[Minimally invasive treatment of pelvic congestion syndrome]

Complex clinical and ultrasound examination of 81 women with chronic venous insufficiency (CVI) of the pelvis was analyzed. All the patients had left-side regional renal venous hypertension which caused valvular insufficiency of the left ovarian vein with spread of the reno-ovarian blood reflux onto the pampiniform, uterovaginal, presacral, vesical and rectal plexuses. Right-side cavaovarial reflux of blood was found but in 29.6% of the patients and in combination with reno-ovarial reflux caused complete decompression of the venous outflow from the pelvis. The treatment was performed depending on the stage of CVI of the pelvis. At the stage of compensation (59.3% of patients) complex conservative treatment was used, at the stage of subcompensation (17.3%)--sclerotherapy, at the stage of decompensation (23.4%)--operative dissection of gonad veins. Excellent results were registered in 34.5%, good--in 43.2%, satisfactory--in 21%, unsatisfactory in 1.2% of the patients. On the basis of self-assessment of quality of life 77.8% of the patients thought to be completely restored, 16%--improved, 6.2% of women had no changes.

Predictability of cerebral embolization from aortic arch manipulations during thoracic endovascular repair

There is no sensitive tool to monitor embolic events and predict patients at a risk for strokes during thoracic endovascular aortic repair. We examined the relationship between the number of high intensity transient signals (HITS) by transcranial doppler ultrasound and the extent of atherosclerotic plaques in aortic arch. Thirteen patients were treated as a part of a single center United States Food and Drug Administration-approved investigational device exemption for various thoracic aortic pathologies. Bilateral transcranial doppler ultrasound transducers recorded the number of HITS. CT angiography and intravascular ultrasound were used to measure the thickness of mural thrombi and determine their arch location. All 13 patients had detectable HITS, and one patient sustained a stroke. Eleven patients had quantifiable mural thrombi. The highest HITS were observed in patients with thrombi in zones 2 to 3. All three patients with bovine arch had more HITS in the right middle cerebral artery whereas the patients with normal arch anatomy had more HITS in the left middle cerebral artery. The presence of mural thrombi in zones 2 and 3, irrespective of their thickness, was associated with increased HITS during thoracic endovascular aortic repair. This is the first study to characterize the significance of mural thrombi in aortic arch and their relationship to embolic events during aortic arch manipulations.

[Diagnostics and strategy of surgical treatment of multifocal atherosclerosis]

The study included 148 patients with different combinations of multifocal atherosclerosis. The inclusion criteria were clinical manifestations of chronic cerebrovascular insufficiency concomitant with diseases of other arterial basins. The treatment strategies were chosen based on the results of examination by non-invasive methods for vascular visualization. Contrast agents were used only for curative purposes. The patients were divided into 2 groups depending on surgical strategy. Patients of group 1 underwent one-step reconstruction of several affected basins, those in group 2 step-by-step revascularization of different arterial basins with the use of X-ray endovascular interventions. The former approach was applied at the initial stage of the work. It creating a high risk of complications, the latter approach was preferred in the subsequent period. The incidence of complications in group 2 was 4.05% and the lethality rate 1.49%. These values were significantly higher in patients of group 1.

Endovascular stent implantation for coarctation of the aorta in children and young adults: intermediate follow-up results from Turkey

The aim of this study was to report the intermediate follow-up results of stent implantation for coarctation of the aorta in children from Turkey. Patients with native or postoperative coarctation, who had abnormal flow at the descending aorta exceeding diastolic phase on Doppler echocardiography or upper extremity hypertension, underwent endovascular stent implantation. Ten patients with a mean age of 12.4 +/- 5.5 years (6-23 years) underwent stent implantation between January 2001 and September 2006. Of these, three had previous surgical repair, and the remainder were native coarctation. Palmaz, Genesis and Numed CP stents were used. All the implantations were successful and there was no major complication during the procedure. The follow-up period was 8-72 months and only one patient needed re-dilatation during this period. Stent implantation may be a feasible alternative to balloon angioplasty and surgery for adolescents. Patients who have previous surgical repair, high surgical risk, unfavorable anatomy, or refuse consent for surgical intervention are the best candidates for stent implantation. However, longer follow-up and new studies are necessary especially in younger patients.

