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Endovascular techniques are being employed with increasing frequency in the management of peripheral arterial aneurysms. A 57-year-old patient with Marfan syndrome presented with a symptomatic 5 cm left subclavian artery aneurysm. He underwent successful endovascular exclusion of the aneurysm with immediate improvement of his symptoms. Duplex ultrasound 3 months after the procedure confirmed a patent graft and complete exclusion of the aneurysm. [ABSTRACT FROM AUTHOR]

Background: The advent of endovascular techniques has revolutionized the care of patients with uncomplicated abdominal aortic aneurysms. This analysis compares the overall survival and the freedom from reintervention rate between open surgical repair (OSR) and endovascular repair (EVAR) in patients undergoing elective abdominal aortic aneurysm (AAA) repair., Methods: PubMed, Scopus, and Cochrane databases were searched for studies including patients who underwent either OSR or EVAR for uncomplicated AAA. All randomized controlled trials and propensity-score-matched cohort studies reporting on the outcomes of interest were considered eligible for inclusion. The systematic search of the literature was performed by 2 independent investigators in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. We conducted 1-stage and 2-stage meta-analyses with Kaplan-Meier-derived time-to-event data and meta-analysis with a random-effects model., Results: Thirteen studies met our eligibility criteria, incorporating 13 409 and 13 450 patients in the OSR and EVAR arms, respectively. Patients who underwent open repair had improved overall survival rates compared with those who underwent EVAR (hazard ratio [HR]=0.93, 95% confidence interval [CI]=0.88-0.98, p=0.004) during a mean follow-up of 53.8 (SD=29.8) months and this was validated by the 2-stage meta-analysis (HR=0.89, 95% CI=0.8-0.99, p=0.03, I 2 =62.25%). Splitting timepoint analysis suggested that EVAR offers better survival outcome compared with OSR in the first 11 months following elective intervention (HR=1.37, 95% CI=1.22-1.54, p<0.0001), while OSR offers a significant survival advantage after the 11-month timepoint and up to 180 months (HR=0.84, 95% CI=0.8-0.89, p<0.0001). Similarly, freedom from reintervention was found to be significantly better in EVAR patients (HR=1.28, 95% CI=1.14-1.44, p<0.0001) within the first 30 days. After the first month postrepair, however, OSR demonstrated higher freedom-from-reintervention rates compared with EVAR that remained significant for up to 168 months during follow-up (HR=0.73, 95% CI=0.66-0.79, p<0.0001)., Conclusions: Despite the first-year survival advantage of EVAR in patients undergoing elective AAA repair, OSR was associated with a late survival benefit and decreased risk for reintervention in long-term follow-up., Clinical Impact: Open surgical repair for uncomplicated abdominal aortic aneurysm offers better long-term outcomes in terms of survival and freedom from reintervention rate compared to the endovascular approach but in the first year it carries a higher risk of mortality. The novelty of our study lies that instead of comparing study-level effect estimates, we analyzed reconstructed individual patient-level data. This offered us the opportunity to perform our analyses with mathematically robust and flexible survival models, which was proved to be crucial since there was evidence of different hazard over time. Our findings underline the need for additional investigation to clarify the significance of open surgical repair when compared to the latest endovascular devices and techniques within the evolving era of minimally invasive procedures., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Thrombosis in COVID-19 worsens mortality. In our study, we sought to investigate how the dose and type of anticoagulation (AC) can influence patient outcomes., Methods: This is a single-center retrospective analysis of critically ill intubated patients with COVID-19, comparing low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) at therapeutic and prophylactic doses. Of 218 patients, 135 received LMWH (70 prophylactic, 65 therapeutic) and 83 UFH (11 prophylactic, 72 therapeutic). The primary outcome was mortality. Secondary outcomes were thromboembolic complications confirmed on imaging and major bleeding complications. Cox proportional-hazards regression models were used to determine whether the type and dose of AC were independent predictors of survival. We performed Kaplan-Meier survival analysis to compare the cumulative survivals., Results: Overall, therapeutic AC, with either LMWH (65% vs 79%, P = .09) or UFH (32% vs 46%, P = .73), conveyed no survival benefit over prophylactic AC. UFH was associated with a higher mortality rate than LMWH (66% vs 28%, P = .001), which was also evident in the multivariable analysis (LMWH vs UFH mortality, hazard ratio: 0.47, P = .001) and in the Kaplan-Meier survival analysis. Thrombotic and bleeding complications did not depend on the AC type (prophylactic LMWH vs UFH: thrombosis P = .49, bleeding P = .075; therapeutic LMWH vs UFH: thrombosis P = .5, bleeding P = .17). When comparing prophylactic with therapeutic AC, the rate of both thrombotic and bleeding complications was higher with the use of LMWH compared with UFH. In addition, transfusion requirements were significantly higher with both therapeutic LMWH and UFH., Conclusions: Among intubated critically ill COVID-19 intensive care unit patients, therapeutic AC, with either LMWH or UFH, conveyed no survival benefit over prophylactic AC. AC with LMWH was associated with higher cumulative survival compared with AC with UFH., (Published by Elsevier Inc.)

Background: Obesity is a widely accepted risk factor for the development of severe COVID-19. We sought to determine the survival benefit of early initiation of aggressive anticoagulation in obese critically ill COVID-19 patients., Methods: We retrospectively reviewed 237 intubated patients at a single academic accredited bariatric center and stratified them based on their BMI into 2 groups, obese (BMI > 30) and non-obese (BMI ≤ 30). We used chi-square tests to compare categorical variables such as age and sex, and two-sample t-tests or Mann Whitney U-tests for continuous variables, including important laboratory values. Cox proportional-hazards regression models were utilized to determine whether obesity was an independent predictor of survival and multivariable analysis was performed to compare risk factors that were deemed significant in the univariable analysis. Survival with respect to BMI and its association with level of anticoagulation in the obese cohort was evaluated using Kaplan-Meier models., Results: The overall mortality in the obese and non-obese groups was similar at 47% and 44%, respectively (p = 0.65). Further analysis based on the level of AC showed that obese patients placed on early aggressive AC protocol had improved survival compared to obese patients who did not receive protocol based aggressive AC (ON-aggressive AC protocol 26% versus OFF-aggressive AC protocol 61%, p = 0.0004)., Conclusions: The implementation of early aggressive anticoagulation may balance the negative effects of obesity on the overall mortality in critically ill COVID-19 patients., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Examine the possible beneficial effects of early, D-dimer driven anticoagulation in preventing thrombotic complications and improving the overall outcomes of COVID-19 intubated patients. Methods: To address COVID-19 hypercoagulability, we developed a clinical protocol to escalate anticoagulation based on serum D-dimer levels. We retrospectively reviewed all our first 240 intubated patients with COVID-19. Of the 240, 195 were stratified into patients treated based on this protocol (ON-protocol, n = 91) and the control group, patients who received standard thromboprophylaxis (OFF-protocol, n = 104). All patients were admitted to the Stony Brook University Hospital intensive care units (ICUs) between February 7th, 2020 and May 17, 2020 and were otherwise treated in the same manner for all aspects of COVID-19 disease. Results: We found that the overall mortality was significantly lower ON-protocol compared to OFF-protocol (27.47 vs. 58.66%, P < 0.001). Average maximum D-dimer levels were significantly lower in the ON-protocol group (7,553 vs. 12,343 ng/mL), as was serum creatinine (2.2 vs. 2.8 mg/dL). Patients with poorly controlled D-dimer levels had higher rates of kidney dysfunction and mortality. Transfusion requirements and serious bleeding events were similar between groups. To address any possible between-group differences, we performed a propensity-matched analysis of 124 of the subjects (62 matched pairs, ON-protocol and OFF-protocol), which showed similar findings (31 vs. 57% overall mortality in the ON-protocol and OFF-protocol group, respectively). Conclusions: D-dimer-driven anticoagulation appears to be safe in patients with COVID-19 infection and is associated with improved survival. What This Paper Adds: It has been shown that hypercoagulability in patients with severe COVID-19 infection leads to thromboembolic complications and organ dysfunction. Anticoagulation has been variably administered to these patients, but it is unknown whether routine or escalated thromboprophylaxis provides a survival benefit. Our data shows that escalated D-dimer driven anticoagulation is associated with improved organ function and overall survival in intubated COVID-19 ICU patients at our institution. Importantly, we found that timely escalation of this anticoagulation is critical in preventing organ dysfunction and mortality in patients with severe COVID-19 infection., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Tassiopoulos, Mofakham, Rubano, Labropoulos, Bannazadeh, Drakos, Volteas, Cleri, Alkadaa, Asencio, Oganov, Hou, Rutigliano, Singer, Vosswinkel, Talamini, Mikell and Kaushansky.)

