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Objective. To present our experience using fenestrated and branched endoluminal grafts for Para-anastomotic aneurysms (PAA) following prior open aneurysm surgery, and after previous endovascular aneurysm repair (EVAR) complicated by proximal type I endoleak.Methods. Fenestrated and/or branched EVAR was performed on eleven patients. Indications included proximal type I endoleak after EVAR and short infrarenal neck (n = 4), suprarenal aneurysm after open AAA (n = 4), distal type I endoleak after endovascular TAA (n = 1), proximal anastomotic aneurysm after open AAA (n = 1), and an aborted open AAA repair due to bleeding around a short infrarenal neck.Results. The operative target vessel success rate was 100% (28/28) with aneurysm exclusion in all patients. Mean hospital stay was 6.0 days (range 2-12 days, SD 3.5 days). Thirty day mortality was 0%. All cause mortality during 18 months mean follow-up (range 5-44 months, SD 16.7 months) was 18% (2/11) with no deaths from aneurysm rupture. Cumulative visceral branch patency was 96% (27/28) at 42 months. Average renal function remained unchanged during the follow-up period.Conclusions. Our report highlights the potential of fenestrated and branched technology to improve re-operative aortic surgical outcomes. The unique difficulties of increased graft on graft friction hindering placement, short working distance, and increased patient co-morbidities should be recognized.

Introduction. A proximal neck of 15 mm length is usually required to allow endovascular repair of abdominal aortic aneurysms (EVAR). Many patients have been refused EVAR due to a short neck. By customising fenestrated grafts to the patients' anatomy, we can offer an endovascular solution, especially for patients who are unsuitable for open repair. Methods. Eighteen patients were selected for fenestrated stent-grafting if they presented with an abdominal aneurysm of at least 55 mm in diameter, a short neck (less than 15 mm), plus contra-indications for open repair (cardiopulmonary impairment or a hostile abdomen). The stent-graft used was a customised fenestrated model based on the Cook Zenith ® composite system. We used additional stents to ensure apposition of the fenestrations with the side branches. Results. All endovascular procedures were successful. Out of the 46 targeted side branches (10 superior mesenteric arteries, 36 renal arteries), 45 were patent at the end of the procedure. One accessory renal artery became occluded by the stent-graft. There was one possible proximal type I endoleak, which later proved to be a type II endoleak. There was no mortality, but complications occurred in six patients: two cardiac complications, three urinary complications and one occlusion of a renal artery. At follow-up (mean 9.4 months, range 1–18), there were no additional renal complications and all the remaining targeted vessels stayed patent. Discussion. By customizing fenestrated stent-grafts, it is possible to position the first covered stent completely inside the proximal neck, thus achieving a more stable position. The additional side-stents may also contribute to a better fixation. This technique may become a valuable alternative for patients who are at high risk from open surgery.

Background Despite several modifications to the original design, patency rates of radiocephalic arteriovenous fistulas have changed little since the first report in 1966. The use of non-penetrating clips for vascular anastomosis on the outcome of such fistulas was studied. Methods Between January 2000 and August 2003, 107 primary radiocephalic fistulas were constructed in 98 patients. The vascular anastomoses were performed at random with either sutures (n = 56) or clips (n = 51). Results Although there were trends for better primary and primary assisted patency of clipped fistulas, the differences were not statistically significant. The 6-month primary patency rate was 61 per cent with sutures and 69 per cent with clips (P = 0·393). The mean(s.d.) primary patency was 315(306) and 285(285) days for clipped and sutured fistulas respectively. With regard to secondary patency, clipped fistulas were better (P = 0·009). The mean(s.d.) secondary patency was 435(376) and 344(316) days for clipped and sutured fistulas, respectively. There were no significant differences in flow characteristics, number of revisions or other morbidity. Conclusion This randomized clinical trial provided further evidence that the use of vascular clips may improve the patency rate of radiocephalic arteriovenous fistulas for haemodialysis.