Aortoesophageal fistula following endovascular exclusion of a thoracic aneurysm

The aim of this study was to report a case of aortoesophageal fistula following endovascular exclusion of a thoracic aneurysm, treated conservatively with fatal outcome. Endovascular exclusion of a thoracic aneurysm was performed in a 64-year-old female patient. Three months later the diagnosis of an aortoesophageal fistula was made and minimal surgery (cervicotomy and jejunostomy) was performed, combined with antibiotherapy and catheter flushing of the infected excluded aneurysm thrombus. The patient died in septic shock 9 weeks later. As reported, following conventional thoracic aortic aneurysm surgery, endovascular stenting of the thoracic aorta can be complicated by aortoesophageal fistula. Management should be surgical, since the outcome under conservative management seems invariably fatal. However, it looks as if the poor condition of these patients may not permit open surgical treatment.

Complications of aortic endografting

Endovascular repair of abdominal aortic aneurysm has been shown to have a significantly lower perioperative mortality rate compared with open repair. It has been a blessing for patients at high risk who were previously denied treatment for their aortic aneurysms. It does, however, have a substantial need for re-intervention for complications. Many of these complications including endoleak, endotension, migration, post implant syndrome and conversion to open repair are unique to endovascular aneurysm repair. Others including injury to the iliac arteries, graft limb thromboses and structural failure of prostheses occur with greater frequency in endovascular repair compared with open repair. It is important, therefore, for vascular surgeons to be aware of these complications including their prevention and appropriate that patients are informed of their incidence. This review discusses the local and vascular complications of endovascular repair of abdominal aortic aneurysm with an emphasis on newer aspects.

Endotension--a late complication successfully treated by open repair

Endotension is a late complication following endovascular treatment of abdominal aortic aneurysm (AAA). A 83-year-old male had a successful endovascular repair of a 5.6 cm diameter AAA. During the follow-up period it was marked that the aneurysm continued to increase in size, became 6.6 cm maximal diameter and pulsatile with no evidence of endoleak. On laparotomy no endoleak was identified and the graft was left in situ. Postoperatively and on follow-up the patient remains asymptomatic while the aneurysm continued to appear shrunk.

The Pneumatic Tourniquet Technique for Endoscopic Radial Artery Harvest

BACKGROUND

Endoscopic vessel harvest is viewed as a safe, reliable, and cost-effective method for greater saphenous vein removal. As the radial artery has more recently become a popular conduit choice in coronary artery revascularization, we describe herein an endoscopic technique for radial artery harvest in our first 50 patients as an alternative to the more traditional open technique.

METHODS

From November 2001 to July 2002, 54 radial arteries were harvested endoscopically in 50 patients utilizing the VasoView Endoscopic Vessel Harvesting System, an Esmark bandage, and a pneumatic cuff tourniquet.

RESULTS

No patients experienced symptoms of vascular compromise, or signs of infection in the donor arm. No adjunctive procedures were required during the vessel harvest, i.e., conversion to open technique. All radial arteries were successfully removed with endoscopic technique and 53 of the 54 radial arteries were successfully used as bypass conduits. Although the quality of the radial artery harvested remains subjective, we found less vasospasm than in our experience with the open technique. Thirty-day follow-up revealed no readmissions, no cardiac ischemic complications, no significant complications with the donor arm, and an excellent cosmetic result.

CONCLUSIONS

Endoscopic harvest of the radial artery with the tourniquet technique may offer advantages over the more traditional open technique.

Division of incompetent perforator veins and subfascial interposition of a polypropylene foil in post-thrombotic syndrome. Preliminary results

AIM

The safety, feasibility and early efficacy of subfascial endoscopic perforator surgery was gradually accepted for patients who had severe chronic venous insufficiency but, in the literature, the recurrence rate of ulceration is about 10-40%, especially in patients with previous deep vein thrombosis (DVT).

