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Objectives: The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. Materials and methods: A literature review was performed with a focus on data from recent studies. Results: Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. Conclusions: Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients. (c) 2021 Elsevier Inc. All rights reserved.

Introduction: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection. Methods: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed. Results: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs . 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs . 29%, P < 0.01) Conclusion: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material.

Supplemental Material, supplemantary_file for Statins’ Withdrawal Induces Atherosclerotic Plaque Destabilization in Animal Model—A “Rebound” Stimulation of Inflammation by Marianna Stasinopoulou, Nikolaos P. E. Kadoglou, Eirini Christodoulou, Efthymios Paronis, Nikolaos G. Kostomitsopoulos, Georgia Valsami, Christos D. Liapis, and John Kakisis in Journal of Cardiovascular Pharmacology and Therapeutics

Extrahepatic portal vein aneurysm is a relatively uncommon entity. We reported the case of a 51-year-old man, who was incidentally diagnosed with an asymptomatic 52 x 65 mm portal vein aneurysm, which was located at the main trunk of the portal vein, just before its bifurcation. The patient was treated with partial clamping of the portal vein aneurysm and aneurysmorrhaphy. Postoperative course was uneventful. Surgical intervention should be considered for patients with large, symptomatic or expanding portal vein aneurysms.

Background: The effect of carotid artery stenting (CAS) on cognitive function in patients with extracranial carotid artery stenosis is equivocal. The aim of this study was to examine the impact of CAS on various domains of cognitive function. Methods: We performed a meta-analysis of the studies evaluating various domains of cognitive function before and after CAS, namely, (1) global cognition using Mini-Mental State Examination (MMSE) and Rey Auditory Verbal Learning Test (RAVLT), (2) executive function using Trail Making Test (TMT) A or Color Trails Test (CTT) A and TMT B or CTT B, (3) language ability using Boston Naming Test (BNT), (4) memory, (5) attention/psychomotor speed, and (6) functional ability, using various cognitive tests. Pooled weighted mean differences (WMDs) and standardized mean differences (SMDs) with 95% confidence intervals (95% CIs) were appropriately calculated using fixed or random effects models after assessing between-study heterogeneity. Meta-regression analysis was performed with number of patients per study; mean age (years); follow-up (months); proportion of men; proportion of patients with hypertension, diabetes mellitus, hyperlipidemia, smoking, and coronary artery disease; proportion of symptomatic patients; and degree of ipsilateral and degree of contralateral carotid stenosis as covariates. Results: Sixteen studies were eligible, including a total of 626 CAS patients. A statistically significant improvement of global cognition was detected with MMSE (WMD = 0.67, 95% CI = 0.29-1.05, P < 0.001; follow-up = 5.6 months), but not with RAVLT (SMD = 0.45, 95% CI = -0.03 to 0.93, P = 0.07; follow-up = 2.4 months). Significant improvement of memory (SMD = 0.33, 95% CI = 0.11-0.55, P < 0.01; follow-up = 4.1 months) and attention/psychomotor speed (SMD = 0.21, 95% CI = 0.04-0.39, P = 0.02; follow-up = 4 months) was also detected. No statistically significant effect on executive function (TMT A/CTT A and TMT B/CTT B; SMD = 0.08, 95% CI = -0.10 to 0.26, P = 0.39; follow-up = 3.9 months and SMD = -0.02, 95% CI = -0.20 to 0.16, P = 0.82, respectively; follow-up = 3.9 months), language ability (BNT; SMD = 0.24, 95% CI = -0.05 to 0.54, P = 0.10; follow-up = 4 months), and functional ability (SMD = -0.05, 95% CI = -0.25 to 0.15, P = 0.63; follow-up = 3.8 months) was observed. No significant effects of the examined covariates were demonstrated in the meta-regression analyses. Conclusions: CAS may be associated with improvement in global cognition, memory, and attention/psychomotor speed. There was no positive effect on executive function, language, and functional ability, but CAS was not associated with a decline in any area of cognitive function. Future studies in larger groups of patients are probably needed to fully investigate the long-term effect of CAS on cognition in patients with carotid artery stenosis.

Objective: The objective of this study was to evaluate the impact of contrast medium volume, inferior mesenteric artery (IMA) patency, and pre-existing as well as new-onset thrombus on the inflammatory response after elective endovascular aneurysm repair (EVAR). Methods: The study included 87 patients undergoing elective endovascular repair of asymptomatic infrarenal aneurysms between January 2011 and November 2011. The patency of the IMA was determined by preoperative computed tomography angiography; the volume of the contrast medium used during the procedure was measured, and the volumes of chronic mural as well as new-onset thrombus were calculated from the preoperative and postoperative computed tomography angiograms with dedicated imaging software. The results were correlated to the occurrence of post-implantation syndrome (PIS) as well as to the main clinical and laboratory components of PIS: fever; increased white blood cell (WBC) count and C-reactive protein (CRP) level; decreased platelet count; and increased interleukin (IL)-6, IL-8, and IL-10 levels. Results: Postoperatively, a statistically significant increase was recorded in the mean values of body temperature, WBCs, CRP, IL-6, IL-8, and IL-10, and a statistically significant decrease was recorded in the number of platelets. After adjustment for endograft type, the volume of new-onset thrombus was found to be significantly correlated with the peak postoperative temperature (beta = .307; P < .05) and the increase in WBC count (beta = .271; P < .05), CRP level (beta = .484; P < .001), and IL-6 level (beta = .288; P < .05). On the contrary, the volume of chronic mural thrombus, the patency of the IMA, and the volume of contrast medium were not found to significantly affect any parameter of the PIS. PIS occurred in 34 patients (39%). Multiple logistic regression analysis showed that both the volume of new-onset thrombus and the type of endograft were independently associated with the development of PIS. Conclusions: The volume of new-onset thrombus is associated with the development of PIS after EVAR, whereas chronic mural thrombus appears to be an inert material. IMA patency and contrast medium volume are irrelevant to the inflammatory response after EVAR.

