RESULTS

A total of 79 limbs from 67 patients were enrolled. The mean age was 59.82 ± 12.86 years, the mean body mass index was 28.68 ± 6.41 kg/m², and 41.8% were men. The prevalence of >50% ICVO in the patients with SVR was 31.6%. Univariate analysis showed a history of deep vein thrombosis (DVT) in the affected leg (P = .001), a VLU in the left leg (P = .033), a history of a recurrent VLU (P = .038), and reversed flow in the superficial epigastric vein (P = .004) were significantly associated with >50% ICVO in patients with CVI and SVR. Multivariate analysis revealed a history of DVT in the affected leg (adjusted odds ratio [aOR], 8.31; 95% confidence interval [CI], 2.29-30.19; P = .001), a VLU in the left leg (aOR, 3.95; 95% CI, 1.18-13.19; P = .026), and a history of a recurrent VLU (aOR, 3.08; 95% CI, 1.02-9.32; P = .047) to be independently associated with combined >50% ICVO and SVR in patients with CVI.

CONCLUSIONS

The prevalence of combined >50% ICVO and SVR in patients with CVI and CEAP C5 or C6 was 31.6%. The independent predictors of combined >50% ICVO and SVR in those with CVI were a history of DVT in the affected leg, a VLU in the left leg, and recurrent VLUs.

The Geriatric Nutritional Risk Index predicts amputation after infrapopliteal angioplasty in critical limb ischemia patients

OBJECTIVE

To validate the Critical Limb Ischemia Frailty Index (CLIFI), and to identify independent predictors of 2-year amputation-free survival after infrapopliteal endovascular treatment for chronic limb-threatening ischemia (CLTI) in Thai patients.

METHODS

This retrospective study was conducted during the June 2014 to February 2017 study period. CLTI patients treated with infrapopliteal angioplasty were enrolled and analyzed. A patient was defined as CLIFI positive if two or more of the following criteria were present: Geriatric Nutritional Risk Index (GNRI) < 89.8, low skeletal muscle mass index (<6.87 kg/m² in males, and <5.46 kg/m² in females), and/or non-ambulatory status. Kaplan-Meier survival analysis was used to assess 2-year amputation-free survival (AFS), and comparisons were performed using log-rank test. Univariate and multivariate Cox proportional hazards models were used to analyze for significant and independent association, respectively, between preoperative characteristics and AFS.

RESULTS

A total of 266 patients and 286 limbs were included. Forty (15.0%) patients were CLIFI positive, and 226 (85.0%) patients were CLIFI negative. The 2-year amputation-free survival rate was 90.3% in the CLIFI positive group, and 86.6% in the CLIFI negative group (p = 0.59). Multivariate analysis revealed the GNRI to be an independent risk factor for amputation within two years after infrapopliteal revascularization (adjusted hazard ratio: 4.87, 95% confidence interval: 1.20-19.70; p = 0.02).

CONCLUSIONS

The GNRI was found to independently predict 2-year amputation after infrapopliteal angioplasty in Thai CLTI patients; however, the CLIFI was not found to significantly predict 2-year amputation in this patient population.

Early and Late Outcomes of Endovascular Aneurysm Repair for Infected Abdominal Aortic and/or Iliac Aneurysms

BACKGROUND

Infected abdominal aortic and/or iliac aneurysm (AAIA) is a rare condition with a high mortality rate when treated with open surgery. In the past decade, the condition has increasingly been treated with endovascular aneurysm repair (EVAR). However, early and late outcomes, including the continued need for antibiotic treatments and predictors of persistent infection, are poorly understood.

METHODS

We evaluated the outcomes of patients who underwent EVAR for infected AAIA from January 2010 to October 2017. We collected data including patient age, gender, clinical presentation, aneurysm location, culture results, intraoperative details, postoperative complications, 30-day mortality, in-hospital mortality, persistent infection, reintervention, and survival.

RESULTS

Among 792 patients diagnosed with AAIA, 64 were diagnosed with primary infected aneurysm, underwent EVAR, and were included in this study (81.3% male; median age, 72 years; range, 18-94 years). The most commonly isolated organisms were Salmonella species (34%), followed by Streptococcus (21%), and Staphylococcus species (21%). Aneurysms were intact in 48 patients (75%) and were ruptured in 16 (25%). The perioperative mortality was 4.7% (3 patients) of whom one was diagnosed with ruptured infected AAIA. Six (9.4%) patients died during hospitalization, 5 of severe sepsis with multiorgan failure and one of myocardial infarction. Among the 58 surviving patients, 34 (58.6%) had persistent infection, of whom 13 (22.4%) required early and late reintervention, including 2 with endograft infection, 8 with primary and secondary aortoenteric fistula, 2 with recurrent new aortic infection, and one with graft limb occlusion. The remaining 24 patients were able to discontinue antibiotics and had no recurrence or need for reintervention. Overall survival rates at 1, 3, and 5 years in the antibiotic-discontinuation group were 91.7%, 87.5%, and 68.0%, respectively, and 82.4%, 52.6%, and 32.9%, respectively, in the persistent-infection group (P = 0.009). In multivariable analysis, primary aortoenteric fistula (Adjusted OR [aOR], 20.469; 95% confidence interval (CI), 1.265-331.320; P = 0.034) and preoperative serum albumin level <3 g/dL (aOR, 7.399; 95% CI, 1.176-46.558; P = 0.033) were preoperative parameter that predicted persistent infection. A C-reactive protein level more than 5 mg/L (aOR, 34.378; 95% CI, 4.888-241.788; P < 0.001) was observed in patients with persistent infection.

CONCLUSIONS

EVAR is a feasible treatment with acceptable perioperative mortality for infected AAIA. Patients able to discontinue antibiotics have better survival and lower reintervention rates than those with persistent infection. A preoperative albumin level below 3 g/dL and primary aortoenteric fistula predicted persistent infection in this population.

Thrombus extension after cyanoacrylate closure of incompetent saphenous veins

BACKGROUND

Cyanoacrylate closure (CAC) is a minimally invasive surgery to treat incompetent saphenous veins. This study aimed to investigate the incidence, the risk factors for, and the management of thrombus extension after cyanoacrylate closure (TEACAC) of incompetent saphenous veins in patients with chronic venous disease.

METHODS

This retrospective study included patients aged >18 years who were diagnosed with chronic venous disease with superficial venous reflux in the great saphenous vein, anterior accessory saphenous vein, or small saphenous vein, and who were treated with CAC at Siriraj Hospital (Bangkok, Thailand) during January 2017 to December 2018.

RESULTS

A total of 126 saphenous veins of 101 patients were included. TEACAC occurred in 5 of 101 (4.9%) patients, and in 5 of 126 (3.9%) treated saphenous veins. The mean follow-up time was 285±12 days. Based on Kabnick classification of endovenous heat-induced thrombosis (EHIT), the following TEACAC grades were observed: grade I (n=2), grade II (n=1), grade III (n=2), and grade IV (n=0). No patient or procedural predictive factors for TEACAC were identified. In patients with TEACAC-1 or TEACAC-2, the thrombus spontaneously disappeared by the 2-week follow-up. Patients with TEACAC-3 received therapeutic rivaroxaban or dabigatran, which resolved the thrombus within 2-4 weeks. No deep vein thrombosis or symptomatic pulmonary embolism was found.

CONCLUSIONS

TEACAC was found not to be a rare complication after CAC. All patients should be informed of the risk of TEACAC prior to treatment. Treatment of TEACAC class 1-3 following EHIT guideline seems to be both safe and effective.

Cyanoacrylate Granuloma After Cyanoacrylate Closure of Incompetent Saphenous Veins

BACKGROUND

Cyanoacrylate closure (CAC) is a minimally invasive surgery to treat incompetent saphenous veins.

OBJECTIVE

To evaluate the incidence, the risk factors for, and the management of cyanoacrylate granuloma (CAG) after CAC of incompetent saphenous veins in patients with chronic venous disease.

MATERIALS AND METHODS

Data specific to incompetent saphenous veins, including great saphenous veins, anterior accessory saphenous veins, and small saphenous veins, that were treated with CAC were retrospectively evaluated.

