Alireza Daryapeyma

Treatment of a Hepatic Artery Aneurysm by Endovascular Stent-Grafting

Aneurysms of the visceral arteries are rare. Traditional treatment has been surgical or endovascular with coil embolization. Recently, however, reports on endovascular therapy with stent-grafts have been published. We report the case of a 61-year-old man who was successfully treated with a stent-graft for a symptomatic combined celiac/hepatic artery aneurysm.

Healthcare-associated Infections After Lower Extremity Revascularization

OBJECTIVE This population-based study aims to elucidate the incidence of healthcare-associated infections (HCAI) and related risk factors in non-emergent, open and endovascular lower extremity vascular procedures. METHOD This was a retrospective analysis of prospectively collected data from the Swedish National Vascular Surgery registry (Swedvasc), National Patient registry, and Cause of Death registry. A nationwide survey of all postoperative infections among patients who have undergone non-emergent open and endovascular surgery for lower extremity arterial disease between January 2005 to December 2010 (n = 10,547) has been performed. Data were retrieved from the National Vascular Surgery registry and cross-matched with the National Patient and Cause of Death registries. The primary purpose of the study was to identify the rate of 30-day postoperative infections and the associated risk factors for the different classes of lower extremity ischemia and operative procedures. RESULTS The study cohort included patients with claudication 27.0% (n = 2,827) and critical limb ischemia (CLI), consisting of rest pain 17.0% (n = 1,835) and ulceration/gangrene 56.0% (n = 5,885) undergoing endovascular intervention (n = 6,262; 59.0%), thromboendarterectomy (n = 1,061; 10.0%), or bypass surgery (n = 3,224; 31.0%). The total incidence of postoperative infection (<30-days) was 9.7% (n = 1,019), including skin and soft tissue infection (n = 735; 6.9%), urinary tract infection (n = 168; 1.6%), pneumonia (n = 114; 1.1%), and sepsis (n = 91; 0.9%). In claudicants, the risk of infection was increased eightfold for bypass surgery compared with endovascular intervention (odds ratio 8.4, 95% confidence interval 5.0-14). Risk factors associated with infection were degree of lower extremity ischemia, diabetes, renal insufficiency, and heart and lung disease (p < .05). CONCLUSION The postoperative rate of HCAI is associated with cardiovascular risk factors, operative method, and degree of lower extremity ischemia. This may be of assistance when deciding on the type of operative procedure for these patients.

Dysglycaemia in Vascular Surgery Patients

UNLABELLED Oral glucose tolerance tests (OGTTs) have detected a pathologic glucose metabolism in up to 60% of patients with acute coronary syndromes. Only one-third of these were previously diagnosed. The purpose of this study was to determine the prevalence of abnormal glucose metabolism among vascular surgery patients. METHODS Between October 2006 and September 2007, 465 consecutive patients admitted to the vascular surgery unit were asked to participate in the study; however, 121 declined. Among the patients included, 68 had previously known diabetes. A total of 276 patients performed an oral glucose tolerance test (OGTT). We categorised the findings based on fasting and 2-h plasma glucose levels into four groups: diabetes mellitus, impaired glucose tolerance (IGT), impaired fasting glucose (IFG) and normal glucose metabolism. Information regarding the affected vascular bed and relevant medical history was also registered. RESULTS Of the 276 patients who underwent OGTT, 66 (24%) had IGT, 23 (8%) had IFG and 33 (12%) had diabetes. As many as 17 of the 33 patients with newly diagnosed diabetes would have fulfilled the criteria for diagnosis based only on their fasting glucose levels. Including the patients with previously known diabetes, the prevalence of dysglycaemia was 55% and that of diabetes 29%. CONCLUSIONS Total prevalence of dysglycaemia in vascular surgery patients corresponds well to that of acute coronary syndromes. The prevalence of unknown pathological glucose metabolism was 44% in our OGTT material. The use of fasting glucose as the sole diagnostic tool for diabetes would have resulted in the correct diagnosis in only half of the patients tested. OGTT should be considered as a routine investigation in non-diabetic vascular surgery patients. It remains to be seen whether early diagnosis and treatment of dysglycaemia in this patient group will influence the surgical treatment and outcome.

