Yuk Law

Cyanoacrylate glue used to treat great saphenous reflux: Measures of outcome

Introduction This is a single-center clinical study for the evaluation of safety, efficacy, and performance of endovenous cyanoacrylate (Sapheon Venaseal Closure System, now Medtronic Medical) for the treatment of great saphenous vein (GSV) reflux. Methods Primary outcome measures included the GSV obliteration, with clinical recurrence on follow up as detected by serial clinical and duplex examinations of patients at 1 week, 1 month, 6 months, and 1 year. Venous clinical severity score (VCSS), Aberdeen varicose vein questionnaire (AVVQ), Short Form Health Survey 36 Item (SF-36) questionnaires were used at clinical follow up. Diameter of the GSV, treatment length of the GSV, and pretreatment clinical severity of the varicose vein were analyzed to predict recanalization using Cox regression analysis. Results Fifty-seven legs in 29 patients with primary varicose veins were included. One week follow-up duplex showed successful obliteration of the GSV in all except one of the legs. Two legs had minimal extension of thrombus to deep vein. None of the patients had deep venous thrombosis. All the patients were discharged the same day of operation. Median time to return to work was 1u2009day (range 1–16 days). Our VCSS, AVVQ, and the SF-36 physical and mental scores changed from a mean of 6.91, 23.66, 44.24, 54.26 at baseline to 2.43, 6.10, 43.85, 52.50 at 1 month post operation, respectively. Kaplan–Meier analysis showed that the GSV closure rates were 98.2%, 94.3%, 89.7%, and 78.5% at post-op 1 week, 1 month, 6 months, and 1 year, respectively. With median follow-up period of 9 months (range 1–13 months), no clinical recurrence of varicosity was observed. Mean GSV diameter ≥8u2009mm was a significant predictor for recanalization (hazard ratio 6.92, 95%CI 1.34–35.67, pu2009=u20090.021). Conclusion This study showed that the use of endovenous cyanoacrylate in the treatment of the GSV reflux was safe. All patients had symptomatic improvement as shown by the VCSS and AVVQ.

Influence of meteorological factors on acute aortic events in a subtropical territory

BACKGROUND/OBJECTIVEnThis study aims to examine the relationship between weather changes and acute aortic events in a subtropical territory.nnnMETHODSnA linear regression analysis was performed in a pan-territory epidemiological survey for a period of 10xa0years on the impacts of meteorological factors (ambient temperature, atmospheric pressure, relative humidity, amount of cloud, rainfall, number of lightning strikes, presence of typhoon, and thunderstorm warning) on the daily incidences of acute aortic dissections and ruptured aortic aneurysms. Meteorological variables were retrieved on a daily basis from a well-established observatory, and the daily incidences of aortic dissections and rupture of aortic aneurysms were retrieved from the Clinical Data Analysis and Reporting System.nnnRESULTSnDuring the study period (January 2005 to December 2014), 3878 patients were identified as having acute aortic dissections, and 1174 patients had ruptured aortic aneurysms. Corresponding averaged daily incidences were 1.06 and 0.32, respectively. The incidences of aortic dissection and ruptured aortic aneurysm in a day could be predicted by ambient temperature in degrees Celsius using the following linear regression models: (1) incidence of aortic dissectionxa0=xa01.548xa0-xa00.021xa0×xa0temperature; (2) incidence of ruptured aortic aneurysmxa0=xa00.564xa0-xa00.010xa0×xa0temperature. In addition, both high atmospheric pressure and absence of thunderstorm warning are positively associated with more aortic dissections. For rupture of aortic aneurysms, high atmospheric pressure and low relative humidity were positive predictors. In multiple regression analysis, however, ambient temperature was the only significant predictor for both acute aortic dissections and ruptured aortic aneurysms.nnnCONCLUSIONnThis is the first pan-territory study to show an attributable effect of ambient temperature on acute aortic events. This paper confirms that even in a subtropical country, meteorological variables were important factors influencing acute aortic events.

