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Summary Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding UK Medical Research Council and Health Technology Assessment Programme.

Objective: Despite significant advances in the understanding of vein graft remodeling during the post-implantation, vein graft disease is still a major limitation of surgical revascularization. The study objective was to evaluate the performance of a new cobalt chrome external support device designed to mitigate vein graft remodeling and development of intimal hyperplasia. Methods: Bilateral carotid interposition of reversed saphenous vein graft segments was performed in seven‏ adult sheep. Following completion of the first anastomosis, randomization was performed to allocate the experimental and control grafts in each animal. Post-procedure, Doppler US was used to assess grafts lumen diameter at T0 and then 3-5 and 12-14 weeks after surgery. At 12-14 weeks, all sheep underwent angiography to assess grafts patency and lumen uniformity (coefficient of variance - CV) after which they were sacrificed, and all grafts were harvested for microscopic histological analysis. Results: Baseline (T0) internal diameter was not significantly different between the supported and unsupported grafts. At twelve to fourteen weeks, the internal diameter of supported grafts remained unchanged and was significantly lower compared to the non-supported grafts (6.6mm±0.4mm vs. 12.8mm±4.0mm respectively, p= 0.0001). Percentage coefficient of variance (%CV) was 4.6%±4.3 in the supported grafts as opposed to average CV% of 14.7%±6.5 in the non-stented group (p=0.011). Neointimal area was significantly lower in the stented compared to the non-stented group (1.4 mm2±3.3mm2 versus 9.6mm2±9.7mm2 respectively, p=0.009). Conclusions: External support of vein grafts using a braided cobalt chrome external stent reduces early vein graft remodeling and mitigates the development of neointimal hyperplasia. [Arch Clin Exp Surg 2018; 7(3.000): 108-115]

Three dimensional printing (3D printing) technology is increasingly used to improve results in many areas of medicine. Physical models produced by this technology allow better appreciation of complex anatomical and pathologic conditions. In cardiovascular medicine and surgery, 3D modeling has been reported to be of help in treatment planning of abdominal aortic aneurysm, especially in cases of complex angulations and branching at the aneurysm neck. Here we report the use of 3D printing in cases of renal aneurysms. Enhanced 3D models of CTA images of renal aneurysms were prepared in house using common and freely available software programs, and an accurate desktop 3D printer. Eight reconstructed models were enlarged by a factor of 2 or more and then differentially painted to delineate normal arteries and aneurysmatic ones. These enhanced 3D solid models allowed visual and tactile inspection for a better appreciation of complex aneurysms. Color enhancement of these models added another dimension of comprehension, even for experienced surgeons and invasive radiologists, and allowed more accurate measurements of branch numbers, distances, and angles in space even with severe tortuosity. Endovascular use of covered stents and embolization techniques could be easily envisioned preoperatively. We conclude that enhanced, enlarged, and colored 3D printed models are a powerful tool for preoperative endovascular treatment planning of complex renal artery aneurysms.

Graft infection following prosthetic vascular reconstruction is an uncommon but severe complication. The clinical presentation is often subtle and nonspecific and may occur long after surgery. Although defining a prosthetic vascular graft infection can be difficult, early diagnosis and treatment are essential for the correct choice of treatment to prevent further complications as well as the high morbidity and mortality associated with repeat surgery and removal of infected grafts. False-positive results may lead to unnecessary surgery while failure to diagnose graft infection may have life-threatening sequels. Scarce literature that is currently available regarding the role of (18)F-labeled fluorodeoxyglucose imaging for assessment of vascular graft infection suggests that this modality may represent reliable noninvasive imaging modality in this specific clinical setting. PET/CT increases the test specificity and thus improves diagnostic accuracy. The precise anatomic localization of increased (18)F-labeled fluorodeoxyglucose PET/CT enables accurate differentiation between graft and adjacent soft tissue infection leading to more accurate diagnosis and subsequent optimized therapeutic strategy.

Background. Vascular injuries often result in life threatening hemorrhage or limb loss. When they present with a single entry or exit wound, surgery is immediately indicated. With multiple injuries, however, imaging such as CTA is necessary for diagnosis and choice of treatment.Methods. For all combat-related vascular cases admitted to our medical center during the Lebanon wars in 1982 and 2006, we compiled and compared presenting signs and symptoms, means of diagnosis, treatments, and results.Results. 126 patients with vascular injuries were admitted (87 in 1982, 39 in 2006). 90% were male; mean age of 29 years (range 20–53). All injuries were accompanied by insult to soft tissue, bones, and viscera. 75% presented with injury to arteries in the extremities. 75% of these patients presented with limb ischemia, and 25% sustained massive blood loss. Treatments included venous interposition graft, end-to-end anastomosis, venous patch, endovascular technique (only in 2006), and ligation/observation. Complications included thrombosis and wound infections. Mortality and amputations occurred only in 1982, and this may be attributed to the use of imaging, advanced technique, and shorter average time from injury to hospital (7 hours).Conclusions. We recommend CTA as the first line modality for diagnosis of vascular injuries, as its liberal use allowed for early and appropriate treatment. Treatment outcomes improved with fast and effective resuscitation, liberal use of tourniquets and fasciotomies, and meticulous treatment by a multidisciplinary team.