RESULTS

A total of 126 saphenous veins from 101 patients were included. Recapture of the delivery catheter before withdrawal was not performed in all patients. Cyanoacrylate granuloma occurred in 3 of 101 (2.9%) patients, and in 3 of 126 (2.3%) treated saphenous veins. All patients with CAG presented with granuloma and abscess at the puncture site 3 to 5 months after CAC. All patients were treated with incision, drainage, and removal of the glue foreign body. No recurrent granuloma was observed during the study period. No patient or procedural predictive factor for CAG was identified.

CONCLUSION

Cyanoacrylate granuloma is not a rare complication after CAC when recapture of the delivery catheter is not performed. Patients should be advised of the possibility of CAG after CAC.

Novel culture media enhances mononuclear cells from patients with chronic limb-threatening ischemia to increase vasculogenesis and anti-inflammatory effect

Background

Quality and Quantity culture media (QQ culture media) was reported to enhance vasculogenesis and angiogenesis function of mononuclear cells (MNCs) from healthy volunteers. In this study, MNCs from chronic limb-threatening ischemia (CLTI) patients were cultured in QQ culture media, and then investigated for angiogenesis-related phenotype and function.

Methods

Patients aged ≥ 18 years with CLTI caused by atherosclerosis of the lower extremities were prospectively recruited at Siriraj Hospital (Bangkok, Thailand) during July 2017–December 2018. Peripheral blood mononuclear cells (PBMNCs) were isolated from peripheral blood. PBMNCs were cultured in either QQ culture media or standard culture media. The number of CD34+CD133+ cells, CD206+ cells, CD4+CD25+CD127+ cells, colony formation assay, and human umbilical vein endothelial cell (HUVEC) tube formation assay in MNCs were compared between those cultured in QQ culture media and those cultured in standard culture media.

Results

Thirty-nine patients were included with a mean age of 69 ± 11 years. Diabetes mellitus was found in 25 (64%) patients. The percentage of CD34+CD133+ progenitor cells in MNCs cultured in QQ culture media and in MNCs cultured in standard culture media was 4.91 ± 5.30% and 0.40 ± 0.46%, respectively (p < 0.0001). The percentage of CD206+ cells in MNCs cultured in QQ culture media and in MNCs cultured in standard culture media was 19.31 ± 11.42% and 4.40 ± 2.54%, respectively (p < 0.0001). The percentage of inactive population of T regulatory cells (CD4+CD25+CD127+ cells) in MNCs cultured in standard culture media and in MNCs cultured in QQ culture media was 14.5 ± 10.68% and 1.84 ± 1.37%, respectively (p < 0.0001). The total number of colony-forming units from MNCs cultured in QQ culture media and in MNCs cultured in standard culture media was 8.86 ± 8.35 of 2 × 10⁵ cells/dish, and 0.58 ± 1.05 of 2 × 10⁵ cells/dish, respectively (p < 0.0001). The mean intensity of Dil-Ac-LDL uptake that incorporated into the HUVEC forming tube was 1.37 ± 0.88 in MNCs cultured in QQ culture media, and 0.78 ± 0.41 in MNCs cultured in standard culture media. (p < 0.0003).

Conclusions

MNCs from CLTI patients that were cultured in QQ culture media had a significantly higher number of CD34+CD133+ cells and anti-inflammatory cells, and higher angiogenesis-related function compared to MNCs cultured in standard culture media.

Peripheral blood mononuclear cell transplantation to treat no-option critical limb ischaemia: effectiveness and safety

OBJECTIVE

Local intramuscular transplantation of granulocyte colony-stimulating factor (G-CSF)-mobilised peripheral blood mononuclear cells (PB-MNC) has been shown to be effective for treating patients with no-option critical limb ischaemia (CLI) who are not considered suitable to undergo surgical bypass or percutaneous transluminal angioplasty. The aim of this study was to investigate the effectiveness and safety of PB-MNCs as a treatment for no-option CLI patients.

METHOD

This prospective cohort study was conducted between April 2013 and December 2017. Patients with no-option CLI were treated with G-CSF 5-10 µg/kg/day for 3 days. PB-MNCs (7.1±2.2×10¹⁰) with CD34+ cells (2.1±1.2×10⁸) were collected by blood cell separator and then injected into the calf or thigh of ischaemic limbs. Ankle-brachial index, toe-brachial index and transcutaneous oxygen tension were recorded at 1 and 3 months after injection. The amputation rate and the wound healing rate were also recorded.

RESULTS

Eight patients took part in the study. Two patients experienced rest pain relief 1 month after PB-MNC therapy. Five patients had healed ulcer at 6 months after PB-MNC therapy. Limb ischaemia did not improve after PB-MNC therapy in one patient. Below-knee amputation was performed in that patient due to extension of gangrene. Two patients required reinjection of PB-MNCs because of recurrence of ischaemic ulcer. The limb salvage rate after 1 year was 87.5%.

CONCLUSION

Local intramuscular transplantation of G-CSF-mobilised PB-MNCs might be a safe and effective treatment for no-option CLI patients.

Hypersensitivity reaction after cyanoacrylate closure of incompetent saphenous veins in patients with chronic venous disease: A retrospective study

PURPOSE

The objective of this study was to evaluate the incidence of, the risk factors for, the nature of the disease, and the management of hypersensitivity reaction (HSR) after cyanoacrylate closure (CAC) of incompetent saphenous veins in patients with chronic venous disease.

METHODS

Data consisting of all incompetent saphenous veins, including great saphenous veins, anterior accessory saphenous veins, and small saphenous veins, treated with CAC at Siriraj Hospital (Bangkok, Thailand) from January 2017 to December 2018 were retrospectively evaluated.

RESULTS

A total of 126 saphenous veins, including 106 great saphenous veins (84.1%), 7 anterior accessory saphenous veins (5.6%), and 13 small saphenous veins (10.3%) of 126 limbs from 101 patients were included. A HSR occurred in 16 of 101 patients (15.8%), in 19 of 126 limbs (15.0%), and in 19 of 126 treated saphenous veins (15.0%). HSR-related erythema, itching, swelling, and pain occurred in 100.0%, 95.0%, 68.4%, and 52.6%, of HSR patients, respectively. HSR occurred 1 week after CAC. All HSR symptoms were mild, could be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and antihistamine, and were resolved within 1 week. The risk factors for HSR were suprafascial saphenous vein with a depth <1 cm from the skin, and saphenous vein diameter of ≥8 mm.

CONCLUSIONS

A HSR occurred in 15.8% of patients and in 15.0% of limbs after CAC. Risk factors for HSR were a suprafascial saphenous vein located close to the skin and a large saphenous vein. All HSR symptoms were mild in severity, occurred at 1 week after CAC, and were resolved within 1 week after treatment with nonsteroidal anti-inflammatory drugs and antihistamines. To prevent HSR, CAC should be avoided in suprafascial saphenous veins that are located close to the skin, and CAC in saphenous veins with a size of ≥8 mm should be performed with caution.

Early and late outcomes of endovascular aneurysm repair to treat abdominal aortic aneurysm compared between severe and non-severe infrarenal neck angulation

Background

Abdominal aortic aneurysm with severe infrarenal neck angle (>60°) has long been thought to be an obstacle to endovascular aneurysm repair. However, some previous studies reported endovascular aneurysm repair to be safe and efficacious for treating abdominal aortic aneurysm in patients with severe neck angulation. The aim of this study was to investigate the early and late outcomes of endovascular aneurysm repair to treat abdominal aortic aneurysm compared between patients with severe and non-severe infrarenal neck angulation.

Methods

Fifty-four severe and 144 non-severe neck angulation patients who were treated at Siriraj Hospital (Bangkok, Thailand) during January 2010–October 2013 were recruited. The primary endpoints were intraoperative neck complications (e.g., type 1A endoleak or proximal graft migration) and immediate adjunct aortic neck procedures. The secondary endpoints included perioperative mortality, overall survival, and the proportion of patients that were reintervention-free at five years compared between the severe and non-severe groups.

