A systematic review and meta-analysis of two novel techniques of nonthermal endovenous ablation of the great saphenous vein.

BACKGROUND: Endothermal treatment of the great saphenous vein (GSV) has become the first-line treatment for superficial venous reflux. Nonthermal ablation has potential benefits for acceptability by patients and decreased risk of nerve injury. We performed a systematic review and meta-analysis to evaluate the efficacy of mechanochemical endovenous ablation (MOCA) and cyanoacrylate vein ablation (CAVA) for GSV incompetence. METHODS: MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched for papers published between January 1966 and December 2016. Eligible articles were prospective studies that included patients treated for GSV incompetence and described the primary outcome. Exclusion criteria were full text not available, case reports, retrospective studies, small series (n < 10), reviews, abstracts, animal studies, studies of small saphenous vein incompetence, and recurrent GSV incompetence. Primary outcome was anatomic success. Secondary outcomes were initial technical success, Venous Clinical Severity Score, Aberdeen Varicose Vein Questionnaire score, and complications. RESULTS: Fifteen articles met the inclusion criteria. Pooled anatomic success for MOCA and CAVA was 94.7% and 94.8% at 6 months and 94.1% and 89.0% at 1 year, respectively. Venous Clinical Severity Score and Aberdeen Varicose Vein Questionnaire score significantly improved after treatment with MOCA and CAVA. CONCLUSIONS: These results are promising for these novel techniques that could serve as alternatives for thermal ablation techniques. However, to determine their exact role in clinical practice, high-quality randomized controlled trials comparing these novel modalities with well-established techniques are required.

Clarivein mechanochemical ablation of the great and small saphenous vein: Early treatment outcomes of two hospitals.

OBJECTIVES: Mechanochemical endovenous ablation is a novel technique for the treatment of great saphenous vein and small saphenous vein incompetence which combines mechanical injury of the endothelium with simultaneous infusion of liquid sclerosant. The main objective of this study was to evaluate early occlusion. METHODS: All consecutive patients who were eligible for the treatment with mechanochemical endovenous ablation were included. Inclusion period was from the introduction of the device in the hospitals (September 2011 and December 2011) until December 2012. RESULTS: A total of 449 patients were included representing 570 incompetent veins. In 506 treated veins, duplex ultrasonography was performed at follow-up: 457 veins (90%) were occluded at a follow-up of 6 to 12 weeks. In univariate and multivariate analysis, failure of treated great saphenous vein was associated with saphenofemoral junction incompetence (OR 4; 95% CI 1.0-17.1, P = 0.049). CONCLUSIONS: The Clarivein device proves to be safe and had a high short-term technical effectiveness.

Antibiotic Prophylaxis in Autologous Vein Graft Reconstructions of the Lower Extremity.

BACKGROUND: Different factors contribute to infection after arterial reconstructive surgery. Prophylactic antibiotic use during surgery is widespread, however, there is insufficient evidence to support the use of prophylactic antibiotics with autologous vein grafting. The aim of our study was to assess the effect of single-dose prophylactic antibiotics in patients undergoing autologous vein grafting. METHODS: Patients undergoing arterial bypass reconstruction in the lower extremity between 2004 and 2012 were retrospectively screened for use of vein grafts. Patients receiving single-dose antibiotic prophylaxis (group 1) were compared with those not receiving prophylaxis (group 2). RESULTS: Primary outcome was surgical site infection (SSI), and 142 patients were included. The SSI occurred in 22% of patients in group 1 and in 29% of patients in group 2 (P = .39; odds ratio: 1.46 confidence interval 95%: 0.61-3.47). CONCLUSIONS: Results showed no significant effect from single-dose antibiotic prophylaxis on lowering the incidence of SSI.

[Patient with ruptured abdominal aortic aneurysm better off with centralized care]. / Patiënt met ruptuur aneurysma aortae abdominalis beter af met centralisatie van zorg.

Current debate on complex medical care in the Netherlands includes the treatment of ruptured abdominal aortic aneurysm (RAAA). Topics of interest are hospital volume, patient selection and the use of minimally invasive but more expensive techniques. Based on two recent randomized trials investigating open and endovascular repair for RAAA, we discuss the advantages and disadvantages of techniques, quality of life and age. We conclude that optimal treatment can only be provided in a vascular centre with 24/7 availability of both open and endovascular repair, a top level intensive care unit and a demonstrable low decline rate for surgery. Age should be abandoned as an eligibility criterion for surgery.

Comparative study of venous arterialization and pedal bypass in a patient cohort with critical limb ischemia.