METHODS

From October 1998 to February 2002, 205 patients with 280 inferior leg ulcers were followed; 115 had venous ulcers but only 20 patients had chronic ulcers with previous DVT; 4 patients were excluded and only 16 patients (9 female, 7 male, mean age 61 years) with 18 chronic ulcers were included. These patients underwent sub-aponeurotic interruption of perforating veins with blind technique in association with subfascial interposition of a hand-made polypropylene foil. Eight of these patients had persistent non-healing ulcers at the time of surgery and 10 had chronic recurrent ulceration healed at the time of the surgical procedure. All patients were assessed clinically and with duplex scanning.

RESULTS

The follow-up was done clinically and with eco-Doppler from 6 to 38 months with a mean follow up period of 23.2 months. The healing rate was 100%. The 2-year life table incidence of ulcer recurrence was 0%. Hospital stay ranged from 1-2 days, early operative complications included extensive ecchymosis in 1 patient, oedema in 3 patients.

CONCLUSION

The division of perforating veins, with the subfascial support of a polypropylene foil give promising results in the treatment of venous ulcers in post-thrombotic syndrome with low morbidity and short hospital stay.

Review of efforts to decrease costly leg wound complications in the medicare population following coronary revascularization

BACKGROUND

Current trends show that patients referred for coronary artery bypass grafting (CABG) are significantly older, sicker, and at higher risk for complications than ever before. Eliminating leg wound complications would significantly benefit these patients and reduce the consumption of health care time and dollars. Endoscopic vein harvesting (EVH) decreases the risk of wound complications in patients following CABG and may decrease costly long-term wound-related problems.

METHODS

In this retrospective study, the cases of 1909 Medicare patients who had undergone EVH or open vein harvesting (OVH) for CABG were reviewed. The risk factors of these patients were examined and compared with those of 1485 non- Medicare patients. Readmissions, home health care costs, and office lengths of service were reviewed and analyzed.

RESULTS

The results of univariate analyses of the Medicare versus non-Medicare populations indicated significant differences for peripheral vascular disease (25.4% versus 17.2%; P <.0001), renal failure (6.0% versus 2.8%; P <.0001), hypertension (75.4% versus 71.5%; P =.011), female sex (31.1% versus 22.4%; P <.0001), mean age (69.8 years versus 57.1 years; P <.0001), and mortality risk (4.6% versus 2.2%; P <.0001). The wound rates in the Medicare group were 1.1% for EVH (n = 741) versus 2.8% for OVH (n = 1168), and this difference was significant (P =.0163) despite a higher frequency of morbid obesity in the EVH population (P <.0001). No significant differences were found in readmission frequency, home health care costs, or office length of service.

CONCLUSION

EVH benefits Medicare patients. Although this study is the largest to date to use disposable instruments, there is a lack of statistical power in the analysis of cost comparisons due to the small sample size of wound complications. However, there appears to be a general trend toward a lower treatment cost per patient and less resource use with EVH.

Endoscopically assisted in situ lower extremity bypass graft: a preliminary report of a new minimally invasive technique

OBJECTIVE

Lower extremity arterial reconstructions with in situ greater saphenous vein (GSV) are an important component of limb salvage surgery. Initially, the procedure was performed through continuous skin incisions for side branch occlusion and valve lysis with a wound complication rate of 5% to 25%. To decrease these complications, we used endoscopic GSV harvest equipment in 25 in situ vein bypass grafts in 25 patients performed over 24 months.

METHODS

The procedures were performed with three skin incisions: two for arterial access and a 2-cm incision above the knee to insert the Endopath device (Ethicon) to locate and clip the GSV side branches. After completion of the proximal anastomosis, the valves were lysed through the distal end of the vein with a flexible valvulotome. Completion cineangiography was performed to confirm side branch occlusion and evaluate the entire reconstruction. The results of this technique were compared with our last 25 in situ bypass grafts done with standard long incisions.

RESULTS

In the endoscopic group there was one (4%) minor wound complication (cellulitis). No postoperative arteriovenous fistulas were detected by means of duplex examination, and the average hospital stay was 6.2 +/- 1 days. One graft closed at 9 months as a result of distal vein hyperplasia, but the other grafts have remained patent, with follow-up from 6 to 30 months (mean, 18 months). Patients with the standard in situ bypass grafts had significantly (P < .05) more wound complications (20%) and longer average hospital stay (9.2 +/- 2 days) than the endoscopic group. Patency rates were comparable for both groups.

