[Operate, cancel, postpone or select?] / Operieren, Absagen, Verschieben oder Selektionieren?: Ergebnisse einer Umfrage unter gefäßchirurgischen Zentren während der Covid-19-Krise in Österreich.

Regional centers performing vascular surgery in Austria (n = 15) were invited in mid-April 2020 by the Austrian Society of Vascular Surgery (ÖGG) to participate in a nationwide survey about implications of the COVID-19 pandemic. Ultimately, a total of 12 centers (80%) answered the questionnaire.All centers were confronted with patients who tested positive for COVID-19 and 75% also had medical personnel who were positive. In contrast, only 25% of the departments of vascular surgery had positively tested patients and 33% had positive staff members. In all departments of vascular surgery elective vascular procedures were either stopped (cancelled or deferred) or selectively limited, including patients with asymptomatic carotid stenosis, aortic aneurysms smaller than 7 cm, peripheral arterial aneurysm, peripheral artery occlusive disease Fontaine stage II and varicosities. All centers continued to carry out operations for all types of vascular surgical emergencies. The strategies of the centers were heterogeneous for patients with chronic ulcers, chronic mesenteric insufficiency, asymptomatic aortic aneurysms larger than 7 cm and shunt surgery.Decisions on surgery cancellation seemed to be particularly problematic due to the uncertain time period of the COVID-19 measures. As a consequence, the risk associated with cancellation or delayed treatment was difficult to assess. At present, especially indications with nonuniform management strategies need selective attention and additional analysis in single center and multicenter studies. In addition, patients might suffer from relevant psychological problems because of surgery cancellations. Changes in the daily routine due to the COVID-19 pandemic may have a long-term impact on health status and may show significant demographic and geographic variations.

Pararenal Aortic Ulcer Repair.

OBJECTIVE/BACKGROUND: In order to investigate techniques and outcomes of pararenal penetrating aortic ulcer (PAU) repair, a retrospective cohort study was performed. METHODS: Over the 6 year study period, 12 patients treated for a pararenal PAU were included. Outcome measures included technical success, survival, and peri-operative complications, as well as stent patency. RESULTS: Treatment modalities included hybrid procedures with endovascular aneurysm repair (EVAR) and bypass grafting, chimney EVAR (Ch-EVAR), and fenestrated EVAR (FEVAR). Four of the 12 patients were symptomatic, and eight patients underwent elective surgery. The technical success rate was 100%. Symptom resolution was recorded in all symptomatic patients immediately post-operatively. Complications encountered included one type I endoleak in a patient who underwent Ch-EVAR, and one case of post-operative stroke, paralysis, and death in a patient who underwent FEVAR. No adverse events were recorded in the remaining 10 patients. The PAU protrusion distance was significantly greater in symptomatic patients. Perforation and leakage were more prevalent in patients with pre-operative abdominal or back pain. CONCLUSION: Encouraging results of endovascular treatment of pararenal PAUs were observed. One major and fatal complication was encountered, which underlines the complexity and risks of the techniques. Another patient required re-intervention owing to an endoleak following off label use of covered stents for Ch-EVAR. FEVAR, which generally requires a custom made graft, was increasingly applied over the study period, potentially because of an increased awareness of this distinct pathology allowing for elective procedure planning. Ch-EVAR and hybrid procedures were predominantly used in symptomatic patients, whereas FEVAR was the preferred elective treatment option.

[Aortofemoral vascular graft infections and their prevention]. / Protheseninfektionen im aortofemoralen Bereich und ihre Vermeidung.

Vascular prosthesis infections are potentially severe adverse events following vascular reconstruction. They are often associated with a high morbidity and mortality, especially in the aortofemoral region. The present article outlines the diagnosis, prevention and treatment of vascular graft infections in a clinical setting. The clinical presentation, inflammatory markers, microbiological work-up and imaging studies can contribute to diagnosing a prosthesis infection. Regarding the bacterial spectrum involved in the etiology of prosthesis infections, single organism infections (monoinfections) have become less significant over the past years, whereas infections with multiple organisms now constitute the most abundant microbiological constellation. Also, infections with resistant bacterial strains have been increasing in number over the past years and deserve special consideration. It remains unclear whether both aspects are due to a true epidemiological change or are the result of advanced molecular microbiological diagnostic methods. While during the past decades perioperative antibiotic prophylaxis was regarded as the most important measure for preventing prosthesis infections in vascular surgery, other primary preventive hygiene strategies have been increasingly explored and grouped together in the sense of preventive bundles. In most cases of deep postoperative infections involving a prosthetic device in the aortofemoral region, explantation of the prosthesis will be required. In situ and extra-anatomical reconstructions are often performed in such cases and the decision process to develop an optimal treatment plan must consider several individual factors. In select patients, palliative preservation of the prosthesis despite surrounding infection (i.e. graft salvage) and best conservative management in combination with local surgical measures, such as incision and drainage and vacuum therapy, deserve consideration as a treatment option for patients with a high surgical risk.