Background: A novel coronavirus (COVID-19) erupted in the latter part of 2019. The virus, SARS-CoV-2 can cause a range of symptoms ranging from mild through fulminant respiratory failure. Approximately 25% of hospitalized patients require admission to the intensive care unit, with the majority of those requiring mechanical ventilation. High density consolidations in the bronchial tree and in the pulmonary parenchyma have been described in the advanced phase of the disease. We noted a subset of patients who had a sudden, significant increase in peak airway, plateau and peak inspiratory pressures. Partial or complete ETT occlusion was noted to be the culprit in the majority of these patients., Methods: With institutional IRB approval, we examined a subset of our mechanically ventilated COVID-19 patients. All of the patients were admitted to one of our COVID-19 ICUs. Each was staffed by a board certified intensivist. During multidisciplinary rounds, all arterial blood gas (ABG) results, ventilator settings and ventilator measurements are discussed and addressed. ARDSNet Protocols are employed. In patients with confirmed acute occlusion of the endotracheal tube (ETT), acute elevation in peak airway and peak inspiratory pressures are noted in conjunction with desaturation. Data was collected retrospectively and demographics, ventilatory settings and ABG results were recorded., Results: Our team has observed impeded ventilation in intubated patients who are several days into the critical course. Pathologic evaluation of the removed endotracheal tube contents from one of our patients demonstrated a specimen consistent with sloughed tracheobronchial tissues and inflammatory cells in a background of dense mucin. Of 110 patients admitted to our adult COVID-19 ICUs, 28 patients required urgent exchange of their ETT., Conclusion: Caregivers need to be aware of this pathological finding, recognize, and to treat this aspect of the COVID-19 critical illness course, which is becoming more prevalent.

Background: Carotid body tumors (CBTs) are highly vascularized tumors which can render tumor resection surgery challenging. There is evidence suggesting that preoperative selective embolization can reduce blood loss during surgery and decrease the risk of perioperative complications; however, recent reports have questioned the benefits that preoperative embolization provides. The objective of this study is to investigate the impact of preoperative embolization on CBT surgical resection., Methods: This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible studies were identified through a search of PubMed, Scopus, and Cochrane Central Register of Controlled Trials until March 2019. A random effects model meta-analysis was conducted, and the I 2 statistic was used to assess for heterogeneity., Results: Twenty-five studies comprising 1326 patients were included. Patients who received preoperative embolization had statistically significant lower intraoperative blood loss (weighted mean difference [WMD], -135.32; 95% confidence interval [CI], -224.58 to -46.06; I 2  = 78.6%). Duration of the procedure was statistically significantly shorter in the preembolization group than the nonembolization group (WMD, -38.61; 95% CI, -65.61 to -11.62; I 2  = 71.9%). There were no differences in the rates of cranial nerve (CN) injuries (odds ratio [OR], 1.13; 95% CI, 0.68-1.86; I 2  = 12.9%), stroke (OR, 1.75; 95% CI, 0.70-4.36; I 2  = 0%), transient ischemic attacks (TIAs) (OR, 0.55; 95% CI, 0.11-2.65; I 2  = 0%), or length of stay (WMD, 0.32; 95% CI, -1.35 to 1.98; I 2  = 96.4%) between the 2 groups., Conclusions: Patients who received embolization prior to CBT resection had statistically significant lower blood loss and shorter duration of operation. The rates of CN palsy, stroke, TIA, and length of stay were similar between patients who had preoperative embolization and those who did not., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The abdominal aorta is the most common site of an aortic aneurysm. The visceral and most proximal infrarenal segment (aneurysm neck) are usually spared and considered more resistant to aneurysmal degeneration. However, if an abdominal aortic aneurysm (AAA) is left untreated, the natural history of the aortic neck is progressive dilatation and shortening. This may have significant implications for patients undergoing endovascular repair of AAAs (EVAR) as endograft stability and integrity of the repair are dependent on an intact proximal seal zone. Compromised seal zones, caused by progressive diameter enlargement and foreshortening of the aortic neck, may lead to distal endograft migration, type Ia endoleak, aortic sac repressurization, and, ultimately, aortic rupture.

Objective: The purpose of this study was to evaluate potential factors affecting patient non-compliance after endovascular aneurysm repair., Method: We performed a retrospective review of patients undergoing elective or emergency endovascular repair for thoracic, abdominal aorta, or iliac artery aneurysm at a single institution from November 2007 to March 2014. Compliance to follow-up at 1, 6, and 12 months was assessed. Factors evaluated included patient demographics, size of aneurysm, distance between the patient's residence and outpatient clinic, urgency of surgery, and time of year in which the follow-up visits were scheduled., Results: During the study period, 205 patients (75% male and 25% female) fulfilled the inclusion criteria. One-month mortality was 1.1% for elective procedures and 16.1% for emergency procedures (p = 0.001). Overall mortality at 12 months was 6.3% and 32.3% for elective and emergency procedures, respectively (p = 0.0002). Highest compliance was observed at 1 month, with 184 patients (93%) attending. A significant decrease was seen at 6 (n = 102, 54%) and 12 (n = 89, 48%) months. At the 12-month mark, a larger proportion of minority patients were non-compliant compared with Caucasian patients. Confounders for non-compliance were analyzed using multivariate analysis, and statistical significance was found for widowed marital status (p = 0.008), travel distance >25 miles to the outpatient clinic (p = 0.032), and emergency repair of aneurysms (p = 0.022)., Conclusion: Despite emphasizing the importance of follow-up after endovascular aortic procedures, almost half of the treated patients were non-compliant. Our study identified travel distance, marital status, and urgency of surgery as factors that may affect patients' compliance to scheduled follow-up visits.