CONCLUSION

These results show that less invasive endoscopic in situ bypass grafting minimizes wound complications and reduces the need for hospitalization without decreasing patency or increasing operative time.

Complications in subfascial endoscopic perforating vein surgery: a report of two cases

Subfascial endoscopic perforating vein surgery is a safe method for the division of incompetent perforating veins. Nevertheless, we report two cases with unfortunate complications: the posterior tibial artery and tibial nerve were damaged during the procedures. In one patient this resulted in a reintervention, but in both patients it resulted in permanent discomfort. We then present a guideline that may prevent damage to these critical structures.

Angioscopy

Angioscopy provides a magnified, real-time, 360-degree view of the endoluminal surface of blood vessels, yielding unique information that is often complementary to conventional angiography. This unique perspective can significantly enhance one's perception and appreciation of endovascular disease. Although angioscopy is primarily used as a research tool, its ability to characterize accurately the morphology and color of atherosclerotic lesions may lead to improved treatment and better clinical outcomes.

The use of arm vein in lower-extremity revascularization: results of 520 procedures performed in eight years

PURPOSE

The absence of an adequate ipsilateral saphenous vein in patients requiring lower-extremity revascularization poses a difficult clinical dilemma. This study examined the results of the use of autogenous arm vein bypass grafts in these patients.

METHODS

Five hundred twenty lower-extremity revascularization procedures performed between 1990 and 1998 were followed prospectively with a computerized vascular registry. The arm vein conduit was prepared by using intraoperative angioscopy for valve lysis and identification of luminal abnormalities in 44.8% of cases.

RESULTS

Seventy-two (13. 8%) femoropopliteal, 174 (33.5%) femorotibial, 29 (5.6%) femoropedal, 101 (19.4%) popliteo-tibial/pedal, and 144 (27.7%) extension "jump" graft bypass procedures were performed for limb salvage (98.2%) or disabling claudication (1.8%). The average age of patients was 68.5 years (range, 32 to 91 years); 63.1% of patients were men, and 36.9% of patients were women. Eighty-five percent of patients had diabetes mellitus, and 77% of patients had a recent history of smoking. The grafts were composed of a single arm vein segment in 363 cases (69. 8%) and of spliced composite vein with venovenostomy in 157 cases (30.2%). The mean follow-up period was 24.9 months (range, 1 month to 7.4 years). Overall patency and limb salvage rates for all graft types were: primary patency, 30-day = 97.0% +/- 0.7%, 1-year = 80.2% +/- 2.1%, 3-year = 68.9% +/- 3.6%, 5-year = 54.5% +/- 6.6%; secondary patency, 30-day = 97.0% +/- 0.7%, 1-year = 80.7% +/- 2.1%, 3-year = 70.3% +/- 3.4%, 5-year = 57.5% +/- 6.2%; limb salvage, 30-day = 97.6% +/- 0.7%, 1-year = 89.8% +/- 1.7%, 3-year = 82.1% +/- 3.3%, 5-year = 71.5% +/- 6.9%. Secondary patency and limb salvage rates were greatest at 5 years for femoropopliteal grafts (69.8% +/- 12.8%, 80.7% +/- 11.8%), as compared with femorotibial (59.6% +/- 10. 3%, 72.7% +/- 10.5%), femoropedal (54.9% +/- 25.7%, 56.8% +/- 26.9%, ) and popliteo-tibial/pedal grafts (39.0% +/- 7.3%, 47.6% +/- 15.4%). The patency rate of composite vein grafts was equal to that of single-vein conduits. The overall survival rate was 54% at 4 years.

CONCLUSION

Autogenous arm vein has been used successfully in a wide variety of lower-extremity revascularization procedures and has achieved excellent long- and short-term patency and limb salvage rates, higher than those generally reported for prosthetic or cryopreserved grafts. Its durability and easy accessibility make it an alternative conduit of choice when an adequate saphenous vein is not available.

