Arjun Jayaraj

Three-dimensional ultrasonography measurements after endovascular aneurysm repair.

BACKGROUND Ultrasonographic (US) assessment of abdominal aortic aneurysms is typically performed by measuring maximal aneurysm diameter from two-dimensional images. These measurements are prone to inaccuracies owing to image planes and interobserver variability. The purpose of this study was to compare the variability in diameter, cross-sectional area (CSA), and volume measurements of abdominal aortic aneurysms obtained using a three-dimensional (3D) US imaging system with those obtained using computed tomographic (CT) angiography, and to determine the reliability of these measures. METHODS Seven patients in whom endovascular aneurysm repairs were performed underwent CT angiography in addition to a 3D US scan. Measurements computed using 3D surface reconstructions of CT and 3D US scans included maximum diameter, CSA, and aneurysm volume. The seven matched CT and 3D US scans were compared at baseline and 6 to 8 weeks later. RESULTS The average aneurysm measured 57.2 mm on CT and 56.2 mm on US (P = 0.14). Correlation coefficients for diameter, CSA, and volume were 0.88, 0.90, and 0.93, respectively (all P values < 0.001). A Bland-Altman analysis demonstrated a strong agreement between 92% of the diameter, 96.4% of the CSA, and 100% of the volume measurements. The interrater reliability was remarkably high comparing the modalities (CT vs. US), and ranged from 0.934 to 0.997 for single measurements and 0.965 to 0.998 for all measurements together; moreover, there was a strong reliability when the tests were reviewed 6 to 8 weeks later, with a reliability of 0.962 to 0.998 for single measurements and 0.992 to 0.999 for all tests (all P values < 0.001). CONCLUSIONS The 3D US is an accurate and noninvasive method of determining aneurysm size and geometry that is reproducible. Volumetric measurements may represent a significant advancement in long-term follow-up after endovascular aneurysm repair.

A comparison of Villalta-Prandoni scale and venous clinical severity score in the assessment of post thrombotic syndrome.

BACKGROUND Post-thrombotic syndrome (PTS) is the most important late complication of acute deep venous thrombosis (DVT), with as many as two-thirds of patients developing symptoms of pain, edema, hyperpigmentation, or ulceration. Although several instruments are available for evaluation of the severity of PTS, including the Villalta-Prandoni scale (VPS) and Venous Clinical Severity Score (VCSS), no studies have yet compared the 2 instruments. The purpose of this study is to compare the 2 instruments as part of a larger randomized controlled study that assessed the impact of graduated compressive stockings in the prevention of PTS. METHODS Sixty-nine consecutive patients with acute DVT documented by duplex ultrasonography were randomized to treatment with 30-40 mm Hg graduated compressive stockings (GCS) or no stockings. Patients were followed clinically at months 1, 3, 6, 12, 18, and 24 after the diagnosis of DVT. PTS as defined by the VPS and VCSS were assessed at these follow-up visits. Based upon the VPS, PTS was scored as absent (score <3 or 3 without objective criteria), mild to moderate (score ≥3 with 1 objective criteria), or severe (score ≥4). For the VCSS, PTS was considered to be absent (score ≤3), mild to moderate (score 4-7), or severe (score ≥8). The 2 instruments were compared for mild to moderate and severe disease using the Pearson chi-squared test and gamma statistic. RESULTS Good correlation was detected in the ability of VPS and VCSS instruments to detect mild to moderate disease (gamma statistic = 0.71-0.98; P < 0.05). For severe disease, a statistically significant correlation was not found in the ability of the 2 instruments to detect disease (gamma statistic = 0.5-0.98; P > 0.05), especially at 12 and 24 months. CONCLUSION Both VPS and the VCSS scoring systems are important tools in the identification and follow-up of PTS. There exists agreement between the 2 instruments for detecting mild to moderate disease. For severe disease however, VCSS may possibly be a more sensitive instrument.