Vascular trauma is common in Israel, as it is in other western societies; and it includes a variety of etiologies such as traffic accidents, extremity fractures, falls, gunshot wounds and, increasingly, iatrogenic causes. However, in addition to the regular civilian pattern of vascular injuries, Israel is involved in frequent armed conflicts; the civilian vascular community has to care for military-type injuries, such as penetrating wounds from bullets, from ball bearings, and from other fragments and foreign bodies from explosive devices. The Israeli experience in vascular trauma shows that injuries may be caused by blunt trauma; but more often they are the result of penetrating injuries and are the main causes of severe bleeding, ischemia, disabilities, amputations, and death. Vascular injuries take first priority in treatment paradigms since shortening of the time of bleeding and the time of ischemia are of paramount importance in saving limbs and lives of the injured. Identification of the specific injured arteries and veins allows accurate control of blood loss and allows appropriate repair of vessels. Use of fasciotomies in this setting should be liberal to prevent compartment syndrome and to improve functional outcome. To lessen the risk of infection and thrombosis, primary repair of vessels and use of autologous vein are preferred over the use of synthetic conduits. In the battlefield and during evacuation, rubber and improvised tourniquets are used to stop life-threatening bleeding; but in the setting of the operating room these should be removed as soon as possible to prevent continued ischemia of nerves and other soft tissues. In the modern specialized vascular facilities of Israel, the rate of success in repairs of vascular injuries is high; and the amputation rate is low and constantly continues to decrease. The mortality rate of those who reach a surgical facility is near zero.

Background/Aims: Endothelin (ET)-1 is produced by most renal cell types. Renal tubular and vascular cells express both the ET receptors ETA and ETB. Since significant amounts of ET-1 of renal origin were detected in human urine, urinary ET-1 has been used as an index for the capacity of renal ET-1 production. Here, we determine the existence of additional components of the intrarenal ET system, namely the ETA and ETB receptor subtypes, in the urine of normal and hypertensive subjects. Methods: ETA and ETB receptors were detected in urine samples that were concentrated by TCA precipitation, Speedvac or ProteoSpin™. Results: Analysis of the human urine extracts revealed the existence of approximately 50 and 55 kDa of immunoreactive proteins, corresponding to ETB and ETA, respectively, indicating that intact ETA and ETB are excreted in the urine of healthy subjects and hypertensive patients. Normotensive and hypertensive subjects had statistically comparable ETB excretion normalized to creatinine (0.58 ± 0.16 vs. 0.83 ± 0.17 μg/mg creatinine, respectively; p = 0.304). In contrast, ETA excretion was higher among hypertensive subjects (0.05 ± 0.01 vs. 0.11 ± 0.02 μg/mg creatinine; p = 0.0451). Immunostaining of ETA and ETB in the human urinary system revealed expression of both receptors, principally in tubular cells (mainly in medullary collecting ducts) and in the bladder urothelium, and ETA expression in the peritubular capillaries and arterioles. Urinary ET receptors closely and inversely correlated with indices of urine concentration, suggesting that their shedding is principally affected by urine flow. Conclusion: ET receptors are present in human urine, conceivably originating within the urinary system. Their excretion is principally affected by urinary concentration. It remains to be determined whether urinary ETA/ETB is of physiological/pathophysiological relevance.

Arginine vasopressin (AVP) plays an important role in renal hemodynamic alterations, water retention, and cardiac remodeling in congestive heart failure (CHF). The present study evaluated the acute and chronic effects of vasopressin V(1a) receptor subtype (V(1a)) and vasopressin V(2) receptor subtype (V(2)) antagonists on renal function and cardiac hypertrophy in rats with CHF. The effects of acute administration of SR 49059 [(2S)1-[(2R,3S)-5-chloro-3-(2-chlorophenyl)-1-(3,4-dimethoxybenzene-sulfonyl)-3-hydroxy-2,3-dihydro-1H-indole-2-carbonyl]-pyrrolidine-2-carboxamide)] (0.1 mg/kg) and SR 121463B (1-[4-(N-tert-butylcarbamoyl)-2-methoxybenzenesulfonyl]-5-ethoxy-3-spiro-[4-(2-morpholinoethoxy)cyclohexane]indol-2-one, fumarate; equatorial isomer) (0.3 mg/kg), V(1a) and V(2) antagonists, respectively, on renal function, and of chronic treatment (3.0 mg/kg/day for 7 or 28 days, via osmotic minipumps or p.o.), on water excretion and cardiac hypertrophy were studied in rats with aortocaval fistula and control rats. CHF induction increased plasma AVP (12.8 +/- 2.5 versus 32.2 +/- 8.3 pg/ml, p0.05). Intravenous bolus injection of SR 121463B to controls produced dramatic diuretic response (from 5.5 +/- 0.8 to 86.3 +/- 21.9 microl/min; p0.01). In contrast, administration of SR 49059 did not affect urine flow. Likewise, administration of SR 121463B, but not SR 49059, to rats with CHF significantly increased urinary flow rate from 20.8 +/- 6.4 to 91.6 +/- 26.5 microl/min (p0.01). The diuretic effects of SR 121463B were associated with a significant decline in urinary osmolality and insignificant change of Na+ excretion. In line with its acute effects, chronic administration of SR 121463B to CHF rats increased daily urinary volume 2 to 5-fold throughout the treatment period. Both SR 121463B and SR 49059 significantly reduced heart weight in CHF rats when administered for 4 weeks, but not 1 week. These results suggest that V(2) and V(1a) antagonists improve water balance and cardiac hypertrophy in CHF and might be beneficial for the treatment of water retention and cardiac remodeling in CHF.