Austrian national carotid intervention numbers prompt improvement in secondary stroke prevention.

BACKGROUND: As recent data suggest a variable benefit of carotid endarterectomy (CEA) or stenting (CAS), a careful selection of patients is mandatory for efficient stroke prevention. This retrospective study analyzed carotid intervention rates from 1999-2008 in Austria. The aim was to assess whether interventions for carotid stenosis were performed with respect to epidemiological trends and published data taking into account intervention type, age and gender. METHODS: Intervention numbers for internal carotid artery (ICA)-stenosis from a 10 years period (1999 to 2008) were retrieved from the national Austrian registry for hospital funding. Patients were grouped by gender, age (0-64, 65-74, older than 75 years) and intervention type. RESULTS: CEA rates amounted to 32.2±1.4 per 100000 persons annually (female: 22.1±0.7, male: 43.0±2.3). Each year 9.1 CAS±1.6 per 100000 Austrians were performed (female: 9.3±1.8, male 8.9±1.7). CAS numbers increased (P<0.05), whereas CEA numbers stagnated, especially in older age groups. Women were more likely to undergo CAS than CEA compared to men. CONCLUSION: Relative intervention rates for carotid stenosis have rather stagnated, although stroke incidence increases continuously in an overaging society. Despite controversial data, CAS rates have been rising constantly in elderly women. Secondary stroke prevention in Austria can be improved by a careful selection of future patients, especially with regard to female gender and type of intervention.

Indications and techniques for emergency carotid interventions.

Mutual understanding exists among specialists of neurology, interventional radiology and vascular surgery concerning the need of interventional treatment for patients with symptomatic carotid artery stenosis. However, identification of individuals that will most likely benefit from treatment, timing of the intervention and selection of treatment mode continue to be a matter of intense debate. The aim of this manuscript was to discuss the changing attitude to this high-risk population and present evidence that points towards a resolute, fast-track approach.

[Improve your skills!: evaluation of a 2.5-day basic course in vascular surgery for surgical trainees]. / Besser und schneller! : Evaluation eines 2,5-tägigen gefäßchirurgischen Grundkurses für ChirurgInnen in Weiterbildung.

BACKGROUND: The traditional surgical training in the operating room (OR) is often complemented by participation in workshops and on simulators. The foundation Vascular International offers basic courses for vascular surgery techniques with training on pulsatile circulation, lifelike anatomical models. The aim of this study was to assess the efficacy of a 2.5-day intensive course on basic skills in vascular surgery. MATERIAL AND METHODS: A total of 24 participants (67% male with an average age of 35 years) performed a vein patch-plasty before and after the basic vascular surgery instruction course. Endpoints of the study were the time needed for suturing and the technical quality, which were evaluated by two course trainers on a scale of 0-10. Furthermore, the participants were asked to evaluate their own technical competence. The statistical analysis was carried out using MS Excel (t-test and analysis of correlation). RESULTS: A significantly shortened time for the suturing (19.5 min versus 14.1 min, p < 0.001) and improved quality of the vein patch were found after the workshop (p < 0.05) with a high correlation between the two observers (r = 0.885). The participants also evaluated their own surgical competence better at the end of the training but there was no correlation between the self-assessment and the quality of the patch (r = 0.146 before and r = 0.109 after the workshop). CONCLUSIONS: A significant improvement in the time needed for suturing and the quality of the vein patch-plasty was shown in this study. Further studies are necessary to demonstrate the long-term success and possible shortening of the learning curve in hospitals with professional training. With regard to the current curriculum of surgical trainees in Germany basic vascular surgery courses should be considered as a potential valuable part of the surgical common trunk.

Local anesthesia and exposure for carotid endarterectomy: background and technical realization.

While carotid endarterectomy is an established method for the treatment of symptomatic as well as high-grade asymptomatic carotid artery stenoses, there is a considerable variation concerning the kind of anesthesia used as well as technical details of the operation. In the present article differing arguments on local versus general anesthesia as well as a transverse versus a longitudinal skin incision will be discussed. Furthermore, possible access routes to the carotid bifurcation, the retrojugular compared to the ventrojugular approach, will be presented in detail.

