Jan Bosma

Hybrid Treatment of a Ruptured Diverticulum of Kommerell

Purpose: To report a patient with a ruptured diverticulum of Kommerell and to discuss treatment options and complications. Case Report: An 82-year-old woman with no prior medical history was diagnosed with a ruptured aneurysmal proximal aberrant right subclavian artery (diverticulum of Kommerell). She was treated with a carotid-subclavian bypass, a thoracic aortic stent-graft covering both subclavian orifices, and a vascular plug in the proximal right subclavian artery. After an initially uneventful recovery, the patient developed delayed ischemic esophageal ulcerations and subsequent perforation at 6 weeks postoperatively, leading to mediastinitis and stent-graft infection. Conclusion: A hybrid approach may be of value in cases of ruptured diverticulum of Kommerell. However, despite the anticipated reduction in perioperative mortality, this technique still yields a considerable risk of postoperative complications and mortality.

Comparative Study of Venous Arterialization and Pedal Bypass in a Patient Cohort with Critical Limb Ischemia

OBJECTIVES Patients with critical limb ischemia (CLI) have a poor life expectancy, and aggressive revascularization is accepted as a means to maintain their independence in the end stage of life. The goal of this case-control study was to evaluate the clinical outcome of distal venous arterialization and compare this with pedal bypass surgery in patients with CLI, and to identify potential risk factors that could be used to effectively identify patients at high risk of graft occlusion and amputation. METHODS A retrospective cohort of patients was treated for CLI using venous arterialization or pedal bypass between 2007 and 2012. Kaplan-Meier and Cox regression analyses were used to evaluate predictors for limb salvage and patency. RESULTS In 40 patients with CLI, 21 venous arterializations and 19 pedal bypasses were performed. In the venous arterialization group, early occlusion was 15%, 1-year patency was 71%, and limb salvage was 53%. In the PB group, early occlusion was 23%, one-year patency was 75% and limb salvage was 47%. The only independent risk factor for limb salvage in multivariate analysis was bypass occlusion (P<0.001). CONCLUSIONS Limb salvage after venous arterialization was equal to limb salvage after pedal bypass surgery in this clinical comparative study.

Clarivein mechanochemical ablation of the great and small saphenous vein: Early treatment outcomes of two hospitals

Objectives Mechanochemical endovenous ablation is a novel technique for the treatment of great saphenous vein and small saphenous vein incompetence which combines mechanical injury of the endothelium with simultaneous infusion of liquid sclerosant. The main objective of this study was to evaluate early occlusion. Methods All consecutive patients who were eligible for the treatment with mechanochemical endovenous ablation were included. Inclusion period was from the introduction of the device in the hospitals (September 2011 and December 2011) until December 2012. Results A total of 449 patients were included representing 570 incompetent veins. In 506 treated veins, duplex ultrasonography was performed at follow-up: 457 veins (90%) were occluded at a follow-up of 6 to 12 weeks. In univariate and multivariate analysis, failure of treated great saphenous vein was associated with saphenofemoral junction incompetence (OR 4; 95% CI 1.0–17.1, P = 0.049). Conclusions The Clarivein device proves to be safe and had a high short-term technical effectiveness.

Systematic Review on Health-Related Quality of Life After Revascularization and Primary Amputation in Patients With Critical Limb Ischemia

BACKGROUND The purpose of this study was to assess the effect of revascularization (bypass surgery, angioplasty) and primary amputation on health-related quality of life (QoL) in patients with critical limb ischemia (CLI; resting pain or tissue loss). METHODS A systematic review of the literature was performed through an electronic search of PubMed (from 1985 to 2012) and Embase (from 1985 to 2012) by two independent investigators to identify English-language articles investigating health-related QoL in regard to CLI. RESULTS Three observational studies were identified describing a comparison between primary amputation and revascularization and their effects on QoL in patients with CLI, all concluding that revascularization should be attempted. Data pooling was omitted due to the impossibility of combining outcome parameters. A separate analysis of each article is presented. CONCLUSIONS Patients with CLI have poor health prospects and life expectancy, irrespective of treatment administered. Randomized trials of health-related QoL after revascularization versus primary amputation are nonexistent. Also, the available observational studies do not allow sound conclusions, due to small numbers and methodologic imperfections. Therefore, no recommendations of either therapy in patients with CLI can be made with respect to an anticipated improvement in QoL.

