Preoperative duplex vein mapping (DVM) reduces costs in patients undergoing infrainguinal bypass surgery: results of a prospective randomised study.

OBJECTIVES: Surgical site infections (SSIs) after bypass procedures provoke major costs. The aim of this prospective randomised trial was to assess if preoperative duplex vein mapping (DVM) reduces costs generated by SSI. MATERIALS/METHODS: Patients undergoing primary infrainguinal bypass were randomised to DVM of the ipsilateral greater saphenous vein (group A) or none (group B). Costs were calculated by the hospital's accounting department. RESULTS: From December 2009 to April 2011, 130 patients (65 each group) were enrolled. Both cohorts were equal regarding demographics, risk factors and costs for primary bypass surgery, respectively. SSIs were classified minor (A: n = 13 vs. B: n = 13, P = n.s.) and major (A: n = 1 vs. B: n = 12, P = .0154). Preoperative DVM was the only significant factor to prevent major SSI (P = .011). Theatre costs for SSI: A: 537 € versus B 6553 € (P = .16). Recovery room/intensive care unit (ICU) costs for SSI: A: 0 € versus B: 8016 € (P = .22). Surgical ward costs for SSI: A: 2823 € versus B: 22 386 € (P = .011). Costs for outpatient visits due to SSI: A: 6265 € versus B: 12 831 € (P = .67). Total costs of patients without SSI: 8177 € versus major SSI: 10 963 € (P < .001). CONCLUSION: DVM significantly reduces costs generated by re-admission in patients suffering from major SSI.

Proximal common carotid artery lesions: endovascular and open repair.

OBJECTIVES: Management of proximal common carotid artery (pCCA) lesions is infrequently reported. We described open and endovascular treatment with regard to the neurological outcome and patency in patients suffering from atherosclerotic pCCA lesions. METHODS: Data were collected prospectively and analysed in a retrospective manner. RESULTS: From November 1991 to January 2010, 52 procedures, 24 surgical (11 bypasses, 12 transpositions and retrograde endarterectomy) and 28 endovascular (13 open transcervical and 15 transfemoral stent implantations) were performed (40.4% female, mean age 62.3 years, 65.4% left-sided). A total of 25 lesions (48.1%) were symptomatic (13 stenoses and 12 occlusions); 27 (51.9%) lesions were asymptomatic (22 stenoses and five occlusions). Two bypasses occluded within 30 days. Two early ipsilateral strokes were observed (3.8%). There was one perioperative death due to myocardial infarction after transcervical stent (1.9%). Mean follow-up was 61 months. In one transposition and two stent implantations, late redo interventions were performed. Fourteen of 48 patients died during follow-up. CONCLUSION: pCCA repair for atherosclerotic lesions is associated with a substantial perioperative risk (combined stroke/death rate: 5.7%). Endovascular intervention is the preferred invasive treatment option in patients suffering from stenotic pCCA lesions. In cases of pCCA occlusion, open surgery is a valid alternative. Late survival in patients suffering from pCCA lesions is poor.

Endovascular management versus surgery for proximal subclavian artery lesions.

Current management of subclavian artery (SA) lesions is controversial. Subclavian-to-carotid artery transposition (SCT) may be challenging but exhibits unparalleled long-term results. Stent-supported percutaneous transluminal angioplasty (sPTA) is technically easier but not always feasible. Long-term results and comparisons have not been published. We compared both methods performed by vascular surgeons. Data were collected prospectively with retrospective analysis at a tertiary-care center. sPTA was performed through a retrograde transbrachial access using self-expanding nitinol stents. Open surgery was SCT only. Society for Vascular Surgery/International Society of Cardiovascular Surgery reporting standards were applied. Seventy-four patients underwent treatment from January 1995 to August 2007 (median age 62.6 years, 40 female; left-sided pathology 60 [81.1%]; risk factors: hypertension 45 [60.8%], dyslipidemia 47 [63.5%], diabetes 21 [28.4%], smoking 43 [58.1%], SA occlusion 50 [67.6%]). Forty patients (54.1%) underwent primary sPTA (62.5% occlusions) and 34 SCT (73.5% occlusions). The two groups were comparable with regard to risk factors. In 12 patients occlusions could not be recanalized (30%), and in two stents failed within 1 month (both for stenosis). All but one underwent subsequent uneventful SCT. All SCTs were successful. No risk factor could be identified for treatment failure except sPTA (p = 0.002, Fisher's exact test). Median follow-up was 50.1 months with sPTA and 52.6 months with SCT. No procedure failed during follow-up in either group. sPTA can be performed successfully by surgeons. Primary sPTA failed in 48% of occlusions (30% of all sPTAs). Prediction of failure is not possible. According to our experience, we recommend primary sPTA for SA stenosis and surgery for SA occlusions.