Comparison of enoxaparin and unfractionated heparin in endovascular interventions for the treatment of peripheral arterial occlusive disease: a randomized controlled trial.

BACKGROUND: Although unfractionated heparin (UFH) is an effective antithrombotic agent in endovascular interventions for the treatment of peripheral occlusive arterial disease (PAOD), it produces a highly variable anticoagulant response. Intravenous (i.v.) enoxaparin might be an effective and safe alternative. PATIENTS AND METHODS: In a prospective, open-label, randomized, single-center trial, 210 patients with PAOD (Fontaine stage IIb to IV) were randomly assigned in a 1 (UFH): 2 (enoxaparin) fashion to receive an i.v. bolus of 60 units UFH per kg body weight or 0.5 mg enoxaparin per kg body weight, respectively, before endovascular intervention. The primary composite endpoint assessed the clinical performance of enoxaparin by comparing the peri-interventional rate of thromboembolia/occlusion (efficacy) of endovascularly reconstructed areas, of bleeding according to the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) criteria (safety) and of any necessary re-intervention for any percutaneous transluminal angioplasty (PTA)-related bleeding. The secondary endpoint evaluated anti-factor (F)Xa levels during intervention. RESULTS: The primary composite endpoint showed a better performance of enoxaparin (10.5% vs. 2.5% absolute difference - 8.0%; P < 0.05). The concomitant use of acetylsalicylic acid (ASA) significantly (P < 0.05) increased the risk of a complication in the UFH group, but not in the enoxaparin group. Within 15 min, anti-Xa levels were reached by 63.7% of patients treated with enoxaparin and only by 39.1% with UFH. CONCLUSION: Enoxaparin has a better performance than UFH in endovascular interventions for the treatment of PAOD. In patients with concomitant use of ASA, the risk of complications with UFH increases significantly compared with enoxaparin.

WITHDRAWN: Rationale and Design of a Randomised Controlled Trial Comparing Stent-Protected Angioplasty with Bypass Surgery for Intermittent Claudication: The ABC Study.

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Carotid plaque composition in chronic kidney disease: a retrospective analysis of patients undergoing carotid endarterectomy.

OBJECTIVES: Calcified plaques are suggested to represent atherosclerotic lesions with stabilising properties. However, patients with chronic kidney disease (CKD) frequently have calcified plaques but significant higher prevalence of cardiovascular complications. The aim of our study was therefore to analyse the effect of CKD in patients with advanced carotid stenosis (>70%) on plaque composition, lesion stability and risk of rupture. METHODS: We investigated retrospectively, by histology, carotid plaques of patients with high-grade internal carotid artery stenosis undergoing carotid endarterectomy. Comparison of plaque morphology was performed on 41 patients with CKD with estimated glomerular filtration rate (eGFR) <60 ml min(-1) (according to the Modification of Diet in Renal Disease formula, MDRD-eGFR) and 56 patients with normal renal function. RESULTS: Patients with CKD had significantly higher percentage of total calcification (17% vs. 7%, p<0.001), unstable and ruptured plaques (83% vs. 52%, p=0.001 and 59% vs. 36%, p=0.039, respectively) compared with patients with normal renal function. By contrast, the content of collagenous fibres was significantly reduced in CKD patients (40% vs. 57%, p=0.011). No significant differences were found for neurological symptoms and soft plaque content. CONCLUSION: Our results demonstrate that CKD significantly affects plaque composition in patients with advanced carotid artery stenosis. Enhanced calcification and reduced collagenous plaque may lead to plaque instability and rupture.

Traditional versus endoscopic saphenous vein stripping: a prospective randomized pilot trial.

