Endovenous Laser Ablation of the Great Saphenous Vein with a 1470 nm Wavelength Laser : Results of a Prospective, Single Centre Cohort Study.

BACKGROUND: Endovenous laser ablation (EVLA) is a widely accepted treatment for venous insufficiency. Our aim was to report the standardised technique used in our centre and to evaluate the anatomic and clinical success rates. METHODS: All details of patients treated with EVLA were prospectively collected in a database. A standardized examination and surgical protocol was used, and every detail in the technique was registered. A follow-up visit was organised after 1 week and after 4-6 weeks with a duplex. RESULTS: A total of 441 limbs were treated in 366 patients using a 1470 nm wavelength laser with bare tip fiber -(Biolitec(®)). At 6 weeks postoperative a total obliteration of the vein was established in 98.62% of the cases with 78.67% of the patients free from complaints. No major complications were reported. Minor complaints were low (10.74% induration, 3.9% paresthesia). 93.11% reported no pain, 5.2% mentioned moderate pain. Mean duration of absence was equal or less than 1 week (65,28%). Satisfaction level was high (92.84%, level 10). CONCLUSIONS: EVLA of the GSV and the Anterior Accessory Vein (AAV) with a 1470 nm wavelength laser with bare tip fiber is a minimally invasive, safe and effective technique. We are convinced that every detail is important : tumescence technique, Trendelenburg position, no external compression, and the position of the vein in the fascial sheath. Further reduction of linear endovenous energy density (LEED) used for EVLA can improve the therapy. This is possible by using a new fiber tip design (radial optical fiber) and needs further investigation.

BRAVISSIMO: 12-month results from a large scale prospective trial.

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

Autologous transplantation of bone marrow mononuclear cells for limb ischemia in a caucasian population with atherosclerosis obliterans.

BACKGROUND: Autologous transplantation of bone marrow mononuclear cells (ATBMMNC) has been used successfully in critical limb ischemia. All reported patients were of Asian descent, however, and several studies included only young patients with thromboangiitis obliterans. Whether the beneficial results can be extrapolated to older Caucasian patients with atherosclerosis obliterans and a heavy burden of cardiovascular risk factors remains unclear. METHODS: We enrolled 16 patients (age 78 +/- 2 year) with critical limb ischemia and a high prevalence of hypertension, smoking, diabetes, hypercholesterolemia and uremia. Mononuclear cells were isolated from the bone marrow and injected in the gastrocnemius muscle of the affected limb. RESULTS: Four patients died because of progressive gangrene (two) or unrelated causes (two). Three patients required an amputation and one patient a femorocrural bypass within 12 weeks. The remaining eight patients had a modest improvement of resting pain and/or trophic lesions. Transcutaneous oxygen pressure (ratio lesion/reference) improved from 0.51 +/- 0.11 before to 0.86 +/- 0.03 (P < 0.001) after 12 weeks, whereas ankle-brachial index did not change significantly (0.42 +/- 0.15 vs. 0.59 +/- 0.1; P = 0.23). The number of visible collateral vessels on digital subtraction angiography changed with 0.89 +/- 0.86 on a scale of 1-4 (P = 0.33). Capillary surface area in a biopsy of gastrocnemius, evaluated by immunostaining for endothelial nitric oxide synthase, increased from 0.61 +/- 0.07% to 2.38 +/- 0.73% (P < 0.05). CONCLUSIONS: Although ATBMMNC was associated with objective signs of neovascularization, symptomatic improvement was only modest and restricted to the least affected patients. The discrepancy with previous findings may be related to the high prevalence of cardiovascular risk factors which causes endothelial progenitor cell dysfunction.

Endovenous laser treatment for primary varicose veins.

Venous insufficiency of the lower extremities is a highly prevalent condition. Successful treatment of superficial venous insufficiency will most often necessitate treatment of the saphenofemoral junction incompetence with correction of saphenous vein reflux. In the majority of patients it concerns a reflux of the greater saphenous vein. The standard procedure consists of ligation and stripping of the greater saphenous vein combined with with additional phlebectomies or ligation of insufficient perforant veins if necessary. Although the standard procedure is widely known and accepted, the postoperative morbidity and postoperative limitations of activity are high. In this context minimally invasive percutaneous endovenous techniques were developed to improve the patients comfort and faster resumption of work. Among these, endovenous laser ablation of the greater saphenous vein is a relatively new procedure. Percutaneous introduction of a laser fiber into the incompetent vein and ablation with pulsed laser energy is far less invasive than stripping.