Perioperative cytokine response to infection associated with elective arterial surgery.

Objective: The aim was to assess the cytokine response to acute inflammation and infection in vascular surgery. Design of Study: Single-center, prospective cohort study. Methods: Blood samples from 96 consecutive patients undergoing elective vascular surgery were analyzed for C-reactive protein (CRP), total leukocyte counts (LPK), neutrophil CD64 expression, and cytokines using enzyme-linked immunosorbent assay. Results: Of the 25 investigated cytokines, 22 had lower postoperative mean values compared to preoperative values. Interleukin (IL) 6 (IL-6) was the only cytokine that increased significantly postoperatively. Combined analysis of CRP and CD64 together with IL-6 or IL-10 showed an individually unique association with postoperative infection (P < .05). Conclusion: We have shown a positive correlation with perioperative infection for the proinflammatory cytokines and the anti-inflammatory cytokine IL-10 as well as a number of chemokines. To our knowledge, this is the first report linking IL-10 and chemokine plasma levels to perioperative infection in vascular surgery.

Novel Visceral-Anastomosis-First Approach in Open Repair of a Ruptured Type 2 Thoracoabdominal Aortic Aneurysm: Causes behind a Mortal Outcome

Case reports to analyze causes and possible prevention of complications in a new setting are important. We present an open repair of a ruptured type 2 thoracoabdominal aortic aneurysm in a 78-year-old man. Lower-body perfusion through a temporary extracorporeal axillobifemoral arterial prosthesis shunt was combined with the use of a branch to the permanent aortic prosthesis to enable rapid visceral revascularization using a visceral-anastomosis-first approach. The patient died due to transfusion-induced capillary leak syndrome and left colon necrosis; the latter was probably caused by a combination of back-bleeding from lumbar arteries causing a steal effect, an accidental shunt obstruction, and hemodynamic instability towards the end of the operation. The visceral-anastomosis-first approach did not contribute to the complications. This approach reduces the time when visceral organs are perfused only via collateral arteries to the time needed for suturing the visceral anastomoses. This may be important when collateral perfusion is marginal.

Endovascular treatment of isolated atherosclerotic lesions of the infrarenal aorta is technically feasible with acceptable long-term results

OBJECTIVES To investigate the results of endovascular treatment of symptomatic, atherosclerotic lesions of the infrarenal aorta. PATIENTS AND METHOD This is a retrospective study including 30 procedures performed on 25 patients in the period from 1990 through 2003. There were 16 women (64%) and 9 men, with a mean age of 55 years (range 35-81 years). The indication was disabling intermittent claudication in all cases. Preoperative assessment was done with ankle-arm pressure measurement and angiography. The mean length of the lesions was 2.5cm (range 1-6cm). One lesion was a short occlusion and nine were >90% stenoses. The remaining 20 lesions were significant (>70%) stenoses. The procedure was done with PTA alone in 13 cases, and with additional stenting in 17. RESULTS The procedures were technically successful in 28 cases and clinically successful in all 30. In two cases, a >50% residual stenosis was not dilated further because of stretch pain. The mean observation time was 40 months (range 0-135 months). The primary 2 and 5 year patency rates calculated on basis of intention to treat were 90 and 77%. The primary assisted patency rate was 90% at 2 years and 83% at 5 years. Eight patients developed significant restenosis, of which five were treated with a new endovascular procedure. Two failures were treated conservatively and one with surgical thrombendarterectomy. CONCLUSION Endovascular treatment of isolated atherosclerotic lesions of the infrarenal aorta is feasible in patients with suitable anatomy. Clinical success rates are high and long-term patency is good. Complications are few and minor. The majority of failures are amenable to new endovascular treatment.