Results

Severe angulation patients were significantly older than non-severe angulation patients (77 ± 6.3 vs. 74 ± 7.9 years; p =  0.021). The median proximal angle was significantly greater in the severe group (82° vs. 13.5°; p <  0.001). Intraoperative proximal neck complications developed in 29.6% of patients in the severe angulation group compared with 9.0% in the non-severe group ( p <  0.001). Significantly more patients in the severe group required intraoperative adjunct procedures (29.6% vs. 7.6%; p <  0.001). There was no significant difference in perioperative mortality between groups. At the five-year follow-up, there was no significant difference between groups for overall survival or the proportion of patients that remained reintervention-free.

Conclusions

Endovascular aneurysm repair to treat abdominal aortic aneurysm in patients with severe proximal neck angulation is technically feasible and safe Although the severe angulation group had a higher rate of intraoperative neck complications and immediate adjunct neck procedures than the non-severe group, there was no significant difference between groups for 30-day mortality, overall survival or the proportion of patients who remained reintervention-free at five years.

Factors that influence venous leg ulcer healing and recurrence rate after endovenous radiofrequency ablation of incompetent saphenous vein

OBJECTIVE

Endovenous radiofrequency ablation (RFA) is one of the most popular techniques for correcting superficial vein reflux. However, the effectiveness of RFA of superficial vein reflux in patients with active or healed venous leg ulcer (VLU) is unknown. Accordingly, the objective of this study was to evaluate the healing rate, the recurrence rate, and the factors significantly associated with healing and recurrence in patients with active or healed VLU who had superficial venous reflux treated with RFA.

METHODS

We retrospectively reviewed all healed VLU or active VLU patients treated with RFA at the Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, during January 2011 to December 2017 to evaluate the rate of VLU healing and recurrence. Time to healing and time to ulcer recurrence were determined by Kaplan-Meier survival analysis. Risk factors were assessed to determine their association with VLU healing and recurrence by Cox regression survival analysis.

RESULTS

RFA of the great saphenous vein (n = 56), anterior accessory saphenous vein (n = 5), or both (n = 1) was performed on 62 limbs with active (n = 32) or healed (n = 30) VLUs. The mean age of patients was 65.4 ± 9.8 years, and 80% were female. Deep venous insufficiency was present in 10 limbs (16%). Pathologic perforating vein was found in 17 patients (27%). Concomitant ultrasound-guided foam sclerotherapy (UGFS) of the pathologic perforating vein was performed in 12 limbs (19%). Concomitant phlebectomy was performed in 19 limbs (31%). The median follow-up time was 753 days after RFA. VLU healed in 31% of patients at 3 months, in 56% at 6 months, and in 66% at 1 year after RFA. Concomitant UGFS of the pathologic perforating vein was the only factor significantly associated with VLU healing (hazard ratio, 2.84; 95% confidence interval, 1.07-7.55; P = .037). VLU recurrence was found in 8% of patients at 1 year, in 14% at 2 years, and in 23% at 3 years after RFA. Deep vein reflux was the only identified risk factor for VLU recurrence (hazard ratio, 3.72; 95% confidence interval, 1.05-13.21; P = .042).

CONCLUSIONS

UGFS of the pathologic perforating vein at the time of RFA of saphenous vein reflux improved VLU healing. VLU recurrence was more frequent in patients with concomitant deep vein reflux. The authors suggest performing UGFS of the pathologic perforating vein at the time of RFA to improve VLU healing and monitoring of patients with associated deep vein reflux for ulcer recurrence.

Presence of Residual Venous Thrombus at Warfarin Withdrawal: a Predictor for Recurrence after a First Episode of Symptomatic Provoked Proximal Deep Venous Thrombosis in Thai Population?

Objective: To assess the risk for venous thromboembolism (VTE) recurrence by presence of residual venous thrombus (RVT) at warfarin withdrawal following symptomatic first provoked proximal DVT.Methods: Medical records of 45 consecutive patients with symptomatic first provoked proximal DVTs who had undergone warfarin surveillance for ≥ 3 months were reviewed retrospectively. Altogether, 22 patients discontinued anticoagulation after ≥ 3 months regardless of duplex ultrasonography results of RVT diagnosed by compression ultrasonography. Another 23 patients discontinued anticoagulation after the RVT disappeared. Primary outcome was recurrent VTE.Results: Four of the 45 patients experienced recurrent VTE (8.89%), including 2 (9.00%) of 22 patients who had discontinued anticoagulant regardless of duplex ultrasonography results and 2 (8.70%) of 23 patients who discontinued anticoagulation after RVT disappearance (p = 0.963). All of the recurrent VTE were recurrent DVT.Conclusion: RVT at warfarin withdrawal was not a predictor for recurrence VTE following a first symptomatic provoked proximal DVT.

Peak systolic velocity ratio derived from quantitative vessel analysis for restenosis after femoropopliteal intervention: a multidisciplinary review from Endovascular Asia

With technological improvements in the endovascular armamentarium, there have been tremendous advances in catheter-based femoropopliteal artery intervention during the last decade. However, standardization of the methodology for assessing outcomes has been underappreciated, and unvalidated peak systolic velocity ratios (PSVRs) of 2.0, 2.4, and 2.5 on duplex ultrasonography have been arbitrarily but routinely used for assessing restenosis. Quantitative vessel analysis (QVA) is a widely accepted method to identify restenosis in a broad spectrum of cardiovascular interventions, and PSVR needs to be validated by QVA. This multidisciplinary review is intended to disseminate the importance of QVA and a validated PSVR based on QVA for binary restenosis in contemporary femoropopliteal intervention.

Prevalence, risk factors, and evaluation of iliocaval obstruction in advanced chronic venous insufficiency

OBJECTIVE

The aim of this study was to investigate the prevalence and clinical predictors of >50% iliocaval venous obstruction (ICVO) in Thai patients with lipodermatosclerosis and healed or active venous ulcers and the diagnostic accuracy of duplex ultrasound (DUS) compared with computed tomography venography (CTV).

METHODS

Limbs with lipodermatosclerosis, healed venous leg ulceration, or active venous leg ulceration were prospectively evaluated by DUS and CTV. Loss of respiratory variation in the common femoral vein (CFV) and reversed flow in the superficial epigastric vein (SEV) were evaluated by DUS. Percentage of venous obstruction was measured by CTV. The prevalence and clinical predictors of >50% ICVO were determined, and the accuracy of DUS for diagnosis of >50% ICVO was compared with the diagnostic accuracy of CTV.

RESULTS

A total of 106 patients (135 limbs) were enrolled. The mean age was 58 ± 12 years, and 57 (54%) patients were female. Previous history of deep venous thrombosis (DVT) in the symptomatic leg was documented in 21 (15.6%) limbs; >50% ICVO by CTV was found in 38 (28.1%) limbs. Independent predictors of >50% ICVO included left leg (P = .001) and previous history of DVT in the affected leg (P = .001). For diagnosis of >50% ICVO, the sensitivity and specificity of loss of respiratory variation in the CFV were 23.7% and 100%, respectively; the sensitivity and specificity of reversed flow in the SEV were 7.9% and 100%, respectively.

CONCLUSIONS

Limbs with lipodermatosclerosis or with healed or active venous ulceration, especially in the left limb or in limbs with a history of DVT in the affected limb, had a high prevalence of ICVO; these limbs should be routinely studied with DUS. Limbs with an abnormal finding on DUS, including loss of respiratory variation in the CFV or reversed flow in the SEV, should be routed for venous intervention, and those with normal DUS findings should be referred for CTV.

Contemporary critical limb ischemia: Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care

The burden of peripheral artery disease (PAD) and diabetes in Asia is projected to increase. Asia also has the highest incidence and prevalence of end-stage renal disease (ESRD) in the world. Therefore, most Asian patients with PAD might have diabetic PAD or ESRD-related PAD. Given these pandemic conditions, critical limb ischemia (CLI) with diabetes or ESRD, the most advanced and challenging subset of PAD, is an emerging public health issue in Asian countries. Given that diabetic and ESRD-related CLI have complex pathophysiology that involve arterial insufficiency, bacterial infection, neuropathy, and foot deformity, a coordinated approach that involves endovascular therapy and wound care is vital. Recently, there is increasing interaction among cardiologists, vascular surgeons, radiologists, orthopedic surgeons, and plastic surgeons beyond specialty and country boundaries in Asia. This article is intended to share practical Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care for CLI.