Evaluation of disinfection and sterilization of reusable angioscopes with the duck hepatitis B model

PURPOSE

Nosocomial transmission of viral hepatitis and retrovirus infection has been reported. The expected risk is greatest for the hepatitis B virus (HBV). The duck HBV (DHBV) has similar biologic and structural characteristics to HBV and has been adopted as a suitable model for disinfectant testing.

METHODS

Angioscopic examination of the external jugular vein was performed on DHBV-infected ducks. After use, the instrument was air dried for 3 minutes. Samples were obtained by flushing the channel with 5 mL of phosphate buffered saline solution. The samples were collected immediately after drying (control), after flushing with 5 mL of water, after glutaraldehyde disinfection for 5, 10, and 20 minutes, and after ethylene oxide gas sterilization. Angioscopes were either precleaned or uncleaned before disinfection/sterilization. Residual infectivity was assessed with inoculation of samples into the peritoneal cavity of day-old ducks (n = 231).

RESULTS

DNA analysis results of liver samples showed that all 38 control ducks became infected. The frequency of DHBV infection was reduced to 93% (14 of 15) by flushing the angioscope with 5 mL of sterile water. No transmission occurred after the use of any of the properly precleaned and disinfected/sterilized angioscopes. However, after the use of the uncleaned angioscopes, the transmission rate was 90% (9 of 10) and 70% (7 of 10) after 5 and 10 minutes of contact time, respectively, in 2% glutaraldehyde. Even after the recommended 20 minutes of contact time, there was still 6% (2 of 35) transmission. After ethylene oxide sterilization, two of the recipient ducklings (2 of 35) were infected with DHBV.

CONCLUSION

There was no disease transmission after reuse of disposable angioscopes adequately cleaned before disinfection or sterilization. However, if the angioscopes are inadequately cleaned, DHBV can survive despite glutaraldehyde disinfection or ethylene oxide sterilization. This contrasts with previous in vitro and in vivo data with solid surgical instruments. It is postulated that the presence of a narrow lumen or residual protein shielding within the lumen may compromise effective inactivation of hepadnaviruses on angioscopes, with the potential risk for patient-to-patient transmission.

Influence of angioscopic vein graft preparation on development of neointimal hyperplasia in an organ culture model of human saphenous vein

PURPOSE

Angioscopy for in situ vein graft preparation has been criticized on the basis that the trauma of instrumentation may predispose to accelerated intimal hyperplasia, jeopardizing patency rates following infrainguinal revascularization. The aim of this study was to assess the effects of angioscopic preparation on endothelial integrity and smooth muscle cell (SMC) behavior in an established organ culture model of human saphenous vein (HSV).

METHODS

HSV was harvested from 12 patients during bypass surgery before and after angioscopic preparation. Endothelial integrity was evaluated by immunohistochemical staining with JC-70 and scanning electron microscopy (SEM); remaining segments of pre- and postangioscopy vein were maintained in culture for 14 days in medium supplemented with 30% fetal calf serum. Viability was confirmed by measurement of tissue adenosine triphosphate on day 14 and thickness of the neointima was measured by computerized image analysis of histologic sections. Monoclonal antibodies to proliferating cell nuclear antigen (PCNA) were used as an immunohistochemical marker for proliferating SMCs.

RESULTS

There was a significant reduction in the percentage staining by JC-70 (71.3% versus 20.4%) in pre- versus postangioscopy vein (p = 0.002 by Wilcoxon's rank test; n = 12). This was supported by SEM images. Despite this, there were no significant differences between the pre- and postangioscopy HSVs after 14 days of culture with respect to neointimal thickness (61 versus 56 microns) and staining with PCNA (4.80 versus 4.08 nuclei per 10 microns), all according to Wilcoxon's rank test.

CONCLUSIONS

Angioscopic vein graft preparation is associated with endothelial cell loss but does not induce additional neointimal hyperplasia in HSV in vitro. These results suggest that angioscopic manipulation does not alter SMC behavior.

[Coronary angioscopy: initial experience during coronary interventions]

BACKGROUND AND OBJECTIVE

Percutaneous coronary angioscopy (CAG) provides in vivo visual information about the luminal aspect of the vessel. In this report we describe our initial experience with CAG during coronary angioplasty (PTCA).