Cine-viewing of overlapping thin collimation images: an improved diagnostic tool in multislice helical CT of the bowel.

As compared to single slice helical CT, multislice helical CT does not only improve the quality of the individual images (in terms of slice sensitivity profile and image artifacts) and the range of scan coverage, it also enforces the CT postprocessing possibilities. The advantage of post-processing thin collimation bowel CT images with overlap and cine-viewing or paging is reported. The case report illustrates that cine-viewing of overlapping thin collimation images obtained with multislice helical CT, allows an excellent evaluation of the bowel loops resulting in the diagnosis of a perforated sigmoid carcinoma and its complications.

Traumatic pseudo-aneurysm and dissection of the thoracic aorta in the presence of an aberrant right subclavian artery: value of multi-slice helical CT.

A case of traumatic pseudo-aneurysm and dissection of the proximal descending thoracic aorta in association with an aberrant right subclavian artery and a common trunk for both common carotid arteries is presented. The diagnosis of this traumatic pseudo-aneurysm and dissection in association with these congenital anomalies by means of a multi-slice helical CT is discussed. To our knowledge, this is the first such case reported in the literature.

Cerebral ischemic disease and morphometric analyses of carotid plaques.

Atherosclerotic carotid plaque morphology and especially, intraplaque hemorrhage are assumed to be related to neurological symptoms. Most researchers have only investigated the incidence of intraplaque hemorrhage in symptomatic and asymptomatic patients. In the present study, the amount of intraplaque hemorrhage is determined in carotid endarterectomy specimens from 33 symptomatic and 14 asymptomatic patients that caused >70% luminal stenosis. The plaque components (fibrosis, lipids, intraplaque hemorrhage, calcification, and intraluminal thrombosis) were quantified as a percentage of the total plaque volume. A high incidence of intraplaque hemorrhage was found in both the symptomatic (94%, 31/33) and asymptomatic (71%, 10/14) patients. The amount of intraplaque hemorrhage was very small within the plaques of the symptomatic (0.39% +/- 0.70%) and asymptomatic (0.37% +/- 1.12%) patients. The plaques of the symptomatic patients contained more fibrosis than lipids (45.62% +/- 14.99% and 20.45% +/- 21.45%, respectively), as did the plaques of the asymptomatic patients (42. 51% +/- 15.28% and 15.46% +/- 15.22%, respectively). Finally, intraluminal thrombosis and calcification were rare. We conclude that the amount of intraplaque hemorrhage was very small and therefore question its direct role in the development of neurological symptoms. In general, the "unstable" plaque contained more fibrosis than lipids.

Transcranial cerebral oximetry during carotid endarterectomy: agreement between frontal and lateral probe measurements as compared with an electroencephalogram.

OBJECTIVE: Transcranial cerebral oximetry, which is considered a novel technique, was evaluated during carotid endarterectomy. For practical reasons, the use of a single probe attached to the forehead and overlying the territory of the anterior cerebral artery is recommended. Other monitoring systems (transcranial Doppler, electroencephalograms (EEG)) focus more on the territory of the middle cerebral artery. The aim of this study was to evaluate whether a probe in the frontal area is as representative for monitoring cerebral ischaemia during carotid cross-clamping as a probe in the lateral area. DESIGN: Clinical prospective study. MATERIALS: Sixty patients who underwent carotid endarterectomy were studied with continuous and simultaneous EEG and transcranial cerebral oximetry. Forty-three patients (72%) simultaneously underwent frontal and lateral transcranial cerebral oximetry. The lateral probe was only used in 17 patients. METHODS: The percentage decrease of transcranial cerebral oximetry was calculated during cross-clamping. Using the EEG findings as the gold standard in order to detect cerebral ischaemia during carotid cross-clamping, the relationship with transcranial cerebral oximetry was described in terms of sensitivity, specificity and the area under the curve in a receiver operating characteristic curve. RESULTS: The 95% confidence interval of the area under the curve of the receiver operating characteristic of the lateral probe was 0.61-1.00 and that of the frontal probe was 0.65-1.00; therefore there is virtually no difference between the two methods. In 18% of the cases the lateral transcranial cerebral oximetry was hindered by practical failures. CONCLUSION: Considering the lack of additional information and the practical problems experienced with the lateral probe, it was concluded that transcranial cerebral oximetry with a single frontal probe is a practical non-invasive monitoring system and is at least as representative for monitoring cerebral ischaemia during carotid cross-clamping as a lateral probe.