Objective: Dilatation of the aorta within the proximal neck after endovascular aneurysm repair (EVAR) can be associated with late endoleaks and migration. This study was designed to identify predictors of early neck dilation in patients undergoing EVAR with Heli-FX EndoAnchors (Medtronic, Santa Rosa, Calif) measured perioperatively to 1 year at different longitudinal levels of neck length., Methods: The study group of Aneurysm Treatment Using the Heli-FX Aortic Securement System (ANCHOR) comprises 257 consecutive patients prospectively enrolled between April 2012 and September 2014 undergoing EVAR with Heli-FX EndoAnchor implantation at 38 investigational sites. Only patients undergoing EndoAnchor implantation at the time of the initial EVAR were included (primary treatment arm). Aortic diameter was measured at the suprarenal level and at three levels within the proximal neck. Neck dilatation was assessed in 209 patients with adequate computed tomography imaging at baseline and 1 month and in 62 patients at 1 month and 1 year (mean, 11.9 ± 4.0 months). Multivariable analyses were performed to identify independent predictors of perioperative (baseline to 1 month) and early postoperative (1 month to 1 year) aortic dilation at each level; analyses included 6 candidate variables, 6 clinical, and 14 anatomic run in eight models (one at each of the four aortic levels for both time frames)., Results: The mean aortic neck dilation at 1 month was 0.2 ± 1.7 mm, 0.7 ± 2.2 mm, and 0.9 ± 3.6 mm at 0 mm, 5 mm, and 10 mm below the lowest renal artery, and 0.0 ± 1.5 mm at the suprarenal level. From 1 month to 1 year, neck dilatation was 0.5 ± 1.6 mm, 0.4 ± 1.5 mm, 0.2 ± 1.8 mm, and -0.3 ± 1.1 mm at the same four levels, respectively. Dilatation of ≥3 mm at level 5 mm distal to the lowest renal artery was observed in 26 patients (12.5%) from preoperative to 1 month and in 5 patients (8.1%) between 1 month and 1 year. Multivariable regression identified several variables predictive of perioperative (preoperative to 1 month) neck dilatation: baseline neck diameter, mural calcium (protective), and endografts with a suprarenal stent. Neck dilatation between 1 month and 1 year was associated with baseline neck diameter, neck length (protective), neck angulation, device oversizing, number of EndoAnchors implanted (protective), and endografts with a suprarenal stent., Conclusions: Aortic diameter and graft oversizing appear to be independent risk factors for early aortic neck dilatation. EndoAnchors have a protective effect on neck dilatation at their usual level of deployment., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: We report a case of endovascular treatment of a complex renal artery aneurysm using the Pipeline Embolization Device, a flow diverting stent which is indicated for the treatment of large and giant cerebral aneurysms., Methods: A forty-year-old female with medically refractory hypertension and congenital agenesis of the right kidney was found to have a 2.8-cm left superior renal artery branch aneurysm. The patient was treated successfully using the Pipeline Embolization Device (Medtronic, Irvine, CA) with coil embolization of the aneurysm and of one outflow vessel., Results: On 3-year follow-up, her renal function was normal, vascular imaging showed complete occlusion of the aneurysm, and physiological remodeling of the reconstructed artery and parenchymal imaging showed no evidence of renal infarction., Conclusion: Flow diverting stents are a valuable treatment option for visceral aneurysms with complex anatomy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

True aneurysms of the tibioperoneal trunk are rare. Given the scarcity of reports, the clinical presentation and treatment is not well defined. This is a case report of a 50-year-old male patient presenting with severe lower extremity swelling and compartment syndrome with neurological compromise secondary to a tibioperoneal trunk aneurysm. He was also noted to have discrete ipsilateral popliteal and dorsalis pedis artery aneurysms. Given the location and size of the aneurysm, the severe leg swelling, and venous hypertension, aneurysmorrhaphy or aneurysm sac excision with arterial reconstruction was prohibitively dangerous. Thus, following fasciotomies, a hybrid repair utilizing a saphenous vein superficial femoral to anterior tibial artery bypass along with coil embolization of the aneurysm sac was performed. The patient recovered full function of his leg and follow-up computed tomography angiogram demonstrated thrombosis and regression of the aneurysm sac with a patent bypass., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aortic thrombus complicated by mesenteric ischemia is a rare but rather challenging entity. With the recent advancements of endovascular techniques, there is a trend to replace the traditional open surgery with an endovascular approach. We report a patient with paravisceral aortic thrombus involving the celiac artery and superior mesenteric artery (SMA). The patient was complaining of worsening abdominal pain, with clinical findings of leukocytosis, normal lactate, and diagnostic laparoscopy demonstrating a segment of threatened jejunum. We describe the novel use of vacuum-assisted suction filtration device in combination with over-the-wire thrombectomy and stenting to successfully restore blood flow within the SMA. The patient had resolution of her symptoms with improved blood flow to the bowel and no need for resection., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aim: Percutaneous transluminal angioplasty (PTA) is an effective treatment for renal artery stenosis secondary to fibromuscular dysplasia (FMD). This study aimed to evaluate the short-and long-term outcomes of percutaneous transluminal angioplasty in patients with hypertension and renal artery fibromuscular dysplasia (FMD). Additionally, we sought to identify specific patient factors that may affect outcomes., Methods: This study prospectively enrolled 29 patients with uncontrolled hypertension and renal artery FMD diagnosed by duplex ultrasound and angiography. All patients underwent PTA with the goal of cure or improvement of hypertension. Follow-up was at one-month, 6 months, 12 months and then yearly with minimum follow-up of 2 years and maximum of 5 years., Results: Technical success from the intervention was 100%. 21 patients were included in the final analysis. Short-term outcomes: One month after PTA mean systolic blood pressure (138.1 mmHg), diastolic blood pressure (78.6 mmHg), and number of anti-hypertensive medications (1.4) were significantly reduced. Blood pressure improvement was driven by 14/21 (67%) patients who had significant improvement in blood pressure, while 7/21 (33%) did not. These two groups (improved vs. not improved) differed significantly in mean age at intervention (40.6 vs. 58.3 years), duration of hypertension (3.1 vs. 15.4 years), systolic blood pressure (150.4 mmHg vs. 162.1 mmHg), diastolic blood pressure (86.4 mmHg vs. 95.7 mmHg), number of anti-hypertensive medications (2.2 vs. 3.0), serum creatinine (0.82 vs. 1.45), and renal resistive index (0.59 vs. 0.74) prior to intervention. Long-term outcomes: Mean follow-up was 3.86 years. Improvements in blood pressure and anti-hypertensive medications remained significant at five-year follow-up., Conclusion: PTA is effective at reducing blood pressure in patients with renal artery FMD. Age at intervention, duration of hypertension, and renal function may be used to predict outcomes prior to intervention.