Impact of graduated compression stockings on the prevention of post-thrombotic syndrome - results of a randomized controlled trial.

Objective Post-thrombotic syndrome is a chronic complication of acute deep venous thrombosis in the lower extremity. The role of graduated compression stockings in the prevention of post-thrombotic syndrome has been studied with opinion being divided on the beneficial effects. We aim to answer this question with a randomized controlled study that uses multiple scoring instruments to assess post-thrombotic syndrome. Methods Sixty-nine consecutive patients with acute deep venous thrombosis diagnosed by duplex ultrasonography were randomized to treatment with graduated compression stockings or no graduated compression stockings. Venous Clinical Severity Score and Villalta-Prandoni Score, commonly used scoring systems, were used to appraise post-thrombotic syndrome at 3, 6, 12, 18, and 24 months following diagnosis of deep venous thrombosis. In both scoring systems, the individual either had post-thrombotic syndrome or no post-thrombotic syndrome. Cumulative incidence was computed using Kaplan–Meier analysis. Relative risk was assessed for age, obesity, varicose veins, and iliofemoral deep venous thrombosis. Results As measured by both Villalta-Prandoni Score and Venous Clinical Severity Score instruments, the graduated compression stockings group had a lower incidence of post-thrombotic syndrome compared to the control group, but only when one month was used as cut off time for the first diagnosis of post-thrombotic syndrome. When 6 or 12 months were used, there was no difference in the incidence of post-thrombotic syndrome between the two groups. The burden of post-thrombotic syndrome was significantly more when the Villalta-Prandoni Score instrument (∼75%) was used as compared to the Venous Clinical Severity Score instrument (∼30%) at 24 months’ follow-up. Obesity was the only statistically significant predictor for the development of post-thrombotic syndrome. Conclusion As assessed by both Villalta-Prandoni Score and Venous Clinical Severity Score instruments, use of graduated compression stockings does not reduce the incidence of post-thrombotic syndrome. There is a significant difference in the incidence post-thrombotic syndrome as detected by Villalta-Prandoni Score and Venous Clinical Severity Score instruments with incidence of post-thrombotic syndrome dependent on instrument and cut off time interval used to assess post-thrombotic syndrome. However, larger prospective studies are required to confirm these differences.

Cystic Adventitial Disease of the Common Femoral Vein

Cystic adventitial disease of blood vessels is a rare condition, more so when veins are involved. We report the case of a 36-year-old man who was referred to us after an intraoperative diagnosis of a left common femoral vein mass. This patient, who had a history of deep vein thrombosis and pulmonary embolism, had presented to an outside facility with recurrent left lower extremity pain and swelling. At our hospital, he underwent excision of the vein mass with interposition vein grafting using the left internal jugular vein. In this report, we discuss the presentation, diagnosis, treatment, and pathology of this rare condition.

Novel Repair of an External Iliac Vein Aneurysm

Aneurysms involving the venous system are a rare entity. We report the case of a 37-year-old woman who presented to us with activity-limiting left gluteal pain and who on consequent workup was found to have a left external iliac vein aneurysm in a setting of iliocavomegaly. She underwent successful treatment of her aneurysm with a novel approach that involved staple plication and resection of the aneurysm over a balloon mandrel. We discuss the presentation, diagnosis, and surgical technique adopted for the treatment of this uncommon condition.

