Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines

Lower extremity deep vein thrombosis is a serious medical condition that can result in death or major disability due to pulmonary embolism or post-thrombotic syndrome. Appropriate diagnosis and treatment are required to improve symptoms and salvage the affected limb. Early thrombus clearance rapidly resolves symptoms related to venous obstruction, restores valve function and reduces the incidence of post-thrombotic syndrome. Recently, endovascular treatment has been established as a standard method for early thrombus removal. However, there are a variety of views regarding the indications and procedures among medical institutions and operators. Therefore, we intend to provide evidence-based guidelines for diagnosis and treatment of lower extremity deep vein thrombosis by multidisciplinary consensus. These guidelines are the result of a close collaboration between interventional radiologists and vascular surgeons. The goals of these guidelines are to improve treatment, to serve as a guide to the clinician, and consequently to contribute to public health care.

Anatomical Features and Early Outcomes of Endovascular Repair of Abdominal Aortic Aneurysm from a Korean Multicenter Registry

PURPOSE: To introduce a nation-based endovascular aneurysm repair (EVAR) registry in South Korea and to analyze the anatomical features and early clinical outcomes of abdominal aortic aneurysms (AAA) in patients who underwent EVAR. MATERIALS AND METHODS: The Korean EVAR registry (KER) was a template-based online registry developed and established in 2009. The KER recruited 389 patients who underwent EVAR from 13 medical centers in South Korea from January 2010 to June 2010. We retrospectively reviewed the anatomic features and 30-day clinical outcomes. RESULTS: Initial deployment without open conversion was achieved in all cases and procedure-related 30-day mortality rate was 1.9%. Anatomic features showed the following variables: proximal aortic neck angle 48.8+/-25.7degrees (mean+/-standard deviation), vertical neck length 35.0+/-17.2 mm, aneurysmal sac diameter 57.2+/-14.2 mm, common iliac artery (CIA) involvement in 218 (56.3%) patients, and median right CIA length 34.9 mm. Two hundred and nineteen (56.3%) patients showed neck calcification, 98 patients (25.2%) had neck thrombus, and the inferior mesenteric arteries of 91 patients (23.4%) were occluded. CONCLUSION: Anatomical features of AAA in patients from the KER were characterized as having angulated proximal neck, tortuous iliac artery, and a higher rate of CIA involvement. Long-term follow-up and ongoing studies are required.

Clinical Implications of Methylenetetrahydrofolate Reductase Mutations and Plasma Homocysteine Levels in Patients with Thromboembolic Occlusion

PURPOSE: Hyperhomocysteinemia has been identified as an independent risk factor in arterial and venous thrombosis. Mutations in genes encoding methylenetetrahydrofolate reductase (MTHFR), involved in the metabolism of homocysteine, may account for reduced enzyme activity and elevated plasma homocysteine levels. In this study, we investigated the interrelation of MTHFR C677T genotype and level of homocysteine in patients with arterial and venous thrombosis. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 146 patients who were diagnosed as having arterial and venous thrombosis. We excluded patients diagnosed with atrial fibrillation. We examined routinely the plasma concentration of total homocysteine level and MTHFR C677T polymorphism for evaluation of thrombotic tendency in all patients. Screening processes of MTHFR C677T polymorphism were performed by real-time polymerase chain reaction. RESULTS: Investigated groups consisted of thrombotic arterial occlusion in 48 patients and venous occlusion in 63 patients. The distribution of the three genotypes was as follows: homozygous normal (CC) genotype in 29 (26.1%), heterozygous (CT) genotype in 57 (51.4%), and homozygous mutant (TT) genotype in 25 (22.5%) patients. There were no significant differences among individuals between each genotype group for baseline characteristics. Plasma concentration of homocysteine in patients with the TT genotype was significantly increased compared to the CC genotype (P<0.05). CONCLUSION: We observed a significant interaction between TT genotypes and homocysteine levels in our results. The results might reflect the complex interaction between candidate genes and external factors responsible for thrombosis.