Background The present study reviewed a 30-year experience of managing carotid body paraganglioma (CBP) and analysed clinical findings associated with perioperative morbidity. Methods Clinical records, radiological findings and pathological reports of all patients who presented with CBP between 1966 and 1997 were reviewed. There were 39 consecutive patients with 45 tumours and median follow-up was 10 years. The Shamblin classification was used to define complication rates and long-term surgical results. Results Preoperative information derived from magnetic resonance angiography (MRA) and colour Doppler imaging (CDI) was comparable to that from standard four-vessel arteriography. Forty-one CBPs were resected in 35 patients. Six patients had bilateral tumours and seven had multicentric tumours. The median duration of operation and blood loss were substantially higher for Shamblin type III tumours. All major vascular complications (four of 39 patients) and permanent neurological complications (three of 39) were observed in type III tumours. Conclusion Surgical planning and prediction of perioperative complications can be obtained by staging derived from MRA and CDI. Severe complications occur predominantly in type III CBPs.

BackgroundVascular repair with sutures is associated with disruption of the endothelial lining and subsequent thrombus formation on the intraluminal lesions. This experimental study was designed to determine whether the use of non-penetrating clips improved endothelial preservation.MethodsIn ten female pigs, 25-mm arteriotomies were made in both carotid arteries. The arteriotomies were repaired with jugular vein patches. On the left side, the repair was done with 1·4-mm titanium clips, and on the right side with two running 6/0 polypropylene sutures. Next, the aorta was divided and subsequently repaired with 2-mm clips in five of these pigs, and with two running 5/0 polypropylene sutures in the remaining five pigs. Endothelial function was studied at the anastomotic site in the carotid arteries by determination of endothelium-dependent and -independent relaxatory responses. Morphometric examination of the carotid arteries and inspection of the aortic endothelium were performed by means of scanning electron microscopy.ResultsMaximal endothelium-dependent relaxation to adenosine 5′-diphosphate was less in sutured than in clipped carotid arteries (P < 0·05), while there was no difference in maximal endothelium-independent relaxation to sodium nitrite. This result in clipped carotid arteries was not accompanied by less intimal hyperplasia. Screening of the aortic anastomotic line showed better preservation of endothelial architecture after clip anastomosis. Mean cross-clamp time for carotid patch repair was significantly less when using clips than with sutures.ConclusionThe use of non-penetrating clips for vascular anastomoses preserved endothelial function and structural integrity better than running sutures, although the degree of intimal hyperplasia was similar.

When blood flow through a carotid artery is impaired and vascular surgery is necessary to restore adequate circulation a vascular shunt can be applied to maintain cerebral blood flow. Several vascular shunts are commercially available, but there is only limited test data on their flow capacity. The purpose of this study is to determine the flow capacity of three vascular shunt systems. A theoretical model has been developed for this purpose. To validate the model, in vitro flow measurements were taken. Application of the model showed that all shunts cause a decrease in blood flow. The amount of flow decrease varied widely from 13% (Javid shunt) to 55% (Pruitt-Inahara). In vitro measurements confirmed the validity of the model. In conclusion, it is important for the vascular surgeon to realise that vascular shunts show large differences in flow capacity. Of the three investigated shunts, the Javid has the highest flow capacity.

Objective: Patients with extra-cardiac arterial disease (ECAD) are at high risk of coronary artery disease (CAD). Prevalence of silent, significant CAD in patients with stenotic or aneurysmal ECAD was examined. Early detection and treatment may reduce CAD mortality in this high-risk group.Materials and methods: ECAD patients without cardiac complaints underwent computed tomography (CT) for calcium scoring, coronary CT angiography (cCTA) if calcium score was 1,000 or under, and adenosine perfusion magnetic resonance imaging (APMR) if there was no left main stenosis. Significant CAD was defined as calcium score over 1,000, cCTA-detected coronary stenosis of at least 50% lumen diameter, and/or APMR-detected inducible myocardial ischemia. In cases of left main stenosis (or equivalent) or myocardial ischemia, patients were referred to a cardiologist.Results: The prevalence of significant CAD was 56.8% (95% Cl 47.5 to 66.0). One-hundred and eleven patients were included. Eighty-four patients (76%) had stenotic ECAD, and 27 (24%) had a-neurysmal disease. In patients with stenotic ECAD, significant coronary stenosis was present in 32 (38%) and inducible ischemia in eight (12%). Corresponding results in aneurysmal ECAD were eight (30%) and two (11%), respectively (p for difference >.05). Sixteen (19%) patients with stenotic and six (22%) with aneurysmal ECAD were referred to a cardiologist, with subsequent cardiac intervention in seven (44%) and three (50%), respectively (both p >.05).Conclusions: Patients with stenotic or aneurysmal ECAD have a high prevalence of silent, significant CAD. (C) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

