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Contains fulltext : 291124.pdf (Publisher’s version ) (Open Access) BACKGROUND: In upper extremity thrombosis research, the occurrence of upper extremity postthrombotic syndrome (UE-PTS) is commonly used as the main outcome parameter. However, there is currently no reporting standard or a validated method to assess UE-PTS presence and severity. In a recent Delphi study, consensus was reached on a preliminary UE-PTS score, combining 5 symptoms, 3 signs, and the inclusion of a functional disability score. However, no consensus was reached on which functional disability score to be included. OBJECTIVES: The aim of the current Delphi consensus study was to determine the specific type of functional disability score to finalize UE-PTS score. METHODS: This Delphi project was designed as a three-round study using open text questions, statements with 7-point Likert scales, and multiple-choice questions. The CREDES recommendations for Delphi studies were applied. In this context, a systematic review was conducted before the start of the Delphi rounds to identify the available functional disability scores as available in the literature and present these to the expert panel. RESULTS: Thirty-five of 47 initially invited international experts from multiple disciplines completed all the Delphi rounds. In the second round, consensus was reached on the incorporation of the quick disabilities of the arm, shoulder, and hand (QuickDASH) in the UE-PTS score, rendering the third round obsolete. CONCLUSION: Consensus was reached that the QuickDASH should be incorporated in the UE-PTS score. The UE-PTS score will need to be validated in a large cohort of patients with upper extremity thrombosis before it can be used in clinical practice and future research. 01 januari 2023

Objective: To compare cost effectiveness of endovascular revascularisation (ER) and supervised exercise therapy (SET) as primary treatment for patients with intermittent claudication (IC) due to iliac artery obstruction. Methods: Cost utility analysis from a restricted societal perspective and time horizon of 12 months. Patients were included in a multicentre randomised controlled trial (SUPER study, NCT01385774, NTR2648) which compared effectiveness of ER and SET. Health status and health related quality of life (HRQOL) were measured using the Euroqol 5 dimensions 3 levels (EQ5D-3L) and VascuQol-25-NL. Incremental costs were determined per allocated treatment and use of healthcare during follow up. Effectiveness of treatment was determined in quality adjusted life years (QALYs). The difference between treatment groups was calculated by an incremental cost utility ratio (ICER). Results: Some 240 patients were included, and complete follow up was available for 206 patients (ER 111, SET 95). The mean costs for patients allocated to ER were €4 031 and €2 179 for SET, a mean difference of €1 852 (95% bias corrected and accelerated [bca] bootstrap confidence interval 1 185 – 2 646). The difference in QALYs during follow up was 0.09 (95% bcaCI 0.04 – 0.13) in favour of ER. The ICER per QALY was €20 805 (95% bcaCI 11 053 – 45 561). The difference in VascuQol sumscore was 0.64 (95% bcaCI 0.39 – 0.91), again in favour of ER. Conclusion: ER as a primary treatment, results in slightly better health outcome and higher QALYs and HRQOL during 12 months of follow up. Although these differences are statistically significant, clinical relevance must be discussed due to the small differences and relatively high cost of ER as primary treatment.

Item does not contain fulltext OBJECTIVE: Randomized trials have shown an initial survival benefit of endovascular over conventional open abdominal aortic aneurysm repair but no long-term difference up to 6 years after repair. Longer follow-up may be required to demonstrate the cumulative negative impact on survival of higher reintervention rates associated with endovascular repair. METHODS: We updated the results of the Dutch Randomized Endovascular Aneurysm Management (DREAM) trial, a multicenter, randomized controlled trial comparing open with endovascular aneurysm repair, up to 15 years of follow-up. Survival and reinterventions were analyzed on an intention-to-treat basis. Causes of death and secondary interventions were compared by use of an events per person-year analysis. RESULTS: There were 178 patients randomized to open and 173 to endovascular repair. Twelve years after randomization, the cumulative overall survival rates were 42.2% for open and 38.5% for endovascular repair, for a difference of 3.7 percentage points (95% confidence interval, -6.7 to 14.1; P = .48). The cumulative rates of freedom from reintervention were 78.9% for open repair and 62.2% for endovascular repair, for a difference of 16.7 percentage points (95% confidence interval, 5.8-27.6; P = .01). No differences were observed in causes of death. Cardiovascular and malignant disease account for the majority of deaths after prolonged follow-up. CONCLUSIONS: During 12 years of follow-up, there was no survival difference between patients who underwent open or endovascular abdominal aortic aneurysm repair, despite a continuously increasing number of reinterventions in the endovascular repair group. Endograft durability and the need for continued endograft surveillance remain key issues.