Purpose: To review the published outcomes of aortic endograft infection treated with preservation of the stent-graft. Methods: An extensive electronic health database search was undertaken to identify all articles published up to May 2013 that reported endograft infection after endovascular aneurysm repair (EVAR) in which treatment included preservation of the stent-graft. The search found 17 articles with 29 patients (27 men; mean age 73.1 +/- 7.6 years) fulfilling the inclusion criteria. Results: In 2 (7%) cases, the endograft infection was diagnosed within 30 days of the initial procedure; 4 (14%) were identified within 3 months and the remaining 23 (79%) within 12 months. Staphylococcus species, Streptococcus species, and Escherichia coli were the most common isolated microorganisms. Seven (24%) had a secondary aortoenteric fistula after EVAR. Twelve (41%) patients received only antibiotic therapy, while the remaining had an additional procedure (drainage, surgical debridement, sac irrigation, and/or omentoplasty). The in-hospital mortality was 21% (n=6). During a mean follow-up of 11.4 +/- 3.1 months, 7 more patients died (overall mortality 45%). None of the 7 patients with fistula survived. Half (50%) of the 12 patients who received only antibiotic therapy died, while 7 (41%) of the 17 patients who underwent an additional procedure died during follow-up. Conclusion: Among patients treated for endograft infection without explantation, those with aortoenteric fistula had the worst outcome. There is evidence for lower mortality in patients who underwent an additional procedure, such as drainage, surgical debridennent, and sac irrigation. Larger studies are needed to examine the efficacy of this approach compared to surgical conversion with endograft excision and in situ reconstruction or extra-anatomical bypass.

We present 3 cases of stent graft infection in patients who were treated with preservation of the endograft. In the first patient, the contamination of the endograft was the consequence of a bleeding aortoenteric fistula, whereas in the second patient, the endograft was implanted into a ruptured contaminated aortic aneurysm because of the patient’s hemodynamic instability. In the third patient, the presence of a consistent type Ia endoleak after a chimney graft procedure followed by secondary interventions led to an infection of the stent graft. In each case, a laparotomy was performed with debridement, followed by appropriate antibiotic therapy. The first patient suffered a fatal pulmonary embolism. The other 2 patients are alive 4 and 24 months after the diagnosis of endograft infection. In unstable patients or those with severe comorbidities who cannot tolerate endograft excision and aortic reconstruction, surgical debridement followed by appropriate antibiotic therapy can be a temporary or bridging solution.

Introduction: Soluble P selectin (sPsel), a member of the selectin family of cell adhesion receptors, has been proposed as a key molecule in hemostasis and thrombosis mediating platelet rolling, generating procoagulant microparticles and enhancing fibrin deposition. The aim of this study was to examine the role of sPsel in the diagnosis of venous thromboembolism (VTE). Materials and Methods: We performed a systematic review and we used meta-analysis to synthesize data from published studies reporting sPsel levels in patients with i) VTE (deep venous thrombosis; DVT or DVT and pulmonary embolism; PE) and ii) DVT only. Pooled Odds Ratios (ORs) with 95% Confidence Intervals (CIs) were appropriately calculated among patients and controls. Diagnostic performance of sPsel was tested with pooled sensitivity, specificity, Diagnostic Odds Ratio (DOR) and summary receiver operator characteristic (SROC) curve. Results: Eleven studies, comprising of 586 VTE patients and 1,843 controls were deemed eligible. The sPsel was significantly increased after VTE (OR = 2.89, 95%CI = 2.31-3.61, p < 0.001), or DVT only (OR = 2.64, 95%CI = 1.95-3.56, p < 0.001). Subgroup analysis evidenced that sPsel was also increased after VTE when evaluating only studies with patients that had no prior medical history (OR = 2.88, 95%CI = 1.98-4.19, p < 0.001). Exclusion of studies including patients with solid organ tumor, HIV or lupus anticoagulants positive patients did not alter findings. Pooled sensitivity and specificity of sPsel was 0.57 (95%CI = 0.30-082, p < 0.001) and 0.73 (95%CI = 0.51-0.90, p < 0.001), respectively and DOR was 4.31 (95%CI = 2.22-8.37, p < 0.01). SROC curve yielded in significant accuracy of sPsel performance (AUC = 0.74, p = 0.05). Conclusions: The sPsel was significantly elevated in patients with DVT, both uncomplicated and complicated with PE and presented with high levels of diagnostic performance. sPsel is a plasma biomarker that may help in the diagnosis of VTE. (C) 2013 Elsevier Ltd. All rights reserved.

Objective: Endograft infection after thoracic endovascular aortic repair (TEVAR) is associated with a substantial mortality rate that exceeds 70% in the largest published series. The aim of this study was to review all published reports on infection after TEVAR treated with either preservation of the endograft or surgical excision of the stent graft with the intention of providing a comparison of the safety, efficacy, and durability of the two different treatment strategies. Methods: An extensive electronic health database search was undertaken to identify all articles that were published up to December 2013 reporting on endograft infection after TEVAR. Overall, 55 patients treated with endograft preservation (group A) and 41 patients treated with endograft explantation (group B) were included in this review. Results: The most frequently isolated microorganisms were Streptococcus species (29.4%) and Staphylococcus species (29.4%). The mortality for both groups was 66.6%. The in-hospital mortality rate in group A was 42% and reached 81.8% in a mean follow-up period of 8.6 months. The in-hospital mortality rate in group B was 36.6%. Four (9.7%) further deaths due to reinfection or fistula recurrence were recorded in a mean follow-up period of 15.3 months, leading to an overall mortality of 46.3%. The meta-analysis showed a trend of better outcome with endograft explantation compared with endograft preservation (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.18-1.48). In group A, a trend of better outcome was revealed when drainage and repair of the fistula were applied (OR, 2.22; 95% CI, 0.55-8.90). A trend of worse outcomes was detected in fistula patients compared with nonfistula patients (OR, 1.26; 95% CI, 0.43-3.74). Conclusions: Endograft preservation seems not a durable option. It can be offered to patients who refuse surgery or as a palliative option or bridging procedure for severely ill patients. Compared with antibiotic therapy alone, antibiotic therapy followed by drainage and repair of the fistula may control the sepsis, providing, however, mainly a temporary benefit. The presence of fistula is a predictor of dismal outcome. Endograft explantation remains the “gold standard” of treatment. The mortality rate of surgical conversion is much higher in the presence of fistula.