Preoperative high-frequency duplex scanning of potential pedal target vessels.

OBJECTIVE: The aim of this prospective study conducted at a tertiary referral center was to evaluate the efficacy of high-frequency duplex scanning in the preoperative evaluation of potential pedal target vessels. Material and methods The study population consisted of thirty-three consecutive diabetics suffering critical limb ischemia, with indications of infra-popliteal occlusive disease. Duplex ultrasound was performed by an angiologist unaware of any prior imaging procedures. The pedal vessels were divided into four segments. The inner diameter-, the grade of calcification (on a scale from 1-to-3), the maximal systolic velocity, and the resistance index ([V.max syst-V min syst]/V max syst), were assessed by using a 13-MHz probe, and the pedal target vessel best suited for surgery was identified. Results of duplex scanning were compared to (1) the results of selective digital subtraction angiography (DSA) and contrast-enhanced magnetic resonance angiography (CE-MRA) studies interpreted by two radiologists, (2) the site of distal anastomosis predicted by a vascular surgeon according to DSA and CE-MRA studies, (3) the definitive site of distal anastomosis, and (4) early postoperative results (patency at three months). RESULTS: Duplex scanning depicted significantly more pedal vascular segments than selective DSA- (P =.004, McNemar test). Agreement in predicting the site of distal anastomosis expressed as kappa value as follows: duplex versus DSA/CE-MRA, kappa 0.71;-DSA/CE-MRA versus definitive anastomosis, kappa 0.67; -and duplex versus definitive anastomosis kappa 0.82. Two patients were excluded from surgery as all three imaging modalities failed to demonstrate a pedal target vessel. Two patients had exploratory dissection of a pedal vessel (according to CE-MRA findings) that turned out to be occluded (as predicted by duplex scanning). In one patient the operation had to be terminated due to lack of autologous bypass material. In 31 patients who underwent pedal artery bypass, the resistance index could not be correlated to the run-off as assessed by intra-operative angiography. CONCLUSIONS: High-frequency duplex focusing on the vacular-morphology is a worthwhile diagnostic tool to evaluate-potential pedal target vessels and extremely helpful when contrast-related methods (selective DSA, CE-MRA) do not sufficiently depict the pedal vasculature.

Pedal artery imaging--a comparison of selective digital subtraction angiography, contrast enhanced magnetic resonance angiography and duplex ultrasound.

