Systematic approach to ruptured abdominal aortic aneurysm in the endovascular era: Intention-to-treat eEVAR protocol

Emergency endovascular aneurysm repair (eEVAR) for ruptured abdominal aortic aneurysms (rAAA) is still a relatively new treatment option. A pre-defined strategy of an eEVAR first approach for rAAA is associated with improved mortality rates. After establishing and implementing the Intention-to-treat eEVAR protocol for rAAAs the mortality and morbidity rates improved significantly. The presented Intention-to-treat eEVAR protocol starts at the first telephone call to the ambulance department and lasts until the post-operative care unit. The protocol involves the close collaboration between the ambulance department, vascular surgeon, emergency department physicians, anaesthesiologists, operating room staff and, radiology technicians. The availability of a variety of off-the-shelf stent-grafts, and an operating room that is adequately equipped to perform endovascular procedures is crucial in obtaining better outcomes. High volume centres that offer open surgical repair as well as eEVAR for rAAA show that the Intention-to-treat eEVAR protocol is achievable and appears to be associated with favorable mortality over open repair with appropriate case selection. Unstable or older patients with rAAA may particularly benefit by eEVAR

Venous Thoracic Outlet Syndrome Caused by Double Compression of the Axillosubclavian Vein:A Case Report

Introduction: In venous thoracic outlet syndrome (VTOS), pathology around the axillosubclavian vein causes venous compression with the subsequent development of upper extremity symptoms. This case report describes the analysis of all possible compression sites and subsequent treatment of VTOS patients with multiple compression points. Report: A 22 year old male presented with severe pain and swelling in his right arm, which persisted after a conservatively managed primary upper extremity deep vein thrombosis. Compression of the axillosubclavian vein was seen both at the level of the pectoralis minor and the costoclavicular spaces. Both compression points were successfully treated by combining thoracic outlet decompression surgery with pectoralis minor tenotomy. Discussion: This report underlines the importance of considering the possibility of multiple compression sites in patients with VTOS. Incomplete surgical release of all compression points leaves patients prone to re-thrombosis and/or persistent post-thrombotic syndrome. Timely recognition of all abnormalities on venography may allow for adjustment of surgical treatment accordingly

SBC2011-53463 IN VITRO THREE DIMENSIONAL IMAGING OF HUMAN CAROTID ATHEROSCLEROTIC PLAQUES USING ULTRASONOGRAPHY

INTRODUCTION Ruptured atherosclerotic plaques in the carotid artery are the main cause of stroke (70-80%). To prevent it, carotid endarterectomy is the procedure of choice in patients with a recent symptomatic 70-99% stenosis. Today, the selection of candidates is based on stenosis size only. However, endarterectomy is beneficial for only 1 out of 6 patients [1], the patients with unstable plaques To determine the mechanical properties of healthy coronary arteries an in vitro model was developed by Van Den Broek et al. [2]. In this model an arterial segment can be fixed in a water bath, and a pressure pump induces a pulsatile pressure through the segment. By using ultrasonography (US), distension of the vessel wall can be visualized in 2D (ART.LAB, Esaote Europe, The Netherlands). With this in vitro model the pressure-diameter and pressure-axial force relation can be obtained. In this study, human atherosclerotic segments obtained from an endarterectomy procedure are used to determine the mechanical properties of the atherosclerotic components (local ethical committee approval was obtained for this study). The aim of this study is to adjust the existing set-up for use on atherosclerotic plaques and to design a tool for the conversion of 2D utrasound datasets to 3D data, to obtain the geometry of the artery including pressure and distension information over time. Eventually these datasets will be used as input for inverse numerical computations for the determination of mechanical properties of the plaques

Surgery versus continued conservative treatment for neurogenic thoracic outlet syndrome:the first randomised clinical trial (STOPNTOS-trial)

OBJECTIVES: Neurogenic Thoracic Outlet Syndrome (NTOS) is one of the most controversial clinical entities in medicine. Several major case series have shown promising results of surgery, however solid scientific evidence is lacking. The aim of this trial was to objectify the effect of thoracic outlet decompression (TOD). DESIGN: Randomised controlled clinical trial METHODS: We conducted a single center (high volume, tertiary TOS center), non-blinded, randomized controlled trial with parallel group design. Patients with a diagnosis of NTOS refractory to conservative therapy were randomized into one of two intervention arms and either received a trans-axillary thoracic outlet decompression (TA-TOD) or continued conservative treatment. After 3 months, the conservative treated group was also offered a TA-TOD. Primary outcome was the change in Disability of the Arm, Shoulder and Hand, (DASH) questionnaire score. Secondary outcomes were the change in Cervical-Brachial Symptoms Questionnaire (CBSQ), TOS disability scale and quality of life scores. Outcomes were assessed at baseline, 3, 6 and 12 months after inclusion. RESULTS: In total, 50 patients were enrolled in this trial: 25 in the TA-TOD group and 25 in the continued conservative treatment group. Follow up was completed in 24 and 22 patients respectively. At 3 months, there was a significant difference in DASH scores (TA-TOD: mean: 45.15; confidence interval (CI) [38.08 - 52.21]; conservative treatment: mean 64.92, CI [57.54 -72.30]; p<.001). All patients in the conservative treatment group applied for surgery 3 months after randomization. After surgery of the conservative treatment group, there was no significant difference between the groups for all primary and secondary outcome measures. CONCLUSIONS: TA-TOD for NTOS is effective in patients that do not respond to conservative treatment. TRIAL REGISTER NUMBER: NL63986.100.17

