The relationship between psychological distress and impairment of disease-specific quality-of-life compared between liquid sclerocompression therapy and invasive treatments in patients with superficial venous disease during a one-year follow-up.

INTRODUCTION: Superficial venous disease (SVD) is a very common disease and much research has been done towards finding the ideal treatment and discovering the pathophysiology of SVD. Not much is known about the psychological burden of SVD. Current guidelines and scientific publications tend to focus on clinical and physiological aspects of SVD. The aim of this study was to relate the changes in Quality-of-Life (QoL) after SVD treatment to possible changes in psychological distress (PD). METHODS: A prospective cohort was set up with the assistance of 5 specialized vein clinics in the Netherlands. Inclusion criteria were: 18 years of age or older, fluent in Dutch language, C1 to C6 (CEAP) class intended to be primary treated with either endovenous laser(LA), radiofrequency ablation (RFA) and phlebectomy(PHL) or sclerocompression therapy alone (SCT). Patients were divided in two groups:1. C1-C3 patients treated by SCT2. C1-C6 patients treated invasively (LA, RFA and PHL)Outcomes were a disease specific QoL questionnaire (CIVIQ-20) and a questionnaire to assess PD (Hospital Anxiety and Depression Scales (HADS)). This study was approved by the local institutional review board, following the principles outlines in the Declaration to Helsinki. This trial was registered in the ISRCTN registry with study ID ISRCTN12085308. RESULTS: 442 patients were included in the study and completed the T0 measurements. Mean age of these patients is 54.4 years (s.d. 12.9, 17-90). Number of females: 349 (79.0%), of males: 93 (21.0%). The mean baseline (T-0) HADS depression (0-3) scale scores is 2.54 (s.d. 0.51, n = 412). The mean one-year difference between T-12 HADS depression (0-3) scale scores and baseline T-0 scores is +0.06. The mean baseline (T-0) HADS anxiety (0-3) scale scores is 2.19 (s.d. 0.5, n = 283). The mean one-year difference between T-12 HADS anxiety (0-3) scale scores and baseline T-0 scores is +0.06. Controlled for baseline scores, gender, age, weight and length(BMI), patients in group 2 (receiving invasive treatment) show significantly higher one-year improvement in the QoL of their psychological state of mind than patients in group 1 (receiving SCT and having C1,2,3) (beta 0.158 p = 0.002). CONCLUSIONS: The significant improvement in psychological, QoL and clinical scores that we observe after successful invasive treatment compared to no significant improvement after SCT and the lack of psychological distress in patients with "simple" SVD indicates that SCT is mainly performed for cosmetic reasons. One could thus argue that reimbursement of SCT as a stand-alone medical treatment is debatable.

Duplex-guided versus Conventional Percutaneous Transluminal Angioplasty of Iliac TASC II A and B Lesion: A Randomized Controlled Trial.

BACKGROUND: Percutaneous transluminal angioplasty (PTA) requires the use of nephrotoxic contrast. Patients with chronic kidney disease are more prone to develop contrast-induced nephropathy after utilization of contrast. Doppler ultrasound (duplex)-guided PTA (DuPTA) is a novel technique and has recently proven to be a successful alternative to conventional PTA in the treatment of iliac stenotic disease, without the use of contrast. In this randomized controlled trial, we evaluated whether DuPTA is as effective as conventional PTA in the treatment of iliac arterial stenotic disease. METHODS: From June 2013 till January 2017, 142 patients with symptomatic peripheral arterial disease (PAD), with significant (>70%) iliac stenotic lesions (both isolated and patients with multilevel disease without treatment of other lesions), were randomized to receive either conventional PTA or DuPTA of the iliac lesion, regardless of renal function. All patients received an ankle-brachial index, arterial mapping with duplex, and magnetic resonance angiography in the pre-operative work-up. Primary end point was procedural success, defined as passing the guidewire through the stenotic lesion and performing a PTA, with or without stenting. Reduction in peak systolic velocity (PSV) of ≥50% after successful PTA was required in the DuPTA group. Angiographic reduction of more than 50% was required in the interventional group. Decrease in PSV was evaluated in both groups 4 weeks post-procedure. RESULTS: Passing of the guidewire through the stenotic lesion was achieved in 96.5% of the DuPTA group and 98.8% of the PTA group (P = 0.34). Although PSV decreased significantly in both groups 4 weeks post-operative, PSV reduction ≥50% was significantly higher in the DuPTA group, respectively 78% vs. 58% in the PTA group (P < 0.01). The utilization of stents was significantly greater in the DuPTA group (52% vs. 18%, P < 0.01). After correction of potential confounders, significant difference in ≥50% PSV reduction remained; technical success did not differ significantly. CONCLUSIONS: DuPTA is a feasible alternative to conventional PTA in the treatment of PAD on the iliac anatomic level. Duplex examination before removal of the guidewire is recommended to evaluate adequate decrease in PSV and identify potential recoil.