OBJECTIVE: to evaluate selective digital subtraction angiography (DSA), contrast-enhanced magnetic resonance angiography (CE-MRA) and duplex ultrasound (duplex) in preoperative pedal artery imaging. MATERIAL AND METHODS: DSA, CE-MRA and duplex were studied prospectively in 37 patients suffering from critical leg ischaemia. Two radiologists independently reviewed both the CE-MRA and DSA images. The pedal vessels were scored on a scale from 0 to III (0=vessel not visualised, I=vessel faintly visualised, II=stenosis >50%, III=vessel without relevant stenosis). Duplex ultrasound was performed by an angiologist blind to both the DSA and MRA findings and the pedal arteries were scored 0-III according to their diameter. Each examiner named the pedal artery best suitable for bypass surgery. Agreement in artery assessment was expressed as kappa values. Patency of the bypass at 30 days was used as validation of the artery's suitability as the run-off vessel. RESULTS: interobserver agreement for DSA (weighted Kappa 0.63, CI 0.53-0.73 and CE-MRA (weighted kappa 0.60, CI 0.5-0.7) was moderate to substantial. CE-MRA depicted significantly more vascular segments than DSA (p congruent with 0.0001).In the prediction of the distal outflow vessel duplex and CE-MRA proved to be superior to DSA. CONCLUSION: because of the moderate inter-observer agreement it may be questionable to regard selective DSA as gold standard imaging procedure in preoperative pedal artery imaging. CE-MRA and duplex are very helpful in assessing the pedal artery morphology and should be used if selective DSA does not sufficiently depict the pedal vasculature.

Influence of lipoprotein(a) on restenosis after femoropopliteal percutaneous transluminal angioplasty in Type 2 diabetic patients.

OBJECTIVE: The influence of vascular morphology and metabolic parameters including lipoprotein(a) (Lp(a)) on restenosis after peripheral angioplasty has been compared in Type 2 diabetes (DM) vs. non-diabetic patients (ND). RESEARCH DESIGN AND METHODS: The clinical course and risk profile of 132 (54 DM vs. 78 ND) patients with peripheral arterial occlusive disease (PAD) were observed prospectively following femoropopliteal angioplasty (PTA). Clinical examination, oscillometry, ankle brachial blood pressure index (ABI) and the toe systolic blood pressure index (TSPI) were used during follow-up. Duplex sonography and reangiography were also used to verify suspected restenosis or reocclusion. RESULTS: At the time of intervention patients with DM had a lower median Lp(a) of 9 vs. 15 mg/dl (P < 0.01) in patients without diabetes. Recurrence within 1 year after PTA occurred in 25 diabetic (= 46%, Lp(a) 12 mg/dl) and 30 non-diabetic (= 38%, Lp(a) 48 mg/dl) patients. DM patients with 1 year's patency had a median Lp(a) of 7 vs. 11 mg/dl in non-diabetic patients (P < 0.05). However, 12 months after angioplasty Lp(a) correlated negatively with the ABI (r = -0.44, P < 0.01) in diabetic and in non-diabetic patients (r = -0.20, P < 0.05). The probability of recurrence after PTA continuously increased with higher levels of Lp(a) in each subgroup of patients. CONCLUSIONS: Our data indicate that Lp(a) is generally lower in those with peripheral arterial occlusive disease and Type 2 diabetes than in non-diabetic individuals. The increased risk for restenosis with rising levels of Lp(a) is set at a lower Lp(a) in diabetes and may be more harmful for diabetic patients.

Colour duplex sonography-guided local lysis of occlusions in the femoro-popliteal region.

BACKGROUND: To evaluate colour duplex sonographic guidance of local lysis of occlusions in the femoropopliteal region. METHODS: Thirteen consecutive patients (8 female, mean age 67) with peripheral artery disease with acute and subacute occlusions in the superficial femoral or popliteal artery were included in this study. The lesions were identified by colour duplex ultrasound (Acuson 128 XP/10) After anterograde puncture the guidewire was advanced through the arterial lesions under B-mode image control. The Mewissen Infusion Catheter and a Katzen infusion wire were then accurately positioned within the lesion under B-mode image control. The fibrinolytic drugs were then inserted into the occlusions, initially 2.5 mg rt-PA as a bolus followed by Urokinase (50,000 IU/h) for 24 hours. After control duplex sonography (over 24 hours) the additional angioplasty was performed either under fluoroscopic or exclusively under ultrasound guidance. RESULTS: Eleven of 13 patients with occlusions in the femoro-popliteal region were partially recanalised after ultrasound guided local lysis and after the additional angioplasties (nine under fluoroscopic and three under ultrasound guidance) the arteries were completely recanalised. CONCLUSIONS: Our data show that not only is the positioning of the catheter and the guidewire for local lysis exclusively under colour duplex guidance possible, but also the surveillance of the local lysis and the additional angioplasty. In the case of any complications, however, easy access to angiography should be possible.