Overstenting the hypogastric artery during endovascular aneurysm repair with and without prior coil embolization: A comparative analysis from the ENGAGE Registry

Background Endovascular aneurysm repair of aortoiliac or iliac aneurysms is often performed with stent graft coverage of the origin of the hypogastric artery (HA) to ensure adequate distal seal. It is considered common practice to perform adjunctive coiling of the HA to prevent a type II endoleak. Our objective was to question the necessity of pre-emptive coiling by comparing the outcomes of HA coverage with and without prior coil embolization. Methods Data from the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE), which prospectively enrolled 1263 endovascular aneurysm repair patients between March 2009 and April 2011 from multiple centers worldwide, were used for this study. We identified patients in whom the Endurant stent graft (Medtronic Vascular, Santa Rosa, Calif) covered one or both HAs and grouped them into cases in which prior HA embolization—coils or plugs—was performed (CE) and cases in which HA embolization was not performed (NE). The occurrence of covered HA-related endoleak and secondary interventions were compared between groups. Results In 197 patients, 225 HAs were covered. Ninety-one HAs were covered after coil embolization (CE group), and 134 HAs were covered without prior coil embolization (NE group). Both groups were similar at baseline and had comparable length of follow-up to last image (665.2 ± 321.7 days for CE patients; 641.6 ± 327.6 days for NE patients; P =.464). Importantly, both groups showed equivalent iliac morphology concerning common iliac artery proximal, mid, and distal dimensions and tortuosity, making them suitable for comparative analysis. During follow-up, HA-related endoleaks were sparse and occurred equally often in both groups (CE 5.5% vs NE 3.0%; P =.346). Secondary intervention to resolve an HA-related endoleak was performed twice in the CE group and three times in the NE group. Late non-HA-related endoleaks occurred more often in the CE group compared with the NE group, (25.0% vs 15.0%; P =.080). Secondary interventions for other reasons than HA-related endoleaks occurred in 7.5% of NE cases and 15.4% of CE cases (P =.057), mostly for occlusions in the ipsilateral iliac limb. During follow-up, 19 NE patients and 9 CE patients died, which is not significantly different (P =.225), and no deaths were related directly or indirectly to HA coverage. Also, no reports of gluteal necrosis and bowel ischemia were made. Conclusions This study shows that HA coverage with the Endurant endograft without prior coil embolization does not increase the incidence of endoleak or related secondary interventions. These findings together with the already available evidence suggest that omission of coil embolization may be a more resource-effective strategy whenever HA coverage is required

智慧權法典（四版 ）

Abdominal aortic aneurysms (AAAs) are local dilations of the aorta which can lead to a fatal hemorrhage when ruptured. Wall stress analysis of AAAs has been widely reported in literature to predict the risk of rupture. Usually, the complete AAA geometry including the aortic bifurcation is obtained by computed tomography (CT). However, performing wall stress analysis based on 3D ultrasound (3D US) has many advantages over CT, although, the field-of-view (FOV) of 3D US is limited and the aortic bifurcation is not easily imaged. In this study, the influence of a limited FOV is examined by performing wall stress analysis on CT-based (total) AAA geometries in 10 patients, and observing the changes in 99th percentile stresses and median stresses while systematically limiting the FOV.Results reveal that changes in the 99th percentile wall stresses are less than 10% when the proximal and distal shoulders of the aneurysm are in the shortened FOV. Wall stress results show that the presence of the aortic bifurcation in the FOV does not influence the wall stresses in high stress regions. Hence, the necessity of assessing the complete FOV, including the aortic bifurcation, is of minor importance. When the proximal and distal shoulders of the AAA are in the FOV, peak wall stresses can be detected adequately

Supervised Exercise Therapy for Intermittent Claudication Is Increasingly Endorsed by Dutch Vascular Surgeons

Although supervised exercise therapy (SET) is generally accepted as an effective noninvasive treatment for intermittent claudication (IC), Dutch vascular surgeons were initially somewhat hesitant as reported by a 2011 questionnaire study. Later on, a nationwide multidisciplinary network for SET was introduced in the Netherlands. The aim of this questionnaire study was to determine possible trends in conceptions among Dutch vascular surgeons regarding the prescription of SET. In the year of 2015, Dutch vascular surgeons, fellows, and senior residents were asked to complete a 26-item questionnaire including issues that were considered relevant for prescribing SET such as patient selection criteria and comorbidity. Outcome was compared to the 2011 survey. Data of 124 respondents (82% males; mean age 46 years; 64% response rate) were analyzed. SET referral rate of new IC patients was not different over time (2015: 81% vs. 2011: 75%; P = 0.295). However, respondents were more willing to prescribe SET in IC patients with chronic obstructive pulmonary disease (2015: 86% vs. 2011: 69%; P = 0.002). Nevertheless, a smaller portion of respondents found that SET was also indicated for aortoiliac disease (2015: 63% vs. 2011: 76%; P = 0.049). Insufficient health insurance coverage and/or personal financial resources were the most important presumed barriers preventing patients from initiating SET (80% of respondents). Moreover, 94% of respondents judged that SET should be fully reimbursed by all Dutch basic health insurances. The concept of SET for IC is nowadays generally embraced by the vast majority of Dutch vascular surgeons. SET may have gained in popularity in IC patients with cardiopulmonary comorbidity. However, SET remains underutilized for aortoiliac disease. Reimbursement is considered crucial for a successful SET implementatio