Edwin C. Gravereaux

VEGF-C gene therapy augments postnatal lymphangiogenesis and ameliorates secondary lymphedema

Although lymphedema is a common clinical condition, treatment for this disabling condition remains limited and largely ineffective. Recently, it has been reported that overexpression of VEGF-C correlates with increased lymphatic vessel growth (lymphangiogenesis). However, the effect of VEGF-C-induced lymphangiogenesis on lymphedema has yet to be demonstrated. Here we investigated the impact of local transfer of naked plasmid DNA encoding human VEGF-C (phVEGF-C) on two animal models of lymphedema: one in the rabbit ear and the other in the mouse tail. In a rabbit model, following local phVEGF-C gene transfer, VEGFR-3 expression was significantly increased. This gene transfer led to a decrease in thickness and volume of lymphedema, improvement of lymphatic function demonstrated by serial lymphoscintigraphy, and finally, attenuation of the fibrofatty changes of the skin, the final consequences of lymphedema. The favorable effect of phVEGF-C on lymphedema was reconfirmed in a mouse tail model. Immunohistochemical analysis using lymphatic-specific markers: VEGFR-3, lymphatic endothelial hyaluronan receptor-1, together with the proliferation marker Ki-67 Ab revealed that phVEGF-C transfection potently induced new lymphatic vessel growth. This study, we believe for the first time, documents that gene transfer of phVEGF-C resolves lymphedema through direct augmentation of lymphangiogenesis. This novel therapeutic strategy may merit clinical investigation in patients with lymphedema.

Carotid stenting in the bovine arch

We report our experience in stent‐supported angioplasty of the left internal carotid artery in patients with anomalous origin of the left common carotid, the so‐called bovine arch, in which the right brachiocephalic and left carotid share a common trunk from the aortic arch. The occurrence of the anatomic variant is discussed, and techniques of femoral, brachial, and radial approaches are described. Catheter Cardiovasc Interv 2003;60:566–569.

An unusual cause of claudication

We describe a case of a patient who presented with claudication 3 months following a coronary angiogram in which the femoral arterial puncture site had been closed with an AngioSeal. The lesion was found to be due to the anchor of the AngioSeal, which embolized during attempted percutaneous revascularization and had to be snared and retrieved to the level of the sheath in the left femoral artery and was then surgically removed. Catheter Cardiovasc Interv 2003;60:562–565.

Recent advances in peripheral angioplasty and stenting.

Utilization of percutaneous interventions for arterial and venous occlusive lesions continue to increase. With the progression of the technology supporting these therapeutic measures, the results of these interventions may be expected to improve. In general, a comparison of tech niques for revascularization demonstrates similar initial technical success rates for surgery and percutaneous transluminal angioplasty. Angioplasty is often associated with lower proce dural morbidity and mortality rates. Conversely, surgery frequently provides greater long-term patency. Late failure of percutaneous therapies may often be treated successfully with rein tervention, however. The continued accumulation of experience with PTA and stenting will ultimately define its role in the management of occlusive disease.

Superior Medial Geniculate Artery Pseudoaneurysm After Primary Total Knee Arthroplasty

Vascular complications after total knee arthroplasty are rare. To date, there are 7 reported cases of pseudoaneurysms affecting the popliteal artery and 6 cases affecting one of the geniculate arteries. We present a case of a geniculate artery pseudoaneurysm that shared symptoms of a deep venous thrombosis on physical examination of a patient who underwent primary total knee arthroplasty. To date, there are no reports in American literature of pseudoaneurysms affecting the superior medial geniculate artery after primary total knee arthroplasty. After a vascular workup including computed tomographic angiography, surgical management included evacuation of the pseudoaneurysm and ligation of the feeding artery. The patient went on to successful recovery.

Volumetric Quantification of Type II Endoleaks: An Indicator for Aneurysm Sac Growth Following Endovascular Abdominal Aortic Aneurysm Repair

Delayed enhanced phase CT images can be used to perform volumetric quantification of type II endoleak cavities, a parameter that can be used to indicate which aneurysm sac will enlarge and which will be stable or shrink at follow-up CT.

