E. Laxdal

Editor's Choice: Contemporary Treatment of Popliteal Artery Aneurysm in Eight Countries: A Report from the Vascunet Collaboration of Registries

OBJECTIVES To study contemporary popliteal artery aneurysm (PA) repair. METHODS Vascunet is a collaboration of population-based registries in 10 countries: eight had data on PA repair (Australia, Finland, Hungary, Iceland, New Zealand, Norway, Sweden, and Switzerland). RESULTS From January 2009 until June 2012, 1,471 PA repairs were registered. There were 9.59 operations per million person years, varying from 3.4 in Hungary to 17.6 in Sweden. Median age was 70 years, ranging from 66 years in Switzerland and Iceland to 74 years in Australia and New Zealand; 95.6% were men and 44% were active smokers. Elective surgery dominated, comprising 72% of all cases, but only 26.2% in Hungary and 39.7% in Finland, (p < .0001). The proportion of endovascular PA repair was 22.2%, varying from 34.7% in Australia, to zero in Switzerland, Finland, and Iceland (p < .0001). Endovascular repair was performed in 12.2% of patients with acute thrombosis and 24.1% of elective cases (p < .0001). A vein graft was used in 87.2% of open repairs, a synthetic or composite graft in 12.7%. Follow-up was until discharge or 30 days. Amputation rate was 2.0% overall: 6.5% after acute thrombosis, 1.0% after endovascular, 1.8% after open repair, and 26.3% after hybrid repair (p < .0001). Mortality was 0.7% overall: 0.1% after elective repair, 1.6% after acute thrombosis, and 11.1% after rupture. CONCLUSIONS Great variability between countries in incidence of operations, indications for surgery, and choice of surgical technique was found, possibly a result of surgical tradition rather than differences in case mix. Comparative studies with longer follow-up data are warranted.

SURGICAL TREATMENT OF POPLITEAL ARTERY ANEURYSMS

Objectives: To report the results of surgical treatment of popliteal aneurysms with respect to symptoms and aneurysm size. Design: A retrospective study based on prospectively registered data, in a single vascular unit. Patients and Methods: Forty-nine patients were subjected to 57 operations from May 1974 to June 2000. Patency and limb salvage rates are compared for limbs with and without symptoms of ischaemia, and for small (2 cm or less) and large (> 2 cm) aneurysms. The long-term survival rate was calculated and compared with that of an age and sex-matched population. Results: The overall 5 year graft patency was 60 %. It was 83 % for asymptomatic limbs and 49 % for limbs with ischaemic symptoms. This difference was significant (p < 0,05). The overall 5 year limb salvage rate was 76 %. It was 100 % for asymptomatic and 64 for symptomatic limbs and this difference was significant (p < 0,05). Twenty-one of the aneurysms were 2 cm or less in diameter and 85 % of these caused symptoms of ischemia. The operative mortality was 4 %. The 5-year survival rate was 57 % and significantly lower than that of a demographically matched population. Conclusion: The results of prophylactic operations for popliteal aneurysms on asymptomatic limbs are significantly better than those of operations done on limbs with ischaemic symptoms. The aneurysm size at which to recommend surgery is still not settled.

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.

Neutrophil CD64 as a Marker for Postoperative Infection: A Pilot Study

The aim of this pilot study was to evaluate the clinical utility of quantitative CD64 measurements to differentiate between systemic inflammation in response to surgical trauma and postoperative bacterial infection. In a consecutive series of 153 patients undergoing elective vascular surgery, peripheral venous blood samples were taken preoperatively on admission and postoperatively during the first 24h. The samples were analysed for C-reactive protein (CRP), total leucocyte counts (white blood cell (WBC)), serum procalcitonin (PCT) and neutrophil CD64 expression. Of the 153 patients, the focus is on those with (1) postoperative infection alone (group 1; n=1 4); (2) pre- and postoperative infection (group 2; n=6); and (3) postoperative fever with no other signs of infection (group 3; n=29). In group 1, all four markers were significantly increased in the 24h after surgery: CD64 (p=0.001), CRP (p=0.001), WBC (p=0.002) and PCT (p=0.012); in group 2, there was no significant difference in the CD64 (p=0.116), WBC (p=0.249) and PCT (p=0.138) values, whereas a marginal significance was shown for CRP (p=0.046); and the results for group 3 were similar to those of group 1. This pilot study suggests that the role of neutrophil CD64 measurements in facilitating the diagnosis of early postoperative infection merits further investigation.

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.