Customizing elastic pressure bandages for reuse to a predetermined, sub-bandage pressure: A randomized controlled trial

Objective

A randomized clinical trial was performed to compare the effectiveness of unmarked bandages and customized bandages with visual markers in reproducing the desired sub-bandage pressure during self-bandaging by patients.

Method

Ninety patients were randomly allocated to two groups (“customized bandages” and “unmarked bandages”) and asked to perform self-bandaging three times. The achievement of a pressure between 35 and 45 mmHg in at least two of the three attempts was defined as adequate quality.

Results

Adequate quality was achieved by 33.0% when applying the unmarked bandages, and 60.0% when applying the customized bandages ( p = 0.02). Use of the customized bandage and previous experience of bandaging were independent predictors for the achievement of the predetermined sub-bandage pressure ( p = 0.005 and p = 0.021, respectively).

Conclusion

Customized bandages may achieve predetermined sub-bandage pressures more closely than standard, unmarked, compression bandages.

Clinical trials registration

ClinicalTrials.gov (NCT02729688). Effectiveness of a Pressure Indicator Guided and a Conventional Bandaging in Treatment of Venous Leg Ulcer. https://clinicaltrials.gov/ct2/show/NCT02729688

Use of customised pressure-guided elastic bandages to improve efficacy of compression bandaging for venous ulcers

Compression bandaging is a major treatment of chronic venous ulcers. Its efficacy depends on the applied pressure, which is dependent on the skill of the individual applying the bandage. To improve the quality of bandaging by reducing the variability in compression bandage interface pressures, we changed elastic bandages into a customised version by marking them with circular ink stamps, applied when the stretch achieves an interface pressure between 35 and 45 mmHg. Repeated applications by 20 residents of the customised bandage and non-marked bandage to one smaller and one larger leg were evaluated by measuring the sub-bandage pressure. The results demonstrated that the target pressure range is more often attained with the customised bandage compared with the non-marked bandage. The customised bandage improved the efficacy of compression bandaging for venous ulcers, with optimal sub-bandage pressure.

Risk factors for endovenous heat-induced thrombosis after endovenous radiofrequency ablation performed in Thailand

Objective

We aimed to determine the incidence of and associated risk factors for endovenous heat-induced thrombosis (EHIT) after endovenous radiofrequency ablation (RFA).

Methods

We retrospectively reviewed the medical records of 82 patients with 97 great saphenous veins undergoing RFA from 2012 to 2014.

Results

The incidence of EHIT was 10.3%. Class 1, 2, and 3 EHIT was found in 50%, 30%, and 20% of legs, respectively. No class 4 EHIT, deep vein thrombosis, or pulmonary emboli occurred. Univariate analysis revealed that the associated risk factors for EHIT were a vein diameter of >10 mm, operative time of >40 min, and Caprini score of >6. Multivariate analysis revealed that the independent risk factors associated with EHIT were a vein diameter of >10 mm and operative time of >40 min.

Conclusions

A vein diameter of >10 mm and operative time of >40 min might be predictive factors for EHIT following RFA.

A new pretest probability score for diagnosis of lower limb deep vein thrombosis in unselected population of outpatients and inpatients

Objective

To develop a new pretest probability score for deep vein thrombosis (DVT) in unselected population of outpatients and inpatients.

Methods

The new score was developed using independent factors from 500 patients clinically suspected of leg DVT. The new score was validated in a second group of 315 patients.

Results

The score consists of four components: unilateral leg pain, confinement to bed, calf enlargement >3 cm compared with the other side, and previous venous thromboembolism. A score ≥2 indicated a high probability while a score <2 indicated low probability. The sensitivity and specificity of the new score were 71.60% and 79.49%, respectively. The area under the receiver operating characteristic curve for the new score was 0.79. The combination of a new score <2 and D-dimer level <500 µg/L had a negative predictive value of 96.43%.

Conclusions

Our new score was valid in an unselected population of outpatients and inpatients.

Carotid Endarterectomy in Symptomatic Extracranial Internal Carotid Artery Stenosis: A Result of the First 100 Consecutive Cases in a University Hospital

BACKGROUND

Extracranial carotid artery stenosis has been recognized in 9.2% of ischemic stroke patients by duplex ultrasonography in Thailand. The treatment program of this disease has not been established countrywide.

OBJECTIVE

Carotid endarterectomy in our institute was firstly evaluated for safety and long-term efficiency in order to assess the possibility of expanding this treatment throughout the country.

MATERIAL AND METHOD

An observational study with long-term follow-up was carried out in 100 consecutive symptomatic patients with severe stenosis (70-99% diameter stenosis) of extracranial internal carotid artery that underwent carotid endarterectomies. All carotid endarterectomies were performed under general anesthesia, with routine use of intravascular shunts during carotid cross clamps and saphenous vein patches for arteriotomy closures. Perioperative mortality and morbidity were evaluated for the safety of this procedure. The long-term stroke-free survival was assessed to announce the efficiency of this treatment.

RESULTS

One hundred consecutive patients (68% male and 32%female) with the mean age of 69.9 years were included in the present study. Mean duration of neurological symptoms prior to surgery was 2.5 months. Hemiplegia (64%) was the most common symptom leading to surgery. Hypertension (87%) was the most common comorbidity in the present series. Mean duration of surgical procedure was 210 minutes. Mean durations of total carotid shunting and carotid cross clamp during shunt removal were 75 minutes and 4.5 minutes respectively. Mean length of ICU stay was 1.4 days. The perioperative mortality rate was 1%. The perioperative major stroke rate was also 1%. Ten-year follow-up of the patients revealed no death related to neurovascular event and no evidence of recurrent ipsilateral stroke in the present series. The cumulative 5- and 10-year stroke-free survivals were 86.1% and 73.7% respectively. Duplex ultrasonography in all survivors demonstrated no recurrent stenosis in the affected carotid artery.

CONCLUSION

Carotid endarterectomy with a consistent technique in the present series had a comparable outcome of safety and long-term efficiency with the standard surgical practice. The information may initiate the treatment guideline for the patient with extracranial carotid artery stenosis in Thailand.

Outcomes and factors influencing prognosis in patients with vascular pythiosis

OBJECTIVE

Vascular pythiosis, caused by Pythium insidiosum, is associated with a high mortality rate. We reviewed the outcomes and established the factors predicting prognosis of patients treated in our institution with surgery, antifungal therapy, or immunotherapy.

METHODS

We undertook a retrospective record review of patients with vascular pythiosis treated in Siriraj Hospital, Bangkok, Thailand, between January 2005 and January 2015. Patient characteristics, type of surgery, adjunctive antifungal treatment, adjunctive immunotherapy, and disease status of surgical arterial and surrounding soft tissue margins were recorded. We calculated the mortality rate and established factors predicting prognosis.

RESULTS

The records of 11 patients were reviewed. All patients had thalassemia. Nine patients (81.8%) had a history of contact with contaminated water. The clinical presentations were chronic ulcers (45.5%), toe gangrene (27.3%), pulsatile mass (27.3%), and acute limb ischemia (27.3%). Above-knee amputation was required in 10 patients (90.9%). The mortality rate was 36.4%. Independent variables between survivors and nonsurvivors were lack of an arterial disease-free surgical margin (P = .003), lack of a surrounding soft tissue disease-free surgical margin (P < .05), a suprainguinal lesion (P < .05) and duration of symptoms (P < .05). Adjuvant itraconazole, terbinafine, and Pythium vaccine have a role to play in patients with a disease-free arterial surgical margin but in whom infected surrounding soft tissue could not be completely excised.

CONCLUSIONS

Achieving adequate disease-free surgical margins-especially the arterial margin-at amputation or débridement is the most important prognostic factor in patients with vascular pythiosis. Early detection combined with a multidisciplinary approach to treatment, including surgery, antifungal agents, and immunotherapy, allows the best possible outcome to be obtained.