Loss of Kidney Function after Endovascular Treatment of Peripheral Arterial Disease.

BACKGROUND: Administration of radiocontrast during endovascular procedures for peripheral arterial disease (PAD) may cause acute kidney injury, which generally recovers with supportive treatment. Long-term effects of endovascular procedures on renal function remain to be investigated. METHOD: This retrospective observational cohort study includes all patients who newly presented to the vascular surgery outpatient clinic with Rutherford class II or III PAD and who were treated with either supervised exercise therapy or endovascular interventions. Changes in estimated glomerular filtration rates (eGFR) after 1 year were compared between the 2 treatment groups. Multivariate regression analysis and propensity score-matched paired analysis were done to correct for potential confounders. RESULTS: One year after treatment, eGFR was reduced by 8.6 mL/min (95% confidence interval [CI], 7.3-9.9, P < 0.001) after endovascular intervention (n = 284) and by 1.7 mL/min (95% CI, 0.9-25, P < 0.001) after supervised exercise therapy (n = 299). After correction for potential confounders, endovascular interventions were associated with 9.2 mL/min (95% CI, 5.9-12.4, P < 0.001) more renal decline compared to exercise therapy. Similar results were found in the propensity score-matched paired analysis. CONCLUSIONS: Endovascular procedures for PAD are associated with clinically relevant and long-term loss of kidney function.

Loss of kidney function in patients with critical limb ischemia treated endovascularly or surgically.

BACKGROUND: Acute kidney injury after the administration of contrast material during endovascular procedures for peripheral arterial disease generally recovers with supportive treatment. However, long-term effects of endovascular procedures for critical limb ischemia on renal function remain to be investigated. METHODS: This retrospective observational cohort study included all patients who newly presented to the vascular surgery outpatient clinic with Rutherford class 4 to class 6 peripheral arterial disease and who were treated with either endovascular or surgical interventions. Changes in estimated glomerular filtration rate (eGFR) after 1 year were compared between the two types of intervention. Multivariate linear regression analysis was done to correct for potential confounders. RESULTS: One year after treatment, eGFR was reduced by 15.0 mL/min (95% confidence interval [CI], 13.1-17.0; P < .001) after endovascular interventions (n = 209) and by 7.6 mL/min (95% CI, 5.1-10.0; P < .001) after surgical therapy (n = 81). Although eGFR rates decreased in both groups, loss of renal function was significantly greater in patients after endovascular interventions (P < .001). Furthermore, 77% of patients receiving endovascular interventions experienced fast renal decline (defined as >4 mL/min loss of eGFR within 1 year) compared with 54% of patients treated surgically (P < .001). After correction for potential confounders, endovascular intervention was associated with 7.4 mL/min (95% CI, 5.4-9.3; P < .001) greater loss of renal function compared with patients treated surgically. CONCLUSIONS: Endovascular procedures for critical limb ischemia are associated with clinically relevant permanent long-term loss of kidney function. This loss of renal function is greater than in comparable patients who were treated with open surgery.

Radiation Exposure during Percutaneous Transluminal Angioplasty for Symptomatic Peripheral Arterial Disease.