OBJECTIVES: Patients with critical limb ischemia (CLI) have a poor life expectancy, and aggressive revascularization is accepted as a means to maintain their independence in the end stage of life. The goal of this case-control study was to evaluate the clinical outcome of distal venous arterialization and compare this with pedal bypass surgery in patients with CLI, and to identify potential risk factors that could be used to effectively identify patients at high risk of graft occlusion and amputation. METHODS: A retrospective cohort of patients was treated for CLI using venous arterialization or pedal bypass between 2007 and 2012. Kaplan-Meier and Cox regression analyses were used to evaluate predictors for limb salvage and patency. RESULTS: In 40 patients with CLI, 21 venous arterializations and 19 pedal bypasses were performed. In the venous arterialization group, early occlusion was 15%, 1-year patency was 71%, and limb salvage was 53%. In the PB group, early occlusion was 23%, one-year patency was 75% and limb salvage was 47%. The only independent risk factor for limb salvage in multivariate analysis was bypass occlusion (P<0.001). CONCLUSIONS: Limb salvage after venous arterialization was equal to limb salvage after pedal bypass surgery in this clinical comparative study.

The costs and effects of contrast-enhanced magnetic resonance angiography and digital substraction angiography on quality of life in patients with peripheral arterial disease.

BACKGROUND: Contrast-enhanced magnetic resonance angiography (MRA) and intra-arterial digital subtraction angiography (DSA) both have a high diagnostic performance in the imaging of peripheral arterial occlusive disease (PAOD). However, little is known about the effects of initial, preoperative imaging using MRA or DSA on quality of life (QoL) in relation to costs (cost-utility). PURPOSE: To compare cost-utility of treatment strategies using either MRA or DSA as the principal imaging tool, related to QoL, in patients with PAOD. MATERIAL AND METHODS: In a prospective subgroup analysis of patients randomized between MRA and DSA (n = 79) for preoperative imaging, QoL questionnaires (SF-36) were obtained at randomization and at 4-month follow-up. Cost-effectiveness from hospital perspective was subsequently compared between groups and the difference in gained or lost QoL per € spent assessed using bootstrap analysis. RESULTS: No difference in quality of life was found. A treatment trajectory employing MRA as the principal imaging modality was almost 20% cheaper, leading to a better cost-utility ratio in favor of MRA. CONCLUSION: A treatment plan for peripheral arterial occlusive disease employing MRA versus DSA as the principal imaging modality yields a better cost/QoL ratio for MRA.

Systematic review on health-related quality of life after revascularization and primary amputation in patients with critical limb ischemia.

BACKGROUND: The purpose of this study was to assess the effect of revascularization (bypass surgery, angioplasty) and primary amputation on health-related quality of life (QoL) in patients with critical limb ischemia (CLI; resting pain or tissue loss). METHODS: A systematic review of the literature was performed through an electronic search of PubMed (from 1985 to 2012) and Embase (from 1985 to 2012) by two independent investigators to identify English-language articles investigating health-related QoL in regard to CLI. RESULTS: Three observational studies were identified describing a comparison between primary amputation and revascularization and their effects on QoL in patients with CLI, all concluding that revascularization should be attempted. Data pooling was omitted due to the impossibility of combining outcome parameters. A separate analysis of each article is presented. CONCLUSIONS: Patients with CLI have poor health prospects and life expectancy, irrespective of treatment administered. Randomized trials of health-related QoL after revascularization versus primary amputation are nonexistent. Also, the available observational studies do not allow sound conclusions, due to small numbers and methodologic imperfections. Therefore, no recommendations of either therapy in patients with CLI can be made with respect to an anticipated improvement in QoL.

Aluminium foil for the prevention of post-amputation pain: a randomised, double-blinded, placebo-controlled, crossover trial.

INTRODUCTION: Phantom limb pain (PLP) is a painful sensation perceived in the missing limb after amputation. The underlying pathophysiology remains unclear. Until recently, only opioid analgesics have been proven to be effective in prospective studies. Anecdotally, patients with PLP employ self-help measures, sometimes including 'wrapping up' or rubbing their stump with aluminium foil for relief. Our hypothesis is that wrapping an amputation stump with aluminium foil perioperatively will prevent PLP in the postoperative period. METHODS: From September 2007 to September 2009, 32 consecutive patients were included in a crossover, double-blinded, randomised clinical trial. Perioperative fitting of an aluminium stump bandage was compared with a placebo paper foil. Scores were noted daily in a variable diary. The observation period was 2 weeks: in the first week participants were double blinded, and in the second week there was a change of bandage from aluminium to placebo or vice versa. A visual analogue scale (VAS) score was used as primary research variable. Secondary variables were use of analgesics, VAS measures of wound pain and the incidence of wound infections. Statistical analysis was done by means of Student's t-test for non-paired observations. RESULTS: Baseline characteristics were similar between groups. A period effect (p= 0.84) and treatment-period interaction (p = 0.79) were not present. There was no significant difference (mean difference 0.42) between both treatments in PLP VAS scores (95% CI -2.56 to -1.81, p = 0.71). VAS measure of wound pain showed no significant difference between both groups (mean difference 0.34, 95% CI -2.32 to -1.66, p = 0.72). Also, the other secondary endpoints did not differ. CONCLUSION: Patients receiving an aluminium foil stump wrapping do not experience less phantom pain than with a placebo.