Background: Internal carotid artery (ICA) occlusion is associated with acute stroke and carries significant morbidity and mortality. The aim of this study was to examine whether ultrasonographic carotid plaque type may be associated with ICA occlusion. Methods: Two hundred eleven patients (85% men, mean age 66.0 +/- 9.5 years, 28.9% asymptomatic) with ICA occlusion were included in this case-control study. Ultrasonographic Gray-Weale plaque type (I-IV, echolucent to echogenic) characterization was obtained in both the occluded and the contralateral ICA. Univariate and conditional logistic regression analyses with 1:1 pair matching per artery were undertaken. Each contralateral carotid artery with stenosis was treated as control to the ipsilateral-occluded ICA of the same patient. Results: A total of 261 ICAs (61.9%) were recorded with type I-II plaque, of which 165 (63.2%) were among the occluded and 96 (36.8%) were among the contralateral ICAs with stenosis (P < 0.001). Mean contralateral ICA stenosis was 58.2% +/- 20.4%. Regression analysis showed that carotid plaque type I-II was significantly associated with carotid artery occlusion compared with plaque type III-IV (crude odds ratio [OR] = 4.29, 95% confidence intervals [Cl] = 2.81-6.57%, P < 0.001, adjusted OR = 5.60, 95% Cl = 3.23-9.70, P < 0.001). Previous neurological events did not seem to be significantly associated with plaque echolucency (OR = 0.62, 95% Cl = 0.29-1.35, P = 0.23). Conclusions: A significant association between echolucent plaque and ICA occlusion was observed. This observational hypothesis may prompt for further investigation of the causal mechanism between carotid plaque type and ICA occlusion by larger cohort studies.

Purpose: To evaluate the differential effects of endograft fabric types on pulse wave velocity (PWV), a valid, clinically feasible marker of arterial stiffness, in patients undergoing endovascular repair (EVAR) of abdominal aortic aneurysms (AAAs). Methods: As part of a registered study,118 consecutive men (mean age 7168 years) with AAA undergoing elective EVAR were divided into groups according to the type of fabric in the implanted endografts: 46 had polytetrafluoroethylene (PTFE)-covered stent-grafts and 72 received stent-grafts covered with polyester fabric. Patients with Marfan syndrome, collagen-related disorders, and end-stage renal failure were excluded. PWV, clinical characteristics (comorbidities, body mass index, blood pressure, lipids, and glucose profile), novel biomarkers [interleukin (IL)-6, IL-8, IL-10, and osteoprotegerin OPG)] were determined at baseline and prospectively after 12 months. Results: At baseline, standard multiple regression analysis revealed the independent association of mean blood pressure, OPG, and AAA diameter with PWV after adjustment for age (R-2=0.729, p=0.036). At follow-up, serum levels of both IL-8 and IL-10 were significantly increased, while OPG decreased in both groups (p

To present a case of a wandering stent within the pulmonary circulation that was managed conservatively with the “wait-and-see” strategy. Accidental dislodgement of a left brachiocephalic vein stent into the left lower lobe pulmonary artery occurred in an 83-year-old patient suffering from end-stage renal disease during placement of a left jugular vein catheter. The following day, a second X-ray revealed migration of the stent from the left to the right lower lobe pulmonary artery. Our patient was managed conservatively with low-molecular-weight heparin and was discharged on clopidogrel. The patient remained asymptomatic with regard to the migrated stent for four and a half years and died of old age. This is the first case of a wandering stent within the pulmonary circulation reported in the literature, supporting the “wait-and-see” policy in the management of such patients.

Objective: We investigated the relationship of circulating novel adipokines, retinol-binding protein 4 (RBP4) and omentin-1, with advanced carotid atherosclerosis and ultrasound indexes of severity (total plaque area-TPA) and plaque echogenicity and vulnerability (Gray-Scale median - GSM score). Methods: We enrolled 225 patients with high-grade carotid stenosis (HGCS) who underwent carotid revascularization (73 Symptomatic patients, 152 asymptomatic patients) and 75 age-and sex-matched, asymptomatic individuals with low-grade (< 50%) carotid stenosis (LGCS). Seventy-three individuals without current manifestations of atherosclerotic disease served as control group (COG). All participants underwent carotid ultrasound with TPA and GSM score assessment. Moreover, clinical parameters, metabolic profile, and circulating levels of hsCRP and adipokines were assessed. Results: RBP4 was significantly elevated in HGCS (51.44 +/- 16.23 mg/L) compared to LGCS (38.39 +/- 8.85 mg/L), independent of symptoms existence, whereas RBP4 levels in COG were even lower (25.74 +/- 10.72 mg/L, p < 0.001 compared to either HGCS or LGCS). Inversely, serum omentin-1 levels were significantly lower across HGCS (490.41 +/- 172 ng/ml) and LGCS (603.20 +/- 202.43 ng/ml) than COG (815.3 +/- 185.32, p < 0.001). Moreover, the considerable difference between HGCS and LGCS (p < 0.001) was exclusively attributed to the excessive suppression of omentin-1 concentrations in symptomatic versus asymptomatic (p = 0.004) patients. HGCS and LGCS did not differ in the rest of clinical and biochemical parameters. In multiple regression analysis, RBP4 (beta = 0.232, p = 0.025) and hsCRP (beta = 0.300, p = 0.004) emerged as independent determinants of TPA in patients with carotid atherosclerosis. Low serum levels of omentin-1 correlated with GSM score and symptoms but that association was lost in multivariate analysis. Conclusion: RBP4 serum levels were significantly elevated in patients with established carotid atherosclerosis and were positively associated with atherosclerosis severity. The association of low serum omentin-1 with carotid plaque echolucency requires further investigation. (C) 2014 Elsevier Ireland Ltd. All rights reserved.

Evolution in the endovascular era has influenced the management of aortic arch pathologies. Several studies have described the use of a combined endovascular and open surgical approach to the treatment of arch diseases. Hybrid repair of arch pathologies has been considered as a less invasive method, and is therefore an appealing option for high-risk patients who are unsuitable for open repairs. The aim of the present meta-analysis was to assess the efficacy of hybrid techniques in patients with aortic arch pathologies.Extensive electronic literature search was undertaken to identify all articles published up to December 2012 that described hybrid aortic arch repair with intrathoracic supra-aortic branch revascularisation and subsequent stent graft deployment. Eligible studies were divided into two groups: group I included studies on the aortic arch debranching procedure and group II included studies that reported an elephant trunk technique (either "frozen" or stented). Separate meta-analyses were conducted in order to assess technical success, stroke, spinal cord ischemia (SCI), renal failure requiring dialysis, and cardiac and pulmonary complications rate, as well as 30-day/in-hospital mortality.Forty-six studies were eligible for the present meta-analysis: 26 studies with a total of 956 patients reported aortic arch debranching procedures, and 20 studies with 1,316 patients performed either 'frozen' or stented elephant trunk technique. The pooled estimate for 30-day/in-hospital mortality was 11.9% for the arch debranching group and 9.5% for the elephant trunk group. Cerebrovascular events of any severity were found to have occurred postoperatively at a pooled rate of 7.6% and 6.2%, while irreversible spinal cord injury symptoms were present in a pooled estimate of 3.6% and 5.0% in the arch debranching and elephant trunk group, respectively. Renal failure requiring dialysis occurred at 5.7% and 3.8% in both groups, while cardiac complications rate was 6.0% in the arch debranching cohort and pulmonary complication was 19.7% in the elephant trunk cohort.Hybrid arch techniques provide a safe alternative to open repair with acceptable short- and mid-term results. However, stroke and mortality rates remain noteworthy. Future prospective trials that compare open conventional techniques with the hybrid method or the entirely endovascular methods are needed.

