Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines

Lower extremity deep vein thrombosis is a serious medical condition that can result in death or major disability due to pulmonary embolism or post-thrombotic syndrome. Appropriate diagnosis and treatment are required to improve symptoms and salvage the affected limb. Early thrombus clearance rapidly resolves symptoms related to venous obstruction, restores valve function and reduces the incidence of post-thrombotic syndrome. Recently, endovascular treatment has been established as a standard method for early thrombus removal. However, there are a variety of views regarding the indications and procedures among medical institutions and operators. Therefore, we intend to provide evidence-based guidelines for diagnosis and treatment of lower extremity deep vein thrombosis by multidisciplinary consensus. These guidelines are the result of a close collaboration between interventional radiologists and vascular surgeons. The goals of these guidelines are to improve treatment, to serve as a guide to the clinician, and consequently to contribute to public health care.

Anatomical Features and Early Outcomes of Endovascular Repair of Abdominal Aortic Aneurysm from a Korean Multicenter Registry

PURPOSE: To introduce a nation-based endovascular aneurysm repair (EVAR) registry in South Korea and to analyze the anatomical features and early clinical outcomes of abdominal aortic aneurysms (AAA) in patients who underwent EVAR. MATERIALS AND METHODS: The Korean EVAR registry (KER) was a template-based online registry developed and established in 2009. The KER recruited 389 patients who underwent EVAR from 13 medical centers in South Korea from January 2010 to June 2010. We retrospectively reviewed the anatomic features and 30-day clinical outcomes. RESULTS: Initial deployment without open conversion was achieved in all cases and procedure-related 30-day mortality rate was 1.9%. Anatomic features showed the following variables: proximal aortic neck angle 48.8+/-25.7degrees (mean+/-standard deviation), vertical neck length 35.0+/-17.2 mm, aneurysmal sac diameter 57.2+/-14.2 mm, common iliac artery (CIA) involvement in 218 (56.3%) patients, and median right CIA length 34.9 mm. Two hundred and nineteen (56.3%) patients showed neck calcification, 98 patients (25.2%) had neck thrombus, and the inferior mesenteric arteries of 91 patients (23.4%) were occluded. CONCLUSION: Anatomical features of AAA in patients from the KER were characterized as having angulated proximal neck, tortuous iliac artery, and a higher rate of CIA involvement. Long-term follow-up and ongoing studies are required.

Analysis of Intermediate Term Results of Short Vein Bypass Graft in the Patient with Critical Limb Ischemia

PURPOSE: Since the introduction of short vein bypass (SVB), many have reported its feasibility when long vein bypass (LVB) cannot be performed due to limited vein conduit. However, the presence of inflow-vessel disease may affect graft patency and thus require endovascular treatment prior to surgery. Our study aims to analyze the results between SVB and LVB. MATERIALS AND METHODS: From 2009 to 2013, 27 bypass procedures were reviewed retrospectively. Outcomes such as patency rate, postoperative ankle brachial index (ABI) and limb salvage rate between SVB and LVB were compared. Wound healing time and primary patency rate were analyzed and the former was also analyzed according to the respective angiosome and revascularization type. RESULTS: There were 11 males and 16 females and the mean age was 66.6+/-12.3 years. Twenty four patients had TransAtlantic Inter-Society Consensus (TASC) D and 3 patients had TASC C lesions below knee. The 1-year cumulative patency rate between SVB and LVB were 63% and 66%, P=0.627. The limb salvage rate (100% vs. 73%; P=0.280) and postoperative ABI (0.592 vs. 0.508; P=0.620) were higher in the SVB group than in the LVB group, although the differences were not significant. There was no difference in wound healing time by angiosomal revascularization type. In situ vein graft showed higher patency rate than reversed greater saphenous vein (75% vs. 61%; P=0.00) CONCLUSION: The results of SVB were similar to those of LVB. SVB is feasible in the setting of limited conduit availability, in combination with endovascular treatment in the presence of proximal lesions.

