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The population of elderly with cardiovascular diseases and multimorbidity is rapidly growing. For decades, different antithrombotic therapies have been studied to find the most effective therapy in reducing the risk of cardiovascular events. Recently, large trials have investigated a new antithrombotic therapy consisting of a platelet aggregation inhibitor and a low-dose anticoagulant (aspirin plus rivaroxaban). This combination inhibits both primary and secondary haemostasis, and is therefore called 'dual pathway inhibition' (DPI). DPI leads to a further reduction of the risk of ischemic cardiovascular events as compared to aspirin monotherapy, but increases the risk of bleeding. The population at high risk of ischemic events, but without an increased bleeding risk, is expected to experience the highest risk reduction and therefore the highest net clinical benefit of DPI. This population consists of patients with polyvascular disease, heart failure, renal insufficiency, diabetes mellitus and other uncontrolled risk factors.

The forthcoming increase in the number of people with diabetes mellitus (DM) is likely to lead to an absolute and relative increase in the number of people with a combination of DM and peripheral artery disease (PAD). Due to different pathophysiological processes and presentation, diagnosis and treatment in these patients are more complicated compared to non-DM related PAD. Understanding the differences, pitfalls and concerns in patients with combined DM-PAD would result in better care for these patients, who are at high risk of cardiovascular comorbidities, mortality and amputation. Introduced by two case reports, we provide an overview of current guidelines, recent literature and innovations to address these critical issues.

Penetrating neck injuries (PNIs) as a result of stabbing or deliberate self-harm are complex and potentially life-threatening. Nowadays, selective non-operative management of PNI has become common practice. Diagnostic and treatment algorithms originating from high-volume trauma centres in South-Africa and North-America are used in Dutch clinical practice. Three patients that sustained a PNI are discussed. Two patients, aged 61 and 37, only had mild signs on physical examination that justified additional diagnostic investigations. In the first patient, a penetrating oesophageal injury was found and repaired. The latter had a partial Horner syndrome as a result of PNI, no underlying injuries were found. One patient, aged 57, was haemodynamically unstable and therefore received immediate surgical exploration of the neck. A penetrating injury of the jugular vein was discovered and repaired. A summary of literature and guidelines is presented for the benefit of Dutch physicians that may be confronted with these complex injuries.

Penetrating neck injuries (PNIs) as a result of stabbing or deliberate self-harm are complex and potentially life-threatening. Nowadays, selective non-operative management of PNI has become common practice. Diagnostic and treatment algorithms originating from high-volume trauma centres in South-Africa and North-America are used in Dutch clinical practice. Three patients that sustained a PNI are discussed. Two patients, aged 61 and 37, only had mild signs on physical examination that justified additional diagnostic investigations. In the first patient, a penetrating oesophageal injury was found and repaired. The latter had a partial Horner syndrome as a result of PNI, no underlying injuries were found. One patient, aged 57, was haemodynamically unstable and therefore received immediate surgical exploration of the neck. A penetrating injury of the jugular vein was discovered and repaired. A summary of literature and guidelines is presented for the benefit of Dutch physicians that may be confronted with these complex injuries.

Criteria for carotid endarterectomy are based on the results of clinical trials that were conducted more than two decades ago. In the meantime medical treatment has improved, and surgery can be performed more safely. As such, it is currently unknown which patients should be recommended to undergo carotid surgery. The aim of the currently running European Carotid Surgery Trial 2 is to find better answers to this dilemma.

Vascular surgery in the groin is highly susceptible to wound infection (up to about 30%). Wound infections associated with exposed vascular prosthetic grafts are difficult to treat and may lead to acute bleeding or graft failure, requiring amputation of the lower limb in extreme cases. Negative pressure wound therapy is a method to promote wound healing in case of infected vascular grafts. Since there is suspected risk of bleeding, this technique has been adapted with a double-sponge technique in combination with lower negative pressure.

- Platelet aggregation inhibitors, also known as antiplatelet therapy (APT), are prescribed for the prevention of secondary cardiovascular events (CVE) after endovascular revascularization procedures.- Platelet aggregation inhibitors are not equally effective in all patients. The phenomenon of high residual platelet reactivity despite APT is called 'high on-treatment platelet reactivity' (HTPR); it bears an increased risk of secondary CVE.- Platelet function tests (PFT) can be used to diagnose HTPR. There are various tests available; of those, light transmission aggregometry (LTA) is considered the gold standard. Some tests are only suitable for determining the effect of a certain category of APT.- Research into the usefulness of PFTs to optimise treatment with APT has not yet produced an unambiguous conclusion.- Currently there is not yet an indication for routine use of PFT in clinical practice. However, for the treatment of certain categories of patients with thromboembolic disease - such as those with renal failure or a history of kidney transplant - PFT can be considered.