Ultrasonographic characterization of carotid plaques.

The composition of atherosclerotic plaques in the carotid artery is assumed to be related to the development of neurological symptoms. The echo patterns produced by B-mode ultrasound may be of use in the assessment of the plaques' composition. It is suggested that fibrotic and "stable" plaques are more echogenic than lipid/hemorrhagic and echolucent or "unstable" plaques. B-mode ultrasound procedures were performed 1 day prior to surgery on 46 consecutive endarterectomies. Two observers assessed the plaques according to their echo pattern and echogenicity and sorted them into three categories: 1) predominantly echolucent, 2) heterogeneous, and 3) predominantly echogenic. The intraobserver agreement was moderate (kappa = 0.44) and the interobserver agreement low (kappa = 0.38). Furthermore, subjective categorization of plaque types resulted in type 1 plaques being as fibrotic as type 2 or 3 plaques. We conclude that B-mode ultrasound and subsequent subjective categorization of atherosclerotic plaques cannot adequately determine the volume of fibrosis or lipids within the plaque.

Near-infrared reflected spectroscopy and electroencephalography during carotid endarterectomy--in search of a new shunt criterion.

The aim of this clinical study was to evaluate cerebral oximetry with near-infrared reflected spectroscopy (NIRS) as a monitoring system during carotid endarterectomy. The cross-clamping changes of cerebrovascular hemoglobin oxygen saturation (cereb. O2 satn.) were compared with data from a processed EEG analysis. Using the EEG as the gold standard we try to define a new shunt criterion based on near-infrared spectroscopy. 102 patients were studied. During cross-clamping the percentual decrease of cereb. O2 satn. was calculated. The relation between EEG and cereb. O2 satn. is described in terms of sensitivity and specificity, and is graphically shown in a Receiver Operator Characteristic (ROC) curve. At a cut-off value of 5% decrease or more for the cereb. O2 satn., a sensitivity of 100% was found. However, the specificity was only 44%. Higher cut-off values resulted in a gradual increase of the specificity at the expense of a significant decrease of the sensitivity. In conclusion, improved validation and calibration techniques are necessary before this technique may be used for relevant assessment of cerebral oxygenation during carotid surgery. In particular, in order to define a new shunt criterion, the focal aspect of this new technique is probably one of the limitations.

The myth of the second prophylactic antibiotic dose in aortoiliac reconstructions.

OBJECTIVES: To determine whether a prophylactic second dose of antibiotics is justified when severe blood loss and/or prolonged operation time occurs during aortoiliac reconstructions. METHODS: We measured the cefuroxime concentration in venous blood serum and subcutaneous fat tissue of 30 patients who underwent elective aortoiliac reconstruction after a single intravenous dose of 1500 mg cefuroxime. RESULTS: The mean blood loss was 1912 ml (range 200-7000). The mean operation time was 212 min (range 70-330). The cefuroxime concentration in blood serum 30 min after the gift varied from 53.7-561.6 mg/l and during closure of the abdominal incision from 13.2-90.0 mg/l. Taking the minimum inhibitory concentration for Staphylococcus species as 1.0 mg/l, we found an adequate prophylactic serum cefuroxime concentration in all patients. There was a statistically significant correlation between serum cefuroxime concentration and blood loss (p = 0.01) and operation time (p = 0.0001). CONCLUSIONS: Although serum concentration of cefuroxime is greatly influenced by blood loss and operation time, a second dose of cefuroxime in aortoiliac reconstructions is not necessary if the operation is completed within 5.5 h and if perioperative blood loss does not exceed 7000 ml.