Treatment planning for peripheral arterial disease based on duplex ultrasonography and computed tomography angiography: Consistency, confidence and the value of additional imaging

BACKGROUND Duplex ultrasonography (DUS) can be used for treatment planning for lower extremity peripheral arterial disease (PAD), but has not replaced contrast-enhanced imaging such as computed tomography angiography (CTA). We assessed DUS-based treatment planning for consistency, confidence, and the value of additional CTA among multinational surgeons. METHODS Data from 12 patients with PAD were reviewed by 2 American vascular surgeons individually and 1 Dutch vascular department by consensus. Reviewers selected treatment based on DUS first and based on added CTA second. Agreement and consistency of treatment plans was assessed using kappa statistics (κ). Imaging quality and therapeutic confidence were scored (1-5) and assessed with t-tests. RESULTS Of the 36 treatment plans formulated, additional CTA confirmed 27 (75%), changed 6 (17%), and supplemented 3 (8%) plans. The approach never changed when open revascularization was selected based on DUS (14 plans; 39%). Agreement between DUS- and CTA-based treatment planning was substantial, with a mean kappa (μκ) of 0.68, but agreement between reviewers was fair (μκ DUS, 0.24; μκ CTA, 0.23). CTA received greater average scores than DUS for quality (4.36 vs 3.29; P < .0001) and confidence (4.36 vs 3.26; P < .0001). Reviewers often expressed the need for additional imaging after DUS (mean, 63%). CONCLUSION PAD treatment planning based on CTA was mostly consistent with DUS-based treatment plans, although CTA was still felt to be needed to increase confidence. This observation suggests that to promote greater use of less invasive DUS imaging, not only improvement of DUS quality but also improvement of clinician confidence is required.

Increasing Complexity in the Open Surgical Repair of Abdominal Aortic Aneurysms

BACKGROUND Patient selection and techniques for the operative management of abdominal aortic aneurysms (AAAs) continue to evolve. We sought to examine trends in open surgical repair (OSR) over a 15-year period in which endovascular aneurysm repair (EVAR) has become increasingly prevalent. METHODS Patients undergoing elective repair of infra- and pararenal AAAs were identified through our centers prospective vascular surgery registry during two time periods: 1995 to 2004 (era 1) and 2004 to 2010 (era 2). Data collected included comorbidities, demographics, and operative characteristics. RESULTS A total of 1,188 elective AAAs were repaired during the study period, including 828 (70%) OSRs and 360 (30%) EVARs. The proportion of OSRs requiring suprarenal cross-clamping increased from 14.2% during era 1 to approximately 50% by the end of era 2. Compared with era 1, increases were seen in the unadjusted mortality rates during era 2 for OSR with infrarenal clamping (from 0.62% to 1.73%) and OSR with suprarenal clamping (from 1.22% to 3.98%); after adjusting for other variables, however, no significant temporal trends were seen. Similarly, no significant change in major complication rate was seen after adjusting for other factors. The incidence of major comorbidities among the OSR group was largely unchanged between the two eras. CONCLUSIONS OSR of AAAs has become increasingly complex, with the increased utilization of EVAR. Despite this complexity, risk-adjusted outcomes may remain good in high-volume centers.

Endovascular longitudinal fenestration and stent graft placement for treatment of aneurysms developing after chronic type B aortic dissection

The thickened intimal flap present in cases of chronic aortic dissection can present a challenge to attempts at endovascular stent graft treatment performed for subsequent aneurysmal degeneration by precluding adequate landing zones for the endograft and by constraining the endograft from full expansion. In this report we describe our technique and outcome for longitudinal endovascular fenestration of chronic aortic dissection flaps to facilitate endovascular stent graft treatment for thoracic aortic aneurysms developing after aortic dissection.

Acute Dissection of the Descending Aorta: A Case Report and Review of the Literature

Cardiovascular disease is the leading cause of death worldwide. Acute aortic syndromes, which include aortic dissection, intramural hematoma, and penetrating aortic ulcer, represent the most morbid presentations of aortic disease and can be difficult to diagnose. Recent advances in imaging have allowed for more rapid and accurate diagnosis of acute aortic syndromes and the options for management are expanding. This case report and review presents the case of a 43-year-old man with acute type B aortic dissection who underwent two endovascular procedures for malperfusion syndrome. The review focuses on the presentation, diagnosis, medical management, and procedural options for acute dissection of the descending aorta.