International Consortium of Vascular Registries Consensus Recommendations for Peripheral Revascularisation Registry Data Collection.

OBJECTIVE/BACKGROUND: To achieve consensus on the minimum core data set for evaluation of peripheral arterial revascularisation outcomes and enable collaboration among international registries. METHODS: A modified Delphi approach was used to achieve consensus among international vascular surgeons and registry members of the International Consortium of Vascular Registries (ICVR). Variables, including definitions, from registries covering open and endovascular surgery, representing 14 countries in ICVR, were collected and analysed to define a minimum core data set and to develop an optimum data set for registries. Up to three different levels of variable specification were suggested to allow inclusion of registries with simpler versus more complex data capture, while still allowing for data aggregation based on harmonised core definitions. RESULTS: Among 31 invited experts, 25 completed five Delphi rounds via internet exchange and face to face discussions. In total, 187 different items from the various registry data forms were identified for potential inclusion in the recommended data set. Ultimately, 79 items were recommended for inclusion in minimum core data sets, including 65 items in the level 1 data set, and an additional 14 items in the more specific level 2 and 3 recommended data sets. Data elements were broadly divided into (i) patient characteristics; (ii) comorbidities; (iii) current medications; (iv) lesion treated; (v) procedure; (vi) bypass; (vii) endarterectomy (viii) catheter based intervention; (ix) complications; and (x) follow up. CONCLUSION: A modified Delphi study allowed 25 international vascular registry experts to achieve a consensus recommendation for a minimum core data set and an optimum data set for peripheral arterial revascularisation registries. Continued global harmonisation of registry infrastructure and definition of items will overcome limitations related to single country investigations and enhance the development of real world evidence.

Percutaneous transluminal angioplasty of infrainguinal vein graft stenosis is not a negative predictor for long-term patency.

BACKGROUND: To investigate whether maintenance percutaneous transluminal angioplasty (PTA) for significant stenosis after infrainguinal bypass grafting affects long-term patency of the bypass grafts in comparison to those not needing intervention. PATIENTS AND METHODS: The cohort includes 141 consecutive patients with 157 infrainguinal vein grafts performed from January 1996 to December 2005. Grafts occluded within three months after operation were excluded. Revascularisations needing maintenance PTA for significant stenoses of graft or adjacent in- or outflow vessels (intervention group, n = 39) were compared to those not needing intervention during follow up (non-intervention group, n = 118). Primary end point was bypass occlusion. Secondary end points were major amputation or death. Long-term patency in the intervention and non-intervention groups was estimated using Kaplan-Meier curves and compared using the Tarone-Ware test. RESULTS: In the intervention group, primary assisted patency rate after 36 and 60 months was 94.1 % and 89.4 %, respectively, whereas in the non-intervention group patency rate was 92.5 % and 91.0 %, respectively (p = 0.644). Comparing the intervention group to the non-intervention group, 1 versus 2 major amputations (p = 0.642) and 14 versus 40 deaths (p = 0.233) occurred. CONCLUSIONS: Occurrence of graft stenosis did not decrease long-term patency rate when treated by PTA in comparison to grafts not needing maintenance PTA.

Aortic rupture in high-speed skiing crashes.

BACKGROUND: New equipment and techniques in winter sports, such as carving skis and snowboards, have brought up new trauma patterns into the spectrum of leisure trauma. The injuries resemble high-energy trauma known from road crashes. The aim of the present study was to assess the incidence of acute traumatic descending aortic rupture in recreational skiing-crashes. MATERIAL: Between January 1995 and December 2004, 22 patients were admitted to our hospital for aortic rupture. Four patients had skiing crashes (18.2%). Mean age was 31 years, all patients were male. In two cases, aortic rupture was associated with fractures of the upper and lower extremities. One patient additionally had a cerebral contusion with an initial Glasgow Coma Scale score of 13. In two patients, isolated aortic rupture was diagnosed. RESULTS: Two patients were treated by graft interposition, and one by endograft. One patient arrived under mechanical resuscitation without blood pressure. He died at admission. He had been observed for 5 hours in another hospital, complaining of severe intrascapular back pain, before transport to our trauma unit for unknown bleeding. In the other three cases, treatment was successful. CONCLUSION: Rescue services and paramedics should be aware of this new type of injury. Acute aortic rupture has to be considered as possible injury in high velocity skiing crashes.

Fractured and embolized coronary stent mimicking significant internal carotid stenosis.

We describe the case of 77-year-old woman who underwent five coronary angiographies in 9 months due to in-stent re-stenosis of Cypher-Stents, and who finally required coronary artery bypass grafting surgery. Preoperative investigations revealed a significant internal carotid stenosis, which was due to a fractured and embolized Cypher-Stent.

Combined regional thrombolysis and surgical thrombectomy for treatment of iliofemoral vein thrombosis.

OBJECTIVE: In at least half of patients with iliofemoral deep vein thrombosis post-thrombotic syndrome develops when only anticoagulant therapy is given. We combined thrombolysis, applied under ischemic conditions,with surgical thrombectomy to restore patency and valve function. The technique and the short-term and long-term results in 2 patient series are reported. METHODS: A catheter was inserted into a foot vein of the thrombosed leg, and the limb was excluded from the circulation with a pneumatic cuff placed on the thigh with the patient under general anesthesia. Urokinase (0.5 million-3 million IU) and heparin were infused and allowed to act for 30 minutes while the pelvic axis was cleared with a Fogarty catheter through an inguinal venotomy. The external iliac vein was then clamped and the cuff removed. Thrombi that detached from the wall were flushed out with reactive hyperemia and squeezed out with manual leg compression. The blood was retrieved, washed, and transfused back into the patient. Various additional procedures were performed to secure outflow. Two patient series are reported: 1 with 12 consecutive patients and 1 with 21 patients who were successfully treated 6 to 10 years previously. Follow-up data were obtained for all patients after 1 year and for 18 of 21 patients after 6 to 10 years. Patency and valve function were assessed with duplex scanning or venography. Studies of blood coagulation and the kinetics of urokinase were performed in 5 additional patients. RESULTS: Vein patency and valve function were restored in all consecutive patients. At 1 year none of the 33 patients had had recurrence, and none showed clinical signs of post-thrombotic syndrome. At 6 to 10 years 3 of 18 patients had experienced another venous thromboembolism, but none in the treated leg. Sixteen legs were asymptomatic without compression therapy, and 2 had venous claudication. Coagulation studies showed a trace concentration of urokinase and a mild decrease in fibrinogen in the systemic circulation. The concentration of urokinase in blood collected from the treated leg was only 1% of that infused. CONCLUSION: Regional thrombolysis combined with surgical thrombectomy is relatively easy to perform and seems safe. Vein patency and valve function were restored, and post-thrombotic syndrome was prevented. Additional procedures to overcome pelvic vein obstructions were required in 11 of 33 patients (33%). The procedure should be tested against standard anticoagulation therapy in patients with acute iliofemoral thrombosis.

First clinical experience with an anastomotic device to facilitate aortomesenteric saphenous vein bypass.

The use of a sutureless anastomotic device recently has been reported for the construction of the proximal anastomoses during aortocoronary bypass surgery. In this report, we describe the first reported application of this device for the sutureless aortic anastomosis of an aortosuperior mesenteric artery saphenous vein graft. Sutureless anastomoses reduce the need for extensive dissection of the inflow vessel and may be performed rapidly and without blood loss.