Thoracoscopic-assisted pulmonary resection in lung cancer.

BACKGROUND: Thoracoscopic-assisted pulmonary resection for lung cancer is controversial. The appropriateness of this approach has to be compared with the golden standard of an open resection. METHODS: This study consists of 66 patients with a clinical stage 1 disease. A thoracoscopic exploration was executed in 41 patients. Only in 16 cases was a thoracoscopic resection finally possible. The clinical and pathological TNM classification, the histological types and the surgical procedure are reported. The reasons for conversion are documented. RESULTS: To investigate the appropriateness of the thoracoscopic approach we evaluated only the pathologically proven stage 1 disease in both groups. Postoperative complications, hospital stay and survival are compared. CONCLUSION: Until now we can conclude that there is no adverse effect on survival because of the thoracoscopic approach.

Primary aortoenteric fistula: report of eight new cases and review of the literature.

Primary aortoenteric fistula, a direct communication between the aorta and the intestinal tract, is a rare cause of gastrointestinal hemorrhage. Eight patients who were all treated at one hospital are described, followed by a review of all surgically treated patients reported within the past 10 years. The usual cause is erosion of an atherosclerotic aneurysm into the adherent duodenum, but a wide variety of other causes and localizations have been described. The clinical presentation is usually one of intermittent gastrointestinal hemorrhage resulting in lethal exsanguination within a matter of hours or days. Pain, a pulsatile abdominal mass, or fever may not be present. Endoscopy, arteriography, ultrasound, and CT scan can be useful in the evaluation of these patients, but physical examination and a high index of suspicion remain key to diagnosis. Primary aortoenteric fistula is more often discovered unexpectedly during exploratory laparotomy and is not usually considered as a presumptive preoperative diagnosis. Although contamination is unavoidable, most patients are treated with an in situ vascular graft and primary closure of the intestinal defect with good results.

Thoracoscopic assisted lobectomy.

The advances in endoscopic capabilities expanded the potential role of laparoscopic and thoracoscopic surgery. The introduction of safe linear stapling devices made thoracoscopic assisted segmental lung resections possible. Because of the postoperative advantages of a thoracoscopic operation, a technique for thoracoscopic lobectomies was developed. Three case reports are presented using the same technique. The first two cases report a right lower lobectomy and the third case a bilobectomy, right middle and lower lobe.

Benefits of carotid patching: a prospective randomized study with long-term follow-up.

A prospective study with random selection between primary closure and saphenous vein patching after carotid endarterectomy was conducted. Patients were evaluated with intravenous digital subtraction angiography during the initial postoperative period, followed by duplex scanning at 3 and 6 months, and then yearly examinations. The series consisted of 129 carotid endarterectomies, of which 62 were primary closures and 67 were patch procedures. Both groups were identical with regard to risk factors, symptoms, and postoperative control digital subtraction angiography. Restenosis was defined as a stenosis with > or = 50% diameter reduction, as assessed by duplex scanning. Of special interest was the development of restenosis along with the occurrence of cerebrovascular symptoms at long-term follow-up. The follow-up data from the 129 carotid endarterectomies are presented in a life-table analysis. The mean length of follow-up was 5 years (range 1 to 96 months). During the follow-up period 38 patients who had undergone 39 operations died (mortality rate 30%); three deaths were attributed to cerebral causes (two in-hospital deaths due to intracerebral hemorrhage and one cerebral hemorrhage after 6 months). Restenosis occurred in 25 cases (19%). This restenosis was detected in 5 of 45 men with primary closure (11%), 12 of 17 women with primary closure (70%), 7 of 49 men with patch closure (14%), and 1 of 18 women with patch closure (5.5%). The difference between patch and primary closures was found to be statistically significant (hazard ratio 0.39; 95% confidence interval 0.17 to 0.91; p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Multiple congenital aneurysms of unknown origin.

A case is reported of an 18-year-old man with a syndrome of multiple aneurysms of unknown origin. Several interventions were necessary over a 30-year-period, mainly for haemodynamic reasons or compression. A review of the literature revealed seven similar cases, two of which had Ehlers-Danlos Syndrome.