Analysis of Intermediate Term Results of Short Vein Bypass Graft in the Patient with Critical Limb Ischemia

PURPOSE: Since the introduction of short vein bypass (SVB), many have reported its feasibility when long vein bypass (LVB) cannot be performed due to limited vein conduit. However, the presence of inflow-vessel disease may affect graft patency and thus require endovascular treatment prior to surgery. Our study aims to analyze the results between SVB and LVB. MATERIALS AND METHODS: From 2009 to 2013, 27 bypass procedures were reviewed retrospectively. Outcomes such as patency rate, postoperative ankle brachial index (ABI) and limb salvage rate between SVB and LVB were compared. Wound healing time and primary patency rate were analyzed and the former was also analyzed according to the respective angiosome and revascularization type. RESULTS: There were 11 males and 16 females and the mean age was 66.6+/-12.3 years. Twenty four patients had TransAtlantic Inter-Society Consensus (TASC) D and 3 patients had TASC C lesions below knee. The 1-year cumulative patency rate between SVB and LVB were 63% and 66%, P=0.627. The limb salvage rate (100% vs. 73%; P=0.280) and postoperative ABI (0.592 vs. 0.508; P=0.620) were higher in the SVB group than in the LVB group, although the differences were not significant. There was no difference in wound healing time by angiosomal revascularization type. In situ vein graft showed higher patency rate than reversed greater saphenous vein (75% vs. 61%; P=0.00) CONCLUSION: The results of SVB were similar to those of LVB. SVB is feasible in the setting of limited conduit availability, in combination with endovascular treatment in the presence of proximal lesions.

Staged Hybrid Revascularization in Patients with Peripheral Arterial Occlusive Disease / 대한혈관외과학회지

PURPOSE: With the development of endovascular interventions, hybrid reconstructions, which include the combination endovascular procedure and open bypass surgery, have been increasingly used for the management of peripheral arterial occlusive disease (PAOD). The goal of this study is to present our results in the management of PAOD and to define the role of staged hybrid techniques in patients who need revascularization compared to other revascularization procedures, such as open or endovascular techniques. METHODS: We reviewed 104 patients who underwent arterial revascularization between January 2005 and June 2010, retrospectively. The data were divided into three groups by treatment modality: the open bypass group (n=47, 45.2%), the endovascular group (n=46, 44.2%), and the staged hybrid group (n=11, 10.6%), and were classified according to the Trans-Atlantic Society Consensus II (TASC II) A/B/C/D. Patients' characteristics, overall primary and secondary patency rates, and 30-day complications were compared between the three groups. RESULTS: Mean age was 69.6 years and 84.6% were male. There were more TASC II D lesions and multiple lesions in the hybrid group. There were no statistically significant differences in the 36-month mortality rate, primary patency rate, and secondary patency rate among the three groups (P=0.170, 0.838, and 0.767, respectively). CONCLUSION: Staged hybrid revascularization is an acceptable strategy in patients with PAOD, especially TASC II D and multiple lesions for suitable case with comparable patency, even though the number of cases was relatively small.

Local Complications Associated with Vascular and Endovascular Surgery

Vascular surgeons encounter a myriad of complications during the management of patients. The complications that occur associated with vascular surgery are often life threatening. Vascular surgeons have played a pioneering role in the development and introduction of new vascular and endovascular techniques, and some of the techniques changed the therapeutic options available for patients with vascular disease. Especially, with the development of endovascular surgery, there has been substantial change in the management of most vascular diseases and their complications. The best way to manage complications is to prevent them from occurring by careful planning, appropriate patient selection, extensive operator experience, and the correct use of appropriate devices. Successful operation outcomes depend on avoiding complications, as well as recognizing and promptly managing complications when they occur. This article reviews various local complications and their management in the field of vascular and endovascular surgery.

VTE Prevalence and Prophylaxis in Surgical Patients

No abstract available.