Clinical Implications of Methylenetetrahydrofolate Reductase Mutations and Plasma Homocysteine Levels in Patients with Thromboembolic Occlusion

PURPOSE: Hyperhomocysteinemia has been identified as an independent risk factor in arterial and venous thrombosis. Mutations in genes encoding methylenetetrahydrofolate reductase (MTHFR), involved in the metabolism of homocysteine, may account for reduced enzyme activity and elevated plasma homocysteine levels. In this study, we investigated the interrelation of MTHFR C677T genotype and level of homocysteine in patients with arterial and venous thrombosis. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 146 patients who were diagnosed as having arterial and venous thrombosis. We excluded patients diagnosed with atrial fibrillation. We examined routinely the plasma concentration of total homocysteine level and MTHFR C677T polymorphism for evaluation of thrombotic tendency in all patients. Screening processes of MTHFR C677T polymorphism were performed by real-time polymerase chain reaction. RESULTS: Investigated groups consisted of thrombotic arterial occlusion in 48 patients and venous occlusion in 63 patients. The distribution of the three genotypes was as follows: homozygous normal (CC) genotype in 29 (26.1%), heterozygous (CT) genotype in 57 (51.4%), and homozygous mutant (TT) genotype in 25 (22.5%) patients. There were no significant differences among individuals between each genotype group for baseline characteristics. Plasma concentration of homocysteine in patients with the TT genotype was significantly increased compared to the CC genotype (P<0.05). CONCLUSION: We observed a significant interaction between TT genotypes and homocysteine levels in our results. The results might reflect the complex interaction between candidate genes and external factors responsible for thrombosis.

Staged Hybrid Revascularization in Patients with Peripheral Arterial Occlusive Disease / 대한혈관외과학회지

PURPOSE: With the development of endovascular interventions, hybrid reconstructions, which include the combination endovascular procedure and open bypass surgery, have been increasingly used for the management of peripheral arterial occlusive disease (PAOD). The goal of this study is to present our results in the management of PAOD and to define the role of staged hybrid techniques in patients who need revascularization compared to other revascularization procedures, such as open or endovascular techniques. METHODS: We reviewed 104 patients who underwent arterial revascularization between January 2005 and June 2010, retrospectively. The data were divided into three groups by treatment modality: the open bypass group (n=47, 45.2%), the endovascular group (n=46, 44.2%), and the staged hybrid group (n=11, 10.6%), and were classified according to the Trans-Atlantic Society Consensus II (TASC II) A/B/C/D. Patients' characteristics, overall primary and secondary patency rates, and 30-day complications were compared between the three groups. RESULTS: Mean age was 69.6 years and 84.6% were male. There were more TASC II D lesions and multiple lesions in the hybrid group. There were no statistically significant differences in the 36-month mortality rate, primary patency rate, and secondary patency rate among the three groups (P=0.170, 0.838, and 0.767, respectively). CONCLUSION: Staged hybrid revascularization is an acceptable strategy in patients with PAOD, especially TASC II D and multiple lesions for suitable case with comparable patency, even though the number of cases was relatively small.

Local Complications Associated with Vascular and Endovascular Surgery

Vascular surgeons encounter a myriad of complications during the management of patients. The complications that occur associated with vascular surgery are often life threatening. Vascular surgeons have played a pioneering role in the development and introduction of new vascular and endovascular techniques, and some of the techniques changed the therapeutic options available for patients with vascular disease. Especially, with the development of endovascular surgery, there has been substantial change in the management of most vascular diseases and their complications. The best way to manage complications is to prevent them from occurring by careful planning, appropriate patient selection, extensive operator experience, and the correct use of appropriate devices. Successful operation outcomes depend on avoiding complications, as well as recognizing and promptly managing complications when they occur. This article reviews various local complications and their management in the field of vascular and endovascular surgery.