Background: Blunt thoracic aortic injury (BTAI) is rare and associated with significant morbidity and mortality in trauma patients. As the population ages and life expectancy increases, the frequency of this injury will increase in the elderly and thus it behoves us to understand treatment and outcome in this patient population., Methods: We analysed prospectively collected data of 10 patients > 80 years old with BTAI (Group A) treated among 26,000 trauma patients over a 20-year period in a Level 1 trauma center to investigate BTAI morbidity and mortality. Age, gender, and injurity severity score (ISS) matching was performed to create a case-control study of elderly trauma patients with (Group A) and without BTAI (Group B)., Results: Ten elderly trauma patients were found to have BTAI. Five (50%) were males and 5 (50%) were female. The cohort mean age was 86 years (range: 80 to 95). All but one patient (fall injury) were involved in motor vehicle accidents. The mean ISS in group A was 29 ± 12. In group A, 2 (20%) patients (ISS = 36 and 33) succumbed in the emergency department. Six (60%) patients were treated non-operatively and the remaining 2 (20%) patients (88 and 84 years) underwent open aortic repair with patch angioplasty and Dacron interposition grafting. No postoperative paraplegia or stroke related to surgery occurred. Two patients in Group A survived hospitalization and were eventually discharged. Patients in Group B had lower overall LOS, ICU LOS and 30-day mortality rates despite similar ISS., Conclusion: Patients aged 80 or older who have experienced BTAI tend to have worse outcomes than those without BTAI regardless of similar ISS. Therefore, because of the low incident of this injury in general and particularly in the elderly, only pooled data from multiple institutions will be able to shed light on the complex issues surrounding treatment decisions in a group of patients with an a priori limited life expectancy., (© Acta Chirurgica Belgica.)

Background: Blunt traumatic aortic injury (BTAI) is of very rare occurrence in adolescents. The purpose of our study was to assess the clinical presentation and treatment outcomes of BTAI in this subset of patients., Methods: We reviewed prospective data of 18 patients who were 20 years or younger with BTAI among 28,000 trauma patients from January 1993 to December 2011. Outcomes of interest were the trends on the type of repair (nonoperative [NOP], open repair [OR], or endovascular treatment [ET]) and the impact of concomitant injuries using the Injury Severity Score (ISS) on early morbidity and mortality., Results: Thirteen (72%) patients with BTAI were male with a cohort median age of 16 ± 3 years. The mechanism of trauma was car accident in 12 patients, pedestrian struck by car in 5, and motorcycle crash in 1. The total ISS was 46.2 ± 15.3 being the highest score of the thoracic component (4.6 ± 0.6) followed by the head score (4 ± 1.2). Two (11%) patients were pronounced dead in the emergency department and other 2 succumbed within 24 hr from admission. Of those 14 (78%) patients who survived longer than 24 hr, the ISS was significantly lower compared with those pronounced dead earlier (37.8 ± 10.7 vs. 59.6 ± 11.6; P = 0.0009). Ten patients (71%) underwent OR, 3 (17%) ET, and other 2 (28%) patients were treated nonoperatively. The ISS was similar among all 3 treatment groups (OR: 33 ± 8 vs. ET: 53 ± 9 vs. NOP: 51 ± 6; P = nonsignificant). No paraplegia or renal failure was noted in either ET or OR group. In-hospital and overall mortality were 21% and 39%. Of those who survived hospitalization, 8 (73%) patients were discharged home and 3 (27%) to a rehabilitation center., Conclusions: The incidence of BTAI is very low in adolescents. Mortality rate is considerable even in young patients and it is associated with high ISS and degree of aortic wall disruption. Young patients with BTAI who survive hospitalization have a lower ISS and are often discharged home rather than to a rehabilitation facility., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Information on ovarian vein thrombosis (OVT) is limited to some retrospective studies. The purpose of this prospective study was to evaluate the natural history and treatment outcomes of OVT., Methods: Patients with documented symptomatic OVT who were treated with anticoagulation and had at least 3 months of follow-up were included. Outcomes of interest were recanalization rates, pain resolution, pelvic congestion syndrome, recurrent deep venous thrombosis (DVT), and mortality. All patients underwent clinical examination and duplex ultrasound; computed tomography venography was selectively performed., Results: There were 23 women with a mean age of 44 years (range, 23-68 years). Fifteen (65%) right, 5 (22%) left, and 3 (23%) bilateral OVTs were detected. The median follow-up was 27 months (range, 3 months-7 years). The most common presentation was abdominal pain in nine patients (39%), followed by flank pain in six (26%). Two patients (9%) presented with dyspnea due to pulmonary embolism. The most prevalent condition was the puerperium (n = 9; 39%). Complete recanalization occurred in 16 veins (61%), partial recanalization in four veins (15%), and occlusion in six veins (24%) while patients were receiving anticoagulation. Four patients (17%) had lower extremity DVT during follow-up after the interruption of anticoagulation. Three patients (13%) developed pelvic congestion syndrome. All four deaths (17%) were due to cancer-related complications., Conclusions: Symptomatic OVT is rare. Patients fare well with anticoagulation; complete recanalization occurs in about two thirds of the patients. Recurrent DVT is found in lower extremity veins after the interruption of anticoagulation in 17% of patients; mortality was seen only in cancer patients., (Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Anastomotic pseudoaneurysms represent an uncommon and challenging complication of open aortic repair with prosthetic graft. First characterized by Clayton et al. in 1956, they affect approximately 1.4-4% of arterial anastomoses. These pseudoaneurysms are the result of many factors, foremost of which are infection, integrity of the host tissue, surgical technique, and location of the anastomosis. Pseudoaneurysms were traditionally treated with open resection of the pseudoaneurysm and revision of the anastomosis. This case presents a novel approach to the treatment of pseudoaneurysms in a difficult location. The patient was a 77-year-old man status after repair of a type A aortic dissection with a Dacron tube graft. Follow-up imaging 18 months postoperatively showed a 1.6 cm×1.7 cm pseudoaneurysm off of the posteromedial proximal suture line. Through a right brachial artery approach, a diagnostic angiogram was performed demonstrating a bilobed pseudoaneurysm. A Judkins left 3.5 catheter and 0.035″-angled Glidewire was used to engage the orifice of the pseudoaneurysm. Two 4 mm×6 cm Boston Scientific Interlock coils were then deployed into the pseudoaneurysm sac. Completion angiogram demonstrated complete exclusion of the pseudoaneurysm. The patient did well and was discharged the following day. Follow-up computed tomography scan at 3 months showed regression and complete thrombosis of the pseudoaneurysm. Traditional operative repair of anastomotic pseudoaneurysms can lead to long operations, high blood loss, and increased morbidity and mortality as a result of their reoperative nature. Coil embolization is a safe and effective approach for the treatment of anastomotic pseudoaneurysms in difficult locations., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Pelvic congestion syndrome (PCS) imaging workup algorithms are not well-defined. The purpose of our study is to gauge the impact and accuracy of duplex ultrasound (DU) to assist in the diagnosis of PCS., Methods: We reviewed the records of 48 patients with PCS seen at a vein center from June 2010 to June 2012. All patients had DU plus either computed tomography venography (CTV) or conventional venography (CV). Measurements of the left (LOV) and right ovarian vein (ROV) diameter and the presence or absence of ovarian vein reflux were obtained using DU and compared with either CTV or CV to assess sensitivity and specificity. An ovarian vein diameter >6 mm was considered abnormal., Results: All patients were female (29 Caucasians, 18 Hispanic, and 1 Asian). The mean number of pregnancies was 3 (range, 1-5). All patients had lower extremity varicose veins, and 14 (29%) had vulvar varicosities. Thirty-four (71%) patients reported pelvic pain, 22 (46%) dyspareunia, 2 (4%) dysuria, and 1 (2%) hematuria. The median diameter of the LOVs and ROVs measured using DU compared with either CTV/CV were similar (DU, 8.6 and 5.6; CTV/CV, 8.3 and 6). The sensitivity and specificity of DU to demonstrate a dilated LOV were 100% and 57%, and for the ROV were 67% and 90%. Pelvic varicosities were identified in all but one patient with good correlation between DU and CV., Conclusions: DU has a high sensitivity to identify an abnormal LOV diameter that is greatly reduced when evaluating the ROV; however, the latter can be evaluated with another imaging modality such as CTV especially when DU results are equivocal or negative. A moderate specificity was found to determine both LOV and ROV abnormal diameters. All three imaging modalities are equally accurate to show the presence of pelvic varices., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe a hybrid approach for the treatment of a ruptured juxta-innominate artery saccular aneurysm., Case Report: A 68-year-old smoker male with poor exercise tolerance sustained a contained ruptured saccular aneurysm at the origin of the innominate artery. Although under the femoral-axillary bypass to allow direct brain perfusion, a 36 × 110 mm thoracic endograft was successfully deployed with total coverage of the distal ascending and aortic arch. A sternotomy was performed and an aorto-innominate and left common carotid artery bypass was done. At 1-month follow-up, a type 2 endoleak at the innominate artery stump was noted and successfully treated with coil embolization. The patient remains neurologically intact 1 year after the surgery., Conclusion: Juxta-innominate artery saccular aneurysms are rare. A hybrid open-endovascular repair using a reversed sequence arch debranching after endovascular repair is feasible and may be an alternative to deep hypothermic circulatory arrest particularly in frail patients.