Pancreatic intraductal papillary mucinous neoplasm in a patient with Lynch syndrome

Intraductal papillary mucinous neoplasm (IPMN) is a mucin-producing epithelial neoplasm that carries a risk of progression to invasive pancreatic ductal adenocarcinoma. Lynch syndrome is an autosomal dominant condition caused by germline mutations in mismatch repair genes such as MSH2 that lead to microsatellite instability and increased risk of tumor formation. Although families with Lynch syndrome have an increased risk of pancreatic cancer, a clear connection between Lynch syndrome and IPMN has not been drawn. We present a report of a 58 year-old Caucasian woman with multiple cancers and a germline mutation of MSH2 consistent with Lynch syndrome. A screening abdominal computed tomography scan revealed a dilated main pancreatic duct and cystic ductular structure in the uncinate process that were consistent with IPMN of the main pancreatic duct on excision. Immunohistochemistry and polymerase chain reaction of the patients pancreas specimen did not reveal microsatellite instability or mismatch repair gene loss of expression or function. Our findings may be explained by the fact that loss of mismatch repair function and microsatellite instability is a late event in neoplastic transformation. Given the relative rarity of main duct IPMN, its appearance in the setting of somatic MSH2 mutation suggests that IPMN may fit into the constellation of Lynch syndrome related malignancies.

Thoracic Aorta to Popliteal Artery Bypass for Bilateral Lower-Extremity Critical Limb Ischemia

Thoracic aortic to infrainguinal arterial bypasses are rare in the literature, even more so when the outflow is the popliteal artery bilaterally. The case of a patient presenting with critical limb ischemia, chronic infrarenal aortic occlusion, and recurrent thrombosis of a unilateral axillobifemoral graft managed with thoracoretroperitoneal bitransobturator bipopliteal bypass is presented. The patients vascular history was significant for multiple previous groin procedures for thrombectomy of her axillobifemoral graft, aortomesenteric bypass, redo aortomesenteric bypass for graft thrombosis, and multiple bowel resection procedures for acute mesenteric ischemia. The thoracic aorta and popliteal arteries were selected as sites for proximal and distal anastomoses, respectively, given anticipated difficulty in exposing the supraceliac aorta and femoral arteries. The technique of this operative approach is discussed.

Contemporary management of blunt aortic injury

Blunt aortic injury is second only to head injury as the most common cause of blunt trauma related death. The past several years have seen a tremendous growth in the endovascular treatment of such trauma. Short-term and medium-term follow-up data that are emerging seem to support this trend. In this article, the authors discuss about open and endovascular management of blunt aortic injury and provide the latest information regarding endovascular repair of such injuries.

The Venous Stent: Is It Primetime Yet?

The last 20 years has seen a significant increase in utilization of endovenous interventions in the management of chronic venous insufficiency involving the deep venous system. However, until very recently, the inventory available for such interventions was limited. With multiple stent designs in trials in the United States and in use elsewhere, endovenous stenting is primed for takeoff.

Impact of routine use of a tourniquet during preoperative vein mapping on the diameter of arm veins and creation of functional arteriovenous fistulas

Purpose —To examine the impact of tourniquet usage during preoperative vein mapping on diameter of arm veins and functionality of autogenous arteriovenous fistulas (AVF) thus created. Methods —A total of 160 patients in need of hemodialysis access underwent segmental upper-extremity duplex ultrasonography. Vein measurements were performed with and without application of an upper arm tourniquet. Criteria for AVF creation included superficial veins with diameter ≥3.0 mm and continuity with proximal superficial veins. Group I had patients with veins with diameter ≥3.0 mm attained without use of a tourniquet whereas Group II had patients with vein diameters ≥3.0 mm achieved with a tourniquet. Clinical outcomes were compared between the two groups. Results —Of the 160 patients, 114 underwent placement of an upper extremity AVF, whereas the remaining underwent placement of an AV graft or peritoneal dialysis catheter. Of these, 87 patients were in Group I and 27 in group II. The primary outcome was defined as a functional AVF within 6 months of surgery. In Group I, almost two of every three fistulas created were successful, resulting in a failure rate of 37.5%. In contrast, only one out of every six AVFs in Group II was successful resulting in a failure rate of 86%. Conclusion —The use of tourniquet results in a greater number of patients qualifying for AVF creation. However, AVFs created using vein diameter obtained from the application of a tourniquet have much greater rates of failure compared with AVFs created by using a vein of similar diameter but without a tourniquet.