OBJECTIVES Reports on venous trauma are relatively sparse. Severe venous trauma is manifested by hemorrhage, not ischemia. Bleeding may be internal or external and rarely may lead to hypovolemic shock. Repair of major extremity veins has been a subject of controversy and the current teaching is to avoid venous repair in an unstable or multi-trauma patient. The aim of the current paper is to present our recent experience in major venous trauma during the Lebanon conflict, means of diagnosis and treatment in a level I trauma center. METHODS All cases of major venous trauma, either isolated or combined with arterial injury, admitted to the emergency room during the 33-day conflict were reviewed. RESULTS Out of 511 wounded soldiers and civilians who were admitted to our service over this period, 12 (2.3%) sustained a penetrating venous injury either isolated (5) or combined with arterial injury (7). All injuries were secondary to high velocity penetrating missiles or from multiple pellets stored in long-range missiles. All injuries were accompanied by additional insult to soft tissue, bone and viscera. The mean injury severity score was 15. Severe external bleeding was the presenting symptom in three cases of isolated venous injury (jugular, popliteal and femoral). The diagnosis of a major venous injury was made by a CTA scan in five cases, angiography in one and during surgical exploration in six cases. All injured veins were repaired: three by venous interposition grafts, four by end to end anastomosis, three by lateral suture and two by endovascular techniques. None of the injuries was treated by ligation of a major named vein. Immediate postoperative course was uneventful in all patients and the 30-day follow-up (by clinical assessment and duplex scan) has demonstrated a patent repair with no evidence of thrombosis. CONCLUSIONS Without contradicting the wisdom of ligating major veins in the setup of multi-trauma or an unstable patient, our experience indicates that a routine repair of venous trauma can be safely and effectively performed in young patients. Postoperative course is not compromised and late sequelae of venous interruption may be prevented.

Dietary supplementation with polyphenolic antioxidants to animals was shown to be associated with inhibition of LDL oxidation and macrophage foam cell formation, and attenuation of atherosclerosis development. We investigated the effects of pomegranate juice (PJ, which contains potent tannins and anthocyanins) consumption by atherosclerotic patients with carotid artery stenosis (CAS) on the progression of carotid lesions and changes in oxidative stress and blood pressure. Ten patients were supplemented with PJ for 1 year and five of them continued for up to 3 years. Blood samples were collected before treatment and during PJ consumption. In the control group that did not consume PJ, common carotid intima-media thickness (IMT) increased by 9% during 1 year, whereas, PJ consumption resulted in a significant IMT reduction, by up to 30%, after 1 year. The patients' serum paraoxonase 1 (PON 1) activity was increased by 83%, whereas serum LDL basal oxidative state and LDL susceptibility to copper ion-induced oxidation were both significantly reduced, by 90% and 59%, respectively, after 12 months of PJ consumption, compared to values obtained before PJ consumption. Furthermore, serum levels of antibodies against oxidized LDL were decreased by 19%, and in parallel serum total antioxidant status (TAS) was increased by 130% after 1 year of PJ consumption. Systolic blood pressure was reduced after 1 year of PJ consumption by 12% [corrected] and was not further reduced along 3 years of PJ consumption. For all studied parameters, the maximal effects were observed after 1 year of PJ consumption. Further consumption of PJ, for up to 3 years, had no additional beneficial effects on IMT and serum PON1 activity, whereas serum lipid peroxidation was further reduced by up to 16% after 3 years of PJ consumption. The results of the present study thus suggest that PJ consumption by patients with CAS decreases carotid IMT and systolic blood pressure and these effects could be related to the potent antioxidant characteristics of PJ polyphenols.

The optimal vector, regulatory sequences, and method of delivery of angiogenic gene therapy are of considerable interest. The Spalax ehrenbergi superspecies live in subterranean burrows at low oxygen tensions and its tissues are highly vascularized. We tested whether continuous perimuscular administration of Spalax vascular endothelial growth factor (VEGF) DNA could increase tissue perfusion in a murine hindlimb ischemia model. Placebo or VEGF ± internal ribosome entry site (IRES) was continuously administrated perimuscularly in the ischemic zone by using an infusion pump. None of the mice in the VEGF-treated group (>50 μg) developed visible necrosis vs. 33% of the placebo group. Microscopic necrosis was observed only in the placebo group. Spalax VEGF muscular infiltration resulted in a faster and more complete restoration of blood flow. The restoration of blood flow by VEGF was dose-dependent and more robust and rapid when using the VEGF–IRES elements. The flow restoration using continuous perimuscular infiltration was faster than single i.m. injections. Vessel density was higher in the VEGF and VEGF–IRES (−) groups compared with the placebo. Continuous perimuscular administration of angiogenic gene therapy offers a new approach to restore blood flow to an ischemic limb. Incorporation of an IRES element may assist in the expression of transgenes delivered to ischemic tissues. Further studies are needed to determine whether VEGF from the subterranean mole rat Spalax VEGF is superior to VEGF from other species. If so, 40 million years of Spalax evolution underground, including adaptive hypoxia tolerance, may prove important to human angiogenic gene therapy.