Background: We sought to investigate the incidence and location of new cerebral ischemic lesions after carotid endarterectomy (CEA) using diffusion-weighted magnetic resonance imaging (DW-MRI). Methods: Sixty-six consecutive patients (50 males with a mean [+/- SD] age of 69 +/- 9 years) who underwent CEA were included in this prospective study. Seventeen patients were symptomatic and 49 patients were asymptomatic. CEA was performed with patch closure without using a shunt. Carotid plaque echostructure was evaluated with the grayscale median (GSM) score. DW-MRI scanning of the brain was performed 24 hours before and 48 to 72 hours after the procedure. Results: Thirty-day stroke and mortality rates were 0%. The mean GSM score for symptomatic patients was 27 +/- 15; for asymptomatic patients, the mean GSM score was 39 +/- 18 (P = 0.006). Patients were divided into 2 groups according to GSM score: GSM scores 26 (44 patients). New brain lesions were detected after 6 endarterectomies (8.9%), and all were clinically silent. These lesions were ischemic in 5 cases (7.5%) and micro-hemorrhagic in 1 case (1.4%). In 3 cases, new ischemic lesions were located within the treated carotid artery territory. In 2 cases, new lesions on DW-MRI were located outside of the treated carotid artery territory. There was no significant difference in the incidence of ischemic lesions between the 2 groups (GSM scores 26, 3 lesions; P = 0.544). Conclusions: New ischemic lesions on DW-MRI are detected in 7.5% of patients after CEA, and most of these lesions are clinically silent. Plaque echogenicity does not affect their incidence. New lesions seen on DW-MRI may be generated outside of the treated carotid artery territory.

Purpose: To present a systematic review and meta-analysis investigating the incidence of carotid artery stenting (CAS) induced hemodynamic instability (HI) and to explore differences in periprocedural risk among patients with and without CAS-associated HI. Methods: Multiple electronic health databases were searched for all articles published between January 2000 and December 2011 describing CAS-associated hemodynamic instability. Twenty-seven studies with a total of 4204 patients were analyzed, placing emphasis on the HI incidence and its correlation with postprocedure morbidity and mortality. A meta-regression analysis was conducted to investigate the role of potential meaningful modifiers upon HI. Results: The meta-analysis for overall HI rate showed a pooled proportion of 39.4%. The pooled estimate for hypotension was 12.1%, 12.2% for bradycardia, and 12.5% for both hypotension and bradycardia. Persistent HI was found to occur in a pooled rate of 19.2%. No statistically significant differences were found between patients with and without HI after CAS with respect to death, stroke, transient ischemic attack (TIA), or major adverse events. The meta-regression analysis revealed statistically significant associations of mean age with HI, of

Objective: Most arteriovenous hemodialysis grafts fail

Background: Anatomic factors may limit the application of stent grafts for the treatment of arterial aneurysms. Flow-diverting stents (FDSs) are specially designed to reduce flow velocity in the aneurysm sac and promote thrombosis while maintaining flow in the main artery and branch vessels. FDSs include the Pipeline Embolization Device (ev3, Plymouth, Minn), the SILK Arterial Reconstruction Device (Balt Extrusion, Montmorency, France), and the Cardiatis Multilayer Stent (Cardiatis, Isnes, Belgium). The first two have been mainly used for the treatment of intracranial aneurysms. The aim of this study was to review the current role of FDSs in the treatment of extracranial arterial aneurysms. Methods: A systematic electronic health database search was conducted using PubMed, Ovid, Medline, and the Cochrane Database on all accessible published articles through March 2012. An additional search for abstracts presented in international congresses for vascular surgery was also performed. Full-text articles and abstracts were analyzed separately due to the heterogeneity of the data. Results: Results of the use of FDSs in arterial aneurysms were reported in 12 full-text articles including 35 patients (26 men, age 65.4) with 38 aneurysms. The aneurysms were located in the hepatic (n = 12), splenic (n = 6), renal (n = 5), celiac (n = 4), superior mesenteric (n = 3), subclavian (n = 2), gastroduodenal (n = 1), and popliteal arteries (n = 1) and in the descending thoracic (n = 1), suprarenal (n = 1) and infrarenal aorta (n = 2). The 30-day mortality was 5.7% (2 of 35 patients). Three stent thromboses occurred (8.3%), none of them with clinical consequences. Thirty patients with 33 aneurysms and patent FDSs were monitored for an average of 9.2 months. Thrombosis occurred in 90.6%, and volume reduction was observed in 81% of the aneurysms. No branch vessel occlusion occurred. Twelve abstracts were identified, including 133 patients (mean age, 64.7 years). They included 62 peripheral, 28 visceral, and 43 abdominal and thoracoabdominal aneurysms. The Cardiatis Multilayer Stent was used in all cases. Thrombosis was achieved in all but two peripheral and visceral aneurysms. Volume reduction was observed in 82.7%, and no branch vessel occlusion occurred. In aortic aneurysms, better results regarding aneurysm thrombosis, reduction of the volume, and patency of collateral branches were reported at 12 months rather than at 6 months postoperatively. No aneurysm rupture has yet been described. Conclusions: Initial clinical experience with the use of FDSs in the treatment of visceral and peripheral aneurysms yielded satisfactory results in technical success, aneurysm thrombosis and shrinkage, and in patency of branch vessels. The results in aortic aneurysms are still under investigation. No aneurysm rupture has yet been described. There is a significant incidence of FDS thrombosis. Volume reduction of the aneurysm is a clearer evidence of the clinical success after treatment with FDSs than aneurysm thrombosis. (J Vasc Surg 2012;56:839-46.)