Predictors of Recanalization for Incompetent Great Saphenous Veins Treated With Cyanoacrylate Glue

PURPOSEnTo determine predictors of recanalization in patients treated with endovenous cyanoacrylate.nnnMETHODSnFollow-up by serial clinical and duplex examinations was performed at 1 week, 1 month, 6 months, 12 months, and 24 months of 108 legs in 55 patients (21 men, median age 65 y) with primary varicose veins treated with endovenous cyanoacrylate. Cox regression analysis was used to examine venous characteristics before the procedure: diameter of great saphenous vein (GSV), treatment length of GSV, presence of incompetent perforators, clinical severity of varicose vein, and experience of operator as predictors of recanalization. With the patient in supine position, GSV diameter was measured at 3 levels (proximal thigh 1 cm from saphenofemoral junction, midthigh, and distal thigh above knee).nnnRESULTSnOf 108 legs, 2 had minimal extension of thrombus to deep vein, and 4 had superficial thrombophlebitis. Kaplan-Meier analysis showed GSV closure rates were 97.2%, 92.3%, 89.2%, and 75.7% at 1 week, 1 month, 6 months, and 12 months after the procedure. With a median follow-up period of 5 months (range, 0-18 months), 4 legs had clinical recurrence. Mean GSV diameter ≥xa06.6xa0mm was the only significant predictor for recanalization (hazard ratio 12.1; 95% CI, 1.6-92.7; Pxa0= .016).nnnCONCLUSIONSnThe use of endovenous cyanoacrylate to treat varicose veins caused by incompetent GSV was safe. GSVs < 6.6 mm in diameter had a closure rate of 90.0% at 12 months. Despite 97.2% closure rates at 1 week, recanalization was observed in GSVs with larger diameter.

Epidemiological updates of venous thromboembolism in a Chinese population

BACKGROUND/OBJECTIVEnDeep vein thrombosis (DVT) was thought to be uncommon in Asians and routine thromboprophylaxis in the form of anticoagulation for surgical patients was considered to be unnecessary. The current study aims to provide a contemporary epidemiology of venous thromboembolism in a population-based scale.nnnMETHODSnInformation from January 1, 2010 to December 31, 2011 was retrieved from a centralized computer public healthcare database serving mainly an ethnic Han Chinese population of 7.1 million. The incidence, demographics, and hospital mortality rates of DVT and pulmonary embolism (PE) were obtained, and analyzed for different surgical categories.nnnRESULTSnThe overall annual incidences of DVT, PE alone, and PE with DVT were 30.0 per 100,000 population, 8.7 per 100,000 population, and 3.0 per 100,000 population, respectively. Overall male to female ratio was 1:1.24. Venous thromboembolic disease was more common with increasing age in both sexes. Thirty days mortality rates associated with DVT, PE alone, and PE with DVT were 9.0%, 17.4%, and 13.3% respectively. Among the patients who received 103,023 major and intermediate surgical procedures in the study period, the mean incidence of postoperative DVT, PE alone, and PE with DVT were only 0.20% (203.5 patients), 0.08% (85.5 patients), and 0.04% (40.5 patients) respectively.nnnCONCLUSIONnCompared with a similar study 10 years ago, there seemed to be a general increase in incidence of DVT and PE. This study showed that postoperative thromboembolic events were not uncommon, with DVT occurring in up to 0.2% of patients and PE in 0.12% of patients in this longitudinal survey.

Surgical management of carotid body tumor – Is Shamblin classification sufficient to predict surgical outcome?