Radiology, Rambam Medical Center and The Bruce Rappaport Faculty ofMedicine, Technion – Israel Institute of Technology, Haifa, IsraelIntroductionTrauma to the great vessels in the chest most com-monly affects the aorta and the innominate artery.Although well described series are small and includemainly penetrating trauma. Blunt injuries of theinnominate artery typically involve the origin of theartery. Two rare cases of blunt trauma to the distalinnominate artery are reported herein. CTA andselective angiography were obtained for accuratediagnosis. Treatment was achieved via thoracotomyand placement of a synthetic interposition graft with-out the use of a temporary shunt. Endovascular treat-ment option is discussed. Review of the literature wasdone and a possible cause for this rare trauma issuggested.Case ReportsCase 1A 21-year-old motorcyclist, was involved in a roadaccident and transferred to our medical center intu-bated and in hypovolemic shock (Hemoglobin 7.8g%,Hct 24%). Peripheral pulses were intact. Chest x-rayrevealed a widened mediastinum at the thoracic outletwithout pneumothorax. His injuries included: skullfracture without brain hemorrhage, fracture of thesternum and the first rib on the right side, bilaterallung contusion and fractures of the pubis andextremities.CTA demonstrated an irregular innominate arterialoutline (Fig. 1). Angiography was obtained showing alarge pseudoaneurysm in the distal innominate arterynear its bifurcation (Fig. 2). Upper median sternotomywith a lateral extension was carried out. The dissec-tion revealed a 3-cm pseudoaneurysm in the distalinnominate artery. Proximal control was in the prox-imal part of the innominate artery while distal controlwas in the proximal part of the carotid and subclavianarteries. The innominate artery was disrupted withintimal flap reaching almost to the origin of the carotidartery. After debridement a small rim just at the originof the right carotid artery enabeled the insertion of an8mm PTFE as an interposition graft. The procedurewas done without a temporary shunt. Sequentially, allthe fractures were managed by external fixation. Thepostoperative recovery, albeit long, was unremarkableand without severe complications. CTA was per-formed a week later and demonstrated preservedblood flow. On follow up 13 months later the patientis well.Case 2A 26-year-old male was injured in MVA. On admis-sion he was comatose and in shock. His blood pres-sure 80/50mmHg with heart rate of 130beats/min.No peripheral pulses could be found in the right armwith normally palpated axillary and brachial pulses inthe left. His injuries included subdural and subarach-noid hemorrhage without cerebral herniation, left

A 19-year-old man was admitted with severe symptoms suggestive for bilateral occlusive disease of his lower extremities. Clinical, laboratory, and radiological evaluation established the diagnosis of Buerger’s disease.Buerger’s disease often poses a diagnostic challenge and requires a high degree of suspicion. Although rare for this patient’s young age, it is important that a correct diagnosis is being made, because the disease process can be stopped if the patient stops smoking.

(18)F-FDG PET/CT is of value in the diagnosis of prosthetic vascular graft infection, but potential pitfalls related to tracer uptake in noninfected implants have been described. The current study assesses the incidence and patterns of (18)F-FDG uptake over time in noninfected grafts, in relationship to prosthetic material and location.A 12-y PET/CT database was retrospectively searched for cancer patients with prosthetic vascular grafts. Data retrieved from patient files included graft location, material, and time from surgery. Images were reviewed by 2 nuclear medicine physicians in consensus, with the presence and patterns (focal, diffuse homogeneous, inhomogeneous) of increased (18)F-FDG uptake in grafts recorded. The mean standardized uptake value in grafts (SUV-G) and mediastinum (SUV-M) was measured. The ratio of SUV-G to SUV-M (SUV-G/SUV-M) was calculated for each graft.One hundred seven prostheses were identified in 102 studies in 43 cancer patients. Sixty-seven prostheses were made of Dacron, 33 of Gore-Tex, and 7 were native veins. No increased (18)F-FDG uptake was found in 9 grafts (native veins, 4; Gore-Tex, 3; Dacron, 2). There was diffuse homogeneous uptake in 68 and inhomogeneous uptake in 30 grafts. The homogeneous pattern was more prevalent in Gore-Tex whereas the inhomogeneous uptake was seen more in Dacron vascular grafts. None of the grafts demonstrated focal uptake. The SUV-G range was 0.4-6.3 (average, 1.9), and SUV-M range was 0.6-2.4 (average, 1.4). The intensity of uptake was significantly higher in Dacron (SUV-G = 2.35 and SUV-G/SUV-M = 1.72) than in Gore-Tex (SUV-G = 1.09, SUV-G/SUV-M = 0.91) and native vein grafts (SUV-G = 1.07, SUV-G/SUV-M = 0.75) (P0.005). Native vein grafts showed a significant decrease in (18)F-FDG uptake over time whereas synthetic grafts showed no change in intensity for a follow-up of up to 16 y.Diffuse (18)F-FDG uptake was found in 92% of noninfected vascular prostheses, more in Dacron grafts than with other materials. The intensity of (18)F-FDG uptake of synthetic grafts did not change over time. With knowledge of the presence, patterns, and persistence of (18)F-FDG uptake in noninfected vascular prostheses, misinterpretation of PET/CT studies in patients referred for suspected prosthetic infection and in those assessed for diseases unrelated to their graft status can be avoided.