Background: The purpose of our study was to assess whether the trends in management of blunt thoracic aortic injury (BTAI) have changed its outcomes over the years., Methods: We reviewed data of 88 (0.3%) adult patients with BTAI from January 1993 to December 2010. Primary end points were trends in presentation and time to repair and early morbidity and mortality., Results: Of all, 63 (72%) patients with BTAI were male (age, 38 ± 17). The yearly distribution of cases and severity of associated injuries remain stable. Of all, 16 (21%) patients had no intervention, 47 (63%) underwent open repair, and 12 (16%) underwent endovascular treatment. The postoperative mortality has decreased from 29% to 9% and the time from presentation to repair has increased from 6 to 14 hours during the study period., Conclusions: The incidence of BTAI remains stable with a reduction in postoperative mortality rate and an increasing number of delayed interventions over the past 18 years.

Objective: To evaluate the results of a new thrombin sealant (Recothrom) for the treatment of arterial pseudoaneurysms (PDAs)., Methods: We reviewed 47 consecutive patients prospectively entered in a dedicated data set who underwent ultrasound-guided percutaneous thrombin injection to treat PDA. End points were PDA recurrence, need for reintervention, and related complications such as limb ischemia or allergic reactions., Results: Twenty-six patients were females (55%) and the median age of the entire group was 71 years (range, 45-87). The mean size of the PDA was 2.3 ± 0.9 cm. The mean injected volume was 2.4 ± 1.4 mL containing 500 ± 320 units. Recurrence of the PDA occurred in 4 (8.5%) patients and was not related to anticoagulation status, body habitus, platelets levels, or use of antiplatelets. All recurred PDAs were successfully sealed with a second (n = 3) and a third injection (n = 1). There was no distal embolization or allergic reactions and no surgical intervention was required., Conclusion: The new human recombinant thrombin (Recothrom) is a safer nonimmunogenic option with similar success rates of other fibrin glue sealants.

Background: Vena caval filter (VCF) use has been increasing in recent years. Prophylactic VCF placement has been applied liberally in high-risk patients., Methods: Consecutive patients with VCF placement over a 2-year period at a university hospital were reviewed., Results: A total of 244 patients underwent VCF placement in 2 years. Of all, 54% of the patients had the VCF placed for an absolute indication, 14% for a relative indication, and 32% for prophylaxis. Only 14 (9%) of the retrievable filters were removed. Eight patients had a complication of VCF placement; there were no complications of filter retrieval. Vena caval filter placement for prophylaxis alone was 57% from the division of trauma and surgical critical care, 18.3% from interventional radiology department, and 5.2% from the division of vascular surgery., Conclusions: This study indicates that many VCFs are placed for prophylaxis. A low percentage of VCFs was retrieved. This may be the practice at many other large university-based hospitals, necessitating strategies for reducing their placement.

Objectives: This study was designed to determine the clinical presentation, characteristics, and management of true aneurysms in dialysis access fistulas., Methods: Patients presenting with symptoms or functional arteriovenous fistula (AVF) problems and aneurysmal enlargement of the outflow vein were evaluated with duplex ultrasound scans. Dilatation to more than three times the native vessel diameter was considered aneurysmal. Pseudoaneurysms were excluded from the study. Patients' demographics, aneurysm characteristics (diameter, location, thrombus, association with stenosis, and outflow obstruction), symptoms, type of treatment, and follow-up were recorded., Results: Twenty-three patients with a mean age of 55 years were found to have 29 upper extremity aneurysms of the outflow vein on duplex ultrasound scan. Nine patients (39%) had radiocephalic, 11 patients (48%) had brachiocephalic, 2 patients (9%) had brachiobasilic, and 1 patient (4%) had radiobasilic arteriovenous fistula. The average aneurysm size was 3.3 cm and the mean time from fistula placement to treatment was 47.1 months. Four patients (17%) were asymptomatic and were repaired due to technical and mechanical problems with AVFs, including stenosis and lack of normal vein for cannulation, compromising continued use. Nineteen patients (83%) presented with symptoms, including pain (48%), skin changes (30%), venous hypertension (22%), steal syndrome (22%), and high output failure (9%). Four patients (17%) were found to have outflow vein stenosis, 2 patients (9%) had central venous stenosis, and 2 patients (9%) had central venous occlusion. In 13 patients (56%) who had a functioning kidney transplant, the fistula was ligated with or without aneurysm excision. Three of the 13 patients developed superficial phlebitis with 1 patient requiring surgical evacuation of a clot; the other 2 patients were managed conservatively. Two of the 13 patients required creation of new access due to renal transplant failure. In the remaining 10 patients, the aneurysm was treated and the fistula salvaged due to a persistent need for hemodialysis. The median follow-up of these patients was 19 months ranging from 8 to 25 months. Seven patients (30%) underwent excision and repair with the great saphenous vein and 3 patients (13%) had excision and repair with prosthetic material, 2 of which underwent central venous angioplasty and stenting. Two patients developed thrombosis of their repair requiring new access in the contralateral arm. Three patients needed secondary percutaneous interventions for anastomotic stenosis., Conclusion: Although true aneurysms in patients with dialysis access are uncommon, significant complications may occur as a consequence of their presence. These complications can be treated and the fistulas can usually be salvaged., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Aim: Current debate on how to diagnose giant cell arteritis (GCA) has strayed from the traditional approach of temporal artery biopsy and has instead explored the effectiveness of alternative imaging modalities., Methods: We have reviewed the literature and pooled published results for temporal artery imaging including magnetic resonance imaging (MRI), Duplex ultrasound, positron emission tomography-computed tomography (PET-CT) scan., Results: The results of this review show that ultrasound and MRI both represent viable options for evaluation of GCA; however utilizing ultrasound first may be the best first option in diagnostic tools. In 1990 the American College of Rheumatology offered criteria for positive pathology in GCA., Conclusion: In this study, we propose a risk stratification criteria as well as an algorithm for the best diagnostic approach when GCA is suspected.