Background The study aims to conduct a review of the surgical management of carotid body tumor. Methods Consecutive patients with CBT who received surgical interventions from January 1994 to January 2014 at our institution were reviewed. Clinical, operative, pathological and follow up information were reported. Results Twenty patients (four males; median age was 36) with 21 CBT operations were recorded during the period. One patient undertook sequential operations for bilateral CBTs. Patients had 19 neck mass, 1 incidental finding and 1 facial nerve palsy. Six CBTs (28.6%) were Shamblin class I, ten (47.6%) were class II and five (23.8%) were class III. Nine CBTs had preoperative conjunctive embolization. Two operations required internal carotid artery resection and reconstruction. Four patients received subtotal resections, while 17 achieved complete resection. Complications included two major strokes, three hoarse voice and two Horner’s syndrome. Shamblin class was significant predictor of operative time, blood loss, and whether complete resection accomplished, but could not predict postoperative complication. With median follow up period of 94 months, there was no tumor recurrence found in those had complete resection. Conclusions This small cohort showed that Shamblin class was significant in predicting technical difficulties but could not predict occurrence of complications.

Infectious anastomotic pseudoaneurysm complicating renal allograft: case report and review of literature

Infectious anastomotic pseudoaneurysm complicating renal transplant is rare, but probably under-reported with <30 cases worldwide. We report a 45-year-old man with hypertension, diabetes mellitus and end stage renal failure, who had a renal transplant anastomosed to the right external iliac artery and vein. Postoperatively, he made a slow recovery with malaise and persistent vague right iliac fossa discomfort. Ultrasound scan 1 month postoperatively showed perinephric collection, and fluid culture grew Enterococcus faecium and Pseudomonas aeruginosa. He was started on vancomycin, daptomycin and colistin. MAG-3 scan also showed suboptimal function in the renal allograft. His symptoms persisted with fever, and blood culture yielded P. aeruginosa. Repeated ultrasound scan, and subsequent computed tomography scan a few weeks later, showed perinephric collection and a large, 3.8×3.5 cm pseudoaneurysm posteromedial to the graft kidney. He underwent emergency graft excision, together with resection of the pseudoaneurysm with in situ reversed great saphenous vein interposition graft, and made a good recovery on hemodialysis. The aneurysm wall grew P. aeruginosa, and he was put on imipenem and cilastatin (tienam), colistin, ciprofloxacin and daptomycin. To our knowledge, this is one of very few cases in the world’s literature in which a P. aeruginosa infectious anastomotic pseudoaneurysm developed after a renal allograft.

Outcome and risk factor analysis of patients who underwent open infrarenal aortic aneurysm repair

INTRODUCTIONnThe aim of this study was to evaluate the short- and long-term outcomes in patients who underwent open infrarenal aortic aneurysm repair.nnnMETHODSnConsecutive patients who underwent open repair of infrarenal aortic aneurysms at our institution from July 1(st) 1990 to June 30(th) 2012 were reviewed from a prospective collected departmental database. Short-term outcomes included 30-day mortality and peri-operative complications. Independent risk factors to predict 30-day mortality were identified. Long-term survival and secondary interventions were also reported.nnnRESULTSnThree hundred and eighty-three patients (317 males, median age 72 years with a range of 15-90 years) underwent open infrarenal aortic aneurysm repair during the period, of whom 266 (69.5%) were elective, 18 (4.7%) were urgent for symptomatic but nonruptured cases, and 99 (25.8%) were emergency procedures for ruptured aneurysms. Mean aneurysm size was 6.5xa0cm (ranging from 2.5xa0cm to15xa0cm). All patients were followed up for at least 24 months with a mean follow up period 163 months. Overall 30-day mortality was 11.0% (36.4% for ruptured cases, 11.1% for symptomatic cases, and 1.5% for elective cases; pxa0<xa00.001). Preexisting renal disease and ruptured aneurysms were independent risk factors for 30-day mortality (pxa0=xa00.001 and pxa0=xa00.006 respectively). Systemic complications included 50 cardiac events, 52 respiratory events, six renal events, three cerebral vascular accidents, and one deep vein thrombosis/pulmonary embolism. Local complications included two anastomotic/graft hemorrhage, 10 distal thrombosis/embolisms, five bowel ischemias, one spinal cord ischemia, and 17 wound complications. The ruptured group presented survival rates of 53.5%, 50.5%, 47.5%, 42.3%, 38.0%, 21.9%, and 12.5% at 1 year, 2 years, 3 years, 4 years, 5 years, 10 years, and 15 years, respectively; while nonruptured survival rates were 91.5%, 88.0%, 83.7%, 78.3%, 73.0%, 43.0%, and 25.3%, respectively (log rank pxa0<xa00.001). For those who died 30 days after the operation, only six patients (1.8%) died from aneurysm related mortality. A total of three (0.9%) patients underwent late re-interventions, one for late aorto-enteric fistulae and two for anastomotic pseudoaneurysms.nnnCONCLUSIONnIn the current era of endovascular repair, open infrarenal aneurysm repair is effective and durable, and has very low secondary interventions rates.