Color duplex sonography guided stent placement in a stenosis of the superficial femoral artery. A case report.

We report the first case of a successful stent placement under color coded ultrasound guidance alone in the superficial femoral artery of a 73-year-old woman suffering from intermittent calf claudication following restenosis after an uncomplicated angioplasty five months previously. Because of a hemodynamically residual stenosis after three attempts at dilatation, a percutaneous transluminal angioplasty and stent insertion were performed under the sole guidance of color coded ultrasound. The intervention was performed without complication and at the six-month follow-up examination, the patient was symptom-free and the stent was morphologically intact and hemodynamically functional. This case shows that successful stent placement under ultrasonic guidance alone, without fluoroscopic control is possible, provided that there is adequate sonographic visualization.

Exogenous L-arginine does not affect angiotensin II-induced renal vasoconstriction in man.

AIMS: It has been suggested that provision of the substrate of nitric oxide (NO) synthesis, L-arginine, might influence the effects of renal vasoconstrictors. We have therefore studied the effects of pretreatment or concomitant administration of L-arginine on angiotensin II (ANG II)-increased renovascular resistance. METHODS: The study was conducted in a double-blind, randomized, cross-over design. Eight healthy subjects were assigned to placebo or a continuous intravenous coinfusion of ANG II (5.0 ng kg[-1] min[-1], infusion period 75 min) with L-arginine (17 mg kg[-1] min[-1], infusion period 30 min). Nine further subjects received a continuous infusion of ANG II with or without pretreatment of L-arginine. Changes in renal plasma flow (RPF) were estimated by the steady state clearance of PAH. RESULTS: L-arginine alone increased RPF to 110 +/- 10% over baseline (P < 0.003). The ANG II-induced decrease in RPF was not affected by pretreatment or coinfusion of L-arginine. CONCLUSIONS: Our results demonstrate that a counterregulatory response of the renal vasculature to high levels of ANG II does not depend on exogenous L-arginine. In healthy subjects, this lack of functional antagonism at the renal vasculature is therefore not a result of NO substrate availability.

Ultrasound guided compression therapy in 134 patients with iatrogenic pseudo-aneurysms: advantage of routine duplex ultrasound control of the puncture site following transfemoral catheterization.

BACKGROUND: The following study was designed to evaluate the effectiveness and safety of ultrasound guided compression therapy (UGCT) of iatrogenic postcatheterization pseudo-aneurysms (PA) on the one hand and to justify the usefulness of the routine colour duplex control of the puncture site following transfemoral catheterization, on the other hand. MATERIAL AND METHODS: During the study period 142 patients with (PA) following transfemoral catheterization were identified by means of colour duplex examination Eighty of these 142 patients were identified during a routine colour duplex control of the puncture site the day after PTA/angiography because of peripheral arterial occlusive disease (PAOD) [group A]; the remaining 62 patients with symptomatic groins were referred from other departments [group B]. RESULTS: In 8 patients of group B UGCT was considered to be contra-indicated, they were primarily treated by surgical repair of the PA. A total of 134 patients (group A 80 patients, group B 54 patients) underwent an UGCT. In total the success rate of UGCT was in group A 100% and in group B 78%. 12/54 patients (all group B) with failure of UGCT underwent a secondary surgical repair of the PA. Within group B there was a negative correlation between delay of diagnosis/UGCT and success (p < 0.04), whereas the size of the sheath did not influence the outcome of the UGCT (p = 0.3). CONCLUSION: Our study confirms the effectiveness and safety of UGCT. Routine colour duplex control of the puncture site the day following the removal of the sheath after percutaneous catheterization and UGCT of PAs without delay can increase the success rate of UGCT and minimize the need for surgical repair of PAs.