INTRODUCTION: The aim of this pilot study was to compare two methods of removing the great saphenous vein (GSV) from the groin to the limit of distal venous incompetence. Our aim was to compare endoscopically assisted GSV stripping to conventional stripping. DESIGN: Randomised pilot study. PATIENTS AND METHODS: 60 patients presenting with primary GSV incompetence and symptomatic varicose veins were randomly assigned to sapheno-ligation and either conventional GSV stripping or endoscopically assisted GSV stripping. The primary endpoint was the number of adverse events including haematoma in the thigh, ecchymosis, seroma, wound healing complications and wound infections. The SF-36 health survey was completed before treatment and one and four weeks postoperatively. The study was approved by the local ethics committee (EK 07-041-VK). RESULTS: 60 patients were enrolled in the study and randomized to endoscopic (n=30) and to traditional (n=30) stripping. The patients age ranged from 30 to 75 years (mean 53 years), 18 patients were male, 42 female. The combined rate of postoperative morbidity at week 1 was 32 events (53%), 13 (42%) events in the endoscopic and 19 (63%) in the conventional group (not significant). The SF-36 assessment one week postoperatively showed that patients in the endoscopic group reported significantly less pain (P=0.03, Mann-Whitney). At four weeks, patients in the endoscopic group had significantly less pain (P<0.005) and better physical function (P<0.005) and physical role (P=0.01). For all other parameters no significant difference noted. CONCLUSION: The results of this study suggest that endoscopic GSV excision showed no difference in adverse events between treatments, although our pilot study may have been under-powered to demonstrate this. The SF-36 assessment suggests more rapid return to normal activities post-operatively in the endoscopic group.

Hemodialysis access surgery--is there an increased risk of acquiring hepatitis C virus compared to other elective vascular interventions?

BACKGROUND: To evaluate whether dedicated access surgeons might have a significantly higher risk of acquiring hepatitis C infection compared to other vascular surgeons by assessing the prevalence of hepatitis C patients who are on chronic hemodialysis and to compare the frequency to patients undergoing elective vascular interventions. PATIENTS AND METHODS: A retrospective chart and data analysis of all patients on chronic hemodialysis was conducted. As a comparative group, the prevalence of anti-HCV antibodies and positive HCV RNA PCR among patients admitted for elective vascular surgery was assessed. RESULTS: Of 285 patients on chronic hemodialysis, 202 (71%) were had both tests (antibody test for HCV and specific HCV RNA PCR testing). 5% (n = 11; CI 95 = 3-10%) were antibody positive, and 4% (n = 8; CI 95 = 2-8%) were also PCR positive and therefore infectious. One patient was acutely infected. Of 4963 vascular surgical patients, 1141 (23%) had an anti-HCV antibody ELISA test and specific HCV RNA PCR testing. 0.4% (n = 4; CI 95 = 0.1-1%) were antibody positive and 0.2% (n = 2; CI 95 = 0.03-0.7%) were also PCR positive and hence infectious. No acutely infected patient was detected in this population. The chance of operating on a HCV positive and infectious patient among hemodialysis patients was almost 27 times higher than among elective vascular surgical patients (P < 0.0001; OR = 26.56; CI 95 = 5.42-253.40). CONCLUSIONS: Dedicated hemodialysis access surgeons have a higher risk to acquire hepatitis C infection compared to vascular surgeons performing all other elective vascular surgical interventions. To identify early infected surgeons operating on high risk HCV patient collectives and to start rapid treatment, PCR testing at regular intervals would be advisable.

Homocysteine and early re-stenosis after carotid eversion endarterectomy.

BACKGROUND: Homocysteine (Hcy) appears to be involved in the development of intimal hyperplasia and arterial thrombosis. The purpose of this study was to evaluate the association of plasma Hcy with early re-stenosis following carotid eversion endarterectomy. PATIENTS AND METHODS: Of 398 consecutive patients, 363 were included in this study. 62% of patients had symptomatic internal carotid artery (ICA) stenosis. Patients had preoperative assessment of Hcy and other well established atherosclerosis risk factors. Intraoperatively, completion angiography was performed in 2 planes. Patients had clinical, Hcy and duplex follow up at 1, 3, 18 and 36 months postoperatively. RESULTS: Complete follow up data were available for 312 patients. Five patients suffered from strokes and 2 patients died during the peri-operative period (combined stroke and death rate of 2%). Mean follow up was 26+/-5 months (range 17 to 36 months). Seventeen and six patients (5.5%) developed a 50-69% and >70% re-stenosis, respectively. Serum creatinine was significantly higher in patients with early re-stenosis, occlusion or stroke after CEA (P=0.043). High grade re-stenosis, occlusion and stroke ipsilateral to the operated side (17 patients) was associated with HbA1C and creatinine (P=0.043 and 0.046, respectively) but not Hcy. CONCLUSION: While Hcy is a recognized independent risk factor for atherothrombosis, our study suggests that there is no association of Hcy with early re-stenosis after eversion endarterectomy.

The complement component C5a induces the expression of plasminogen activator inhibitor-1 in human macrophages via NF-kappaB activation.