Objective: Patients with juxtarenal, pararenal, or thoracoabdominal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. The “chimney graft” or “snorkel” technique has evolved as a potential alternative to fenestrated and side-branched endografts. The purpose of this study is to review all published reports on chimney graft (CG) technique involving visceral vessels and investigate the safety and efficacy of the technique. Methods: Studies were included in the present review if visceral revascularization during endovascular treatment of aortic pathologies was achieved via a CG implantation. Reports on the chimney technique for aortic arch branches revascularization were excluded. A multiple electronic health database search was performed on all articles published until April 2011. Results: The electronic literature search yielded 15 reports that fulfilled the inclusion criteria. A total of 93 patients (81.3% male; mean age, 71.9 +/- 0.9 years) were analyzed. In 77.4% of the patients, the CG procedure was applied for the treatment of abdominal aortic aneurysms. Out of the 93 patients, 24.7% were operated on in an urgent setting (symptomatic or ruptured aneurysm). A total of 134 CGs were implanted: 108 to the renal arteries, 20 to the superior mesenteric artery, five to the celiac trunk, and one to the inferior mesenteric artery. In 57 patients, a single CG was deployed; in 32 patients, two CGs; in three patients, three CGs; and in one patient, four CGs were deployed. Ninety-four percent of CGs were directed proximally, whereas 6.0% were directed caudally. Primary technical success was achieved in all patients. A total of 13 patients (14.0%) developed a type I endoleak. Three were detected and treated intraoperatively. Postoperatively, 10 type I endoleaks were revealed, four of which required secondary intervention. During a mean follow-up period of 9.0 +/- 1.0 months, 131 of 134 (97.8%) CGs remained patent. Two CGs to the renal arteries and one to the superior mesenteric artery occluded. Postoperatively, 11.8% of patients suffered renal function impairment and 2.1% a myocardial infarction. Ischemic stroke presented in 3.2% of patients. The 30-day in-hospital mortality was 4.3%. Conclusions: The role of the chimney technique in the management of complex abdominal aortic aneurysms is still unclear. This technique has relatively good results, considering the anatomic limitations of the aortic neck. However, long-term endograft durability and proximal fixation remains a significant concern. Thus, there is a reasonable hesitation to embrace the method for widespread use in the absence of long-term data. (J Vasc Surg 2012;55:1497-1503.)

Patients with juxtarenal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. An alternative procedure that can be used is the “chimney graft” technique. Three cases of abdominal aortic aneurysms were successfully treated in our department with this technique. One type-la endoleak occurred which was successfully treated with coiling and biological glue infusion. All of the chimney grafts have remained patent for the period of observation. The “chimney” technique has good results as a bail out procedure in complex EVAR or in well planned difficult cases. Long-term data is necessary to determine the efficacy of this technique.

Background and purpose Accumulating evidence suggests that carotid plaque vulnerability can be used as a determinant of ischemic stroke risk stratification and carotid intervention. Novelmarkers of high-risk carotid plaque in patients are needed. Summary of review Advances in cellular and molecular pathophysiology, the demand for accurately predicting carotid risk, and choosing the optimal prevention strategy are stimulating great interest in the development of novel surrogate markers. Biomarkers in cardiovascular disease are expected to predict the natural history, clinical outcomes, and the efficacy of disease-modifying interventions. We aimed to review the literature regarding clinical data on novel serum biomarkers related to ischemic cerebrovascular events associated with carotid artery disease. We provide background information on the biomarkers related to all aspects of carotid disease: natural history, carotid intervention strategies for symptomatic and asymptomatic patients, perioperative risk prediction, and their therapeutic implications. Conclusion At present, heterogeneous data support evidence that biological markers can help existing practices to more accurately assess patients at risk for stroke. Randomized-controlled trials for carotid artery disease and carotid intervention, incorporating biomarkers, are needed.

An 82-year-old man was transferred to our emergency department due to acute abdominal pain. He had undergone an endovascular abdominal aortic aneurysm repair (EVAR) six years ago. An intravenous contrast-enhanced abdominal computed tomography revealed the rupture of the abdominal aortic aneurysm (AAA) with a large retroperitoneal hematoma. A Talent (Medtronic, Santa Rosa, CA, USA) modular bifurcated endoprosthesis had vertically collapsed approximately 7 cm after losing its infrarenal fixation. As a result, it led to the repressurization of the aneurysm sac and rupture. The patient was successfully treated by placing three Talent (Medtronic) aortic cuffs. To our knowledge, this is the first reported case of endograft collapse that has manifested with aortic aneurysm rupture. Although they are gradually declining, considerable rates of complications create the ‘Achilles’ heel of endovascular repair of AAAs. A lifelong follow-up strategy for patients treated for AAA with EVAR is essential for the early detection and treatment of complications of the procedure.

In light of the results of randomized trials, it seems that despite the favorable short and midterm outcomes of standard endografts, concern over endograft migration has escalated, as this event will be responsible for almost all late complications in endovascular aneurysm repair (EVAR). Migration forces, both caudal and sideways, depend heavily on blood pressure, inlet diameter, and angulation of the stent-graft, while the bifurcation generates more force than any other segment of the stent-graft. It thus seems that the position of the endograft’s flow divider influences force distribution and migration risk. Additionally, due to concomitant ongoing aortic degeneration, postoperative dilatation of the infrarenal aortic neck poses a threat to EVAR patients as soon as the diameter of the infrarenal neck reaches the dimensions of the proximal graft. This review evaluates the significance of endograft accommodation on the aortic bifurcation and cumulative experience of the only endografts utilizing this feature: the Zenith Composite and the Powerlink. J Endovasc Ther. 2011; 18: 462-470