Ascending thoracic aortobipopliteal bypass for extensive aortoiliac and femoropopliteal arterial occlusive disease

This report describes a patient with disabling intermittent claudication resulting from the complex combination of a heavily calcified abdominal aorta, extensive aortoiliac occlusion, bilateral femoropopliteal arterial occlusion, and thrombosis of a previous right axillobifemoral bypass graft, followed by revision of the graft to the left proximal popliteal artery and subsequent graft removal because of chronic infection. The patient underwent successful ascending thoracic aortobipopliteal bypass surgery and had an uneventful postoperative recovery, with ankle pulses palpable bilaterally. After 6 years of follow-up, he could walk unlimited distances, and computed tomography angiography showed patent grafts.

Balloon assisted valsalva maneuver in the diagnosis of saphenofemoral junction incompetence

BACKGROUND

Conventional Valsalva maneuver (CV) is a standardprocedure to exhibit reverse venous flow atsaphenofemoral junction (SFJ) by duplex ultrasonography (DUS). However some patients could not undergo CV during examination.

OBJECTIVE

Compare blowing party balloon assisted Valsalva (PBAV) with CV for exhibiting the reverse venous flow at SFJ incompetence.

MATERIAL AND METHOD

Forty patients who had symptoms and signs of suspected saphenofemoral junction incompetence were examined for venous reflux by DUS with two techniques of Valsalva maneuver PBAV and CV The design was a 2x2 cross-over study. The patients were randomized to two sequences. The first sequence performed CV before PBAV The second sequence performed PBAV before CV The timing for the instruction, reflux time, and total timing of examination were compared between the two sequences.

RESULTS

There was neither period effect nor treatment-period interaction. Both PBAV and CV could equally identify SFJ reflux, but teaching time and total examination time in PBAV was shorter than CV.

CONCLUSION

PBAV is a new option to exhibit reverse venous flow at SFJ by DUS. PBAV is easier and spend less time than CV

Comparison of clinical prediction scores for the diagnosis of deep vein thrombosis in unselected population of outpatients and inpatients

Objectives

The aim of this research was to compare the accuracy of the modified Wells, the Wells, the Kahn, the St. André, and the Constans score for the diagnosis of deep vein thrombosis of the lower limb in unselected population of outpatients and inpatients.

Method

The pretest of probability score was employed in consecutive 500 outpatients and inpatients with suspicion of deep vein thrombosis. All patients were examined with compression ultrasonography.

Results

Deep vein thrombosis was confirmed in 26.4%. In the unselected population of outpatients and inpatients, the accuracy of the modified Wells score and the Constans score was higher than other scores. Both scores were more accurate for the outpatients. There was no accurate score for the inpatient subgroup.

Conclusions

The modified Wells and the Constans score appear to be useful in the unselected population of outpatients and inpatients and particularly in the outpatient subgroup.

Suprainguinal vascular pythiosis: effective long-term outcome of aggressive surgical eradication

Vascular pythiosis, a vascular infectious disease in hemoglobinopathy patients, caused by Pythium insidiosum, has an endemic area in tropical and subtropical countries. According to literature review, suprainguinal vascular pythiosis leads to 100% of mortality. The authors report a 35-year-old thalassemic patient who presented with a right inflammatory pulsatile groin mass and right limb ischemia. The computerized tomography angiography indicated a false aneurysm at the right external iliac artery and thrombosed entire right leg arteries. The management comprised antifungal agent, immunotherapy, and surgical removal of all infected arteries (high up to the right common iliac artery and above-knee amputation). The patient was found in a good condition at 36 months after the follow-up period.

Outcomes of abdominal aortic aneurysm with aortic neck thrombus after endovascular abdominal aortic aneurysm repair

BACKGROUND

Endovascular abdominal aortic aneurysm repair (EVAR) has increasingly been performed for the last two decades. One of the anatomical exclusion criterion of EVAR is the presence of thrombus within the infrarenal neck of an aneurysm.

OBJECTIVE

To investigate the influence of proximal aortic neck thrombus morphology on clinical outcomes after EVAR.

MATERIAL AND METHOD

The subjects were retrospectively recruited from all the patients whom undergone EVAR in our institution between January 2010 and December 2012. The patients with apparent thrombus of more than 40% at proximal aortic neck were included Primary endpoints consisted of technical success and perioperative mortality. Secondary endpoints included adjuvant procedures at neck, procedural details, perioperative adverse events, ICU, and hospital stay. The late outcomes of stent grafts related complications were the presence of endoleak, aneurysm expansion, stent graft migration, stent graft thrombosis, AAA rupture, secondary intervention rate, and conversion to open repair

RESULTS

Twenty-one out of 145 patients having thrombus of more than 40% of circumferential aortic neck underwent EVAR. The mean follow-up was 15.4 months (range, 2-36 months). There was 100% technical success with no perioperative death. Adjuvant of aortic neck procedure was required in three patients. One patient developed graft limb occlusion. In addition, one patient developed renal infarction requiring long-term hemodialysis and two patients presented with blue toe syndrome and trash feet. During late follow-up, three, five, and two patients had a type II endoleak at one, six, and 12 months, respectively without AAA sac expansion. There was no stent graft migration, stent graft thrombosis, or ruptured AAA. Three patients expired during the late follow-up. In addition, there was neither conversion to opened repair nor secondary intervention.

CONCLUSION

The presence of aortic neck thrombus may not be a contraindication for EVAR in selected patients. However, it seems to negatively influence the outcomes in the aspect of renal and peripheral embolization, which could be prevented during EVAR procedure. There was no adverse graft-related complication, secondary intervention, or aneurysm-related mortality during mid-term follow-up period.

Endovenous radiofrequency thermal ablation and ultrasound-guided foam sclerotherapy in treatment of klippel-trenaunay syndrome

INTRODUCTION

Klippel-Trenaunay syndrome is composed of port-wine stain, limb hypertrophy and varicose veins.

METHODS

The two patients with Klippel-Trenaunay syndrome treated by endovenous radiofrequency thermal ablation and ultrasound-guided foam sclerotherapy of the abnormal veins was conducted.

RESULTS

Radiofrequency thermal ablation resulted in successful occlusion of the incompetent anterior accessory great saphenous vein. Moreover, ultrasound-guided foam sclerotherapy showed complete occlusion of the residual veins. At 6 month follow-up, both patients markedly decreased leg symptoms including pain, cramping, limb swelling, and bulging of veins.

CONCLUSION

Radiofrequency thermal ablation combined with foam sclerotherapy is a minimally invasive procedure alternative to the standard invasive surgery and can be the option for saphenous ablation in Klippel-Trenaunay syndrome patients.

Prevalence of perioperative asymptomatic proximal deep vein thrombosis in Thai gynecologic cancer patients

BACKGROUND

Thromboprophylaxis of deep vein thrombosis in gynecologic cancer surgery in Thai patients is not routinely performed.

OBJECTIVE

The prevalence of perioperative asymptomatic proximal deep vein thrombosis of 100 patients with gynecologic cancer was identified.

MATERIAL AND METHOD

Duplex ultrasonography of proximal vein of legs was performed in each patient, seven to 14 days, before and after surgery.

RESULTS

The prevalence of perioperative asymptomatic proximal deep vein thrombosis was 7%. The prevalence of preoperative asymptomatic proximal deep vein thrombosis of legs was 5% and postoperative incidence of asymptomatic proximal deep vein thrombosis of legs was 2.11%. Acute symptomatic pulmonary embolism was found in only one patient. All patients who developed deep vein thrombosis had adenocarcinoma of ovary or uterus, but not cervical cancer The other risk factors of venous thromboembolism were comparable between deep vein thrombosis and non-deep vein thrombosis group.

CONCLUSION

The patients with adenocarcinoma of ovary and uterus seem to be the greatest risk of perioperative deep vein thrombosis. High prevalence of venous thromboembolism in gynecologic cancer surgery of Thai patients should be concerned.

Catheter-directed thrombolysis for acute limb ischemia caused by native artery occlusion: an experience of a university hospital

OBJECTIVE

To evaluate the efficiency and complications of catheter-directed thrombolysis (CDT) of acute limb ischemia (ALI) resulting from thromboembolic occlusion.