Groin infections are a severe complication in vascular surgery. The treatment of a groin infection with exposed vascular prosthetic material is challenging. Vacuum-assisted closure (VAC) is a therapy frequently used to close wounds. In groin wounds with exposed vascular prosthetic material, however, VAC has been contraindicated because of the risk of bleeding. We successfully treated 17 groin infections with exposed vascular prosthetic material from 2009 to 2011 by using a double-sponge technique (a combination of polyvinyl alcohol and polyurethane sponges and a continuous negative pressure of 50 mmHg); there were no complications involving haemorrhaging, amputations or re-infection. At a median follow-up duration of 380 days, no further complications occurred and all prostheses could be retained. The double-sponge technique appears to be an effective and simple method for closing an infected groin with preservation of the underlying prosthetic material.

The popliteal artery entrapment syndrome (PAES) is a rare cause of lower-leg claudication due to an anatomic anomaly along the course of the popliteal artery and sometimes, the vein. In the absence of an anatomic anomaly, it is termed 'functional entrapment'. We present 3 patients: a 13-year-old boy with PAES caused by an anomaly of a tendon, a 46-year-old soldier with functional PAES and a 36-year-old male with venous entrapment. Doppler or duplex imaging in patients with PAES generally show no abnormalities, unless entrapment is provoked by plantar or dorsiflexion of the foot. When positive, imaging by CT or MR angiography is advised. In healthy individuals, however, vascular occlusion or stenosis on imaging during provocation testing is considered a physiological finding. Surgery is justified in symptomatic as well as asymptomatic patients with an anatomic anomaly. Surgical exploration of the popliteal fossa should also be considered in patients with functional entrapment, since continuing entrapment may lead to damage of the arterial wall.

Objective: To establish whether measures taken to shorten the interval of time between a stroke and carotid endarterectomy (CEA) procedure at two Dutch hospitals had any effect., Design: Retrospective and descriptive., Method: Data were gathered on all patients with symptomatic narrowing of the carotid artery from a non-academic teaching hospital (Amphia Ziekenhuis in Breda) as well as from a university clinic dedicated to carotid abnormalities (University Medical Center Utrecht, UMCU). 'Pass-through' intervals were analysed from 2006 and 2007 and compared with those from 2010 when the sequence of hospital care had been improved in terms of time interval from stroke up to and including CEA. The time interval between the first symptoms of stroke and the first visit to the outpatient clinic specialist was determined, as well as the time interval between the stroke and CEA procedure., Results: After the hospitals had taken measures to shorten the time interval between a stroke and an operation, the percentage of patients who had undergone surgery within 2 weeks in 2010 was 34% at Amphia Ziekenhuis and 21% at the UMCU, as opposed to 5.5% (2006) and 10.5% (2007), respectively. The median time between first symptoms and surgery had decreased from 40 to 19 days at Amphia Ziekenhuis and from 57 to 36 days at the UMCU., Conclusion: At both the non-academic clinic and the university centre dedicated to carotid abnormalities, the majority of symptomatic patients had not undergone surgery within 2 weeks of a stroke in 2010. A CEA must therefore become a semi-acute operation instead of a semi-elective one in order to meet its associated performance criteria in the near future.

Three patients, three women aged 40, 64 and 75, suffered from a trocar hernia, a specific complication of laparoscopic surgery. This type of hernia may result in small bowel obstruction and normally appears within two weeks after laparoscopy. The usual presentation is that of abdominal pain with nausea and vomiting. Trocar herniation implicates the necessity of reposition and might result in bowel resection with prolonged hospital stay. The advice for prevention is to use a trocar with a diameter as small as possible, as the chance of a hernia occurring increases withthe use of larger trocars. Fascial closure is advised for trocars to mm and larger. With a growing number of procedures being performed laparoscopically, the importance of recognizing and preventing this complication is evident. Three cases illustrate the importance of early recognition of small bowel obstruction resulting from trocar herniation.