Stem Cell Therapy in PAD

AbstractCritical limb ischemia (CLI) continues to form a substantial burden on Western health care. Despite recent advances in surgical and radiological vascular techniques, a large number of patients is not eligible for these revascularisation procedures and faces amputation as their ultimate treatment option. Growth factor therapy and stem cell therapy – both therapies focussing on augmenting postnatal neovascularisation – have raised much interest in the past decade. Based on initial pre-clinical and clinical results, both therapies appear to be promising strategies to augment neovascularisation and to reduce symptoms and possibly prevent amputation in CLI patients. However, the underlying mechanisms of postnatal neovascularisation are still incompletely understood. Both fundamental research as well as large randomised trials are needed for further optimisation of these treatment options, and will hopefully lead to needed advances in the treatment of no-option CLI patients in the near future

Ruptured abdominal aortic aneurysms: Factors influencing postoperative mortality and long-term survival

Objective:To update mortality rates and long-term survival of patients admitted to the hospital with ruptured abdominal aortic aneurysm (AAA) and to study prognostic factors associated with mortality.Design:Retrospective follow-up.Materials:309 patients (274 men, 35 women, average age 71) admitted to the hospital between January 1980 and January 1994 who were surgically treated for ruptured AAA were studied.Methods:To identify the preoperative (9), intraoperative (23) and postoperative (49) variables associated with mortality logistic regression analysis (mortality within 48 h) and Cox regression analysis (mortality between 48 h and 30 days) were performed.Results:Hospital mortality improved from 1980 to 1994. Compared with the normal population adjusted for age and sex the long-term mortality rate was increased (standardised mortality ratio 2.1; 95% confidence interval 1.7–2.5). Increased age, peroperative hypotension and need for a bifurcated graft were associated with significantly increased mortality. Co-morbidity was not a predictive variable. Overall hospital mortality was 25%.Conclusion:Surgical repair of ruptured AAA should be considered even in patients with co-morbidity. Elderly patients with severe preoperative hypotension have a very high mortality rate and surgery may not be justified in these cases. Long-term survival is also worse in older patients

The relationship between sigmoidal intramucosal pH and intestinal arterial occlusion during aortic reconstructive surgery

Objectives:To investigate the effects of perioperative occlusion of intestinal arteries on clinical outcome and changes in sigmoidal intramuscular pH (pHi). To determine the value of sigmoidal pHi measurement in predicting ischaemic colitis after aortic reconstructive surgery.Design:Prospective, non-selective, open study.Materials:Forty patients undergoing elective aortic infrarenal surgery were monitored with pHi. Pre- and postoperative digital venous subtraction angiography was combined with operative data to evaluate perioperative occlusion of intestinal arteries.Results:All patients had a significant (p < 0.05) drop in pHi after aortic clamping which returned to baseline 2–4 h after declamping. None of the patients had clinical signs of ischaemic colitis postoperatively. All patients had angiographically proven, patent superior mesenteric arteries pre- and postoperatively. Patients were divided into three groups: patients with no changes in intestinal arteries (n = 13), patients with perioperative occlusion of the inferior mesenteric artery (n = 22) and patients with perioperative occlusion of the inferior mesenteric and one or both iliac arteries (n = 5); there were no significant differences in pHi values between the groups.Conclusions:Return of the sigmoidal pHi to baseline values within 6–12 h after declamping probably predicts a postoperative course without ischaemic colitis. Perioperative occlusion of the inferior mesenteric artery alone, or in combination with occlusion of one or both internal iliac arteries, does not cause ischaemic colitis in patients whose sigmoidal pHi rises after declamping

Oversizing of Aortic Stent Grafts for Abdominal Aneurysm Repair: A Systematic Review of the Benefits and Risks

Objective: Sizing of aortic endografts is an essential step in successful endovascular treatment of aortic pathology, although consensus regarding the optimal sizing strategy is lacking. Some proximal oversizing is necessary to obtain a seat between the stent graft and the aortic watt and to prevent the graft from migrating, but excessive oversizing might influence the results negatively. In this systematic review, we investigated the current literature to obtain an overview of the risks and benefits of oversizing and to determine the optimal degree of oversizing of stent grafts used for endovascular abdominal aortic aneurysm repair. Methods: PUBMED, EMBASE and Cochrane Library databases were searched for articles related to the impact of proximal endograft oversizing on complications after endovascular aneurysm repair. After in- and exclusion, 23 relevant articles reporting on 8415 patients remained for analysis and critical appraisal. Results: Most studies that investigated neck dilatation are flawed by poor methodology. No clear relationship between proximal oversizing and neck dilatation relative to the first postoperative scan was found. None of the studies described a positive relationship between the degree of oversizing and the incidence of endoleaks. On the contrary, oversizing up to 25% seems to decrease the risk of proximal endoleaks. There are conflicting data regarding the risk of graft migration when oversizing by more than 30%. Conclusions: Based on the best available evidence, the current standard of 10-20% oversizing regime appears to be relatively safe and preferable. Oversizing >30% might negatively impact the outcome after EVAR. Studies of higher quality are needed to further assess the relationship between proximal oversizing and the incidence of complications, particularly regarding the impact on aneurysm neck dilatation. (C) 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

Risk Scores for Patients with Chest Pain: Evaluation in the Emergency Department

Chest pain is a common reason for presentation to the emergency department (ED). Absolute criteria for Acute Coronary Syndrome without ST elevation (NSTE-ACS) are lacking. An acute coronary syndrome (ACS) needs to be distinguished from a variety of other cardiac and non-cardiac diseases that may cause chest pain