A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination.

BACKGROUND: Circulatory collapse is a leading cause of mortality among traumatic major exsanguination and in ruptured aortic aneurysm patients. Approximately 40% of patients die before hemorrhage control is achieved. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct designed to sustain the circulation until definitive surgical or endovascular repair. A systematic review was conducted for the current clinical use of REBOA in patients with hemodynamic instability and to discuss its potential role in improving prehospital and in-hospital outcome. METHODS: Systematic review and meta-analysis (1900-2017) using MEDLINE, Cochrane, EMBASE, Web of Science and Central and Emcare using the keywords "aortic balloon occlusion", "aortic balloon tamponade", "REBOA", and "Resuscitative Endovascular Balloon Occlusion" in combination with hemorrhage control, hemorrhage, resuscitation, shock, ruptured abdominal or thoracic aorta, endovascular repair, and open repair. Original published studies on human subjects were considered. RESULTS: A total of 490 studies were identified; 89 met criteria for inclusion. Of the 1436 patients, overall reported mortality was 49.2% (613/1246) with significant differences (p < 0.001) between clinical indications. Hemodynamic shock was evident in 79.3%, values between clinical indications showed significant difference (p < 0.001). REBOA was favored as treatment in trauma patients in terms of mortality. Pooled analysis demonstrated an increase in mean systolic pressure by almost 50 mmHg following REBOA use. CONCLUSION: REBOA has been used in trauma patients and ruptured aortic aneurysm patients with improvement of hemodynamic parameters and outcomes for several decades. Formal, prospective study is warranted to clarify the role of this adjunct in all hemodynamic unstable patients.

[A man with abdominal pain and subsequently a periumbilical haematoma]. / Een man met buikpijn en daarna een navelhematoom.

A 71-year-old male presented with periumbilical ecchymosis formed after acute onset of abdominal pain and near collapse. At the time of presentation the haematoma was the only symptom. Following a CT scan, the diagnosis of a contained rupture of an iliac artery aneurysm was made. The patient was successfully treated with an endovascular stent graft.

A Pseudoaneurysm of the Deep Palmar Arch After Penetrating Trauma to the Hand: Successful Exclusion by Ultrasound Guided Percutaneous Thrombin Injection.

INTRODUCTION: Pseudoaneurysm of the hand is a rare condition; most are treated surgically. Ultrasound guided thrombin injection has not previously been reported as a treatment option for pseudoaneurysms of the deep palmar arch. REPORT: A man was referred to the emergency department with a swollen, painful hand after penetrating trauma. On physical examination, a pulsating tumor was found on the dorsum of the hand. Imaging revealed a pseudoaneurysm vascularized by the deep palmar arch. Ultrasound guided percutaneous thrombin injection was successfully performed. CONCLUSION: Thrombin injection might be a safe alternative option in the treatment of pseudoaneurysm of the deep palmar arch.

[Endovenous laser therapy: a new treatment for varicose veins]. / Endoveneuze lasertherapie: een nieuwe behandeling van varices.

Varicose veins are very common. For years the most commonly applied treatment for great saphenous vein (GSV) insufficiency was saphenofemoral junction ligation with saphenous vein stripping. Minimally invasive methods, such as the endovenous laser therapy, are increasingly used during the last few years. In endovenous laser therapy, a diode laser fibre is inserted percutaneously into the GSV using ultrasonography to confirm the position. Thermal laser energy is applied to the endothelium ofthe GSV, resulting in local venous occlusion. The procedure has rapidly become popular with clinicians who treat varicose veins due to its relative simplicity and high rate of patient satisfaction. Efficacy outcomes are good with an occlusion rate of up to 100%. Recanalisation is rarely occurring even after several years. Pain, haematoma and phlebitis are common adverse events associated with endovenous laser therapy but in most cases are self-limiting. Serious adverse events, such as deep vein thrombosis, are uncommon. The advantages ofendovenous laser therapy are the lack of surgical wounds, so infection and scarring are avoided, and that the procedure can be performed in an outpatient setting using local anaesthesia. Endovenous laser therapy appears to be a safe and effective treatment option for refluxing varicose veins.

Thrombomodulin activity of fat-derived microvascular endothelial cells seeded on expanded polytetrafluorethylene.

Lining the luminal surface of prosthetic vascular grafts with endothelial cells (cell seeding) will lower its thrombogenicity. Commonly used macrovascular human adult endothelial cells (HAEC) require in vitro cultivation before large enough numbers are obtained to cover grafts confluently. Fat-derived microvascular endothelial cells (MVEC) prove to be a good alternative as they can be harvested in much larger numbers while showing similar antithrombotic and fibrinolytic characteristics. An important anticoagulant function of macrovascular endothelial cells is due to the activity of thrombomodulin (TM) on their surface. In this study, the presence and functional activity of TM on fat-derived microvascular cells used in cell seeding was investigated. The expression and localization of TM on MVEC was studied using immunohistochemistry. Functional activity of TM on MVEC was measured by the generation of activated protein C (APC) and was compared to human umbilical vein endothelial cells (HUVEC). TM activity was studied in MVEC seeded on expanded polytetrafluorethylene (ePTFE) vascular prostheses and compared to blank prostheses. We found that TM was expressed on the surface of MVEC, both in vivo and vitro. TM-dependent generation of APC differed significantly between MVEC and HUVEC (3.98 +/- 1.2 vs. 3.0 +/- 0.7 nM, respectively). After seeding MVEC on vascular prostheses, TM activity did not change. APC generation was significantly higher on MVEC-seeded vascular grafts compared to blank grafts (4.0 +/- 0.7 vs. 1.7 +/- 0.5 nM, respectively). We conclude that TM is present and highly active on cultured MVEC. When seeded on ePTFE, MVEC retain the possibility to inhibit thrombin coagulant activity and to activate protein C. Therefore, since MVEC are readily available, the anticoagulant properties demonstrated here indicate that this cell type is suitable for cell seeding of vascular prostheses.