A retrospective case study was carried out from 1971–1990, with a median follow-up of 7 years, to assess the long-term results of thromboendarterectomy of the common iliac artery. The study included 94 consecutive patients, median age 52 years, of whom 84 suffered from atherosclerotic obstructive common iliac disease causing claudication, and 10 suffered from rest pain. Bilateral disease was present in 67 patients, and unilateral disease in 27. A total of 163 semiclosed endarterectomies (with the ringstripper) were performed. The mean ankle:brachial pressure index rose from 0.66 to 0.98. All patients with claudication became symptom-free after endarterectomy. Postoperative morbidity was low and there was no postoperative mortality. Recurrent aortoiliac symptoms were seen in 25 patients, leading to aortobifemoral bypass grafting in 12 cases. The primary cumulative patency rate at 5 and 10 years was 83% and 68% respectively. Thromboendarterectomy of the common iliac artery is a safe procedure with few complications and good long-term results. It is an effective method of treating common iliac artery stenoses or occlusions.

Het dopplereffect berust op het veranderen van de frequentie van geluid dat door stromende erytrocyten wordt teruggekaatst. Deze verschuiving van frequentie kan met een dopplerapparaat hoorbaar gemaakt worden. In het menselijke lichaam is het een ideale methode om stromende rode bloedcellen op te sporen en de bijpassende bloeddruk te meten. Arterien en venen hebben ieder een eigen flowkarakteristiek. Het doppleronderzoek hoort tot de non-invasieve, patientvriendelijke onderzoeken van de arterien.

The popliteal artery is a common site for peripheral arteriosclerotic aneurysm development. The major danger from popliteal aneurysms consists of thrombosis and peripheral arterial embolisation. Rupture is a lesser risk. Most popliteal artery aneurysms are treated on an elective basis. This elective treatment consists of an interposition graft, preferably using vein, through a posterior approach or a medial approach. Recently endovascular treatment has been reported in a number of small series or case reports. We report the endovascular treatment of an acutely occluded popliteal aneurysm with an endovascular stent-graft. This was made possible by successful recanalisation of the occluded artery with thrombolytic therapy.

Background: Subclavian artery aneurysms (SAAs) are rare and may cause life- and limb-threatening complications. Therapeutic options greatly differ as do access alternatives. The aim of the study was to assess its clinical presentation, diagnostics and therapeutic options as reported in the literature. Method: A literature search was performed of the Medline, Cochrane and EMBASE databases. All articles, published until September 2009, describing treatment of an SAA were included. Results: A total of 191 reports, of which 126 met the inclusion criteria, were identified and were published from June 1915 until September 2009. Of these, 394 SAAs were described in 381 patients, with a mean age of 52 +/- 16 years. The median diameter was 40 mm (range: 10-180 mm). The aetiology appeared to change in time towards more exogenous causes. Fifty-one percent of the SAAs presented with a pulsating mass, shoulder pain and/or non-specific chest pain. Embolisation, rupture and thrombosis were present in 16%, 9% and 6% of patients, respectively, and their incidence was related to the anatomical localisation of the SAA. Open surgery and endovascular repair had a complication rate of 26% and 28%, respectively (p = 0.49). Cardiopulmonary complications were restricted to open repair. Mortality rates for open and endovascular techniques were similar (5%). The mortality rates for conventional elective and emergency procedures were 3% and 13%, respectively, and for endovascular repair 4% and 8%, respectively. Conclusion: The profiles of diagnostic and treatment options of SAAs are changing. Although guidelines considering timing of intervention may not be conducted from available literature, intervention appears to be indicated, especially in distal SAAs, due to the risk of thrombo-embolic complications. Endovascular repair and hybrid procedures appear to be the preferred treatment modalities, due to a lower rate of cardiopulmonary complications. (C) 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Fenestrated stent-grafts are designed to treat short-neck abdominal aortic aneurysms. Thanks to customized fenestrations, patency of side branches such as the renal arteries and the superior mesenteric artery can be maintained, whilst positioning the graft across these aortic branches.