Long-Term Quality of Life and Mobility After Prosthetic Above-the-Knee Bypass Surgery

BACKGROUND Multiple studies have addressed above-the-knee femoral artery bypass grafting; however, information on late quality of life (QoL) and mobility is scarce. We studied long-term QoL and mobility after above-the-knee bypass surgery. METHODS Consecutive patients presenting with claudication, ischemic rest pain, or gangrene who received above-the-knee prosthetic bypass grafting between December 1997 and January 2003 were included in this observational study. Data used were recorded in a prospectively collected database of patients receiving Dacron and polytetrafluoroethylene (PTFE) supragenicular bypasses for lower limb ischemia. Primary outcomes were QoL and mobility, and secondary outcomes were patency and patient survival. QoL was measured with the EuroQol questionnaire (EQ-5D/EQ-VAS). Mobility was assessed with the Walking Impairment Questionnaire (WIQ) and analyzed in univariate and multivariate models. Patency and survival were computed with Cox regression. RESULTS One hundred forty patients were treated during the study period. Sixty-nine patients (50%) died during follow-up, leaving 71 survivors who were asked (63 [89%] complied) to complete the EQ-5D/EQ-VAS and WIQ questionnaires. None of the primary outcome parameters (WIQ, EQ-5D, EQ-VAS) were affected by primary bypass occlusion (p = 0.34, p = 0.44, and p = 0.27, respectively) or long-term patency (p = 0.07, p = 0.54, and p = 0.36, respectively). Male sex was significantly associated with a better outcome on all primary outcome parameters. Patients with Dacron versus PTFE grafts had WIQ scores of 0.49 and 0.26, respectively (p = 0.01). EQ-5D scores of patients with Dacron and PTFE were 0.576 and 0.409 (p = 0.08) and EQ-VAS scores were 61 and 54, respectively (p = 0.24). Graft type was not independently associated with occlusion, but runoff was. The 5-year and 10-year patient survival rates were 58% and 51%, respectively. CONCLUSIONS In this study, long-term QoL and mobility did not seem to be associated with bypass patency, as assessed in a single late follow-up. Revision of bypasses did not contribute to long-term QoL and walking ability. Therefore, the necessity of graft surveillance and subsequent revision and/or thrombectomy in case of synthetic bypass failure in absence of critical limb ischemia seems to be questionable.

Primary subclavian vein thrombosis and its long-term effect on quality of life.

We aimed to compare the long-term results of three different strategies for treatment of patients with primary (spontaneous or effort related) subclavian vein thrombosis (PSVT). We followed 45 consecutive patients who had been treated for PSVT receiving either oral anticoagulant therapy only (n = 14, group 1); thrombolysis followed by anticoagulant therapy (n = 14, group 2); or thrombolysis, transaxillary first rib resection and anticoagulant therapy (n = 17, group 3). Endpoints were persisting symptoms and quality of life (QoL). The latter was assessed with the EuroQol (EQ-5D) questionnaire at the end of follow-up. The design is a case-control study with three different groups. Predictors for residual symptoms and QoL were analyzed with logistic and linear regression analysis. Patients in groups 2 and 3 had significantly less pain, swelling and fatigue in the afflicted limb at six weeks. There was no difference in pain (P = 0.90), swelling (P = 0.58), fatigue (P = 0.61), functional impairment (P = 0.61), recurrence (P = 0.10) or QoL (P = 0.25) between groups at the end of follow-up (mean follow-up 57 months [range 2–176, SD ± 46]). Treatment strategy was not predictive of QoL (P = 0.91, analysis of variance). No differences in long-term symptoms or QoL between patients with successful and unsuccessful thrombolysis were present. In conclusion, thrombolysis with or without first rib resection does not appear to contribute to lasting symptom reduction and improvement of QoL in this study. The effect of thrombolysis may be limited to short-term symptom relief. Transaxillary first rib resection was not associated with improved late outcome (symptoms, QoL) and did not reduce recurrence rate.

Transit-Time Volume Flow Measurements in Autogenous Femorodistal Bypass Surgery for Intraoperative Quality Control

The aim of this study was to assess intraoperative transit-time volume flow measurements (VFMs) as a tool for intraoperative evaluation of lower extremity arterial bypass grafts and to predict their patency. We analyzed 273 consecutive patients who had an infrainguinal bypass procedure using the great saphenous vein from 1998 until 2008; 103 had an intraoperative VFM. All intraoperative revisions were recorded and analyzed. Patency and revision rates were compared between those receiving and those not receiving intraoperative VFM. Cox regression was used for analysis of predictors of patency. Primary patency at 1 and 2 years was 75 and 67%, respectively, in patients receiving intraoperative VFM versus 72 and 69% in those without VFM (p = .79). In the VFM group, 12% had an immediate revision versus 6% without VFM (p = .06). In the VFM group, 4% underwent revision to salvage the bypass within the first postoperative 30 days versus 6% without VFM (p = .32). Patency was not associated with the use of VFM. Receiver operating characteristic curve was significant for occlusion at 30 days postoperatively but with a low predictive value (p = .019,area under the curve 0.648). VFM may be helpful in selecting bypasses requiring immediate revision to prevent postoperative occlusion. The use of VFM is not significantly associated with patency.