BACKGROUND: Atherosclerosis is considered to be a chronic inflammatory disorder. Activation of the complement cascade is a major aspect of chronic inflammatory diseases. Complement components were identified in atherosclerotic plaques, and a correlation between adverse events and C5a plasma levels was found. These findings support the notion that complement activation contributes to development and progression of atherosclerotic lesions. OBJECTIVES: We investigated whether complement components C3a and C5a regulate plasminogen activator inhibitor (PAI-1) in human macrophages. METHODS: Human monocyte-derived macrophages (MDM) and human plaque macrophages were cultured and incubated with the complement component C5a. RESULTS: C5a increased PAI-1 up to 11-fold in human MDM and up to 2.7-fold in human plaque macrophages. These results were confirmed at the mRNA level using real time-polymerase chain reaction. Pertussis toxin or anti-C5aR/CD88 antibody completely abolished the effect of recombinant human C5a on PAI-1 production, suggesting a role of the C5a receptor. Experiments with antitumor necrosis factor (TNF)-alpha antibodies and tiron showed that the effect of C5a was not mediated by TNF-alpha or oxidative burst. Furthermore C5a induced NF-kappaB binding to the cis element in human macrophages and the C5a-induced increase in PAI-1 was completely abolished by an NF-kappaB inhibitor. CONCLUSIONS: We conclude that C5a upregulates PAI-1 in macrophages via NF-kappaB activation. We hypothesize that - if operative in vivo- this effect could favor thrombus development and thrombus stabilization in the lesion area. On the other hand one could speculate that C5a-induced upregulation of PAI-1 in plaque macrophages could act as a defense mechanism against plaque destabilization and rupture.

Antiplatelet therapy prior to carotid endarterectomy--still room for improvement.

BACKGROUND: Antiplatelet therapy is one of the most important modalities for secondary prevention of ischemic events. The aim of this prospective study was to evaluate the current practice of antiplatelet therapy in patients with high grade stenosis of the internal carotid artery (ICA), who were referred by neurologists, stroke physicians and cardiologists for carotid endarterectomy. PATIENTS AND METHODS: Patients referred to our department for carotid endarterectomy with ICA stenosis (> 70% according to NASCET criteria) were prospectively evaluated regarding atherosclerosis risk factors and current antiplatelet therapy. During a 7 month period, 235 patients were scheduled for carotid endarterectomy. Their mean age was 70 years (range 42 years to 95 years), 91 patients were female (39%), 144 male (61%). 122 patients (52%) had a symptomatic ICA stenosis, 113 (48%) an asymptomatic ICA stenosis. RESULTS: Of the 235 patients, 29 were either on low molecular weight heparin or vitamin K antagonists for reasons other than ICA stenosis and were therefore excluded from analysis. Therefore, 206 patients (88%) were evaluated for antiplatelet therapy prescribed by their admitting physicians. Of these patients, 77 (37%) (42 (41%) symptomatic and 35 (34%) asymptomatic patients) did not receive any antithrombotic therapy prior to admission for surgery. The majority of patients received aspirin preoperatively (106 patients, 51.5%) 13 (6%) patients were on clopidogrel and 10 (5%) on dual therapy with Aspirin and clopidogrel. CONCLUSIONS: More than one third of patients awaiting carotid endarterectomy did not receive any antiplatelet therapy, despite high grade ICA stenosis. Since this practice does not meet the current guidelines, campaigns to increase the awareness of this problem are urgently needed.

Plasma D-lactate as a potential early marker for colon ischaemia after open aortic reconstruction.

BACKGROUND AND AIM: The breakdown of mucosal barrier function due to intestinal hypo-perfusion is the earliest dysfunction of ischaemic colitis. Severe colon ischaemia after aortic reconstruction is associated with mortality rates up to 90%. Therefore, early detection and treatment of patients with extensive ischaemic colitis is of crucial importance. In experimental studies, both D-lactate and bacterial endotoxin have been reported as markers of intestinal mucosal barrier impairment. However, evidence of their value in clinical practice is lacking. The aim of this pilot prospective cohort study was to assess the association between ischaemia of the colon (assessed histologically) and plasma levels of D-lactate and endotoxin in patients undergoing open aortic reconstruction. PATIENTS AND METHODS: Twelve consecutive patients underwent surgery between February and April 2003. Six patients underwent emergency surgery and six patients elective aortic surgery. D-Lactate and endotoxin levels were measured in blood samples collected according to a standardised protocol. For histological examination biopsies were obtained by sigmoidoscopy on days 4-6 after surgery, or earlier if indicated clinically. RESULTS: As early as 2 h postoperatively, elevated plasma levels of d-lactate were measured in patients with histologically proven ischaemic colitis. The peak of D-lactate elevation was on postoperative days 1 and 2. Concentration of plasma endotoxin was not significantly different in patients with or without ischaemic colitis. CONCLUSION: Our data suggest that plasma D-lactate levels are a useful marker for early detection of ischaemic colitis secondary to aortic surgery.