Background-Many authors using a hybrid debranching strategy for the treatment of thoracoabdominal pathologies have reported disappointing results and the initial enthusiasm for the technique has given way to criticism and ambiguity. The aim of the present meta-analysis study was to assess the safety and efficacy of the technique in patients with thoracoabdominal aortic aneurysms or other aortic pathologies. Methods and Results-A multiple electronic search was performed on all articles describing hybrid open endovascular repair. Separate meta-analyses were conducted for technical success, visceral graft patency, spinal cord ischemia symptoms, renal insufficiency, and other complications as well as 30-day/in-hospital mortality. Nineteen publications with a total of 507 patients were analyzed. The pooled estimates for primary technical success and visceral graft patency were 96.2% (95% CI, 93.5%-98.2%) and 96.5% (95% CI, 95.2%-97.8%) respectively. A pooled rate of 7.5% (95% CI, 5.0%-11.0%) for overall spinal cord ischemia symptoms was observed; whereas for irreversible paraplegia the pooled rate was 4.5% (95% CI, 2.5%-7.0%). The pooled estimate for renal failure was 8.8% (95% CI, 3.9%-15.5%). The pooled 30-day/in-hospital mortality rate was 12.8% (95% CI, 8.6%-17.0%). During the mean follow-up period of 34.5 (95% CI, 31.5-37.5) months, a total of 119 endoleaks were identified in 111 patients (22.7%). Conclusions-The repair of thoracoabdominal pathologies by means of hybrid procedures in patients who are poor surgical candidates is still associated with significant morbidity and mortality rates. Future studies may substantiate whether the technique is amenable to amelioration and improvement. (Circulation. 2011;124:2670-2680.)

Evolving technology has the potential to alter the overall management of carotid body tumors (CBTs). We review our 35-year experience emphasizing on novel modalities available in the evaluation and treatment of CBTs. Medical records of 27 CBT patients between 1975 and 2009 were retrospectively reviewed. The study cohort has been arbitrarily divided into two groups: the early years’ group A (18 patients, 1975-1998) and the later years’ group B (9 patients, 1999-2009). The most common presenting symptom was a painless lateral neck mass (89%). Octreotide scintigraphy and genetic testing were routinely used for group B. In two cases, octreotide scintigraphy was coupled with intraoperative radiolocalization of the lesion. Preoperative embolization was performed in four CBTs. Among group B patients, five were pretreated via a covered stent placement in the external carotid artery (ECA). Twenty-three patients (24 CBTs) were eventually operated upon. One cardiovascular death, one permanent vocal cord paralysis and six transient cranial nerve injuries account for a 4.4% 30-day mortality and a 30.4% morbidity with no significant differences among groups. In conclusion, appropriate use of new techniques in CBT management has improved diagnostic accuracy and early detection without clearly affecting overall outcome in our study cohort.

Purpose: Aim of this study is to present our initial experience with the use of the retrograde popliteal artery access in patients with certain anatomic lesions. Methods: Between September 2008 and September 2010, 24 patients underwent a transpopliteal retrograde subintimal recanalization. Instead of its usage when antegrade recanalization failed, the “facedown” technique was preferred as a first choice in patients with common femoral artery stenosis or occlusion, proximal lesions of the superficial femoral artery (SFA) with no stump, severe obesity, tandem iliac, and SFA lesions. Results: Technical success was achieved in 91.7% of patients.The complication rate was 12.5%. The primary patency at 6, 12, and 18 months was 86.4%, 65.8%, and 65.8%, respectively. Conclusions: The retrograde popliteal artery approach can be considered as the primary SFA recanalization strategy in carefully selected patients, with competitive immediate and midterm results.

Purpose: To review the incidence, causes, and mortality rates of early and late conversion to open surgery after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). Methods: A systematic search of the English-language literature from 2002 to 2009 was performed by interrogation of the PubMed, MEDLINE, and EMBASE databases. Studies were included if they: (1) had >100 patients treated with EVAR and (2) provided adequate data to calculate incidence and associated mortality rates. The search yielded 13 articles with sufficient data to analyze early conversion (12,236 patients, 178 conversions) and 15 articles with available data for late conversion (14,298 patients, 279 conversions). Results: The rate of early conversion among the 13 articles reviewed ranged from 0.8% to 5.9%; more recent studies carried lower rates of early conversion. Mortality rates of early conversion varied between 0% and 28.5%. Overall, there were 178 (1.5%) early conversions among the 12,236 AAAs treated with EVAR, with an average mortality of 12.4%. The rates of late conversion ranged from 0.4% to 22%. Of the 14,289 AAA patients undergoing endovascular repair, 279 (1.9%) required late conversion; the mortality rate was 10%. Conclusion: Though the incidence is gradually declining, secondary interventions persist as the Achilles’ heel of EVAR. A lifelong follow-up strategy for AAA patients treated with EVAR is essential for early detection and treatment of complications of the procedure. Vascular surgeons should be familiar with the complex open conversion procedures. J Endovasc Ther. 2010;17:694-702

According to the current international guidelines, patients with infrarenal or juxtarenal abdominal aortic aneurysms (AAAs) measuring >= 5.5 cm should undergo repair to reduce the risk of rupture. The 5.5-cm-diameter threshold is the size when the AAA rupture rate balances the mortality rates of elective open surgical AAA repair (3%). Endovascular AAA repair (EVAR) is associated with lower perioperative mortality and complication rates compared with open surgical repair. This debate addresses the issue whether the current size threshold for elective AAA repair needs to be lowered in the endovascular era. This article supports the position that the size threshold for AAA repair should not be lowered.

A recent trial attempted to investigate the role of locoregional anesthesia (LA) in carotid endarterectomy (CEA) compared with general anesthesia. The hypothesis regarding the advantage of LA is based on the intraprocedural neurologic evaluation and the early identification of neurologic deficit. The trial has not demonstrated the superiority of the rocoregional anesthesia versus general anesthesia and revealed equal results concerning the prevention of stroke. We analyze the reasons which explain why the hypothesis regarding the advantage of LA in CEA, in comparison to general anesthesia cannot be answered.

Carotid atherosclerosis constitutes an important cause of ischemic brain attack and stroke, accounting for up to 40% of cases of ischemic cerebrovascular disease. Type 2 diabetes mellitus is an independent risk factor for stroke and its recurrence. Thus, identifying diabetic patients who are at high risk of developing stroke is of great clinical importance. Noninvasive measurements of surrogate markers of atherosclerosis, such as novel serum biomarkers, can be helpful in detecting subclinical carotid disease, especially among individuals at the highest cardio-/cerebro-vascular risk. Previous studies have proposed an expanding body of serum biomarkers, such as C-reactive protein, fibrinogen, adipokines, cytokines and growth factors, as novel indicators of carotid atherosclerosis development that predict carotid-related clinical outcomes. Furthermore, those biomarkers are expected to assess the efficacy of both pharmaceutical and interventional strategies. Accordingly, it is increasingly clear that measuring biomarkers may improve the definition of cerebrovascular risk profile in patients with Type 2 diabetes mellitus.