Objective: To determine previous experience and results of autologous splenic vein graft repairs in traumatic superior mesenteric vein (SMV) avulsions., Design of Study: Systemic review was conducted for SMV trauma and methods of repair between 1897 and 2010. Articles were further analyzed for use of the splenic vein as an alternative conduit and were included in this study., Results: Of the 56 articles identified during our search, 4 included use of the splenic vein as an autologous vein graft. A total of 5 cases using the splenic vein turndown repair were identified in addition to our case. Of the 6 patients, 4 survived. Only one other case exists regarding the successful use of the splenic vein turndown technique in blunt abdominal trauma., Conclusion: There is little information regarding the feasibility and success of this technique in traumatic SMV disruption. Future studies are required to assess its role in abdominal vascular trauma.

Non-giant cell arteritis disease of the superficial temporal artery (STA) is rare, appearing only as case reports in the literature. There were nine patients with STA pathology. STA aneurysm (n = 1), pseudoaneurysm (n = 4), thrombosis (n = 1), and arteriovenous malformation (n = 3). Four patients had ligation and excision, three had percutaneous interventions and one had a combination of both. All patients had immediate technical success and eight of the nine total patients had follow-up. We present a variety of ways to approach these unusual pathologies with percutaneous and open techniques demonstrating very good early outcome., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To determine the long-term incidence, risk factors, and associated morbidity and mortality of recurrent deep vein thrombosis (DVT)., Summary Background Data: Few studies have examined the long-term natural history and impact of recurrent DVT., Methods: We conducted a prospective observational study that followed 153 consecutive patients with an acute first episode of DVT. Clinical examination and ultrasound were performed serially for at least 5 years. Location and extent of the initial DVT, recurrence, pulmonary embolism, cause of mortality, signs and symptoms of post thrombotic syndrome (PTS), and the risk factors were recorded., Results: The incidence of recurrence at 5 years was 26.1%. Patients with both proximal and distal DVT had a higher recurrence rate than proximal (17/48 35% vs. 12/49, 24%, P = 0.27) or calf alone (11/56, 20%, P = 0.08). Unprovoked DVT and age >65 years were associated with higher recurrence rates (P < 0.001; relative risk [RR]: 2.9, 95% confidence interval [CI]: 1.5-5.7) and (P = 0.025; RR: 1.5, 95% CI: 1-2.3), respectively. Thrombophilia was not associated with increased risk of recurrence (P = 0.21). Patients with DVT due to surgery or trauma had a lower recurrence (P < 0.001). Ipsilateral recurrence was associated with increased severity of PTS (P < 0.001; RR: 1.6, 95% CI: 1.4-2.2). PE occurred 47 times, 12 (25%) of which were fatal events., Conclusions: Factors associated with a higher rate of recurrence included unprovoked DVT and age >65. Elevated thrombus burden had a trend towards higher risk. Patients with surgery and trauma had low recurrence rates. Ipsilateral recurrence was strongly associated with PTS. PE occurred frequently and was a common cause of death.

Objective: The purpose of this study was to determine the prevalence, distribution, and extent of varicosities and focal dilatations in the saphenous trunks, their association with the sites of reflux, and their correlation with CEAP classes., Methods: This prospective study included patients belonging to different CEAP classes (2-6) and a control group of age- and gender-matched healthy volunteers (group C). Color-flow duplex scan imaging was used to evaluate the entire venous system from groin to ankle for reflux and obstruction. Varicose segments and focal dilatations of the great and small saphenous veins (GSV and SSV) were recorded, and the diameters throughout the length of the saphenous trunks were measured. The presence of varicosities in the tributaries and accessory veins were documented., Results: From the 739 consecutive patients, 239 were excluded due to superficial venous thrombosis (SVT), deep venous thrombosis (DVT), both SVT and DVT, previous interventions, or C3-C6 presentation with no chronic venous disease (CVD). The included 500 patients (681 limbs) were divided into two groups based on CEAP class: group A (C2 + C3) and group B (C4-6). Group A had significantly more women than group B and a younger mean age (48 vs 56 years). Overall, GSV reflux (86%) was more prevalent than SSV reflux (17%), P < .0001. Saphenous trunk diameters, saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) involvement were greater in group B, (P < .01). Group C had smaller saphenous diameters compared to group A in all locations (P < .05) but the malleoli. The prevalence of the saphenous varicose segments in both groups was small with the GSV in group B being the highest (4.3%) and the SSV in group A being the smallest (1.2%). Focal dilatations were significantly more prevalent than varicosities in the saphenous trunks (P < .0001). Varicosities of tributaries and accessory veins were more prevalent than those of saphenous trunks (P < .0001). The mean length of varicose segments in the saphenous trunks was short (3.8 cm, range, 2.1-6.4 for group A vs 4.1 cm, range, 2.3-8.3 for group B, P = .09)., Conclusion: A novel definition for varicosities in the saphenous trunks was established. Using this definition, it was determined that focal dilatations are far more common than varicosities. Because both of these entities are more prevalent in the accessory saphenous veins and tributaries, and CEAP class correlates positively with the extent of reflux and saphenous trunk diameter, studies on earlier interventions are warranted to prevent CVD progression., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Several studies have evaluated the natural history of deep vein thrombosis (DVT), but few have correlated the clinical progression using duplex ultrasound (DU) imaging during the first year. This study was designed to determine the relationship of changes in the venous system and correlate them with long-term progression of disease., Methods: Consecutive patients with a first episode of proximal DVT documented by DU imaging were included prospectively. Clinic examinations were performed at 3, 6, and 12 months, and yearly thereafter. The CEAP system was used to grade disease severity. DU imaging was performed at least once, 1 year after the diagnosis, and repeated at 5 years. The proximal veins were divided the common femoral vein, femoral vein, and popliteal vein segments for analysis. Thrombosed veins were subsequently graded as completely, partially, and fully recanalized. Recurrent DVT cases were also recorded., Results: The study included 64 patients with 73 involved limbs; of which, skin damage was documented in three (4%) at 1 year and in 18 (25%) at 5 years (P = 0.0006; relative risk [RR], 3.92; 95% confidence interval [CI], 1.36-11.3). Overall from 1 to 5 years, 50 limbs remained the same. A change in clinical class occurred in 23 limbs (31.5%), including five limbs that progressed from class 0 to 3, 15 limbs from class 3 to 4 and 6, and three from class 4 to 5 and 6. DU imaging of these 23 limbs progression showed that the most important predictor for class progression was ipsilateral recurrent DVT (RR, 4.4; 95% CI, 1.4-13.3). Recurrent DVT at 1 year occurred in 21.9%, including ipsilateral in 15.6% and contralateral in 6.3%. Total recurrence at 5 years was 31.3%, including ipsilateral in 23.4% and contralateral in 7.8%. Limbs with ipsilateral recurrence were more likely to have partial recanalization, reflux, and more vein segments involved compared with those with contralateral recurrence or no recurrence (11 of 15 vs 16 of 58; RR, 4.7; 95% CI, 1.7-13.3)., Conclusion: Clinical class progression from year 1 to 5 occurs in 30% of post-thrombotic limbs. The most important predictor for progression in clinical class was ipsilateral recurrent DVT.