Nowadays, fewer endarterectomies are performed for treatment of occlusive arterial disease; more often a bypass procedure is done. This study investigates whether the results of the semiclosed endarterectomy for unilateral iliofemoral occlusive discase indeed indicate a wider use of bypass procedures for such short obstructions. Ninety-four patients with an obstructed external iliac and common femoral artery, but with patent ipsilateral common iliac and contralateral iliac arteries, underwent 101 operations. Seven of these patients were operated on at a later stage for occlusive disease on the contralateral side. Ninety-three endarterectomies were performed, and an iliofemoral bypass graft was inserted eight times because an endarterectomy was not feasible. Sixty-two operations were performed for disabling claudication, and 39 operations were performed for limb-threatening ischemia. Eighty-five percent of the patients who underwent an endarterectomy for disabling claudication became asymptomatic. Eighty percent of the patients who underwent an endarterectomy for limb-threatening ischemia became asymptomatic or improved to claudication. After endarterectomy no deaths, false aneurysms, or infections occurred. The patency rates at 1, 5, and 10 years were 94%, 83%, and 65%, respectively. We conclude that the semiclosed endarterectomy with the ringstripper of a unilateral obstruction of one external iliac and common femoral artery can be performed with a low morbidity and without deaths and gives good long-term results.

Fibrodysplasia is a rare and unusual cause of obstruction of the superficial femoral or popliteal artery. Three young patients with intermittent claudication due to occlusion of the femoropopliteal artery are described. Histological examination showed destruction of the elastic and muscle fibres of the media. In one patient secondary fibrosis of the intima was seen. The adventitia showed an increase in elastin fibres in all cases. The lesions described can be respectively classified as perimedial fibroplasia, as medial dissection and as intimal fibroplasia. This is the first description of a patient with histopathologically proven perimedial fibroplasia and medial dissection of the femoropoliteal artery and the second case of intimal fibroplasia.

Objectives. The aim of this study was to analyse the results of brachiocephalic fistulas for haemodialysis and to determine possible predictors of failure.Patients and methods. Between April 1999 and September 2004, a consecutive series of 100 autologous brachiocephalic fistulas were created in 96 patients. There were 57 men and 39 women with a mean (SD) age of 59.2 (15.6) years. Data were prospectively gathered.Results. The mean (SD) follow-up was 20.1 (16.4) months. The primary, primary assisted, and secondary patency rates after 6 months were 73.4, 83.2 and 86.4%, respectively. After 1 year these figures were 54.7, 72.3 and 79.2%, and after 2 years 40.4, 59.2 and 67.5%, respectively. Predictors of failure with regard to primary patency, determined with Cox regression multivariate analysis, included diabetes mellitus (HR 2.81, p Conclusion. Primary patency of brachiocephalic fistulas is comparable to that of radiocephalic fistulas. Primary assisted and secondary patency rates can, however, be brought to a much higher level, especially in patients without diabetes and a large-diameter venous outflow tract.

Objectives. To analyse the results of emergency endovascular aneurysm repair (eEVAR) for acute abdominal aortic aneurysms (AAA), in comparison to open repair, and to evaluate suitability and application rate.Patients and methods. All patients treated for an acute AAA between January 1998 and August 2004 were included. The primary outcome measure was in-hospital mortality. Secondary outcome measures were procedure time, intra-operative blood loss, transfusion requirement, intensive care unit, and hospital length of stay. Suitability and application rate for eEVAR were assessed in a subgroup of patients, from January 2003.Results. A total of 253 patients were treated. eEVAR was performed in 40 patients, 5 (13%) died in-hospital. Open repair was performed in 213 patients, 64 (30%) died in-hospital. Secondary outcome measures were all significantly improved in the eEVAR subgroup. From January 2003, 56 patients were treated. Of the 44 (79%) patients who were evaluated for eEVAR, 16 (36%) patients were anatomically suitable. Eventually, 15 out of the 56 (27%) patients were treated by eEVAR.Conclusion. The results of eEVAR in a selected group of patients are promising, but suitability and application rate were low.