BACKGROUND: Endovascular interventions often are the preferred treatment in peripheral arterial disease for both intermittent claudication and chronic critical limb ischemia. Ever more advanced and anatomically complex procedures are being performed, which may increase the radiation exposure of patients and medical staff. We sought to determine the radiation exposure sustained in contemporary interventional radiology practice. METHODS: A single-center observational cohort study of patients undergoing endovascular interventions for symptomatic peripheral arterial disease between January 1st, 2011 and July 31st, 2013 was performed. Radiation dose area product (DAP), peak skin dose (PSD), fluoroscopy time, and volume of contrast media were either measured or calculated and stratified according to patient demographics and anatomic location. RESULTS: In 951 patients, who were treated with endovascular interventions, mean DAP was 108 ± 88 Gy × cm(2) and mean fluoroscopy time was 13 ± 12 min. DAP was significantly higher for aortoiliac procedures (142 ± 103 Gy × cm(2)) compared with femoral (58 ± 73 Gy × cm(2)), below-knee (45 ± 51 Gy × cm(2)) and multilevel (83 ± 90 Gy × cm(2)) procedures (P < 0.001 for all comparisons). PSD was significantly higher for aortoiliac procedures (0.99 ± 0.54 Gy) compared with femoral (0.55 ± 0.55 Gy), below-knee (0.48 ± 0.27 Gy), and multilevel (0.68 ± 0.47 Gy) procedures (P < 0.001 for all comparisons). In contrast, mean fluoroscopy time in aortoiliac interventions was significantly shorter (10 ± 15 min) compared with femoral (15 ± 12 min), below-knee (19 ± 10 min), and multilevel (23 ± 14 min) procedures (P < 0.001 for all comparisons). CONCLUSIONS: Endovascular interventions in patients with symptomatic peripheral arterial disease involve a substantial radiation dose. Although fluoroscopy time is shorter, aortoiliac interventions result in greater radiation exposure than femoropopliteal or infrapopliteal interventions.

Prospective study of a single treatment strategy for local tumescent anesthesia in Muller phlebectomy.

BACKGROUND: Ambulatory Muller phlebectomy for varicose veins can be performed under local anesthesia. However, subcutaneous injection of local tumescent anesthetics may cause discomfort because of acidity of the solution. Addition of sodium bicarbonate lowers the acidity of anesthetic solutions, which might cause less pain. The objective of this study was to study whether alkalinization of the local anesthetic solution with sodium bicarbonate 1.4% decreases perioperative pain during Muller phlebectomies. METHODS: It is a double-blind single-center randomized controlled trial. In all, 101 patients scheduled for ambulatory Muller phlebectomy were randomized to receive either local anesthesia with alkalinized solution (lidocaine 1% and epinephrine in sodium bicarbonate 1.4%) or standard solution (lidocaine 1% and epinephrine in saline 0.9%). Primary outcome was pain during injection of local anesthetics with the use of the Visual Analogue Scale (VAS). Secondary outcomes were peroperative and postoperative pain, use of analgesics, patient satisfaction, return to function, and complications. RESULTS: Patients receiving subcutaneous injection of local anesthetics diluted in sodium bicarbonate 1.4% experienced significantly less pain during injection compared with patients treated with standard anesthetic solution (VAS, 1.75 ± 1.8 vs. 3.55 ± 2.2, P < 0.00). Peroperative and postoperative pain, complication rates, use of analgesics, patient satisfaction, return to function, and complications did not differ between the 2 groups (P > 0.10). CONCLUSIONS: Alkalinization of local anesthetic solution with sodium bicarbonate 1.4% significantly improves patient comfort during injection of local tumescent anesthesia.

Contrast Free Duplex-Assisted EVAR in Patients with Chronic Renal Insufficiency.

Renal insufficiency and allergy for iodinated contrast are the main contra-indications for Endovascular Aortic Repair (EVAR). Various techniques have been used to minimize utilization of contrast in order to prevent contrast induced nephropathy. EVAR can be performed without nephrotoxic contrast, using additional duplex-guidance. This report describes three cases of duplex-assisted EVAR in patients with chronic renal insufficiency.

Role of compression stockings after endovenous laser therapy for primary varicosis.

OBJECTIVE: The objective of this prospective, randomized trial was to evaluate the effect of compression stockings after endovenous laser therapy (EVLT) for insufficiency of the great saphenous vein. Effect evaluation was focused on differences in postoperative pain within 6 weeks. METHODS: The study randomized 111 patients undergoing EVLT for duplex ultrasound-confirmed great saphenous vein insufficiency (C2-4EPASPR) to receive either 2 weeks of elastic stockings (class II, thigh length) or no elastic stockings after an initial 24-hour period of wearing bandages. Patients registered pain scores (primary outcome) and use of analgesics in a diary on a visual analog scale. At 2 days, 14 days, and 6 weeks after the procedure, leg circumferences, Aberdeen Varicose Vein Questionnaire scores, RAND 36-Item Health Survey scores, patient satisfaction (5-point scale), time before returning to work, and adverse events (secondary outcomes) were evaluated. RESULTS: In the 79 patients (15 men and 64 women; mean age, 52 years) who completed the treatment and follow-up, small but significant differences in pain scores were observed during the first week after laser surgery, with more favorable scores in the group wearing stockings. Patients not wearing stockings used more analgesics than did patients wearing stockings (P < .05). Patients wearing stockings reported a statistically significantly higher score of satisfaction at 2 days (4.44 vs 4.15) and 6 weeks (4.59 vs 4.18), although the absolute differences were small. No significant differences were found regarding time to return to work, Aberdeen Varicose Vein Questionnaire scores, RAND 36-Item Health Survey scores, leg circumference measurements, and risk of complications. CONCLUSIONS: Wearing of postoperative stockings for 2 weeks after an initial 24-hour period of wearing bandages results in a small but significant reduction of postoperative pain and use of analgesics compared with not wearing compression stockings after EVLT for great saphenous vein insufficiency.