A 26-year-old man presented with acute renal insufficiency, and severe lower extremity swelling. Computed tomographic scan revealed retroperitoneal lymphadenopathy encasing both ureters and the inferior vena cava. He underwent placement of ureteral stents to relieve the obstruction and afterward underwent lymph node biopsy, which revealed Kaposi's sarcoma. He subsequently was diagnosed with acquired immunodeficiency syndrome. Abdominal and lower extremity venous duplex ultrasound did not show any evidence of deep vein thrombosis. The inferior vena cava measured 3.5 mm in diameter and was encased by retroperitoneal lymphadenopathy. Bilateral transfemoral venography and intravascular ultrasound demonstrated significant compression of the inferior vena cava below the renal veins. Endovascular treatment was followed with primary stenting under intravascular ultrasound guidance. His symptoms improved with reduction in swelling. At 1-year follow-up, the patient was ambulatory with mild symptoms, and on venography the iliac vein and inferior vena cava stents were widely patent.

Objective: To describe the anatomic variations, symptomatology, and pathophysiology associated with the sciatic nerve (SN), and report the results after treatment of the incompetent veins., Patients and Methods: Retrospective analysis of prospectively collected data from patients with signs and symptoms of chronic venous disease that had superficial varicosities associated with incompetent veins along the SN. Patients were evaluated with duplex ultrasound scans. In patients with enlarged veins along the SN, the anatomy of the incompetent veins, their size and association with superficial varicosities, and the severity of insufficiency were analyzed. The symptoms associated with their presence and the treatment results were also noted. Patients were re-evaluated following treatment for recurrence of varicosities and symptoms., Results: We identified 24 limbs in 21 patients with varicosities along the SN and its branches. The duration of signs and symptoms was 4.5 years ranging from 1 to 14. Reflux was detected in 18 veins of the SN, in three persistent sciatic veins and in three veins of the tibial nerve. All limbs with sciatic and tibial nerve veins had varicosities in the lateral and posterior aspect of thigh and calf and were symptomatic. Ten limbs presented with CEAP class 2, 5 with class 3, 2 with class 4, and 1 with class 1. Pain or tingling was reported in 15 limbs, itching in 8, and heaviness in 7. The distribution of pain and tingling was present along the nerves in 19 limbs. One patient had acute thrombosis in a persistent sciatic vein and died from pulmonary embolism. Of the 21 limbs with SN veins, 16 were treated with subfascial vein ligation and phlebectomies. Three patients had sclerotherapy, 1 refused treatment, and 1 had mild symptoms not requiring treatment. Of the 19 treated limbs, in 11 there was relief of their symptoms, 6 had significant improvement, and 2 had no change. Within a year, 4 patients required additional treatment for veins along the same area. Eleven limbs had a follow-up duplex scan 3 to 19 months after their treatment. All limbs showed significant diameter reduction in the nerve veins while mild reflux was present in 3 (4.1 mm vs 2.1 mm, P < .001)., Conclusion: Reflux is the most common pathology of the sciatic and tibial nerve veins which produces significant symptoms along the distribution of the nerves. Treatment of the varicosities offers significant relief while recurrence or residual varicosities are easily managed.

Purpose: To compare the progression rate of primary with secondary chronic venous disease (CVD)., Methods: Patients with a first episode of proximal deep vein thrombosis (DVT), diagnosed by duplex ultrasound (DU) were included in group A - secondary CVD (41 patients, 46 limbs). DU was performed at least once, 1 year after the diagnosis, and repeated at 5 years. Group B - primary CVD (41 patients, 50 limbs) included age- and sex-matched patients with primary CVD and duration of 5 to 10 years to be comparable with that of group A. They had no history of DVT and were referred for reflux evaluation. All their veins were free of postthrombotic signs upon DU examination. Group C (15 patients, 30 limbs) had no signs and symptoms of CVD and were examined at baseline and 5 years later. This group of patients was also matched for age and sex. Clinic examinations were performed at 3, 6, and 12 months and yearly thereafter. The CEAP system was used to grade disease severity. The proximal veins were divided in the CFV, FV, and POPV segments for analysis. Thrombosed veins were subsequently graded as complete, partial, and fully recanalized. Recurrent DVT cases were also recorded., Results: At 5-year follow-up, the prevalence of skin damage was significantly higher in group A (11/46 vs group B 3/50, P = .019 and vs group C 0/30, P < .01). The progression to skin damage in group A was faster as it changed from 4% (2/46) at 1 year (P = 0.014) compared with the two other groups. In group A, 22 limbs had reflux, three had obstruction, 19 had combine reflux and obstruction, and two were normal. In group B, superficial, deep, and perforator vein reflux were seen in 50, 4, and 15 limbs, respectively. In group C, five limbs in four patients developed superficial reflux in which only two had symptoms. The CEAP class in this group was C0N = 25, C1 = 3, and C2 = 2. In group A, skin damage was significantly higher in limbs with combined proximal and distal obstruction as well as in limbs with combined reflux and obstruction (P = .012 and P = 0.013, respectively). DVT was found in 108 segments (25 CFV, 40 FV, and in 43 POPV), 82 at the first episode and 26 as an ipsilateral recurrence. Ipsilateral and contralateral recurrences were seen in 21.9% and 9.8% of patients, respectively. Complete recanalization occurred in 43 segments, partial in 55, and none in 10. Reflux occurred in 85.5% and 60.5% of the partially and completely recanalized segments, respectively (P = .006)., Conclusions: The progression of CVD is more rapid in postthrombotic limbs when compared with those with primary CVD. The incidence of CVD in normal individuals is small and its progression is slow. Poor prognostic factors for progression to advanced CVD include the combination of reflux and obstruction, ipsilateral recurrent DVT, and multi-segmental involvement.