MATERIAL AND METHOD

A retrospective study of CDT was carried out in patients with acute thromboembolic arterial occlusion and marginally threatened ischemia of the extremities between February 2006 and December 2011. After the tip of the angiographic catheter was placed within the blood clot, recombinant tissue plasminogen activator (rt-PA) was used for thrombolysis. The CDT procedure included an initial bolus injection of high dose rt-PA (5-15 mg) followed by a tapering of infusion rate (1-2 mg/hour) through the catheter Primary outcome was 1-year amputation free survival rate and mortality rate. Secondary outcome included technical and clinical success rates, time to lysis, and complication rate. The complete reestablishment of the occluded arteries without major amputation and death was considered successful treatment.

RESULTS

Thirty-seven patients (30 males and 7 females) with the mean age of 55.6 years (range, 27-86 years) were enrolled in the present study. The number of acute arterial occlusion was 23 (62.2%) of acute arterial embolism and 14 (37.8%) of acute arterial thrombosis. Embolism involved two aortic bifurcations, two iliac arteries, five femoral arteries, 13 popliteal arteries, and one both popliteal arteries. The sites of thrombosis were one of aorto-iliac segment, three of iliac artery, five of femoral artery, three of popliteal artery, one of bilateral popliteal, and one of tibio-peroneal artery. The mean duration of completed infusions was 21.29 hours (range, 2-58 hours). Successful adjunctive percutaneous intervention or arterial bypass was performed in seven patients (18.9%) whose stenotic lesions were disclosed following CDT The 30-day perioperative mortality and 30-day amputation-free survival rates of the patients treated by CDT were 10.8% (4 of 37 patients) and 86.5% (32 of 37 patients) respectively. Both 6-month and 1-year amputation free survival rate were 78.4% (29/37). Technical success rate was 75.7% (28/37) whereas clinical success was 86.5% (32/37). Technical success rate was 80.0% (28/35) if ischemic symptom onset was no longer than six weeks. The 30-day major complications included two patients (5.4%) requiring more than four units of blood transfusion for access site hematoma, two (5.4%) large fatal intracerebral hemorrhages, one (2.7%) small intracerebral hemorrhage, one (2.7%) acute embolic stroke, and one (2.7%) death of multiple organ failure following conversion to surgical revascularization. Minor complications were distal thromboembolization in one patient (2.7%), small hematoma in seven patients (18.9%), and pseudoaneurysm in one patient (2.7%).

CONCLUSION

CDT is an effective armamentarium to salvage the ischemic limb resulting from acute embolism and acute thrombosis of native artery. However bleeding complication is a major problem of this treatment. Although CDT is usually applied for ALI patients with ischemic symptom onset less than 14 days, it also provides technical success for those with the symptom onset between the second and the sixth weeks.

Transfemoral temporary aortic balloon occlusion assisting open repair for ruptured abdominal aortic aneurysms

The mortality rate of ruptured abdominal aortic aneurysm (rAAA) is still high despite an advance in surgical technology and critical care. The authors report three patients who had successful open repairs of rAAA assisted by transfemoral temporary aortic balloon occlusion. Before the operation, these patients had severe abdominal pain with hypotension. An aortic balloon occlusion catheter was introduced into the abdominal aorta under fluoroscopy at pararenal level, which was accessed from the right common femoral artery under local anesthesia. After balloon inflation, a rapid increase in arterial blood pressure was found and general anesthetic induction was started. Finally, open repair of rAAA was successfully carried out with rapid proximal neck control by aortic balloon palpation. All the patients made an uneventful recovery during the postoperative period and were discharged on day 16, day 8, and day 17 respectively.

CONCLUSION

Transfemoral temporary aortic balloon occlusion is an effective strategy in rapid proximal aortic control before a conventional open repair of rAAA. It provides immediate hemostasis resulting in stabilized blood pressure before and during anesthetic induction, and facilitated aortic neck identification.

Successful outcome of obturator bypass surgery in infected femoral pseudoaneurysm: three cases report and literature review

The authors report a successful management of obturator bypass surgery in three patients with infected femoral pseudoaneurysm. This bypass reconstruction is an uncommon operation due to the difficult surgical technique and infrequent indications. In the present report, the authors reviewed the literature published between 1988 and 2008 consisting of 78 cases with the claim of obturator bypass surgery for this condition. It is important to note that this type of extra-anatomical bypass together with debridement and excision of infected femoral pseudoaneurysm might be another option to decrease the risk of vascular conduit infection and increase successful limb salvageability.

Outcomes of permanent inferior vena cava filters: experiences in Thai patients

INTRODUCTION

We aimed to study the outcomes of permanent inferior vena cava (IVC) filter implantation in Thai patients.

METHODS

This was a retrospective study of 28 patients with deep vein thrombosis (DVT) who underwent prophylactic implantation of IVC filters for fatal pulmonary embolism (PE) between January 2005 and June 2008. The patients' operative records, protocol and follow-up data were analysed. 11 (39%) patients had PE at the initial diagnosis. The mean age of the patients was 62.1 (range 33-83) years. Indications for IVC filter implantation included contraindications to and complications of anticoagulant therapy and floating thrombi in the iliofemoral veins.

RESULTS

No significant technical complication was noted, except for malposition in one patient (3.5%) and failure of the permanent IVC filter to open fully in another. During the follow-up period (mean 17.5 ± 10.9 months), no patients had any episode of PE and nine (32%) died of unrelated causes. Two patients were lost to follow-up. Among the 17 survivors, six (35.2%) had non-recanalised thrombosis vein, four (23.5%) had clinical evidence of chronic venous insufficiency, two (11.7%) had recurrent DVT in the contralateral limb and one (5.8%) developed IVC thrombosis. There was no evidence of migration of the caval filters. No statistical significance was observed in the effects of post-filter anticoagulation drug on current DVT and in the relation between PE at initial diagnosis and death during follow-up.

CONCLUSION

Permanent IVC filter implantation may be effective for preventing symptomatic PE in Thai patients, with no significant sequelae in the lower extremities.

Chronic arterial embolism of the lower extremities: an unusual etiology of critical limb ischemia

BACKGROUND

Chronic arterial embolism of the lower extremities, the unusual cause of critical limb ischemia (CLI), is not well recognized in the medical practice.

OBJECTIVE

To study the clinical problem of chronic arterial embolism in the aspects of the clinical characteristics and treatment outcomes.

MATERIAL AND METHOD

Between January 2000 and December 2004, 411 consecutive patients with chronic limb ischemia, including 16 (3.8%) patients with chronic arterial embolism were included in the present study. The diagnosis of chronic arterial embolism was confirmed by angiography, operative finding, and histopathology of amputated specimen. The clinical characteristics and management outcomes were recorded and analyzed.

RESULTS

Of the 16 patients with chronic arterial embolism, the mean duration of clinical manifestation was 2.4 months (range, 1-6). Femoral artery was the most common site of arterial occlusion (63.1%). Atrial fibrillation was the most common clinical risk factor (25.0%). Of the 14 patients (87.5%) suffering from CLI, nine patients (56.25%) underwent the various types of revascularization. In five patients (31.25%), the authors could not perform revascularization due to the fibrotic arteries. Successful limb salvage and disappearance of rest pain with complete healing of ulcer in patients with CLI were only 50%. One patient (6.25%) expired after major amputation.

CONCLUSION

Chronic arterial embolism of the lower extremities is the unusual cause of CLI with a high rate of major amputation. Early detection and appropriate management of arterial embolism at the initial stage may reduce this serious vascular problem.

