Histological Analysis of a Long Term Patent Subintimal Canal in the Superficial Femoral Artery.

INTRODUCTION: Subintimal angioplasty (SIA) was introduced in the late 1980s and is a supplement to bypass surgery. Adaptation of the technique has been hampered by high rates of early intervention to maintain patency, but the long term assisted patency is good. REPORT: The superficial femoral and popliteal artery containing a patent subintimal canal were explanted from a patient who died in the authors' ward. Histological analysis indicated that the lumen was created in the medial layer of the vessel wall. A collagen rich neointima and fragmented internal elastic lamina were observed, presumably as a result of activated smooth muscle cells. The luminal surface was partly covered by a single layer of CD31, von Willebrand factor, and partly CD144 positive cells. An early atherosclerotic lesion was observed distally in the subintimal canal. DISCUSSION: Remodelling and neo-cellularisation of the vascular wall after SIA are described. Notably, hallmarks of early and late stage atherosclerotic disease were evident throughout the subintimal canal. These observations require confirmation in a larger number of specimens but underscore the need for surveillance after SIA.

A comparative cohort study of totally laparoscopic and open aortobifemoral bypass for the treatment of advanced atherosclerosis.

BACKGROUND: Totally laparoscopic aortobifemoral bypass (LABF) procedure has been shown to be feasible for the treatment of advanced aortoiliac occlusive disease (AIOD). This study compares the LABF with the open aortobifemoral bypass (OABF) operation. METHODS: In this prospective comparative cohort study, 50 consecutive patients with type D atherosclerotic lesions in the aortoiliac segment were treated with an LABF operation. The group was compared with 30 patients who were operated on with the OABF procedure for the same disease and time period. We had an explanatory strategy, and our research hypothesis was to compare the two surgical procedures based on a composite event (all-cause mortality, graft occlusion, and systemic morbidity). Stratification analysis was performed by using the Mantel-Haenszel method with the patient-time model. Cox multivariate regression method was used to adjust for confounding effect after considering the proportional hazard assumption. Cox proportional cause-specific hazard regression model was used for competing risk endpoint. RESULTS: There was a higher frequency of comorbidity in the OABF group. A significant reduction of composite event, 82% (hazard ratio 0.18; 95% CI 0.08-0.42, P=0.0001) was found in the LABF group when compared with OABF group, during a median follow-up time period of 4.12 years (range from 1 day to 9.32 years). In addition, less operative bleeding and shorter length of hospital stay were observed in the LABF group when compared with the OABF group. All components of the composite event showed the same positive effect in favor of LABF procedure. CONCLUSION: LABF for the treatment of AIOD, Trans-Atlantic Inter-Society Consensus II type D lesions, seems to result in a less composite event when compared with the OABF procedure. To conclude, our results need to be replicated by a randomized clinical trial.

[Surgical treatment of atherosclerosis in the lower limbs]. / Kirurgisk behandling av aterosklerose i underekstremitetene.

BACKGROUND: Walking exercise, smoking cessation and best medical therapy are cornerstones in all treatment of atherosclerosis. For patients with intermittent claudication or critical limb ischemia, endovascular therapy (which has developed substantially during the last decade) has become the first line treatment (when feasible). The aim of this article is to provide an overview of options for surgical treatment of peripheral atherosclerosis in the lower limbs. MATERIAL AND METHODS: The article is based on literature identified through a non-systematic search in PubMed, vascular textbooks and the authors' own clinical experience. RESULTS: When endovascular therapy has failed or is not feasible, open surgical techniques are used, such as endarterectomy and bypass surgery to the popliteal or distal arteries. Hybrid procedures, with femoral endarterectomy and distal or proximal endovascular intervention, are often used. Increased use of endovascular treatment reduces the procedural time, length of hospital stay and the rate of complications. In patients with extreme disease progression, primary amputation may still be the treatment of choice. INTERPRETATION: Surgical treatment of peripheral artery disease requires competence both within radiological intervention and open surgical treatment modalities.

[Laparoscopic aortic surgery]. / Laparoskopisk aortakirurgi.

BACKGROUND: Laparoscopic aortic surgery (LAS), performed since 1993, has undergone a number of technical improvements during recent years. The published results are comparable with those for open surgery. The aim of this article is to present the method with a focus on technical details, and at the same time present our experience with this technique. MATERIAL AND METHODS: Eight patients with debilitating intermittent claudication were operated with a total laparoscopic aortofemoral bypass. Operations were performed through a transperitoneal retrorenal approach. Median age of the patients was 61 years (range 51-76). All patients had an aortoiliac occlusive disease of type D according to the Transatlantic Inter Society Consensus (TASC). Prior to the procedures an operation team followed a structured training programme that comprised using a training model and operating on pigs, and visited an international referral centre. RESULTS AND INTERPRETATION: All operations were successfully performed. No patient developed per- or post-operative complications. Median post-operative hospital stay was four days. LAS is a technically demanding procedure and it can be established through well targeted and carefully planned training.

[Thoracoscopic sympathectomy in the treatment of palmar hyperhidrosis and facial blushing]. / Torakoskopisk sympatektomi mot uttalt håndsvette og ansiktsrødming.

BACKGROUND: Severe palmar hyperhidrosis and facial blushing are conditions connected with considerable psychosocial burden. Conservative treatment is often of limited value. Several reports have demonstrated high success rates in thoracoscopic sympathectomy. Treatment results from Norwegian centres have not previously been published. MATERIAL AND METHODS: The long term effects of thoracoscopic sympathectomy performed between 1998 and 2002 at Aker University Hospital were evaluated by questionnaire, using VAS scores (visual analogue scales) obtained from 72 out of 76 operated patients. RESULTS: In palmar hyperhidrosis, a reduction in VAS score above 3 was reported in 27 of 28 patients (from mean 9.5 +/- 0.2 to 0.8 + 0.4). In facial blushing, 39 of 44 patients reported a reduction in VAS score above 3 (from mean 8.9 +/- 0.3 to 2.5 +/- 0.4). The overall satisfaction rate was 90 %. A majority of patients (86 %) experienced variable but lasting compensatory general hyperhidrosis. However, only a few patients found this condition disabling to the extent that it caused regret (3 patients) or dissatisfaction (4 patients). CONCLUSION: Thoracoscopic sympathectomy markedly reduces palmar hyperhidrosis and facial blushing, but the indication should be strong and the information thorough because of compensatory hyperhidrosis.