Carotid endarterectomy under local anaesthesia does not increase plasma homocysteine concentration.

INTRODUCTION: The purpose of this cohort study was to evaluate the effect of carotid endarterectomy under local anaesthesia on homocysteine (Hcy) concentrations. PATIENTS AND METHODS: Of 100 patients with internal carotid artery (ICA) stenosis >70%, the complete data set was available for 91 patients (39 asymptomatic and 52 symptomatic). All patients underwent eversion endarterectomy of the ICA under regional anaesthesia. RESULTS: Thirty-two percent of the examined patients had a total Hcy above 15 micromol/l. The mean Hcy levels preoperatively were 13.9+/-4.8 micromol/l. The Hcy levels on day 5 were 13.1+/-5.0 micromol/l and after 6 months 14.0+/-5.8 micromol/l. There was no significant change during follow-up. No intraoperative strokes and deaths were observed and during the 6 months follow-up no recurrent strokes, TIAs or deaths occurred. CONCLUSION: Patients undergoing carotid endarterectomy under regional anaesthesia do not have an increase in total Hcy postoperatively. This finding is in contrast to results from cardiac surgery and carotid endarterectomy in a recently published animal study, both performing surgery under general anaesthesia.

Antithrombotic strategies in vascular surgery: evidence and practice.

BACKGROUND: The aim of this study was to evaluate the current practice of peri and postoperative antithrombotic therapy in vascular surgery in Austria and to compare this with the results of randomised prospective clinical trials. METHODS: A questionnaire assessing intra, postoperative and long-term antithrombotic treatment in 13 different surgical procedures (three supra-aortic, three aorto-iliac reconstructions and seven inguinal and infra-inguinal arterial reconstructions) was sent to all 22 institutions training vascular surgical fellows in Austria. RESULTS: Intraoperative antithrombotic therapy was quite consistently performed with unfractionated heparin (UFH) with or without acetylsalicylic acid (ASA). Early and long-term postoperative therapy differed considerably. Most centres used low molecular weight heparin (LMWH) for early postoperative therapy after vascular reconstructions, in > 75% combined with ASA and/or clopidogrel. Long-term therapy consisted of antiplatelet agents in all centres. Vascular grafts were anticoagulated with UFH in 25% of the centres in the early postoperative period, the remaining institutions used LMWH +/- antiplatelet agents. For long-term antithrombotic therapy cumarins were used in 75% of the centres, predominantly for venous grafts. Distal prosthetic grafts were mainly treated with antiplatelet agents. Intraoperative antithrombotic therapy was in accordance to present guidelines, postoperative antithrombotic therapy, however, differed considerably between the participating institutions and the results of available controlled studies. CONCLUSION: Optimal antithrombotic strategies during and after vascular surgery are still under debate, and current practice often differs from available evidence. Vascular surgical societies should be encouraged to define recommendations on antiplatelet therapy and anticoagulation for different vascular interventions.

Combined open and endovascular stent grafting of internal carotid artery fibromuscular dysplasia: long term results.

BACKGROUND: Symptomatic fibromuscular dysplasia (FMD) of the internal carotid artery (ICA) can present as thrombo-embolic ischemic events, spontaneous or post-traumatic dissection, aneurysmal degeneration or intracranial haemorrhage and needs definitive surgical treatment. PATIENTS AND METHODS: Six patients and nine ICA with FMD were revascularised using a carotid approach with minimal exposure of the common, external and internal carotid arteries for covered stent repair. All patients were female, the age ranged from 30 to 65 years (mean 44). RESULTS: One patient suffered from a perioperative transient neurological deficit. Duplex revealed a patent stent. The patient fully recovered after 5h, not showing any changes on repeat CT scans. One patient developed a recurrent laryngeal nerve palsy. The symptoms gradually resolved within 1 month. No perioperative strokes or deaths occurred. During a mean follow up of 48 months (range 13-63) no thromboembolic neurological events, graft occlusions or haemodynamically significant stenoses occurred. CONCLUSION: ICA FMD stent grafting is an alternative to open surgery or percutaneous endovascular intervention with excellent long-term results.