Femoropopliteal artery: initial and 6-month results of color duplex US-guided percutaneous transluminal angioplasty.

PURPOSE: To evaluate color duplex ultrasonographic (US) guidance of percutaneous transluminal angioplasty (PTA) of femoropopliteal artery stenoses and occlusions. MATERIALS AND METHODS: Twenty-four patients (11 women, 13 men; mean age, 65.0 years) with severe claudication, abnormal ankle-arm pressure indexes, and lesions in the superficial femoral or popliteal artery depicted at US underwent balloon PTA with US guidance. US findings were confirmed before and after PTA by means of intravenous digital subtraction angiography. RESULTS: All of 22 segmental stenoses and three of four superficial femoral artery occlusions were successfully treated (in 23 patients). In three cases, a residual stenosis was detected after initial PTA, and PTA was repeated with a larger balloon catheter. Of the 21 patients followed up for 6 months, one had reocclusion and three had hemodynamically significant restenosis. CONCLUSION: Results of PTA with US guidance in short stenoses or occlusions of the femoral or popliteal artery are similar to those of PTA with fluoroscopic control.

[Leriche syndrome: treatment with local lysis and subsequent percutaneous transluminal angioplasty]. / Leriche-Syndrom: Behandlung mit lokaler Lyse und anschliessender perkutaner transluminaler Angioplastie.

Two cases of Leriche's syndrome treated by local thrombolysis and subsequent percutaneous transluminal angioplasty with or without additional stent implantation are described. The fibrinolytic drugs were applied locally into the occlusions through a Mewissen Infusion Catheter and a Katzen Infusion Wire (initial 2.5 mg rt-PA as bolus followed by Urokinase (50000 IU/h) during 24 and 48 hours respectively. Residual stenotic lesions and occlusions were successfully treated with PTA alone in case 1 and with PTA in combination with a stent implantation in case 2. In accordance with Bean et al. (1985) and Goffette et al. (1989) we recommend local lysis in combination with PTA with or without additional stent implantation as an alternative treatment to surgery or systemic lysis for the treatment of Leriche's syndrome.

Incidence of pseudoaneurysm after diagnostic and therapeutic angiography.

PURPOSE: To investigate prospectively with color flow duplex (CFD) sonography the incidence of pseudoaneurysm or arteriovenous fistula (AVF) after transfemoral arterial catheterization with angiography, percutaneous transluminal angioplasty (PTA), or local lysis (LL). MATERIALS AND METHODS: CFD sonography was used to examine the puncture site in 565 consecutive patients who had undergone PTA, LL, or angiography (581 procedures). RESULTS: The incidence of pseudoaneurysm in the first 300 procedures in which standard compression was used was 14.0% overall, 27.0% after LL with antegrade-puncture PTA, 18.5% after antegrade-puncture PTA, 9.3% after retrograde-puncture PTA, and 1.2% after angiography. To decrease the high incidence, in the next 281 procedures manual compression was continued for at least 5 minutes after local bleeding had stopped. This significantly reduced the incidence to 1.1% overall, 8.0% after LL in combination with PTA, 0.9% after antegrade PTA alone, 0.9% after retrograde PTA, and 0% after angiography (P < .01). CONCLUSION: The incidence of pseudoaneurysm after transfemoral arterial catheterization depends on the type of intervention. The main risk factor is too brief a period of manual compression.

Comparison of effects of high-dose and low-dose aspirin on restenosis after femoropopliteal percutaneous transluminal angioplasty.