Thrombogenesis of different cell types seeded on vascular grafts and studied under blood-flow conditions.

BACKGROUND: Small-diameter vascular grafts tend to have an early and high occlusion rate. Cell seeding on the luminal surfaces of small-diameter vascular prostheses may provide an antithrombotic lining and improve both the short-term and the long-term patency rates. We studied the net results of procoagulant and anticoagulant properties of seeded grafts under blood-flow conditions, and we compared the different available types of donor cells. METHODS: Monolayers of liposuction-derived cultured human microvascular endothelial cells (MVECs), human adult endothelial cells (HAECs), human umbilical vein endothelial cells (HUVECs), and human mesothelial cells (MCs) that had been seeded on expanded polytetrafluoroethylene (ePTFE) grafts were perfused with marginally anticoagulated blood (20 U/mL low molecular weight heparin; shear rate, 400/s, 10 minutes) or with non-anticoagulated blood (shear rate, 100/s, 5 minutes). The thrombin and fibrin generation in time was studied with the measurement of the plasma levels of prothrombin fragment 1 and 2 (F 1+2) and of fibrinopeptide A (FPA). The plain ePTFE graft was taken as a control. RESULTS: When the seeded MCs were perfused with recirculating anticoagulated blood, a linear generation of F 1+2 in time was seen, with high levels of F 1+2 and FPA after 10 minutes (4.38 nmol/L and 362 ng/mL, respectively). Allopurinol was added, and the MCs generated less F 1+2 than the HAECs (0.7 nmol/L vs 1.86 nmol/L; P <.05). No fibrin formation was seen. The MVECs generated low amounts of F 1+2 (0.7 nmol/L; 10 minutes), and the HUVECs and the plain ePTFE graft generated the lowest amounts of F 1+2 (0.26 and 0.25 nmol/L, respectively). When the MCs were perfused with non-anticoagulated blood, high amounts of thrombin and fibrin were generated immediately and constantly and could not be decreased with allopurinol. The perfusion of the plain ePTFE graft showed a dramatic increase in F 1+2 and FPA levels towards the end of the experiments. The seeded HAECs, HUVECs, and MVECs inhibited this increase. These results were confirmed by means of scanning electron microscopy. CONCLUSION: Vascular prostheses that are seeded with cultured MCs are highly procoagulant. Standard ePTFE graft prostheses also initiate coagulation, which supports the idea of cell seeding. The endothelial cells, of which the MVECs are the most readily available, seem to preserve their anticoagulant properties after being seeded on vascular grafts.

Percutaneous transluminal angioplasty of the infrarenal aorta: initial outcome and long-term clinical and angiographic results.

OBJECTIVE: Report of 1-8 year follow-up of patients treated by percutaneous transluminal angioplasty (PTA) for obstructive atherosclerosis of the infrarenal aorta. DESIGN: Cohort study. MATERIALS: Thirty-eight patients aged 26-81 years (mean 50 years) were submitted to undergo percutaneous transluminal angioplasty of the infrarenal aorta. All patients had symptomatic isolated stenotic lesions of the aorta located below the renal arteries and above the bifurcation. Stenoses at bifurcation-level and the iliac arteries were excluded. METHODS: PTA of the aorta was performed under local anaethesia in the radiological department. Clinical symptoms and ankle/brachial indices were registered before, directly after the procedure and at follow-up. Angiography was performed in all patients pre- and post-procedure, and at follow-up. All patients received angiography in March 1995. Clinical data were analysed based on intention-to-treat. RESULTS: Initial clinical and angiographic success was achieved in 36 patients (94%). Mean follow-up was 34 months (range 1-92). Recurrent stenosis was seen in seven patients (19%) at follow-up. Only five (13%) of these had recurrent symptoms and were treated successfully with a second PTA. No major complications were seen. CONCLUSION: These results show PTA to be a safe, minimally-invasive and effective alternative to surgery in case of symptomatic stenosis of the infrarenal abdominal aorta.

Endovascular remote endarterectomy in femoropopliteal occlusive disease: one-year clinical experience with the ring strip cutter device.

OBJECTIVES: One-year clinical outcome of a new endovascular treatment for long segmental arterial occlusive disease using a ring strip cutter (RSC) to minimise surgical exposure. DESIGN: Prospective, open study. MATERIALS: Thirty-eight consecutive RSC procedures in 36 consecutive patients with lengthy occlusive (34) or multiple stenotic (4) femoropopliteal lesions were performed. Indications for operation were disabling claudication in 25 (66%), rest pain in 3 (8%), and gangrene in 10 (26%) patients. METHODS: A newly developed endovascular ring strip cutter device was used to perform a remote endarterectomy through a single groin incision. Clinical data were analysed based on intention-to-treat. RESULTS: Initial angiographic, clinical and haemodynamic success was achieved in all 38 (100%) limbs. Mean ankle-brachial index increased significantly from 0.62 +/- 0.14 to 1.02 +/- 0.14 postoperatively (p = 0.01). Four failures have occurred during follow-up. After one-year experience the cumulative (assisted) primary and secondary patency rates are 80% and 85% respectively. Duplex surveillance has detected progressive recurrent stenoses in 10 cases. CONCLUSIONS: Remote endarterectomy of long segmental femoropopliteal occlusive disease through a single groin incision with the Ring Strip Cutter device is a safe and effective procedure. The early patency rates are good. Further long-term results are needed to evaluate this technique.