The costs and effects of contrast-enhanced magnetic resonance angiography and digital substraction angiography on quality of life in patients with peripheral arterial disease

Background Contrast-enhanced magnetic resonance angiography (MRA) and intra-arterial digital subtraction angiography (DSA) both have a high diagnostic performance in the imaging of peripheral arterial occlusive disease (PAOD). However, little is known about the effects of initial, preoperative imaging using MRA or DSA on quality of life (QoL) in relation to costs (cost-utility). Purpose To compare cost-utility of treatment strategies using either MRA or DSA as the principal imaging tool, related to QoL, in patients with PAOD. Material and Methods In a prospective subgroup analysis of patients randomized between MRA and DSA (n = 79) for preoperative imaging, QoL questionnaires (SF-36) were obtained at randomization and at 4-month follow-up. Cost-effectiveness from hospital perspective was subsequently compared between groups and the difference in gained or lost QoL per € spent assessed using bootstrap analysis. Results No difference in quality of life was found. A treatment trajectory employing MRA as the principal imaging modality was almost 20% cheaper, leading to a better cost-utility ratio in favor of MRA. Conclusion A treatment plan for peripheral arterial occlusive disease employing MRA versus DSA as the principal imaging modality yields a better cost/QoL ratio for MRA.

The utility of contrast enhanced MR angiography as a first stage diagnostic modality for treatment planning in lower extremity arterial occlusive disease.

Abstract Introduction: The aim of this study was to evaluate the applicability of contrast enhanced magnetic resonance angiography (ce-MRA) as a first stage imaging tool for individual treatment planning in patients with lower extremity arterial occlusive disease. Patients and Methods: Between August, 2003 and June, 2004, in 128 consecutive patients (182 extremities) with clinical manifestations of lower limb ischemia eligible for invasive therapy, treatment was planned based on clinical assessment, ankle/brachial pressure index measurements combined with ce-MRA. Additional duplex ultrasonography (DUS) or digital subtraction angiography (DSA) was done when necessary. Ce-MRA findings were compared with findings during open surgical, endovascular or combined procedures. Results: In 28 extremities (15%) ce-MRA was found inconclusive and additional imaging was performed. In the remaining patients (85% of the extremities (n = 154), treatment was initiated as planned. However, in 19 (11%) of these patients, the treatment plan was altered. In 7 of them, procedural findings did not correspond with those at the time of ce-MRA, including 6 patients (3%) with a falsely diagnosed stenosis or occlusion. In total, 62 patients received non-operative treatment (34%), 65 an endovascular procedure (36%), 49 open surgical reconstruction (27%) and 6 a combined treatment. Conclusions: We conclude that in the majority of patients treatment can be planned based on ce-MRA images, although sometimes additional DUS or DSA may be required.

The use of thoracic stent grafts for endovascular repair of abdominal aortic aneurysms

Objectives Stent grafts for endovascular repair of infrarenal aneurysms are commercially available for aortic necks up to 32 mm in diameter. The aim of this study was to evaluate the feasibility of endovascular repair with large thoracic stent grafts in the infrarenal position to obtain adequate proximal seal in wider necks. Methods All patients who underwent endovascular aneurysm repair using thoracic stent grafts with diameters greater than 36 mm between 2012 and 2016 were included. Follow-up consisted of CT angiography after six weeks and annual duplex thereafter. Results Eleven patients with wide infrarenal aortic necks received endovascular repair with thoracic stent grafts. The median diameter of the aneurysms was 60 mm (range 52–78 mm) and the median aortic neck diameter was 37 mm (range 28–43 mm). Thoracic stent grafts were oversized by a median of 14% (range 2–43%). On completion angiography, one type I and two type II endoleaks were observed but did not require reintervention. One patient experienced graft migration with aneurysm sac expansion and needed conversion to open repair. Median follow-up time was 14 months (range 2–53 months), during which three patients died, including one aneurysm-related death. Conclusions Endovascular repair using thoracic stent grafts for patients with wide aortic necks is feasible. In these patients, the technique may be a reasonable alternative to complex endovascular repair with fenestrated, branched, or chimney grafts. However, more experience and longer follow-up are required to determine its position within the endovascular armamentarium.