Experience with Directional Atherectomy in Infrainguinal Peripheral Arterial Disease with Using a Silverhawk Plaque Excision Device

PURPOSE: This study was conducted to report our single center experience with performing directional atherectomy in patients with infra-inguinal arterial disease by using the Silverhawk plaque excision device. This procedure was performed at Washington University Hospital in St. Louis, USA (WASH). METHODS: Fifty-six patients with 102 lesions and who were classified into the Rutherford categories 2 to 6 underwent 66 procedures using the Silverhawk device from November 2004 to July 2007 in WASH. The patients' medical records were retrospectively reviewed. RESULTS: The initial technical success rate was 86.4%. The primary patency rate and limb salvage rate at 1 year was 48.5% and 80.3%, respectively. After 2 year' s follow-up, there was no occlusion or limb loss, and the overall primary patency rate and limb salvage was 45.5% and 75.8%, respectively. The mean preoperative ABI was 0.52+/-0.24 and the postoperative ABI was 0.73+/-0.22 (P=0.001). The one-year primary patency rate in the TASC II A and B group was 56.4% and that in the C and D group was 29.6% (P=0.003, P=0.007), respectively. There was a significantly different between both groups. However, the location, nature and length of the lesion, the Rutherford category and the adjunctive procedures did not statistically affect the primary patency rate. CONCLUSION: In this study, the Silverhawk plaque excision device was a feasible treatment modality for infra-inguinal peripheral arterial disease because of its high technical success rate, the primary patency rate and the limb salvage rate. However, it had an obstacle for being accepted for widespread use because secondary endovascular techniques are frequently required for restenosis after plaque excision. The practical use of the Silverhawk is controversial and further studies will be needed.

Clinicopathologic Findings of Micropapillary Carcinomas, according to Tumor Size

PURPOSE: Papillary thyroid microcarcinomas (PTMC), which are not palpable and have no clinical symptoms are 1.0 cm or less in diameter. The optimal extent of thyroid tumor resection has been controversial. We investigated clinicopathological findings of PTMC of 5 mm or less in diameter for reasonable therapeutic approach. METHODS: From, Jan. 2002 to Dec. 2006, 366 patients underwent thyroidectomy for thyroid papillary carcinoma at our institution. Among these patients, 62 patients with a mass measuring less than 5 mm and 103 patients with a mass 5 mm to 1.0 cm were selected. We retrospectively reviewed their medical records. RESULTS: There was no significant difference on the clinical characteristics except multifocality. We performed more unilateral lobectomy, near total thyroidectomy with or without neck node dissection in patients with PTMC of less than 5 mm (P=0.13). In permanent biopsy, lymph node metastasis more frequently occurred in patients with PTMC of less than 5 mm (P=0.03). There were no differences in capsular invasion, distant metastasis or recurrence. CONCLUSION: In papillary thyroid microcarcinoma less than 0.5 cm, it is very uncommon for capsular invasion, distant metastasis and locoregional metastasis to exist. The extent of tumor resection may be limited less than near total thyroidectomy for suitable cases, because there was no locoregional metastasis or distant metastasis in the follow-up period. Longer follow-up periods would be required to confirm that limited surgery is sufficient for tumors less than 0.5 cm in size.

The Risk Factors Associated with Surgical Site Infection after an Abdominal Operation

PURPOSE: Surgical site infection (SSI) is the most common nosocomial infection in surgical patients, and this accounts for 38% of all patients with nosocomial infections. Despite the advances in techniques and knowledge to prevent infection, SSI remains a significant source of postoperative morbidity and mortality, and it results in a prolonged hospital stay and increased cost. This study aims to assess the incidence of SSI and to identify the risk factors associated with SSI for patients who undergo abdominal operation. METHODS: The data on 347 abdominal operations that were done under general anesthesia from 1 August 2005 to 31 July 2006 was collected and reviewed. RESULTS: The overall incidence of SSI was 4.9%. Comorbidity was the independent risk factor for the development of SSI (P=0.011). The development of SSI was related with the American Society of Anesthesiologists (ASA) preoperative assessment score (P=0.025). The duration of the operation had a statistically significant association with an increased risk of SSI on univariate analysis. The wound classification was not associated with SSI. Staphylococcus aureus was the most frequently isolated organism, and all of the cases were methcillin-resistant Staphylococcus aureus. CONCLUSION: This study demonstrate that comorbidity is a significant independent risk factor for SSI.