Pedal bypass with deep venous arterialization: the therapeutic option in critical limb ischemia and unreconstructable distal arteries

Heavily calcified and severely stenotic distal arteries defined as unreconstructable, precludes the possibility of revascularization, resulting in major amputation in patients with critical limb ischemia. However, providing blood supply to the ischemic foot through the venous system instead of the arterial system may improve the circulation adequately for the healing process in the vascular compromised distal tissue. This study aimed to assess the safety and efficacy of pedal bypass with deep venous arterialization, one of the possible procedures to improve the circulation through the venous system in critically ischemic limbs and unreconstructable distal arteries. Twenty-six patients with critical limb ischemia and an unreconstructable distal artery of the lower extremities were included for the surgical procedure. Arterial bypass with distal anastomosis at the paramalleolar deep vein was carried out through a composite graft combined with adequate destruction of valve competency in the distal vein. The primary endpoint was complete healing of ischemic ulcer with amelioration of rest pain within six months. The secondary endpoints were the outcomes of survival, limb salvage and primary graft patency rate at six-month intervals to 24 months. Nineteen patients (73.1%) had complete healing of ischemic ulcer and disappearance of rest pain within six months. Six patients (23.1%) underwent major amputation. Perioperative mortality was 3.8%. After 24 months of follow-up study, the survival rate was 87.5%, whereas the limb salvage and graft patency rates were 76.02 and 49.17%, respectively. Pedal bypass with deep venous arterialization may be another therapeutic option to enhance the healing of ischemic ulcer and limb salvageability in patients with critical limb ischemia and unreconstructable distal artery.

Successful treatment in superior mesenteric artery embolism: a case report and literature review

The authors report a successful management of acute superior mesenteric artery embolism in a patient during the treatment of popliteal artery embolism. The diagnosis of this disease was confirmed by computerized tomographic angiography. Immediate surgical embolectomy and bowel resection were performed and postoperatively, he made an uneventful recovery except for minimal watery diarrhea for one week. In the present report the authors also review the in-patient records at Siriraj Hospital during 2005-2009 consisting of 14 cases with the claim diagnosis of this condition. Most of the patients developed peritonism on abdominal examinations showing a delay in diagnosis. The mortality rate was 86% (12 cases) which was higher than international reports. It is important to note that patients presenting with abdominal pain with underlying risk factors of arterial embolism is the clue in early diagnosis of this condition. CTA mesenteric artery is the most appropriate investigation to visualize the presence of embolism. Finally, immediate revascularization treatment is essential in the successful management of this fatal vascular problem.

Clinical differentiation between acute arterial embolism and acute arterial thrombosis of the lower extremities

BACKGROUND

The primary treatments of acute arterial embolism and acute arterial thrombosis are different. The clinical differentiation of the two diseases at initial stage can provide the efficient treatment of acute limb ischemia.

OBJECTIVE

Identification of the clinicalfactors significant for the differentiation between acute arterial embolism and acute arterial thrombosis in acute lower extremity ischemia.

MATERIAL AND METHOD

A prospective study of the consecutive 120 patients with acute lower extremity ischemia was carried out between January 2000 and December 2004. All clinical information was compared between the proven acute arterial embolism and acute arterial thrombosis.

RESULTS

Among 120 patients, 91 (75.8%) were with acute arterial embolism and 29 (24.2%) were with acute arterial thrombosis. Normal peripheral pulse on the contralateral limb was more commonly found in patients with acute arterial embolism than in patients with acute arterial thrombosis (71.4% vs. 31.0%, p < 0.001). Atrial fibrillation was detected more in patients with acute arterial embolism than acute arterial thrombosis (31.9% vs. 3.4%, p = 0.004). Mitral valve stenosis (12.1%) and previous arterial embolism (16.5%) were only detected in patients with acute arterial embolism. On the other hand, patients with acute thrombosis had the higher comorbidities such as diabetes mellitus (44.8% vs. 19.8%, p = 0.015), hypertension (55.2% vs. 27.5%, p = 0.012), and hypercholesterolemia (37.9% vs. 6.6%, p < 0.001). Patients with acute arterial embolism had more severe clinical manifestations such as immediately threatened ischemia (56.0% vs. 13.8%, p < 0.001) and higher tendency of suffering from extensive limb gangrene (18.7% vs. 6.9%, p = 0.156). On the contrary, patients with acute arterial thrombosis had the previous symptom of intermittent claudication (51.7% vs. 3.3%, p < 0.001) more than patients with acute arterial embolism.

CONCLUSION

The clinical factors significant for the differentiation between acute arterial embolism and acute arterial thrombosis were the status of peripheral pulse on the contralateral limb, the clinical risk factors of the two diseases, the previous arterial embolism, the clinical manifestation, and progression of ischemic status.

Comparative study of the management of diabetic versus nondiabetic patients with atherosclerosis obliterans of the lower extremities

The aim of this study was to identify the influence of diabetes mellitus on patients with atherosclerosis obliterans (ASO) of the lower extremities. A prospective study was designed to compare differences between ASO patients with and without diabetes mellitus in regard to clinical characteristics and outcomes of management. Two hundred fifty-three consecutive (61.1%) diabetic and 161 (38.9%) nondiabetic patients were included in this study. Crural artery occlusion occurred more frequently in diabetic patients (tibioperoneal segment 26.5% vs 14.3%; p = .003). Diabetic patients had higher comorbidities, such as ischemic heart disease, disabling stroke, and renal failure. Infection requiring urgent surgical intervention was higher in diabetic patients (39.1% vs 24.2%; p = .001). This required primary major amputation in limb-threatening ischemia superimposed with infection (27.6% vs 17.7%; p = .037). The feasibility (67.2% vs 69.8%; p = .651) and success (74.4% vs 79.0%; p = .481) of revascularization between the two groups were comparable. Diabetic patients often needed more distal revascularization for limb salvage (34.4% vs 18.5%; p = .019). The mortality rate after revascularization was higher in diabetic patients (13.3% vs 2.5%; p = .009). Diabetes mellitus per se has no direct impact on limb salvageability in limb-threatening ischemia. The parity of feasibility and success in revascularization between the two groups should encourage attempts at limb salvage revascularization in diabetic patients.

Enhancing limb salvage by non-mobilized peripheral blood angiogenic cell precursors therapy in patients with critical limb ischemia

BACKGROUND

Stem cell therapy has been proposed to enhance the salvage of critically ischemic limbs.

OBJECTIVE

Assess the efficacy and safety of the implantation of non-mobilized peripheral blood angiogenic cell precursors (NMPB-ACPs) in patients with critical limb ischemia (CLI) who were poor candidates for standard revascularization treatment options.

MATERIAL AND METHOD

Six patients with CLI due to the infrapopliteal artery occlusive disease were included in the present study. Intramuscular injections of NMPB-ACPs were administered in the ischemic limbs. The efficacy was evaluated by clinical outcomes, ankle brachial index, toe brachial index, and computerized tomographic angiography.

RESULTS

There was no evidence of local or systemic complication related to the procedure. Five patients (83.3%) had clinically significant improvement of adequate circulation at the distal limb for the complete healing. Four of them had complete healing of ischemic ulcers and stumps of toe amputation. However one patient with adequate granulation tissue at the stump of the left first toe amputation subsequently suffered from severe foot infection originating from the other toes and eventually underwent below knee amputation. There was no improvement of circulation at the distal limb after the administration of NMPB-ACPs in one patient (16.7%) who eventually underwent major amputation.

CONCLUSION

The preliminary result of NMPB-ACPs therapy may be safe and provide benefits in the improvement of circulation in patients with CLI. A larger controlled trial is required to ascertain these preliminary results.

Acute arterial embolism of the lower extremities: impact of 24-hour duration on the outcome of management

OBJECTIVE

Determine the impact of 24-hour duration of arterial embolism on the outcomes of management.

MATERIAL AND METHOD

A prospective study of 91 patients with acute arterial embolism of the lower extremities was carried out.

RESULTS

Among the 91 patients, 31(34.1%) were with early acute embolism(< 24 hours) and 60 (65.9%) were with late acute embolism (> 24 hours). Extensive limb gangrene was more common in patients with late acute embolism (26.7% versus 3.2%, p = 0.009). Subsequently, primary major amputation was higher in those patients (20% versus 3.2%, p = 0.05). In early acute embolism, surgical embolectomy was only the primary treatment of revascularization (87.1%) whereas in late acute embolism, there were varying modalities of revascularization (68.3%) in addition to surgical embolectomy. The successful revascularization after the initial surgical embolectomy was significantly higher in patients with early acute embolism (92.6% versus 43.9%, p < 0.001). Patients with late acute embolism had a higher tendency of undergoing major amputation after revascularization (24.4% versus 7.4%, p = 0.106). Successful outcome was higher in patients with early acute embolism (83.9% versus 58.3%, p = 0.014).