METHODS

Fifty-five patients (age 60 +/- 9 years), 8 female, were included. Most patients, 42 (76%) were treated for unstable angina.

RESULTS

In 49 patients (89%) CAG was performed prior to PTCA, and in all cases the intraluminal material responsible of the stenosis was recognized. This included plaque associated to thrombus in 29 patients (59%), isolated plaque in 15 (31%) and isolated thrombus in 5 (10%). Of these plaques, 25 (57%) were yellow, 14 (32%) were yellow and white and 5 (11%) were white. Of the 34 thrombi, 23 (68%) were mural and 11 (32%) protruding. CAG post-PTCA was performed in 43 patients (78%). CAG visualized residual plaque in 41 patients (95%) and residual thrombus in 34 (79%). In addition, CAG recognized dissections in 30 patients (70%). CAG was more sensitive than angiography for the detection of thrombus (pre-PTCA 34 [69%] vs 11 [22%]; p < 0.05, and post-PTCA 34 [79%] vs 5 [12%]; p < 0.05]) and coronary dissections (post-PTCA 30 [70%] vs 19 [44%]; p < 0.05). CAG before intervention caused angina in 39 patients (80%), ventricular fibrillation (successfully managed with DC cardioversion) in 1, and AV block in another patient. The angiographic result deteriorated in 4 patients (9%) immediately after the CAG performed following PTCA. A repeat balloon PTCA was required in these patients.

CONCLUSIONS

CAG provides unique information on coronary lumen surface that complements angiographic data. As compared with angiography, CAG is more sensitive in the detection of intracoronary thrombi and dissections. Further studies are required to determine whether the additional information provided by CAG may be used, to select coronary interventions according to specific lesion characteristics, to optimize dilation results and, eventually, to improve the clinical outcome of these patients.

[Percutaneous coronary angioscopy: 200 observations in 100 candidates for angioplasty]

Due to the recent technological advances, it is possible to perform percutaneous coronary angioscopy in a straightforward fashion in most patients. To know the safety and usefulness of this technique we present 200 observations in 100 patients candidates for coronary intervention. We used a coronary angioscope (Baxter, Edwards LIS Division), that can be placed using the conventional technique for percutaneous coronary angioplasty. The system incorporates a proximal occluding balloon, and distally a movable optical fiber. Case selection considered non-ostial coronary segments relatively straight. It was possible to obtain adequate images in 86 percent of cases. The technique is safe in experienced hands: there were two cases of ventricular fibrillation, and two cases of local dissection occurred, none of these associated with clinical consequences. No myocardial infarction, surgery or death, related to this procedure occurred. Valuable diagnostic information is derived from angioscopy as the method provides some histopathological correlation. Stable plaques are usually uniformly white or yellow. Unstable plaques are yellow and ulcerated. Thrombus can be easily recognized in acute coronary syndromes. Also in percutaneously treated segments, the final result and the presence of dissection or hemorrhage can be visualized. Coronary percutaneous angioscopy is safe and brings useful clinical information. Its applications in the clinical practice are still to be determined.

Angioscopy in femoral popliteal bypass graft

Angioscopy is part of a new armoury of minimally invasive 'keyhole' surgery. Like other 'scopes' it enables the surgeon to have a direct view of the interior of the body with greatly reduced surgical intervention. An angioscope is an ultra thin multi-bundle fibre scope which has manual flexibility. Its tiny diameter (1.4mm at smallest) enables the scope to be introduced into the distal vessels of the lower leg. As with other scopes the view is seen on a video screen monitor. So, angioscopy enables surgeons to access the interior of body vessels for the first time, providing vital information on vessel condition during operative procedures.

Coronary artery rupture and pseudoaneurysm formation resulting from percutaneous coronary angioscopy

We describe a case in which coronary angioscopy was complicated by inability to deflate the device's occlusion balloon. Rapid over-inflation to rupture the balloon resulted in massive dissection of the artery, pseudoaneurysm formation, and ultimately coronary bypass. While the cause of failure of balloon deflation remains obscure, deliberate over-inflation to cause rupture may be hazardous.