Background: Rupture of infected anastomotic femoral artery pseudoaneurysms (AFAPs) represents a limb and life-threatening condition requiring emergency intervention. This study aimed to evaluate the feasibility, safety, and efficacy of a hybrid repair for ruptured infected AFAPs consisted of percutaneous stent-graft deployment and second-stage surgical debridement. Methods: Between October 2004 and January 2008, 6 patients (3 female, mean age 65.8 +/- 11.4 years) with ruptured infected AFAPs were treated with emergent percutaneous stent-graft implantation and secondary surgical debridement. Three patients had undergone a femoro-popliteal and 1 a femoro-tibial bypass for peripheral arterial disease, while 2 patients had a femoral arteriovenous graft (AVG) for hemodialysis access due to chronic renal failure. Four pseudoaneurysms were located at the common femoral artery (CFA) and 2 involved the superficial femoral artery (SFA). Mean pseudoaneurysm diameter was 6.8 +/- 0.9 mm (range, 5.4-7.8 mm). The mean interval between the initial operation and presentation to our department was 26.7 +/- 14.5 months (range, 7-50 months). All patients suffered from severe comorbidities and were judged unfit for major surgery under general anesthesia. Results: All patients were successfully managed by urgent percutaneous deployment of covered stents at the site of the arterial deficit. Extensive surgical debridement along with pseudoaneurysm excision was accomplished successfully in all 6 patients 1-3 days after stent-graft placement under local anesthesia, without the need for extended vessel exposure for proximal and distal control. No death occurred within 30 days after stent-graft implantation. During follow-up, (mean 14.1 +/- 8.2 months, range, 6 to 25 months) all stent-grafts remained patent without endoleak, while no signs of recurrent local or systemic infection were noticed. Two patients died at 8 and 10 months after the procedure due to heart failure complications and acute myocardial infarction, respectively. Conclusion: Emergency stent-graft deployment, followed by secondary surgical debridement and long-term antimicrobial therapy is a viable alternative for ruptured infected AFAPs. Especially for patients unfit for major surgery, it may be the most favorable treatment option. (J Vasc Surg 2009;49:938-45.)

Aims: Diabetes is the leading cause of lower-extremity amputations worldwide. The objective of this study was to look at the survival after first amputation between subjects with and without diabetes in a sample of Greek Population. Method: We performed a retrospective study of all nontrauma, nonneoplasm-related amputations performed in a tertiary centre during the years 1996-2005 in diabetic (n=183) and nondiabetic patients (n=75). Survival status was assessed from the first amputation until December 31, 2005. Results: A total of 54.6% of amputees with diabetes and 51.6% of those without diabetes died in a mean [95% confidence interval (CI)] time of 4.3 (3.5-5.1) and 6.6 (4.6-8.6) years after the first amputation, respectively (P=.65). Diabetic patients underwent a second amputation (P=.003) and contralateral amputations (P=.02) more often in comparison with nondiabetic subjects. Predictors of all-cause mortality in the diabetic group, after adjustment for sex, were age [hazard ratio (FIR) (95% CI), 1.04 (1.02-1,06); P

Atherosclerosis is a systematic disease presenting with a significant overlapping of cardiovascular disorders implicating coronary heart disease and its equivalents, peripheral arterial disease, carotid arterial disease, and aneurysm disease. Evaluating patient’s atherosclerotic risk profile is essential to guide primary and secondary prevention. Atherosclerotic risk factor modifications reduce, significantly, cardiovascular disease mortality and morbidity, particularly in high-risk patients. This article provides a reference guide for all conventional (eg, smoking, dyslipidemia, hypertension) and evolving (eg, homocysteine, C-reactive protein, fibrinogen, inflammatory markers) risk factors of atherosclerosis and recommends the currently effective strategies for an overall cardiovascular risk reduction. As vascular surgeons, by definition, conduct the overall management of patients with vascular disease understanding of the development, assessment, and management of atherosclerotic risk factors should remain among their highest priorities. (J Vasc Surg 2009;49:1348-54.)

Medline was searched for studies investigating the perioperative and long-term results that derive from statin use in patients with abdominal aortic aneurysm and the clinical and experimental evidence dealing with aneurysm expansion. Data suggest that statins improve the perioperative and long-term outcomes of aneurysm operations and may also reduce expansion rates. International guidelines recommend the use of statins in these patients because abdominal aortic aneurysms are considered as a coronary heart disease equivalent. These guidelines do not appear to have been widely implemented. Preliminary results suggest that statins might play a role in the management of abdominal aortic aneurysms. Verification of these results in large-scale trials may hold implications for a more comprehensive approach of patients with abdominal aortic aneurysms as well as population-wide aneurysm screening programs. Irrespective of the role of statins on aneurysm expansion rates, it is important to ensure that all abdominal aortic aneurysm patients receive statin therapy to improve perioperative and long-term morbidity and mortality

In 1958, the Union Europeene des Medecins Specialistes (UEMS), or European Union (EU) of Medical Specialists the European Union, was founded by the professional organizations of medical specialists in Europe. Among the objectives of the U EMS arc to promote the highest level of patient care in the EU and to promote the harmonization of high-quality training programs within the various specialities throughout the EU. Within the 38 Specialist Sections of the UEMS are the European Boards, which are the working groups of the Specialist Sections. In 2005 Vascular Surgery was recognized as a separate and independent Section, a monospecialty, within the UEMS. The efforts of the UEMS are directed at facilitating the free exchange of training and work of trainees and medical specialists between EU countries. This situation, in combination with large differences in requirements and length of training in vascular surgery within the EU, stresses the importance of harmonization in training and certification in vascular surgery within the EU. For that reason, the European Board of Vascular Surgery has organized voluntary examinations yearly since 1996. The candidates who pass qualify as “Fellow of the European Board of Vascular Surgery” (FEBVS) since 2005. The first part of the examination evaluates the eligibility of the candidate (Certificate of Completion of Specialist Training, training center, logbook). The second part is a viva voce assessment that includes (1) case analyses, (2) a review of a scientific article, (3) an overall assessment, (4) a technical skills, and (5) an endovascular skills assessment. To pass the examination, the candidates must achieve a 67% success rate in each part of the examination. During the last 10 years, approximately 75% of the candidates have successfully taken the examination. In the near future the Section and Board, in close collaboration with the vascular societies in the EU, will develop a European vascular surgical syllabus and curriculum that will further harmonize and professionalize the training and certification of vascular surgery in Europe. (J Vasc Surg 2008;48:69S-75S.)