Objectives serious vascular injuries to the neck may be asymptomatic or masked by other life-threatening conditions. Angiography, the “gold standard” vascular imaging modality, is an invasive procedure. Moreover, it is time-consuming and thus may delay a needed vascular intervention. The results of screening angiography are negative in more than 80% of cases. Therefore other less invasive and faster screening tests, such as the Doppler ultrasound and magnetic resonance angiography, have been tested. This retrospective study was done to evaluate the use of CT angiography (CTA) in suspected vascular injuries of the neck. Methods from 1995 to 1998, 16 patients with suspected traumatic carotid artery injury underwent CTA. Twelve of these patients had penetrating injuries and four had blunt injuries to the neck. CTAs were obtained by Elscint Twin Flash Spiral Scanner, while MIP reconstructions were carried out on an Omnipro, Elscint (Indy, Silicon Graphics) work station and interpreted by a radiologist. Results all the CTAs were diagnostic. Positive findings included one complete tear of the right common carotid artery (confirmed by surgery) due to a penetrating injury and one bilateral internal carotid artery thrombosis after blunt injury to the neck. In addition, three patients with multiple trauma were operated on, due to either proximity only or questionable neurological findings. Surgical exploration confirmed the negative findings seen on CTA.Conclusion CT angiography of the carotid arteries in cervical trauma may be used as an accurate decisive tool for a needed surgical intervention. More studies with larger number of patients and comparison with angiography are needed.

Pyogenic granuloma (PG) is a common benign tumor that occurs mainly on cutaneous and mucosal surfaces. 1 Intravascular occurrence is extremely uncommon. 2 Here we describe a PG of the basilic vein diagnosed preoperativelyon the basis of color Doppler sonography.

Vascular injuries of the limbs are common in armed conflicts and they are the main cause of severe bleeding, ischemia, amputations, and death. Vascular injuries may be caused by blunt trauma, but more often they are the result of penetrating fragments, bullets, and recently by ball bearings, foreign bodies, and high explosives. Vascular injuries take priority in treatment paradigms since shortening of the time of bleeding and the time of ischemia are of paramount importance in saving limbs and lives of the injured. In the battlefield and during evacuation, rubber and improvised tourniquets are used to stop life threatening bleeding, but in the setting of the operating room these should be taken off as soon as feasible, to prevent continued ischemia of nerves and other soft tissues. Identification of the specific injured arteries and veins allows accurate clamping and appropriate repair of the involved vessels. Use of fasciotomies in this setting should be liberal to improve functional outcome. Primary repairs of vessels and use of autologous veins are preferred over synthetic grafts because of a greater risk of infection and thrombosis. In modern specialized vascular facilities, the success rate of repairs of combat vascular injuries is high, and mortality and amputation rates are low and continue to decrease.

Primary antiphospholipid syndrome (PAPS) is an autoimmune disorder manifested by recurrent thrombosis in the venous and arterial system. We report a group of seven patients with lower limb ischaemia associated with PAPS. Four were male patients and three were females, with a mean age of 37 years. All had a previous deep vein thrombosis and the majority, five out of seven, had a prior cerebrovascular accident (CVA). Prolonged activated thromboplastin time was demonstrated in all our patients and PAPS was established by positive thromboplastin titration index, circulating anticoagulant index and increased anticardiolipin levels. Symptoms included claudication in three, rest pain in four and gangrene in five patients. Angiography demonstrated thrombosis of various segments of the arterial tree including: aorta, iliac, femoral and popliteal arteries. Two patients were treated conservatively and one by percutaneous transluminal angioplasty (PTA) of the distal aorta. A total of eleven vascular surgical procedures were performed in four patients resulting in early postoperative thrombosis (2 h-30 days) in 10 cases. Only one graft remained patent, when full heparinisation (1000 units/h) was used perioperatively. We conclude that PAPS patients are at high risk for graft thrombosis and should only be operated upon on full anticoagulation, starting at operation and proceeding indefinitely.

Vascular injuries are manifested by life-threatening hemorrhage or limb loss and their diagnosis and treatment are challenging. Angiography is beyond the capability of available teams during wartime. Thus, computed tomographic angiography (CTA) may become a major triage tool. This study reports on the presentation, diagnosis, management and outcome of combat vascular injuries with emphasis on the utility of CTA. Presenting signs and symptoms, means of diagnosis, treatments and results of all combat sustained vascular cases were collected and compiled with follow-up. Of 511 patients, 39 patients (7.6%) with vascular injuries were admitted. Injuries were penetrating and accompanied by soft tissue and bone insult. Diagnosis was made by CTA in 62% and by surgical exploration in 38%. Extremity arteries were injured in 72% of cases. Treatment included surgical and endovascular techniques. Complications: one late amputation, 5% thrombosis, 24% wound infections with no mortalities or early amputations. Although similarities exist between this experience and recent wartime reports, differences are apparent including the effectiveness of CTA. High index of suspicion and liberal use of CTA allows for an early and accurate diagnosis of a vascular injury resulting in high rates of limb salvage and low mortality. CTA should be the first line modality for diagnosis of vascular injuries, reserving angiography for endovascular treatment.

Blunt trauma to the common iliac artery is rather rare. Moreover, seatbelt injuries to the common iliac artery have not yet been reported. This article presents two cases of seatbelt injury involving the common iliac artery. A deceleration-type mechanism is suggested as the primary cause of injury, resulting in the production of an intimal flap. The diagnosis of such an injury is based on clinical suspicion, a change of pulse, or lower limb ischemia. On arteriotomy the damage is greater than seen on external examination. Once diagnosed prompt treatment should follow to prevent loss of life or limb. The signs, symptoms, and modalities of treatment are reported, as well as a review of the literature.