Purpose. To describe frequency, type, and outcome of re-intervention after endovascular aortic aneurysm repair (EVAR). Methods. Between September 1996 and December 2003, 308 patients were treated, with data collected prospectively. No patient was lost to follow up, but two were excluded (one primary conversion, and one post-operative death). Vanguard, Talent, Excluder, Zenith, and Quantum devices were used. Follow up required a CT scan before discharge. Initially, a CT scan was done at each follow up. Subsequently, we used duplex ultrasound and abdominal X-ray, with CT scan used selectively. Results. Mean follow-up was 36±22 months. Re-interventions were required in 47 (15%) patients, 31 (66%) elective and 16 (34%) emergency cases. In 32 patients, the primary re-intervention was successful; in 15 patients an additional 13 secondary and four tertiary re-interventions were required. A total of 72 adjunctive manoeuvres were performed: 49 endovascular (68%) and 23 open (32%). The success of endovascular re-interventions was 80%. The success of open re-interventions was 96%. Open conversions were required in nine patients (3%). There was no mortality. Conclusion. EVAR was associated with a low burden of re-interventions, with only 15% patients requiring re-intervention. Our long-term follow up, without regular CT, was simple and effective.

Background The main aim of performing a vascular anastomosis is to achieve maximal patency rates. An important factor to achieve that goal is to minimize damage to the vessel walls. Sutures inevitably induce vascular wall damage, which influences the healing of the anastomosis. Over time, several alternatives to sutures have become available. Methods A Medline literature search was performed to locate English, German and French language articles pertinent to non-suture methods of vascular anastomosis. Manual cross-referencing was also performed and many historical articles were included. Results and conclusion The non-suture techniques can be categorized into five groups based on the materials used: rings, clips, adhesives, stents and laser welding. With all these techniques a faster and less traumatic anastomosis can be made compared with sutures. However, each device is associated with technique-related complications. As a consequence, suturing continues to be the standard approach. The disadvantages of the non-suture techniques include: rigidity and a non-compliant anastomosis with rings; toxicity, leakage and aneurysm formation with adhesives; early occlusion with stents; cost, reduced strength in larger-sized vessels and demand for surgical skills with laser welding. Further refinement is needed before widespread adoption of these techniques can occur. Clips, however, may be particularly promising but long-term evaluation is required.

We compared the hemocompatibility of the Polystan bubble oxygenator and the Travenol TMO and SciMed spiral-coil membrane oxygenators in 43 patients undergoing aortic valve replacement. In a subgroup of 27 patients, we collected hematological data and correlated platelet behavior with hemostasis. We found no differences in blood loss or blood (product) requirements among the groups. Platelet and erythrocyte damage was less in the membrane oxygenator groups than in the bubble oxygenator group. Differences in adenosine diphosphate-induced platelet aggregation were equivalent. Drops in this function concurred with intensified cardiotomy suction and administration of protamine. Leukocytosis after bypass was most marked in the SciMed group. Duration of bypass correlated with blood loss and blood requirements in the operating theater. Platelet counts shortly after bypass correlated negatively with duration of bypass and blood loss in the intensive care unit. Platelet function correlated with none of the factors just mentioned. We conclude that platelets and erythrocytes are preserved better by the membrane oxygenator than by the bubbler. The TMO system causes more erythrocyte damage than the SciMed oxygenator, probably due to TMO's dual-pump system. Clinical evidence for these improvements was not found, and this will be possible only when the other factors responsible for blood damage can be controlled.