Primary aortoduodenal fistula and Q-fever.

Patients with abdominal aortic aneurysm (AAA) are prone to vascular infection with chronic Q-fever. There is a rising incidence of up to 8% of chronic Q-fever in The Netherlands. Increased vascular aortic aneurysm infection with chronic Q-fever is reported. This report shows two rare cases of primary aortoduodenal fistulae in patients with chronic Q-fever and an AAA. We describe the clinical symptoms, diagnostic tools for detection of Coxiella burnetii infection and treatment.

Minimally invasive vein harvesting in femoropopliteal bypass surgery: does using an old technique give new perspectives? Short report of five patients.

BACKGROUND: Femoropopliteal bypass surgery is the most commonly performed type of peripheral bypass in vascular surgery. The great saphenous vein (GSV) is the preferred bypass conduit. Commonly used methods of GVS harvesting are related to morbidity, such as wound infection, skin necrosis, hematoma, and edema. METHODS: In this feasibility study we present an "old-new" way of harvesting of the GSV by inversion stripping, which is significantly less invasive than conventional GSV harvesting, resulting in less morbidity. RESULTS: All patients recovered uneventfully and all lower limb wounds healed with conventional wound management. No excessive bruising was seen in the VSM trail nor were there any surgical wound infections. CONCLUSIONS: The inversion stripping of the GSV is an easy, safe, and minimally invasive harvesting technique for bypass surgery.

Anterior tibial artery aneurysm: Case report and literature review.

INTRODUCTION: We present a patient with a true anterior tibial artery aneurysm without any causative history. PRESENTATION OF CASE: A 59 year old male was referred with a swelling on his left lateral ankle which he noticed 2 months ago, with symptoms of soaring pain. Additional radiological research showed a true arterial tibialis anterior aneurysm. True anterior tibial artery aneurysm is a rare condition. The aneurysm was repaired by resection and interposition of a venous bypass. DISCUSSION: Patients may complain about symptoms like calf pain, distal ischemia, paresthesias due to nerve compression and the presence of a pulsating or increasing mass. Symptomatic aneurysms require surgical intervention, where bypass with a venous saphenous graft have shown good patency and endovascular treatment have shown good short term results. Asymptomatic and small aneurysm can be followed for several years with DUS. CONCLUSION: Clinical features, radiographic findings, surgical management, and a review of the literature on true anterior tibial aneurysms are discussed.

Aberrant insertion of the right subclavian artery: an unusual cause of dysphagia in an adult.

INTRODUCTION: Within this report, we present a patient with difficulty of swallowing caused by an aberrant right subclavian artery. DISCUSSION: This is a congenital anomaly with the right subclavian artery originating from the dorsal part of the aortic arch and coursing through the mediastinum between the esophagus and the vertebral column. The diagnosis and treatment of this disorder is discussed based on the findings from the literature.

Retarded hand growth due to a hemodialysis fistula in a young girl.

Long-term presence of an arteriovenous hemodialysis fistula (AVF) may lead to alterations in hand perfusion. In the case reported here, a 14-year-old girl developed pain associated with hand ischemia 5 years after a successful kidney transplantation. At age 8 years, she required a period of hemodialysis using an autogenous left upper arm AVF. Compared to the healthy right hand, a smaller ischemic left hand was observed in the presence of a patent AVF. Access flow was 1400 ml/min. Seldinger angiography demonstrated a stenotic brachial artery, and duplex measurements indicated a reversed blood flow in the radial artery. AVF ligation abolished the ischemic symptoms. Distal hypotension due to an impaired arterial inflow combined with a low resistance elbow AVF may result in chronic hypoperfusion of acral portions of the extremity and growth retardation. Access ligation is advised in children with an optimal renal transplant function and a patent elbow AVF suffering from lowered distal tissue perfusion.