We report the role of the imaging department at a level 1 trauma center during the Second Lebanon War (summer 2006). Our institution received 849 military and civilian casualties, an average of 25 war-injured patients per day, 338 with acute traumatic stress disorders and 511 physically injured, coming in waves after a rocket attack or a battle confrontation. About 12 potentially critical physically injured patients per day were referred to the imaging department for sometimes complex imaging procedures. The unpredictable waves of casualties and nature of the injuries forced us to reorganize our routine workflow to provide adequate care to casualties and to nonemergent patients. Our nurses' station was transformed into a small emergency department. The radiology staff was distributed into 12 diagnostic stations, providing 24-hour service. Communication was improved by means of walkie-talkies. Three ultrasound units were placed at the emergency department for immediate focused assessment with sonography for trauma performance enabling initial triage of patients. The site and extent of injuries were accurately diagnosed on CT and CT angiography. Digital angiography allowed definitive vascular diagnosis and interventional procedures.Adequate communication, strict workflow, and correct use of imaging protocols ensured optimal triage, diagnosis, and therapy of casualties while maintaining care for nonwar patients.

Human atherosclerotic plaque contains a variety of oxidized lipids, which can facilitate further oxidation. Paraoxonase 1 (PON1) is a high-density lipoprotein (HDL)-associated esterase (lipolactonase), exhibiting antiatherogenic properties. The aims of the present study were to examine the oxidizing potency of the human carotid plaque lipid extract (LE), and the antiatherogenic role of PON1 on LE oxidation competence. Human carotid plaques were extracted by organic solvent, and the extract was incubated with lipoprotein particles, with macrophages, or with probes sensitive to oxidative stress, with or without preincubation with PON1, followed by oxidative-stress assessment. Our findings imply that the LE oxidized LDL, macrophages, and exogenous probes and decreases HDL-mediated cholesterol efflux from macrophages, in a dose-dependent manner. Incubation of PON1 with LE significantly affects LE composition, reduces LE atherogenic properties, and decreases the extract's total peroxide concentration by 44%, macrophage oxidation by 25%, and probe oxidation by up to 52%. We conclude that these results expand our understanding of how the plaque itself accelerates atherogenesis and provides an important mechanism for attenuation of atherosclerosis development by the antioxidant action of PON1 on the atherosclerotic plaque.

Graft infection after prosthetic vascular reconstruction is an uncommon but severe complication. The clinical presentation is often subtle and nonspecific and may occur long after surgery. Although defining a prosthetic vascular graft infection can be difficult, early diagnosis and treatment are important because of the relatively high rates of amputation and death. The present study assessed the role of PET/CT using 18F-FDG for the diagnosis of vascular graft infections. Methods: Thirty-nine patients (35 men and 4 women; age range, 44–82 y) with suspected vascular graft infection underwent 18F-FDG PET/CT. The performance of PET/CT for the diagnosis of an infectious process and its localization to the graft or soft tissues was assessed. The final diagnosis was based on histopathologic findings and microbiologic assays obtained at surgery or on clinical and imaging follow-up. Results: PET/CT detected foci of increased 18F-FDG uptake suspected as infection in 27 patients and localized these findings to the graft in 16 patients. Vascular graft infection was confirmed in 14 of these patients (88%). PET/CT excluded graft involvement in 11 patients, and in 10 (91%) of these 11, long-term follow-up further confirmed that the infectious process was limited to surrounding soft tissues only. No abnormal 18F-FDG uptake was found in any of the 12 patients with no further evidence of infection. PET/CT had a sensitivity of 93%, specificity of 91%, positive predictive value of 88%, and negative predictive value of 96% for the diagnosis of vascular graft infection. Conclusion:18F-FDG PET/CT is a reliable noninvasive imaging modality for the diagnosis of vascular graft–related infection. The precise anatomic localization of increased 18F-FDG uptake provided by PET/CT enables accurate differentiation between graft and soft-tissue infection.

Arterial injury during treatment of varicose veins is a rare but devastating complication that can lead to leg amputation. Approximately 6,000 patients were treated by either surgery (4,800 patients treated by ligation, stripping, and stub avulsion) or ultrasound-guided foam sclerotherapy (USGS) (1,200 patients) in the last 7 years for venous insufficiency at three medical centers. Six patients (0.1%) sustained inadvertent arterial injury. The incidence of arterial injury during surgery was 0.06% (3 of 4,800) and was of a mechanical nature amenable to repair. None of these patients had tissue loss. The injury during USGS (0.25%, 3 of 1,200) was of a chemical and irreversible nature. All three patients suffered tissue loss. In our experience, the incidence of arterial injuries during USGS is four times higher than during traditional surgery and carries a much higher risk of tissue loss. Although experience, technical skill, and awareness of this complication help reduce the incidence of arterial injury during surgery, they seem to offer no protection during USGS. Careful mapping of the arterial venous communications and avoidance of high-risk zones will help prevent this complication.