Objective: To provide follow-up in patients treated with pharmacomechanical thrombolysis (PhMT) for lower extremity deep venous thrombosis (DVT)., Methods: Retrospective analysis of prospectively collected data. Patients underwent clinical evaluation, duplex ultrasound, venous clinical severity scoring, venous segmental disease scoring, and venous disability scoring., Results: Fourteen patients were available for evaluation. Median age was 40 years (19-58). Median follow-up was 24 months (13-69 months). Thirteen of 14 patients (93%) had a venous disability score < 1 and 13 of 14 patients (93%) had a venous clinical severity scoring < 5. In all but 1 patient the venous segmental disease scoring score was < 5. All iliac segments were patent, all but 3 patients had partial infrainguinal obstruction and 5 of 14 (36%) had reflux., Conclusions: Our data demonstrate that the good early clinical results after PhMT can be sustained on longer follow-up and may prevent the development of advanced postthrombotic syndrome.

We present 2 cases of hemorrhage from a visceral artery pseudoaneurysm, managed successfully with endovascular covered stent placement. The first case was a 59-year-old man, 3 months after a laparoscopic distal pancreatectomy for adenoma, presenting with diffuse abdominal pain. The patient was evaluated with a computed tomography scan revealing a splenic artery pseudoaneurysm (PA) bleeding into a pancreatic pseudocyst. He was emergently taken to the angiography suite where a covered stent was deployed at the level of splenic artery PA. The second case was a 52-year-old woman with recurrent left retroperitoneal mass 5 years after distal pancreatectomy and splenectomy for a nonfunctional neuroendocrine tumor. She underwent resection of the mass in the left upper quadrant. Postoperative course was complicated by hematoma, abscess formation, reexploration, and repair of the duodenotomy and the portal vein. Subsequently, she was noted to have intermittent gastrointestinal hemorrhage, which prompted an angiogram revealing a hepatic artery PA that was repaired with a covered balloon-expandable stent. A completion angiogram was obtained in each case demonstrating exclusion of the PA. Our experience with these 2 cases supports the notion that endovascular covered stenting is a safe and effective therapy for exclusion of visceral artery aneurysm.

Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease (P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group (P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls (P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.

Objective: To determine the patterns by which perforator vein (PV) reflux develops in patients with primary chronic venous disease (CVD)., Methods: Patients with CVD who had at least two examinations with duplex ultrasonography before any treatment were included in this study. These were patients who were offered an operation at their first visit, but for various reasons treatment was postponed. All affected limbs were classified by the CEAP classification system. A detailed map of normal and refluxing sites was drawn on an anatomic chart by using several landmarks of the skin, muscle, and bone. Reflux was induced by distal limb compression followed by sudden release by using rapid-inflation pneumatic cuffs and dorsiplantar flexion. All new reflux sites were documented. The PV reflux was divided into ascending type, descending type (re-entry flow), and those that developed in new locations, which did not have reflux in any system at that level., Results: The total number of patients studied was 127 (158 limbs). There were 29 limbs (18%) in 26 patients with reflux development in the PV. In total, 38 new incompetent PVs were identified. The median time for the examination was 25 months (range, 9-52 months). Reflux in a previously normal PV at a re-entry site was detected in 15, in an ascending manner from an extension of superficial vein reflux in 18, and in a new, previously intact location in 5. At the new sites, reflux in the superficial veins connected to the incompetent PVs was always present. PVs connected to the great saphenous vein system were most common (n = 27), followed by those connected to short saphenous (n = 8) and nonsaphenous (n = 3) veins. Worsening in the clinical class was observed in 11 limbs: 5 from class 2 to 3, 2 from class 2 to 4, 2 from class 3 to 4, and 2 from class 4 to 6. The worsening could not be attributed to the PV reflux alone, because other veins became incompetent as well., Conclusions: Reflux in PVs develops in ascending fashion through the superficial veins, at re-entry points, and at new sites. Worsening of CVD is observed with new PV reflux, but many other factors play a major role, and therefore a causative association is difficult to prove.

Background: Through site-directed mutagenesis we have created a favorable fibroblast growth factor-1 (FGF-1) mutant (S130K) and linked it to a heparin-binding growth-associated molecule (HBGAM) to form the chimera S130K-HBGAM creating a heparin-independent, endothelial cell (EC)-specific mitogen., Methods: The proliferative responses of primary canine carotid artery smooth muscle cells (SMC) and jugular vein EC to FGF-1, S130K, or S130K-HBGAM, with and without heparin (5 U/mL), was quantitated by measuring tritiated thymidine uptake over 24 hours and expressing the results as percent of positive control (20% fetal bovine serum [FBS]) for group comparison., Results: Unlike FGF-1, both S130K and S130K-HBGAM are heparin-independent mitogens for EC and SMC. S130K-HBGAM was equivalent to FGF-1 with heparin at 6 nmol/L. S130K-HBGAM did not demonstrate relative EC specificity in this assay., Conclusions: At higher concentrations, S130K-HBGAM is a potent, heparin-independent EC and SMC mitogen. Co-culture assays and in vivo delivery models may demonstrate EC specificity not identified in this single cell type proliferation assay.

Patients undergoing endovascular abdominal aortic aneurysm (AAA) repair have lower perioperative morbidity and leave the hospital earlier than patients undergoing open repair. However, potential complications require continuous surveillance of endografts and there are few data regarding their long-term fate. If an open operation were well tolerated, this might be a preferable alternative. The purpose of this study was to identify patients with lower morbidity and shorter hospital stay following open AAA repair and to analyze factors that might point to open repair as the preferred approach. We performed a retrospective review of all patients who underwent AAA repair between 1995 and 2000 at our institution. All patients with ruptured aneurysms and those that required renal, celiac, or superior mesenteric reconstructions during the AAA repair were excluded. Patient demographics, preoperative comorbid conditions, intraoperative data, and postoperative complications were analyzed in detail. A total of 115 patients fulfilled the inclusion criteria. There was only one perioperative death (0.9%). The mean hospital stay was 8.1 days. A history of chronic obstructive pulmonary disease (COPD) and longer operative time were independent factors associated with prolonged hospital stay. Forty-one patients (35.6%) left the hospital in 5 or less days. Compared to the group with hospital stay >5 days, these patients had a lower incidence of COPD (7.3% vs. 25.7%, p < 0.05) and smaller-size AAAs (5.6 vs. 6.4 cm, p < 0.0001), and were more often operated on via a retroperitoneal approach (61% vs. 40.5%, p < 0.05). Their time in the operating room was less (3.5 vs. 4.5 hr, p < 0.0001), and they had less estimated blood loss (750 vs. 1500 cc, p < 0.001) and fewer transfusions (0.95 vs. 2.45 units, p < 0.0001). Patients without COPD and smaller AAAs that can be repaired via a retroperitoneal approach have a lower incidence of perioperative complications and a shorter hospital stay following open AAA repair. Until long-term results for endografts are available, our data suggest that these patients are well served with an open repair.