BACKGROUND: Long-term treatment with aspirin is recommended in patients with large-vessel peripheral arterial disease since these patients have a high risk of death from cardiovascular causes. Recent studies have demonstrated the prophylactic effect of low-dose aspirin in reducing the risk of cardiovascular events. Since aspirin is also recommended for prevention of late recurrence after peripheral angioplasty, the present study was undertaken to compare the effects of high-dose (1000 mg/d) and low-dose (100 mg/d) aspirin on long-term patency after femoropopliteal angioplasty. METHODS AND RESULTS: Two hundred sixteen patients treated successfully by percutaneous transluminal angioplasty for femoropopliteal lesions were randomly allocated to therapy with either 1000 or 100 mg aspirin daily. The follow-up was 24 months. The long-term results were analyzed using the Kaplan-Meier method, and differences between curves of cumulative patency were determined with the Wilcoxon and log-rank statistics. Complete follow-up information (patency after 24 months, restenosis, and death) was obtained in 207 patients. During the 2-year follow-up period, 72 patients--36 in the high-dose and 36 in the low-dose aspirin group, respectively--developed angiographically verified reobstruction within the recanalized segment. By intention-to-treat analysis, the cumulative patency rates at 24 months were 62.5% in the high-dose and 62.6% in the low-dose aspirin group (Wilcoxon, P = .97; log-rank, P = .97). The cumulative survival at 24 months of follow-up was 86.6% in the high-dose and 87.7% in the low-dose aspirin group. The number of patients discontinuing therapy was 30 in the high-dose and 11 in the low-dose aspirin group (P < .01). Fewer patients receiving 100 mg of aspirin discontinued therapy because of gastrointestinal symptoms (4 versus 20). CONCLUSIONS: The data indicate that 100 mg aspirin is no less effective in the prevention of restenosis after femoropopliteal PTA than a 1000-mg dose and has fewer side effects.

Cognitive brain function in non-demented patients with low-grade and high-grade carotid artery stenosis.

Atherosclerotic stenosis of the carotid arteries decreases cerebral flow volume and perfusion, and may result in brain dysfunction. We studied the relationship between the degree of carotid artery stenosis and cognitive brain function in non-demented patients. Cognitive brain function was assessed in 76 patients with carotid artery stenosis (38 patients with low-grade stenosis of 50% or less, and 38 patients with high-grade stenosis of 75% or more) by recording of cognitive P300 auditory evoked potentials and trailmaking test. Results were compared to 70 age-matched healthy subjects. The P300 peak latency was prolonged in patients with high-grade carotid artery stenosis as compared to patients with low-grade stenosis (403 vs. 371 ms, P < 0.01, vertex; 400 vs. 370 ms, P < 0.01, frontal; means). Analysis of variance revealed that the degree of carotid artery stenosis is an independent predictor of prolonged P300 peak latency (P = 0.0001). P300 amplitude (12 vs. 15 microV, vertex; 13 vs. 15 microV, frontal, NS) and trailmaking test (60 vs. 54 s; NS) tended to be worse in the high-grade stenosis group. There was no difference in cognitive brain function between patients with low-grade stenosis and age-matched healthy subjects. Confirmed on sensitive cognitive P300 measurements, we conclude that (a) cognitive brain function is impaired in non-demented patients with high-grade carotid artery stenosis but unaffected in low-grade stenosis; and (b) cognitive brain dysfunction is directly related to the degree of carotid artery stenosis.

[Macroembolism as a complication of ultra-high dose urokinase lysis of occlusion of a bifurcation prosthesis]. / Makroembolie als Komplikation bei ultrahochdosierter Urokinaselyse eines Bifurkationsprothesenverschlusses.

The case of a 70-year-old woman suffering from a long occlusion of the right branch of an aortobifemoral dacron-graft implanted six years ago is reported. Patency could be achieved by a systemic application of an ultrahigh dose of urokinase (UHUK = 9,000,000 I.U/6 h, intermittent daily application, two cycles). As a major complication macro-embolism to the popliteal artery and to the superficial femoral artery occurred, however. A further cycle of UHUK, local thrombolytic therapy (12 mg rtPA) and surgical thrombectomy failed to achieve persistent recanalization. So the patient finally had to be provided with a femoro-crural composite bypass. In conclusion, in a systemic thrombolytic therapy of occlusions of dacron grafts in the aorto-iliacal area a standard dose of urokinase (initial dose 600,000 I.U., maintenance dose 150,000 I.U./h, infusion pump) is recommended.