Incarcerated Femoral Hernia Including a Gangrenous Appendix

Femoral hernias account for up to 4% of all hernias that occur in the inguinal region. The hernial sac usually contains the greater omentum, small intestine, large intestine and preperitoneal fat, but rarely, in only 0.8% of the all cases, it also contains the appendix. Femoral, inguinal and incisional hernias, combined with appendicitis, occur in only 0.13% of cases. Thus, the incidence of appendicitis associated with a femoral hernia would be expected to be very rare. Herein, a case of an incarcerated femoral hernia, including a gangrenous appendix, is reported. An 81-year-old female was admitted with a protruding mass in the right inguinal area of 2 days duration. On inspection, a 4x3 cm sized erythematous bulging mass was noted. On palpation, the mass was tender and fixed in nature. There were no signs of peritoneal irritation or other palpable masses in the whole abdomen. Under the impression of a femoral hernia, a manual reduction was attempted, but to no avail. An immotile edematous intestine was noted on ultrasonography, and fluid retention with decreased blood circulation was noted in the intestine, suggestive of incarceration. An emergency operation was performed, with an incision made through the right groin region, where an incarcerated femoral hernia, including a gangrenous appendix, was found. An appendectomy and McVay repair were performed. The patient was discharged after 5 days, without any complications.

Clinical Analysis of Endovenous Laser Treatment for Primary Varicose Vein Reflux

PURPOSE: Endovenous laser treatment for incompetent great saphenous vein (GSV) has been recently proposed as an effective means of treatment. The aim of this study is to identify the complications and safety of EVLT as the main treatment for primary varicose vein incompetence when used concomitantly with miniphlebectomy and sclerotherapy. METHODS: We reviewed the records of 153 patients who underwent EVLT. Venous duplex scanning was performed 3 months after surgery in all the patients. The clinical outcomes were evaluated using questionnaires at the outpatient clinic or through phone calls. RESULTS: Considering the 97% satisfaction rate of EVLT, EVLT was an effective treatment for primary varicose vein. We observed complications such as paresthesia (20.9%), pain lasting more than 2 weeks (11.8%), ecchymosis or bruising (7.2%) that subsided spontaneously, superficial burn (5.2%) and phlebitis (2%) that was controlled by conservative treatment. The GSV recanalization rate 3 months after the procedure was 3.3%, resulting in a 96.7% success rate. CONCLUSION: The early results indicate that EVLT is an effective and safe procedure to eliminate the SFJ (sapheno-femoral junction) and obliteration of the GSV. However, long-term follow-up is necessary in our study. Better treatment outcomes are possible with accumulated experience and the establishment of strict indications for EVLT.

Local Vascular Complications

No abstract available.

Report of Nation-wide Questionnaire Survey for Abdominal Aortic Aneurysm Treatment in Korea

While endovascular aneurysm repair (EVAR) is prevailing for the treatment of abdominal aortic aneurysm (AAA) in modern vascular practice, PURPOSE: we conducted nationwide questionnaire survey to investigate the current status of AAA treatment and their results in Korea. METHOD: We reviewed the replies from 28 hospitals (33 departments) to the questionnaire inquiring annual number, clinical features, mode of treatment and results of AAA patients during the period from Jan. 2000 to Jul. 2004. Results: 980 AAA patients were reported including 292 ruptured AAA (29.8%) and 688 non-ruptured AAA (70.2%). For treatment of AAA, 834 (85.1%) surgical repairs (SRs) and 111 (11.3%) endovascualr aneurysm repairs (EVARs) were performed while 35 patients (3.6%) died of AAA rupture before operation. The locations of AAA were infrarenal in 889 (90.7%), juxtarenal in 62 (6.3%), and suprarenal in 29 patients (3.0%). Among 834 patients undergoing SR, 577 patients (69.2%) had non-ruptured AAAs and 257 patients (30.8%) had ruptured AAAs. Mean operative mortality rate was 4.1% after elective SRs, 30.7% after SR for ruptured AAAs, and 2.3% after EVARs. The reported brand name of stent graft devices were various including domestic custom-made in 56 (50.5%), imported brand in 18 (16.2%) while 37 (33.3%) stent grafts were not reported their brand name. The frequencies of type I and III endoleaks after EVAR were reported 5.8% and 5.8% respectively in 86 patients with an available data. CONCLUSION: SR has been used as a major treatment option in Korea for the treatment of AAA patients while EVAR is increasing. The mortality rate of SR of AAA was comparable to western multi-center trial reports but mortality or morbidity rates of EVAR were unable to know in this questionnaire survey.