Clinicopathologic Findings of Micropapillary Carcinomas, according to Tumor Size

PURPOSE: Papillary thyroid microcarcinomas (PTMC), which are not palpable and have no clinical symptoms are 1.0 cm or less in diameter. The optimal extent of thyroid tumor resection has been controversial. We investigated clinicopathological findings of PTMC of 5 mm or less in diameter for reasonable therapeutic approach. METHODS: From, Jan. 2002 to Dec. 2006, 366 patients underwent thyroidectomy for thyroid papillary carcinoma at our institution. Among these patients, 62 patients with a mass measuring less than 5 mm and 103 patients with a mass 5 mm to 1.0 cm were selected. We retrospectively reviewed their medical records. RESULTS: There was no significant difference on the clinical characteristics except multifocality. We performed more unilateral lobectomy, near total thyroidectomy with or without neck node dissection in patients with PTMC of less than 5 mm (P=0.13). In permanent biopsy, lymph node metastasis more frequently occurred in patients with PTMC of less than 5 mm (P=0.03). There were no differences in capsular invasion, distant metastasis or recurrence. CONCLUSION: In papillary thyroid microcarcinoma less than 0.5 cm, it is very uncommon for capsular invasion, distant metastasis and locoregional metastasis to exist. The extent of tumor resection may be limited less than near total thyroidectomy for suitable cases, because there was no locoregional metastasis or distant metastasis in the follow-up period. Longer follow-up periods would be required to confirm that limited surgery is sufficient for tumors less than 0.5 cm in size.

Experience with Directional Atherectomy in Infrainguinal Peripheral Arterial Disease with Using a Silverhawk Plaque Excision Device

PURPOSE: This study was conducted to report our single center experience with performing directional atherectomy in patients with infra-inguinal arterial disease by using the Silverhawk plaque excision device. This procedure was performed at Washington University Hospital in St. Louis, USA (WASH). METHODS: Fifty-six patients with 102 lesions and who were classified into the Rutherford categories 2 to 6 underwent 66 procedures using the Silverhawk device from November 2004 to July 2007 in WASH. The patients' medical records were retrospectively reviewed. RESULTS: The initial technical success rate was 86.4%. The primary patency rate and limb salvage rate at 1 year was 48.5% and 80.3%, respectively. After 2 year' s follow-up, there was no occlusion or limb loss, and the overall primary patency rate and limb salvage was 45.5% and 75.8%, respectively. The mean preoperative ABI was 0.52+/-0.24 and the postoperative ABI was 0.73+/-0.22 (P=0.001). The one-year primary patency rate in the TASC II A and B group was 56.4% and that in the C and D group was 29.6% (P=0.003, P=0.007), respectively. There was a significantly different between both groups. However, the location, nature and length of the lesion, the Rutherford category and the adjunctive procedures did not statistically affect the primary patency rate. CONCLUSION: In this study, the Silverhawk plaque excision device was a feasible treatment modality for infra-inguinal peripheral arterial disease because of its high technical success rate, the primary patency rate and the limb salvage rate. However, it had an obstacle for being accepted for widespread use because secondary endovascular techniques are frequently required for restenosis after plaque excision. The practical use of the Silverhawk is controversial and further studies will be needed.

VTE Prevalence and Prophylaxis in Surgical Patients

No abstract available.

The Risk Factors Associated with Surgical Site Infection after an Abdominal Operation

PURPOSE: Surgical site infection (SSI) is the most common nosocomial infection in surgical patients, and this accounts for 38% of all patients with nosocomial infections. Despite the advances in techniques and knowledge to prevent infection, SSI remains a significant source of postoperative morbidity and mortality, and it results in a prolonged hospital stay and increased cost. This study aims to assess the incidence of SSI and to identify the risk factors associated with SSI for patients who undergo abdominal operation. METHODS: The data on 347 abdominal operations that were done under general anesthesia from 1 August 2005 to 31 July 2006 was collected and reviewed. RESULTS: The overall incidence of SSI was 4.9%. Comorbidity was the independent risk factor for the development of SSI (P=0.011). The development of SSI was related with the American Society of Anesthesiologists (ASA) preoperative assessment score (P=0.025). The duration of the operation had a statistically significant association with an increased risk of SSI on univariate analysis. The wound classification was not associated with SSI. Staphylococcus aureus was the most frequently isolated organism, and all of the cases were methcillin-resistant Staphylococcus aureus. CONCLUSION: This study demonstrate that comorbidity is a significant independent risk factor for SSI.