Aspiration Thrombectomy of Acute Atrial Fibrillation-related Renal Artery Thromboembolism in a Patient with Horseshoe Kidney

BACKGROUNDnAcute arterial thromboembolism to the renal arteries can be treated promptly by local thrombolysis, conventional surgical thrombectomy, or anticoagulation.nnnMETHODSnWe report a patient who presented with acute loin pain as a result of atrial fibrillation-related thromboembolism to the right renal artery supplying his horseshoe kidney. He was already on warfarin treatment with international normalized ratio of 1.7 and had acute bleeding from malignant peptic ulcer disease, so thrombolysis was contraindicated.nnnRESULTSnHe underwent timely endovascular revascularization with aspiration thrombectomy, with good clinical and radiological consequence. He subsequently underwent curative partial gastrectomy and made a steady recovery.nnnCONCLUSIONnEarly endovascular target-directed therapy such as intra-arterial thrombolysis and mechanical aspiration in combination with intravenous heparin therapy will result in renal salvage.

Combined Ascending Aortic Stent-Graft and Inner Branched Arch Device for Type A Aortic Dissection

Purpose: To report the use of the Zenith Ascend stent-graft in conjunction with the Zenith inner branched arch device to treat type A aortic dissection. Case Report: Five patients (mean age 66 years, range 52–78; 4 men) with type A aortic dissection (2 acute) and insufficient distal landing zones were treated with the Zenith Ascend stent-graft and inner branched arch devices to extend the distal landing zone. Left carotid–subclavian bypass was performed in a staged or simultaneous setting depending on the urgency of the condition. Technical success (no type I or III endoleak and successful revascularization of all supra-aortic vessels) was achieved in all patients. Median intensive care unit stay was 5 days (range 4–23) and the median hospital stay was 16 days (range 8–25). The 2 patients with acute dissection died in hospital and at 5 months, respectively. The 3 elective patients were followed for 7, 13, and 19 months, respectively. All had false lumen thrombosis with either a reduced or stable aneurysm diameter. Conclusion: This limited experience demonstrated the feasibility and safety of the combined use of the Ascend stent-graft and inner branched arch devices. This strategy may sometimes be more beneficial than either stent-graft used alone.

Transapical Access for Antegrade Catheterization of the Inner Branches of an Arch Stent-Graft Deployed Distal to an Ascending Arch Stent-Graft

Propose: To describe a technique for antegrade cannulation and bridging of the supra-aortic branches through a transapical access in the treatment of an arch aneurysm using combined ascending and branched arch stent-grafts. Technique: An 81-year-old man with a past history of open infrarenal aortic repair, emergent endovascular aortic repair for thoracic aortic rupture, and later perivisceral 4-vessel branched endovascular repair of type I thoracoabdominal aneurysm presented for repair of a concomitant 7.5-cm arch aneurysm. Because of a 44-mm ascending aorta, a tapered 50/44-mm ascending stent-graft was delivered through a transapical access to establish an adequate landing zone before implantation of a 46-mm inner branched arch device via a transfemoral route. Innominate and left subclavian arteries were antegradely cannulated and bridged through the existing transapical path. Conclusion: Our case demonstrates the feasibility of transapical access for cannulation of an arch branched device, while introducing the theoretical possibility of completing the entire procedure through a transapical access.