Results and Risk Factors of Hepatic Resection: Single Center Experience

PURPOSE: Hepatic resection is the treatment of choice for small malignant tumor, intrahepatic cholelithiasis having normal liver function and so on. Partial hepatectomy for liver disease has been performing more commonly than the past. Postoperative mortality and morbidity are decreasing as the operative technique is developed. This report describes a review of our experience for hepatic resection and an analysis of potential risk factors affecting the morbidity and the mortality in a hepatectomy. METHODS: Between Jan. 1997 and Mar. 2001, we performed 112 cases of partial hepatectomy and retrospectively analyzed the clinicopathological features of the cases. RESULTS: The most common disease needing hepatic resection was intrahepatic duct stone (46). The mean operative time was 377 minutes. The overall in-hopital mortality and morbidity rates were 6.8% (6/112) and 25% (59/112), respectively. Various postoperative complications developed; 16 wound infections (14.2%), 6 Bile leakage (5.3%), 6 intraabdominal abscess (5.3%), 5 cardiopulmonary complications (4.4%), 2 hepatic failure (1.7%), 2 postoperative bleeding (1.7%). The old had more cardiopulmonary complications. The significant risk factors for perioperative mortality were preoperative serum bilirubin level, alkaline phosphatase, prothrombin time, partial prothrombin time, perioperative transfusion and bleeding. CONCLUSION: This paper presents risk factors of hepatectomy in our hospital. The results state importance of selection of patients and perioperative bleeding managements to reduce of morbidity and mortality of hepatectomy.

Non-traumatic Small Bowel Perforation: Comparisons of the Clinical Features of 20 Years Ago with Present

The majority of small bowel perforations are caused by an abdominal trauma. However, non-traumatic causes should not be ignored. The etiology of a non-traumatic small bowel perforation is varies and has chronological characteristics. This retrospective study was undertaken to investigate the chronological changes in non-traumatic small bowel perforations over the past twenty years, according to the clinical features, surgical methods, and the prognosis of those with a non-traumatic small bowel perforation. The results of this study showed that the incidence of a bacterial enteritis induced small bowel perforation has significantly decreased, and inflammatory bowel disease or collagen disease has become the major causes of a non-traumatic small bowel perforation. Moreover, geriatric patients over 70 years of age are more vulnerable to a non-traumatic small bowel perforation.

