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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.

Carotid plaque surface morphology appears to play a controversial role in the occurrence of cerebrovascular symptoms, that is, amaurosis fugax, transient ischemic attacks, and episodes of stroke. A number of researchers favor a strong association between the morphologic abnormalities of the carotid plaque surface and the development of cerebrovascular symptoms. The supporters of this theory have demonstrated that surface contour irregularities not only are important potential sources of flow abnormalities but also contribute significantly to the development of ischemic neurologic symptoms through plaque fragmentation, microthrombi formation, and atheroembolism. However, opposers of this theory also exist. The main arguments for and against this theory, as well as the possible underlying pathomechanism linking the morphology of the carotid plaque surface with the development of cerebrovascular symptoms, are outlined. Detection of carotid surface abnormalities with the aid of angiography or color-flow duplex ultrasonography should play a major role in the early identification of patients at increased risk, this way aiding prompt correction of these usually clinically silent but potentially hazardous lesions.

In the last few years, renal artery stenting has gradually evolved into one of the most important therapeutic modalities in the management of atherosclerotic renovascular disease. Stenting is nowadays preferred by a steadily increasing number of physicians, not only because of its significant contribution to blood pressure control, but also because of its documented ability to maintain, and even improve, renal function. At the same time, procedure-related morbidity and mortality rates are extremely low, while recurrent stenosis rates have been repeatedly reported to be minimal. Percutaneous transluminal renal angioplasty (PTRA) and stenting are nowadays considered by many physicians to be the treatment of choice for atherosclerotic renovascular disease.

Leptin seems to regulate various physiological mechanisms besides body weight. Leptin plays a role in vascular biology and pathology as well as renal function. In addition, leptin has been implicated in the regulation of fertility and reproduction. The effect of pharmaceutical agents on circulating plasma leptin levels has been assessed. Among the drugs investigated are glitazones, statins, fibrates, serotonin reuptake inhibitors and cannabinoid-1 receptor antagonists. Since these agents are used to treat pathological conditions there is a potential role for leptin in these states. The degree of involvement of leptin in several pathophysiological states needs to be defined to aid in the development of potentially useful therapeutic agents.