Klippel-Trenaunay syndrome, a congenital disorder, is characterized by capillary malformation, varicosities and bony or soft tissue hypertrophy. Since there is no cure for this disorder, treatment is directed towards secondary prevention of venous hypertension and preservation of functional integrity of the legs. Elastic stockings are the mainstay of treatment and are indicated in all cases. Surgery is reserved only for a few selected symptomatic patients, however the outcome is unsatisfactory in most cases, with recurrent pain, edema, poor cosmetic result and limb deformity. Ultrasound-guided foam sclerotherapy is a recently introduced minimally invasive ambulatory procedure for the treatment of chronic venous insufficiency. It was recently introduced to treat this disorder.To evaluate the efficacy of USFS in the treatment of patients with Klippel-Trenaunay syndrome.Seven patients diagnosed with Klippel-Trenaunay, with massive lower extremity involvement, were treated with USFS between October 2003 and October 2005. Sclerovein (polidocanol, Resinag, Switzerland) 2-4% was used as the sclerosant. The signs, symptoms and overall patient satisfaction were assessed before, during and after the treatment.Patients' mean age was 26 years (range 15-54). The CEAP clinical classification, with ascending severity ranging from 0 (no signs) to 6 (active venous ulcer), was C4 in five patients (71.5%) and C5 and C6 in one patient each. The average number of sessions was 14.5 (range 9-21). No major complications were encountered. All seven patients reported improvement in signs and symptoms. Five of the 7 patients (71%) were very satisfied with the cosmetic result.USFS is an effective minimally invasive ambulatory technique, essentially pain-free and with excellent short-term results in patients with Klippel-Trenaunay syndrome (when the deep system is functional). Long-term results and larger study groups are warranted.

The present study evaluated the role of SPECT/CT as an adjunct to (67)Ga (GS) or (111)In-labeled white blood cell (WBC) scintigraphy for diagnosis or localization of infection.Eighty-two patients (56 male and 26 female; mean age, 62 y) assessed for known or suspected infectious processes underwent 88 SPECT/CT studies. Forty-seven patients underwent GS SPECT/CT (13 with fever of unknown origin, 21 with suspected osteomyelitis, and 13 with suspected soft-tissue infection), and 35 patients underwent WBC SPECT/CT (24 with suspected vascular graft infection, and 11 with suspected osteomyelitis). Ninety-eight suggestive sites were identified (52 on GS and 46 on WBC). Additional information provided by SPECT/CT for diagnosis or localization of infection, as compared with planar and SPECT scintigraphy, was recorded. The SPECT/CT contribution was analyzed on a patient and site basis and was compared for the 2 tracers and clinical indications.SPECT/CT provided additional information for infection diagnosis and localization in 39 (48%) of 82 patients and in 47 (48%) of 98 sites. SPECT/CT defined the extent of infection in 35 patients (43%) in 43 sites (44%) and excluded infection in 4 suggestive sites defined as physiologic bowel uptake on GS. SPECT/CT was incorrect in 2 suggestive sites (1 GS and 1 WBC). The contribution of SPECT/CT was significantly higher for WBC than for GS (P0.05)--in 63% versus 36% of patients, respectively, and in 61% versus 36% of sites, respectively.SPECT/CT made an incremental contribution to GS and WBC in 48% of patients with suspected infections, by improving diagnosis, localization, and definition of extent of disease. SPECT/CT has an important role mainly with highly specific, low-background infection-seeking tracers such as WBC.

Background Data concerning hemodynamic status prior to and after carotid endarterectomy (CEA) in symptomatic and asymptomatic patients is insufficient. Transcranial Doppler (TCD) provides information regarding compensatory collateral flow as well as mechanisms of cerebral autoregulation in patients with carotid stenosis. Patients and methods Forty eight symptomatic and 81 asymptomatic patients with unilateral severe carotid stenosis were examined by TCD before and in early postoperative period after CEA. Results Cigarette smoking was the only risk factor significantly more frequent in symptomatic patients. Preoperative anterior cerebral artery (ACA) and middle cerebral artery (MCA) asymmetry, basilar artery velocity and number of ophthalmic arteries with reversed flow, were not significantly different between the two groups. Pulsatility index, cerebrovascular reactivity and flow acceleration on the side of stenosis were significantly lower in symptomatic patients. After surgery there was a significant improvement of all TCD parameters in symptomatic as well as asymptomatic patients. Conclusions The exhausted ability of cerebral autoregulation is an important factor differentiating between symptomatic and asymptomatic patients with severe carotid stenosis. Successful surgery provides good recovery of cerebral hemodynamics in both symptomatic and asymptomatic patients.

An infected vascular graft was identified using a combined positron emission tomography (PET) and computerized tomography (CT) system. The fusion of 2-deoxy-2-[18F]fluoro-D-glucose (FDG) PET and CT images, acquired in a single session, allowed for the precise localization of the abnormal FDG uptake to the vascular graft and led to the correct diagnosis of prosthetic infection. This hybrid modality, which provides precise registration of metabolic and structural imaging data, may enhance the potential use of FDG in the diagnosis and man-agement of infected vascular grafts.