Background: Identifying patients at risk for aneurysm rupture and sac expansion after open and endovascular abdominal aortic aneurysm (AAA) repair (EVAR) may help to attenuate this risk by intensifying follow-up and early detection of problems. The goal of this study was to validate the St George’s Vascular Institute (SGVI) score to identify patients at risk for a secondary intervention after elective aneurysm repair. Methods: A post hoc on-treatment analysis of a randomized trial comparing open AAA repair and EVAR was performed. In this multicenter trial, 351 patients were randomly assigned to undergo open AAA repair or EVAR. Information on survival and reinterventions was available for all patients at 5 years postoperatively, for 79% at 6 years, and for 53% at 7 years. Open repair was completed in 173 patients and EVAR in 171, based on an on-treatment analysis. Because 17 patients had incomplete anatomic data, 327 patients (157 open repair and 170 EVAR) were available for analysis. During 6 years of follow-up, 78 patients underwent at least one reintervention. The SGVI score, which is calculated from preoperative AAA morphology using aneurysm and iliac diameter, predictively dichotomized patients into groups at highrisk or low-risk for a secondary intervention. The observed freedom from reintervention was compared between groups at predicted high-risk and predicted low-risk. Results: The 20 patients in the high-risk group were indeed at higher risk for a secondary intervention compared with the 307 patients predicted to be at low risk (hazard ratio [HR], 3.82; 95% confidence interval [CI], 2.05-7.11; P < .001). Discrimination between high-risk and low-risk groups was valid for EVAR (HR, 4.06; 95% CI, 1.93-8.51; P < .001) and for open repair (HR, 3.41; 95% CI, 1.02-11.4; P [ .033). Conclusions: The SGVI score appears to be a useful tool to predict reintervention risk in patients after open repair and EVAR.

Routing a bypass through a bony structure in a transverse direction during femorodistal bypass procedures has been previously reported. This paper describes a patient who needed a crural revascularisation, but a normal passage through a deep or superficial route was not possible because of the circumferential ossification of the lower left leg muscles as a result of trauma 7 years earlier. The long saphenous vein in the left leg had been used for an earlier reconstruction, ruling out an in-situ graft. A limb saving bypass to the distal posterior tibial artery was performed through an intra-medullary tibial route.

Peripheral arterial occlusive disease (PAOD) commonly results from progressive narrowing or occlusion of arteries in the lower extremities mostly due to atherosclerosis. The atherosclerotic process of progressive narrowing and hardening of arteries can occur in each artery in the human body, however it mainly affects coronary, cerebral and peripheral arteries especially those in the lower extremities(1). The preferential sites of involvement of PAOD are the femoral and popliteal arteries in 80-90%, the tibial and peroneal arteries in 4050% and in 30% the aorta and iliac arteries(2). The manifestation of PAOD ranges from no symptoms to tissue loss that may eventually requires amputation of an affected limb. The majority of patients with PAOD have asymptomatic or atypical disease (figure 1).

Thrombosis of the inferior vena cava is an uncommon complication of a large aneurysm of the abdominal aorta. The prevalence of symptomatic venous complications secondary to aneurysms of the aorta is not well documented. Combe et al. reported an incidence of less than 9%. 1 Venous compression by an aortic aneurysm often heralds rupture especially into the cava itself causing an aortocaval fistula. The overall mortality rate of aortocaval fistula is about 21%. 2 The mortality in combination with vena cava thrombosis is unknown. If the diagnosis is made before operation, the mortality may be reduced because proper precautions can be made. 3 We describe a patient with gross oedema in the lower body and visible collateral veins on the abdominal wall, resembling an inferior vena cava syndrome. It appeared to be an abdominal aortic aneurysm complicated by total occlusion of the inferior vena cava, due to a thrombotic plug from the wall of the atherosclerotic aneurysm which expanded through an aortocaval fistula. As far as we are aware, a case like this has never been published before. right flank. After the diagnosis of an aortic aneurysm with vena cava thrombosis was made he was transferred to our hospital. On admission, the blood pressure was 105/75 mmHg with a heart rate of 100 per minute. The jugular venous pressure was not elevated. Pre-operative cardiac output was 4.4 l/rain. Prominent veins over the lower abdomen were seen with considerable oedema of scrotum and legs. The abdomen revealed a pulsating mass, without abdominal distention or audible bruit. Ultrasound examination and computerised tomography (CT) of the abdomen (Fig. 1), revealed a large (7.5 cm) abdominal aortic aneurysm. Apart from this finding, an intraluminal thrombotic mass in the abdominal aorta and thrombosis of the inferior vena cava were observed. At operation an abdominal aortic aneurysm was found with an aortocaval fistula. The inferior vena

Neurological deficit after infrarenal abdominal aortic repair is rare. We report on a patient who had an infrarenal aorto-bifemoral bypass for claudication. Postoperatively, the patient developed a partial anterior spinal artery syndrome (ASAS). Factors contributing to the development of ASAS were evaluated using contrast-enhanced magnetic resonance angiography of the spinal cord's blood supply. ASAS was probably caused by a temporarily inadequate blood flow to the cord due to intra-operative hypotensive episodes combined with generalised vascular disease. Since treatment options for ASAS are solely supportive, preventive measures are imperative to avoid neurological deficit.

We describe a case in which a nodular fasciitis tumor process caused vascular impairment in the right femoral region, two weeks after a coronary angiography in which the right femoral artery had been punctured. Nodular fasciitis is a benign tumor of fibrous origin and has been associated with antecedent trauma. Deep venous thrombosis (DVT) due to a nodular fasciitis tumor process has never been reported previously.