Long-term quality of life and mobility after prosthetic above-the-knee bypass surgery.

BACKGROUND: Multiple studies have addressed above-the-knee femoral artery bypass grafting; however, information on late quality of life (QoL) and mobility is scarce. We studied long-term QoL and mobility after above-the-knee bypass surgery. METHODS: Consecutive patients presenting with claudication, ischemic rest pain, or gangrene who received above-the-knee prosthetic bypass grafting between December 1997 and January 2003 were included in this observational study. Data used were recorded in a prospectively collected database of patients receiving Dacron and polytetrafluoroethylene (PTFE) supragenicular bypasses for lower limb ischemia. Primary outcomes were QoL and mobility, and secondary outcomes were patency and patient survival. QoL was measured with the EuroQol questionnaire (EQ-5D/EQ-VAS). Mobility was assessed with the Walking Impairment Questionnaire (WIQ) and analyzed in univariate and multivariate models. Patency and survival were computed with Cox regression. RESULTS: One hundred forty patients were treated during the study period. Sixty-nine patients (50%) died during follow-up, leaving 71 survivors who were asked (63 [89%] complied) to complete the EQ-5D/EQ-VAS and WIQ questionnaires. None of the primary outcome parameters (WIQ, EQ-5D, EQ-VAS) were affected by primary bypass occlusion (p = 0.34, p = 0.44, and p = 0.27, respectively) or long-term patency (p = 0.07, p = 0.54, and p = 0.36, respectively). Male sex was significantly associated with a better outcome on all primary outcome parameters. Patients with Dacron versus PTFE grafts had WIQ scores of 0.49 and 0.26, respectively (p = 0.01). EQ-5D scores of patients with Dacron and PTFE were 0.576 and 0.409 (p = 0.08) and EQ-VAS scores were 61 and 54, respectively (p = 0.24). Graft type was not independently associated with occlusion, but runoff was. The 5-year and 10-year patient survival rates were 58% and 51%, respectively. CONCLUSIONS: In this study, long-term QoL and mobility did not seem to be associated with bypass patency, as assessed in a single late follow-up. Revision of bypasses did not contribute to long-term QoL and walking ability. Therefore, the necessity of graft surveillance and subsequent revision and/or thrombectomy in case of synthetic bypass failure in absence of critical limb ischemia seems to be questionable.

Hybrid treatment of a ruptured diverticulum of Kommerell.

PURPOSE: To report a patient with a ruptured diverticulum of Kommerell and to discuss treatment options and complications. CASE REPORT: An 82-year-old woman with no prior medical history was diagnosed with a ruptured aneurysmal proximal aberrant right subclavian artery (diverticulum of Kommerell). She was treated with a carotid-subclavian bypass, a thoracic aortic stent-graft covering both subclavian orifices, and a vascular plug in the proximal right subclavian artery. After an initially uneventful recovery, the patient developed delayed ischemic esophageal ulcerations and subsequent perforation at 6 weeks postoperatively, leading to mediastinitis and stent-graft infection. CONCLUSION: A hybrid approach may be of value in cases of ruptured diverticulum of Kommerell. However, despite the anticipated reduction in perioperative mortality, this technique still yields a considerable risk of postoperative complications and mortality.

Transit-time volume flow measurements in autogenous femorodistal bypass surgery for intraoperative quality control.

The aim of this study was to assess intraoperative transit-time volume flow measurements (VFMs) as a tool for intraoperative evaluation of lower extremity arterial bypass grafts and to predict their patency. We analyzed 273 consecutive patients who had an infrainguinal bypass procedure using the great saphenous vein from 1998 until 2008; 103 had an intraoperative VFM. All intraoperative revisions were recorded and analyzed. Patency and revision rates were compared between those receiving and those not receiving intraoperative VFM. Cox regression was used for analysis of predictors of patency. Primary patency at 1 and 2 years was 75 and 67%, respectively, in patients receiving intraoperative VFM versus 72 and 69% in those without VFM (p  =  .79). In the VFM group, 12% had an immediate revision versus 6% without VFM (p  =  .06). In the VFM group, 4% underwent revision to salvage the bypass within the first postoperative 30 days versus 6% without VFM (p  =  .32). Patency was not associated with the use of VFM. Receiver operating characteristic curve was significant for occlusion at 30 days postoperatively but with a low predictive value (p  =  .019,area under the curve 0.648). VFM may be helpful in selecting bypasses requiring immediate revision to prevent postoperative occlusion. The use of VFM is not significantly associated with patency.