The effect of prostaglandin E 1 (PGE 1 ) on protection of platelets during cardiopulmonary bypass (CPB) was evaluated in 9 patients, who were compared with an identical control group of 10 patients undergoing coronary artery bypass grafting. To evaluate the hemodynamic side-effects, PGE 1 (0.05 μg/kg/min) was infused prior to CPB, resulting in a 26% drop in mean systemic arterial pressure. With this dose, no inhibition of the adenosine diphosphate-induced aggregation could be measured in the pulmonary artery sample. During CPB, the same infusion dose resulted in a severe drop in systemic arterial pressure below 50 mm Hg in 7 of the 9 patients. In 5 of these patients, volume load and phenylephrine infusion could not compensate for the pressure drop, and PGE 1 had to be reduced to 0.02 μg/kg/min. Platelet aggregation was reduced significantly in the PGE 1 -treated group compared with the control group, but not completely inhibited during CPB. However, in the postbypass period no platelet preservation was seen in the PGE 1 group. In both groups, platelet number and function were equally low. No differences were measured in blood loss or blood transfusion requirements. Except for hypotension, no side-effects of the PGE 1 treatment were seen. It is concluded that the hypotension caused by minimal doses of PGE 1 during CPB precluded using higher doses, which might have had a greater effect on platelet inhibition. These hypotensive side-effects should be reduced or eliminated before PGE 1 can be expected to have the same protective effect on platelet damage that has been demonstrated in animal experiments.

The technique of cardiopulmonary bypass (CPB) to support the patient during cardiac surgery can be performed safely nowadays.

In open heart surgery airborne infection has been identified as one of the main sources of a relatively high incidence of clinically manifest postoperative infections (1). The coronary suction line, through which air is constantly drawn, was considered to be the main source of infection. This was substantiated by the fact that in 75% of the cases the extracorporeal circuit became contaminated during operation. This could be confirmed in our hospital: in 119 open heart operations 79% of the oxygenators proved to be contaminated at the end of bypass (2). The airborne contamination was demonstrated by the fact that this high rate of contamination could be reduced to 17% if a cross-flow ventilation system was used. It could be shown in an experimental set-up that the air flow through the suction lines was mainly responsible for this contamination (3).

To determine whether superhydrophobic modification of small diameter expanded polytetrafluoroethylene (ePTFE) vascular grafts improves the performance of these grafts, we assessed neointima formation and platelet deposition in standard and superhydrophobic modified ePTFE grafts. Standard and superhydrophobic vascular grafts were implanted in the carotid arteries of two rabbits and two pigs. Furthermore, standard and superhydrophobic vascular patches were implanted in the carotid arteries of seven pigs. After 4 weeks of implantation all patches were removed and histomorphometric data were analyzed. The early thrombotic effect of superhydrophobic modification was examined by quantifying platelet glycoprotein receptor IIIa deposition onto each type of vascular graft after 15 min of in vitro circulation with human blood. All superhydrophobic and standard ePTFE vascular grafts occluded 15 min to 1 h after implantation in both rabbit and pig carotid arteries. All implanted patches remained patent and were completely covered by endothelium. Superhydrophobic modification of ePTFE vascular grafts did not lead to less neointima formation and resulted in significantly more platelet deposition than did standard ePTFE vascular grafts. Thus, superhydrophobic modification does not improve the performance of small diameter ePTFE vascular grafts.

Objectives: This study reports the results of a prospective continuous cohort of patients treated for endovascular aneurysm repair (EVAR) with a unified anesthetic strategy based on the use of local anesthesia (LA) in all patients, while reserving regional (RA) or general anesthesia (GA) only for those with predefined individually or surgically specific indications.Methods: All patients treated by EVAR for an elective aortic abdominal aneurysm (AAA) between April 1998 and December 2003 were included. The strategy of treatment generated three cohorts of patients (LA, RA, or GA). Primary outcome included all-cause mortality, nonfatal cardiac morbidity, respiratory complications, and renal failure. Secondary outcome measures included conversion to general anesthesia, use of analgesics, and time-related outcomes (operating time, length of stay in intensive care unit and hospital, time required to resume oral intake, and time to ambulation).Results: A total of 239 patients underwent EVAR: 170 LA, 31 RA, and 38 GA. Overall mortality was one patient (0.4%). LA was associated with a lower incidence of complications compared with GA (P Conclusions. A strategy based on the preferential use of LA for EVAR restricting RA or GA only to those with predefined contraindications is feasible and appears to be well tolerated.