Objectives. To evaluate the effectiveness and safety of percutaneous ultrasonographically guided thrombin injection as treatment of unusually positioned and unusually large iatrogenic pseudoaneurysms. Methods. Five patients with iatrogenic pseudoaneurysms were evaluated by color duplex ultrasonography. Two patients had additional digital angiography, and 2 had additional computed tomographic angiography. In 3 of the patients, large, painful iatrogenic pseudoaneurysms located proximal (2 patients) and distal (1 patient) to the arteriovenous hemodialysis fistulas had developed, most likely due to erroneous puncture of the arterial side (brachial artery) or venous side (cephalic vein) of the fistulas. An iatrogenic pseudoaneurysm of the anterior tibial artery had developed in the fourth patient after osteotomy of the fibula, and an iatrogenic pseudoaneurysm of the superficial femoral artery had developed in the fifth patient after erroneous puncture during venous transfemoral angiography. With a sterile technique and color duplex ultrasonographic guidance, a diluted solution of bovine thrombin was slowly injected directly into the iatrogenic pseudoaneurysms until cessation of blood flow was seen. Follow-up color duplex ultrasonography was performed 24 to 48 hours after the ultrasonographically guided thrombin injection. Results. Four iatrogenic pseudoaneurysms were successfully thrombosed during 1 session. Two large iatrogenic pseudoaneurysms necessitated multiple repositions of the injecting needle and several injections of small amounts of thrombin into the residual patent lumen to induce complete thrombosis without an appreciable increase in the total thrombin dosage. Follow-up examinations revealed complete and persistent thrombosis without evidence of distal embolization. One iatrogenic pseudoaneurysm involving the cephalic vein, distal to an arteriovenous hemodialysis fistula, recurred after apparently successful initial thrombosis. Conclusions. Most iatrogenic pseudoaneurysms are amenable to ultrasonographically guided thrombin injection as long as they are imaged adequately by color duplex ultrasonography.

Hartmann's procedure is often selected in situations in which the construction of a colorectal anastomosis is considered unsafe. Paradoxically, the creation of the rectal stump involves placement of an intestinal suture line that is prone to leakage. We report our experience with 11 patients with a clinically significant leakage from the rectal stump after Hartmann's procedure, which was manifested as persistent postoperative intra-abdominal infection. A method for the treatment and prevention of this potentially lethal complication is presented.

A 72-year old man who underwent aorto-bifemoral bypass with insertion of a Dacron graft 18 years previously presented with an aneurysm in the left limb of his graft. Angiography also demonstrated a bilateral occlusion of the popliteal arteries. Computed tomography (CT) angiography was performed and showed a localized dilation of 3 cm in the left limb of the graft, which had a diameter of 14 mm throughout. In view of the technical difficulties of a surgical procedure, an endovascular stent was considered. Through a left femoral arteriotomy, a stent graft was inserted and deployed in the left limb of the graft. This resulted in total exclusion of the Dacron graft aneurysm. To the best of our knowledge, this is the first report of such a procedure.

Background Angiogenic therapy with vascular endothelial growth factor (VEGF) has been proposed as a treatment paradigm for patients suffering from an insufficiency of collateral vessels. Diabetes is associated with increase in the production of VEGF and therefore additional VEGF may not be beneficial. Accordingly, we sought to determine the efficacy of VEGF therapy to augment collateral formation and tissue perfusion in a diabetic mouse ischemic hindlimb model.

The purpose of this study was to determine the accuracy of CT angiography using a multidetector scanner in the evaluation of patients with peripheral vascular disease.Eighteen patients with peripheral vascular disease who were referred for elective digital subtraction angiography (DSA) also underwent CT angiography. We scanned patients from the level of the superior mesenteric artery to the pedal arteries in a single helical scan. CT angiograms were produced using maximum-intensity-projection reconstructions. Findings were graded according to six categories: 1, normal (0% stenosis); 2, mild (1-49% stenosis); 3, moderate (50-74% stenosis); 4, severe (75-99% stenosis); 5, occluded; and 6, nondiagnostic. CT angiography findings were compared with DSA findings for each arterial segment.We found agreement for the degree of stenosis in 77.7% of the arteries and discrepancy for 22.3% of the arteries when all categories were considered. Grouping the six categories according to the threshold for treatment (categories 1 and 2 as one group and categories 3, 4, and 5 as the second group) resulted in an agreement of 91.95%. Compared with DSA, CT angiography yielded a sensitivity of 90.9% and a specificity of 92.4%.Multidetector CT angiography is an accurate, noninvasive technique for the imaging of peripheral vascular disease.

A 52-year-old woman brought to the emergency room after being involved in a motor vehicle accident as a pedestrian. Physical examination revealed a conscious, anxious patient in pain and in hypovolemic shock. The blood pressure was 90/50 with a heart rate of 128. The haematocrit was 26%. Multiple skin bruises and haematomata were noticed. After fluid resuscitation further assessment was performed in the radiology suite. Fig. 1 shows an axial slice from CTA of the upper chest below the level of the carina. There is a left haemothorax, a fracture of the left fifth and sixth ribs in the mid axillary line with a bony fragment of the sixth rib compressing the posterior wall of the descending aorta. Additional injuries included lung contusion, fractures of the facet process of vertebrae C7 and T1, fractures of spinal process of vertebrae T3-5 and T8-9, fracture of the left scapula, fracture of the pubic ramus and left sacrum, and fracture of the right tibia and fibula. After insertion of a double lumen endotracheal tube, an extended posterolateral thoracotomy was performed. The dissection was carried down to the aorta revealing two rib fragments compressing the aortic wall. Fragments were removed only after obtaining proximal and distal control. There was no active bleeding or injury necessitating a repair of the aorta. Other operations were performed consecutively. The patient had an uneventful, albeit a slow, recovery. Today, 8 months after the injury the patient is back to part-time work. A CTA was obtained after a follow-up visit and no pathology (specifically a pseudoaneurysm) was encountered.