Objective: Metallothioneins (MTs) are antioxidant proteins expressed in response to injury. We evaluated MT immunoreactivity in carotid plaques obtained from asymptomatic and symptomatic patients. We also assessed the relationship between ultrasonic plaque echodensity, histological grading, computed tomography findings and MT expression. Methods and results: In this ongoing prospective study, patients (n = 123, mean age (+/- SD) 68.4 +/- 7.7 years, 97 men) with high-grade carotid stenosis underwent carotid endarterectomy. Specimens were assessed histologically and immunohistochemically. Echolucent plaques (types 1+2) were more common in symptomatic patients (p < 0.0001) and had more advanced histological lesions (p < 0.0001). Echolucent plaques expressed MTs (in macrophages, fibroblasts and T-lymphocytes) significantly more than echogenic plaques (types 3+4) (all p < 0.0001). MT expression was mainly related to carotid plaque echolucency rather than the presence of symptoms. MT expression was significantly more common in advanced histological lesions. Plaques from asymptomatic or symptomatic patients with abnormal computed tomography findings also showed increased MT expression. There was a time-dependent fall in MT expression after cerebrovascular events (p

Carotid artery disease is a well-established cause of cerebrovascular events. This risk is predicted by the severity of stenosis and other plaque characteristics that can be documented using imaging techniques. Among these techniques, ultrasound is the most widely available. Increased carotid intima-media thickness (IMT) measured ultrasonically is associated with a higher risk for cerebrovascular as well as coronary heart disease. Furthermore, it is increasingly recognized that echolucent and heterogeneous carotid plaques in patients with high-grade carotid stenosis are associated with a greater risk for cerebrovascular events. Several local and systemic factors can influence plaque stability. Identifying the high-risk carotid plaque could improve selection for vascular intervention (surgery/angioplasty) and increase cost-effectiveness. Aggressive medical treatment should always be provided for these high-risk patients. For example, lipid-lowering, anthihypertensive and antiplatelet drugs decrease the carotid IMT, stabilize carotid plaques or reduce the risk of cerebrovascular and systemic events. Continuously evolving technology will lead to more accurate identification of high-risk carotid plaques. A combination of comprehensive non- or minimally-invasive imaging techniques together with measuring clinical and systemic biochemical markers of risk may facilitate the identification of the vulnerable plaque in the vulnerable patient, and help select the best treatment options.

Objective: Vascular surgery (VS) practice has expanded to incorporate interventional procedures, and this has stimulated changes in training. The purpose of this study was to review current VS training and certification in different countries. Methods. A survey was completed by vascular surgeons involved with national certification in 34 countries. Results are expressed as the mean +/- SD, with comparisons by chi(2) and t tests. Results. VS is currently an independent specialty in 15 surveyed countries, is a subspecialty of general surgery in 10 countries, and is not recognized as a specialty in nine countries. There has been a clear time trend toward independent certification. In countries with independent VS certification, the length of VS training is 3.7 +/- 0.9 years plus 2.3 +/- 0.7 years of associated core general surgery (GS), for a total training length of 5.9 +/- 1.0 years. In countries with VS subspecialty certification, the length of VS training is 2.4 +/- 0.5 years after 5.0 +/- 1.1 years of GS, for a total training length of 7.4 +/- 1.2 years (each P < .01 vs independent certification). The minimum required volume of major open VS operations during training is 151 +/- 78 in countries with independent VS certification vs 113 +/- 53 in countries with subspecialty certification. Endovascular requirements for training are established in 71% of countries with independent certification vs 37% of countries with subspecialty certification (P < .03). Countries with independent VS certification produce 5.4 +/- 2.8 VS trainees per year per million population 65 years of age or older, vs 3.0 +/- 1.8 in countries with subspecialty certification (P < .02). Conclusions. Considerable variation exists in VS training in different countries. There is an international movement toward independent VS certification, with longer VS specific training but shorter overall residency duration. Counties with independent VS certification produce more trainees per year to serve their elderly population.

Treatment of thromboangiitis obliterans (Buerger’s disease) includes both surgical and nonsurgical approaches, or a combination of both. A definite therapeutic approach has not yet been set. This article reviews the proposed therapeutic strategies and considers the advantages and disadvantages of each treatment. Cessation of smoking seems to be the only globally accepted therapeutic measure to prevent disease progression. A number of promising novel therapeutic strategies may prove useful for the treatment of this physically and socially mutilating disease.

The aim of this article is to investigate the association between internal carotid artery occlusion OCAO) and the presence of atherosclerotic disease and vascular risk factors. The clinical characteristics and risk factors of 120 patients presenting with ICAO were retrospectively reviewed. All patients (n = 120) had at least 1 of the 4 vascular risk factor (diabetes, smoking, hypercholesterolemia, and hypertension); 2, 3, or all 4 risk factors were present in 14 to 82 of the patients (11.7% to 68.3%), 10 to 39 of the patients (8.3% to 32.5%), and 9 of the patients (7.5%). respectively. A total of 84 patients (70%) with ICAO had disease in at least 1 additional vascular bed (aorta, coronary or lower limb arteries). In addition to ICAO, vascular disease was present in 2 and all 3 of these arterial beds in 42 (35%) and 9 (7.5%) patients, respectively. Furthermore, stenosis or occlusion of the ipsilateral or contralateral vertebral arteries was recorded in 19 of 120 patients (15.8%). Regarding the contralateral carotid artery, 1 patient had bilateral ICAO. One patient had contralateral common carotid artery occlusion, and 1 patient was excluded from the analysis because of surgery to the contralateral carotid artery. Of the remaining 117 patients, 34 (29.0%) had less than 50% contralateral carotid artery stenosis. Thirty-two patients (27.4%) had 50% to 69%, and 51 (43.6%) had 70% to 99% stenosis. Ultrasonographic imaging of the carotid plaque of the contralateral carotid artery revealed that 52 of the 120 arteries (43.3%) were uniformly or predominantly echolucent (types I and II, respectively). Fifty-nine (49.2%) were predominantly or uniformly echogenic (types III and IV), and 9 (7.5%) could not be classified. A similar distribution of echomorphology was observed on the occluded side. ICAO is associated with widespread atherosclerotic disease and a high prevalence of vascular risk factors. Detection of ICAO should prompt the investigation of other arterial beds and treatment of risk factors.