Patency Rate of Prosthetic Arteriovenous Fistula Correlated with the Sites

PURPOSE: Patency of the arteriovenous fistula remains the most important support for patients with end stage renal disease. Prosthetic materials have been used only when autogenous arteriovenous fistula procedure is not feasible, because of the relatively low patency in prosthetic arteriovenous fistula. We designed this study to determine the appropriateness of primary prosthetic arteriovenous fistula. METHOD: Twenty-one consecutive patients who underwent prosthetic arteriovenous fistula formation on the arm in Chosun university hospital from Mar. 1998 to Feb. 2001 were retrospectively analysed. RESULT: The median patency in radio-antecubital fistula, brachio-antecubital fistula, and brachio-axillary fistula was 9.6, 11.4, and 16.6 months, respectively. The primary assisted patency rates in radio-antecubital fistula and brachio-antecubital fistula were 44.9% and 70.0% at the first year, respectively (P=0.03). The secondary patency rates in radio-antecubital fistula and brachio-antecubital fistula were 71.4% and 80.0% at the first year and 28.6% and 48.0% at the second year, respectively (0.02). CONCLUSION: The patency rates according to the site of prosthetic arteriovenous fistula were statistically significant in the radio-antecubital fistula and brachio-antecubital fistula groups. Nevertheless, the patency rates of the brachio-axillary fistula group were statistically insignificant. Primary brachio-antecubital fistula with PTFE creation showed favorable patency rates and many other benefits. Therefore, we suggest primary brachio-antecubital fistula with PTFE as the appropriate arteriovenous access in patients with poor vessel condition.

Continuous Distal Ileostomy Drip Feeding with the Secretion of the Proximal Stoma in a Neonate with IIIa Ileal Atresia / 대한소아소화기영양학회지

Short-bowel syndrome is functionally defined as a state of malabsorption following loss of small bowel, which comprises the sequelae of nutrient, fluid, and weight loss. The proximal segment of the bowel of a patient with intestinal atresia is usually grossly distended and atonic. In contrast, distal segment is smaller. For this reason, anastomosis of the proximal and the distal segment is technically difficult and may cause no propulsion even when they are anastomosed. We experienced that continuous drip ileostomy feeding with the secretions from the proximal stoma stimulated the distal bowel to accommodate and resolved many sequelae following loss of small bowel in a patient with short-bowel syndrome due to IIIa ileal atresia.

Neonatal Appendicoumbilical Fistula

Umbilical anomalies arie from fetal structures such as the omphalomesenteric duct (OMD) or urachus, or from the failure to closure the umbilical fascial ring. The persistence of OMD may lead to several anomalies including umbilical sinus, umbilical cyst, Meckel's diverticulum, or patent OMD (POMD). The clinical signs are local swelling, redness, inflammation, umbilical discharge, and bleeding. The passage of the intestinal contents, through the umbilicus i.e., meconeum or gas, implies a fistula to some part of the intestine. A patent omphalomesenteric duct (OMD) is usually associated with the ileum, but rarely with the cecum or appendix. There have only been eight reports of a neonatal appendicoumbilical fistula. Here the authors report a rare and interesting example of an umbilico-appendiceal fistula, and discuss its etiology and treatment.

Correlations of Atherosclerotic Risk Factors and Carotid Artery Intima-media Thickness in Healthy Subjects

PURPOSE: Atherosclerotic risk factors are highly associated with the progression and severity of cerebrovascular disease; the carotid artery intima-media thickness (IMT) correlates well with the known risk factors for atherosclerosis. The aims of this study are to evaluate the associations of the carotid artery IMT with the atherosclerotic risk factors and to determine the reference values of the carotid artery IMT in healthy subjects who were without cardiovascular symptoms. METHOD: Ultrasound high-resolution B-mode imaging of the carotid artery was performed in 273 subjects (168 men, 105 women). We investigated the mean carotid artery IMT and the correlation between the carotid artery IMT and the atherosclerotic risk factors. RESULT: The mean carotid artery IMT values were 0.70+/-0.25 mm in the common carotid artery, 0.61+/-0.15 mm in the internal carotid artery, 0.55+/-0.26 mm in the external carotid artery and 0.92+/-0.45 mm in the carotid bulb. The mean carotid artery IMT was significantly increased with increasing age (P<0.05), and particularly in males. Age, systolic and diastolic blood pressure, body mass index, total cholesterol and LDL cholesterol levels correlated with the mean carotid artery IMT. Especially, the presence of plaque (26 subjects) was correlated with the mean carotid artery IMT in the internal carotid artery (P<0.05) and bulb (P<0.01). CONCLUSION: This study revealed the correlation between the carotid artery IMT and the atherosclerotic risk factors; we also elucidated the reference values for the mean carotid artery IMT in healthy subjects who were without cardiovascular diseases and symptoms.