CONCLUSION

The 24- hour duration of arterial embolism may be a crucial factor influencing the outcome in the management of this disease.

Endovascular abdominal aortic aneurysm repair in high risk patients: outcomes of management

BACKGROUND

The concomitant cardiopulmonary disease precluded the elective repair for abdominal aortic aneurysm (AAA) with acceptable risk. The endovascular abdominal aortic aneurysm repair (EVAR) has become an alternative method for the treatment of AAA with high-risk comorbidities.

OBJECTIVE

Evaluate the results of EVAR in high-risk patients with large AAA.

MATERIAL AND METHOD

A prospective study of high-risk patients with large AAA and suitable morphology who underwent EVAR between August 2003 and August 2005 was conducted. The long-term outcomes were observed up to December 2006. The comorbidities, size of aneurysm, types of procedures, operative time, amount of blood loss and transfusion, length of postoperative stay in intensive care unit and hospital, postoperative complications and mortality were analyzed.

RESULTS

Eight patients (7 males and 1 female) with the mean age of 71.4 years (range 66-83 years) were included in the present study. The comorbidities were six of compromised cardiac status, one of severe pulmonary disease and one of morbid obesity. The average size of aneurysm was 6.2 +/- 0.64 centimetres. One patient also had large bilateral iliac artery aneurysms. Seven patients underwent EVAR with bifurcated aortic stent graft and one proceeded with aorto uni-iliac stent graft. Three patients underwent preoperative coil embolisation into internal iliac arteries when the distal landing zones at the external iliac arteries were considered. The mean estimated blood loss was 369cc and the mean blood transfusion was 0.88 units. There were no perioperative mortality, early graft occlusion, AAA rupture and open conversion in the present study. One patient had cardiac arrest due to upper airway obstruction but with successful treatment. Type II endoleak was observed in one patient and successfully treated by expectant management. One limb of bifurcated stent graft was occluded at the 5th month post EVAR and was successfully treated by artery bypass surgery at both groins. The 3-year primary graft limb patency was 87.5% (7/8). The survivals of patients at 1, 2 and 3 years were 100%, 100% and 87.5% respectively. The cause of death in one patient was not related to EVAR.

CONCLUSION

EVAR may be a safe and effective alternative to open AAA repair especially in high-risk patients.

Treatment of iatrogenic pseudoaneurysm of brachial artery with percutaneous ultrasonographically guided thrombin injection (PUGTI): a case report and a literature review

OBJECTIVE

Report the successful treatment of iatrogenic pseudoaneurysm of the brachial artery with the percutaneous ultrasonographically guided thrombin injection (PUGTI).

MATERIAL AND METHOD

The pseudoaneurysm was caused by an accidental puncture into a native brachial artery instead of the venous side of an arteriovenous fistula during hemodialysis. The aneurysmal sac had a large size with a short neck, vulnerable to intra-arterial thrombosis and distal artery embolization during the thrombin glue injection.

RESULTS

This procedure was secured by using color duplex ultrasonography (CDU) for the accurate positioning of the needle and the assessment of the optimal dosage of the injected bovine thrombin. After the procedure, an elastic compression was applied at the injection site to prevent the reentry of blood flow into the aneurysmal sac. The flow in the aneurysmal sac completely disappeared in seven days after the treatment. The 4-month follow-up demonstrated the complete resolution of the aneurysmal sac.

CONCLUSION

Percutaneous injection of bovine thrombin under ultrasound guidance is possible as one of the minimal invasive procedures to treat the pseudoaneurysm of the extremity artery.

Atherosclerosis obliterans of the lower extremities in Thai patients

BACKGROUND

Major limbs loss and high mortality rate were observed in the management of Thai patients with atherosclerosis obliterans (ASO) of the lower extremities. These were the results of delayed diagnosis and treatment together with the associated morbidities. There is a lack of information of this disease resulting in a lack of knowledge and awareness of this problem among general practitioners in Thailand.

OBJECTIVES

The purposes of this study were (1) to identify the prevalence of this disease in a tertiary care hospital, (2) to enumerate the risk factors and comorbidities, (3) to identify clinical characteristics of the disease and (4) to evaluate the outcomes of treatment.

MATERIAL AND METHOD

A prospective study ofpatients with ASO of the lower extremities was carried out between January 2000 and December 2004. Patients having clinical manifestations of chronic and acute arterial occlusion with the absence of ankle pulse were included in the present study. Evidence of atheromatous plaque by angiography, operative finding, and histopathology of arterial wall from amputated specimens were used to confirm the diagnosis. The selection of surgical treatments for this disease such as revascularization, major amputation, minor amputation and debridement depended on the severity of limb ischaemia, the status of distal artery and the patients' general condition. The risk factors, comorbidities, clinical manifestations, site of arterial occlusion, severity of ischaemia, types of surgical treatment and outcomes of management were analyzed.

RESULTS

Four hundred and fourteen consecutive patients with ASO were diagnosed in the present study with a prevalence of 1.02:1,000. Femoro-popliteal arterial segment was the most common site (221 cases, 53.4%) of the affected arteries. Diabetes mellitus (253 cases, 61. 1%) was the most common risk factor of ASO followed by hypertension (217 cases, 52.4%), smoking (195 cases, 47.1%) and hyperlipidemia (172 cases, 41.5%). Ischaemic heart disease (108 cases, 26.1%) was the most common comorbidity of ASO followed by major stroke (56 cases, 13.5%) and chronic renal failure (20 cases, 4.8%). Patients with ASO presented mostly as chronic manifestations (385 cases, 93%) or with limb-threatening condition (326 cases, 78.7%). The clinical manifestations were ischaemic ulcer and/or digital gangrene (251cases, 60.6%), rest pain (182 cases, 44.0%) incapacitating claudication (62 cases, 15.0%) and acute ischaemic pain (29 cases, 7.0%). One hundred and thirty eight (33.3%) patients had significant lower limb infection at the time of admission. One hundred and seventy one (41.3%) patients underwent revascularization procedures as the major primary treatments to salvage the limbs. The success rate of limb salvage after revascularization was 76.6% (13 1/171). Major amputation after revascularization was 16. 9%(29/ 171). Perioperative mortality rate of revascularization procedure was 8.2 %(14/171). Major amputation was required as the primary treatment due to infective (18.4%, 76/414) and ischaemic process (6.5%, 27/414). The mortality rate of primary major amputation for infection and ischaemia were 19.7%(15/76) and 25.9%(7/2 7) respectively. The total mortality rate in the present study was 11.3% (47/414). The common causes of death were sepsis and ischaemic heart disease.

CONCLUSION

ASO of the lower extremities is one of the major problems for national health care causing major limb loss and death. Arterial bypass surgery was the most effective treatment for limb salvage. Management of this disease at the terminal stage causes high morbidity and mortality. Hence, early detection of this disease and correction of the risk factors should be the most effective strategy to improve the overall outcome of the management of this complicated problem.

Malignant carcinoid tumor of the appendix with liver and lung metastasis: report of a case with a high level of serum carcinoembryonic antigen

We report elevated serum carcinoembryonic antigen (CEA) in a case of malignant carcinoid tumor of the appendix with liver and lung metastasis. A 55-year-old Thai man was found to have multiple nodules in the liver by ultrasonography. Serum CEA was 7,387.9 ng/mL (normal 0-4.1 ng/mL) leading to a clinical impression of colonic carcinoma with liver metastasis. During the investigation, he developed acute abdomen caused by ruptured acute appendicitis. Malignant carcinoid tumor of the appendix, 1 cm in diameter and located proximal to the ruptured acute appendicitis, was identified. The tumor cells showed trabecular or insular growth pattern, some nuclear pleomorphism but typically fine nuclear chromatin, frequent mitoses and focal necrosis. They were immunoreactive for antibody to chromogranin, neuron-specific enolase, CEA, and cytokeratin. Tumor metastases were discovered in the liver, right lung, mediastinal and right supraclavicular lymph nodes. Electron microscopic study demonstrated pleomorphic neurosecretory granules of the midgut type of carcinoid tumor.