Are symptomatic abdominal aortic aneurysms associated with an impaired prognosis? R.S. von Allmen1, D. Müller1,2, C. Tinner1, J. Schmidli1, F. Dick1 (1Bern, 2Lachen)
Objective: Symptomatic abdominal aortic aneurysms (AAA) are believed to indicate impending rupture and, thus, are often treated semi-urgently. Thereby, an opportunity to assess and optimize fitness for surgery may be missed, which could impact on outcome. Consequently, we aimed to determine whether symptomatic status was independently associated with impaired prognosis. Methods: Patients undergoing intact AAA repair between January 2001 and December 2010 were identified consecutively, and their data was registered. Patients presenting with symptomatic AAA were usually treated within 24 hours and were compared to those with asymptomatic AAA regarding procedural and long-term prognosis. To assess the independent influence of symptomatic presentation multivariate regression modelling was used to adjust for suspected confounding factors including age, gender, aneurysm size and anatomical configuration, renal function, body mass index as well as type of repair. Results: A total of 823 patients was analysed, 137 of which (16.6%) presented with aneurysm-related symptoms. Overall, 204 patients (24.8%) underwent endovascular repair, and this was more likely for asymptomatic patients (28.4% vs 6.6%, P<0.001). Median follow-up was similar in asymptomatic and symptomatic patients at 3.87 years (Interquartile range (IQR) 2.01-6.12) versus 3.22 years (1.63-5.89), P= 0.215. Overall 30-day mortality was 1.2% without difference between the groups (1.5% for asymptomatic versus 0% for symptomatic AAA patients, P=0.383). Prognosis was similar between the 2 groups at long-term follow-up: survival estimates at 5 years were 73.4% for asymptomatic and 77.9% for symptomatic patients, respectively, (P=0.343). This corresponds to a confounder-adjusted hazard ratio of 0.88 (95%-CI 0.55-1.41; P=0.591). Conclusion: Symptomatic state of AAA patients did not imply any independent risk for surgical mortality in this contemporary series, even though patient fitness could not be optimised preoperatively due to immediate repair. Thus, clinical presentation as such does not seem to affect long-term prognosis of intact AAA, regardless of type of repair. FP 1.2
Impact of suprarenal cross-clamping during open juxtarenal aortic aneurysm repair F. Dick1, D. Müller1,2, C. Tinner1, J. Schmidli1, R. S. von Allmen1(1Bern, 2Lachen)
Objective: Open repair of juxtarenal aortic aneurysm is burdened with the need for suprarenal aortic cross-clamping and associated risk of complications. As a consequence, the procedure is increasingly challenged in the current era of fenestrated endograft technology. We aimed to establish whether, in fact, there is an independent impact of suprarenal cross-clamping or if the impaired prognosis is simply linked to the patient profile. Methods: Patients undergoing open abdominal aortic aneurysm (AAA) repair between January 2001 and December 2010 were captured consecutively. Patients undergoing juxtarenal AAA repair were compared to those undergoing infrarenal repair regarding early and long-term survival. To quantify any independent effect of supra-renal cross-clamping, multivariate logistic regression was used to adjust for all suspected confounding factors including age, sex, aneurysm-related symptoms, aneurysm
size and complexity (i.e. extent of iliac involvement), time since surgery as well as renal function at the time of repair. Results: A total of 619 patients underwent open AAA repair during the study period, of which 176 (28.4%) needed supra-renal cross-clamping for juxtarenal AAA repair. Median follow up was 4.0 years (interquartile range 2.0 to 6.4) and significantly longer for patients with infrarenal AAA (4.7 vs 3.2, P<0.001) indicating that the complexity of repair increased over the years. Thirty-day mortality was higher in patients undergoing juxtarenal aneurysm repair: both in absolute terms (3.4% versus 0.7%, P=0.019), but also after adjustment for confounding factors (odds ratio 5.9, 95%-confidence interval (CI) 1.2-30.1, P=0.031). However, long-term prognosis was similar between the 2 groups. At 5 years, adjusted survival estimates were 71% and 79%, respectively (hazard ratio 1.23, 95%-CI 0.8- 1.9, P=0.355). Conclusion: Open AAA repair has become increasingly complex over the past decade. Although suprarenal aortic cross-clamping increased the risk of early postoperative death 5-fold, long-term survival remained similar to infrarenal AAA repair indicating that the additional surgical trauma is being compensated shortly and does not affect prognosis. At any rate, these contemporary results of open juxtarenal AAA repair are well in the same range as published outcomes of fenestrated or branched endografts. FP 1.3
In-hospital outcome of synchronous carotid endarterectomy during cardiac surgery V. Makaloski, I. Zubak, M. Czerny, T. Carrel, J. Schmidli (Bern)
Objective: Optimal timing of surgical treatment of relevant carotid stenosis in patients with cardiac disease is controversial. Our objective was to evaluate the clinical outcome in cardiac patients undergoing carotid endarterectomy (CEA) at the same time as coronary artery bypass grafting (CABG) and/or valve replacement (VR). Methods: Observational study of all patients who underwent CEA at the same time as CABG and/or VR between 2005 and 2012. Our main outcome measure was in-hospital stroke or death. Indications for a combined approach were the presence of either a ≥70% asymptomatic or ≥50% symptomatic internal carotid artery stenosis and the need for urgent or elective CABG/VR. Symptomatic carotid artery stenosis was defined as transient ischemic attacks (TIA)/amaurosis fugax or strokes that occurred within the previous 6 months. Results: Of the 117 patients undergoing CEA, 74 patients also had isolated CABG, 33 had CABG with VR and 10 had isolated VR. Mean age was 72 ± 7.2 years and 89 patient (76%) were male. CEA was performed in 21 patients (18%) with symptomatic carotid stenosis. Two patients (1.7%) died during hospital stay, one cardiac related and the otherone stroke related. Perioperative stroke with hemiplegia occurred in 5 patients (4%), two ipsilateral and three contralateral to the operated site. Of the two patients with ipsilateral stroke one had asymptomatic high-grade 70-99% and the otherone had a symptomatic moderate stenosis (50-69%). Of the three patients with contralateral stroke one had preoperative occlusion and two had moderate stenosis (50-69%). Conclusion: CEA and cardiac surgery can be performed synchronously but is associated with slightly higher risk for neurological complications and mortality compared to isolated CEA. An improved selection in patients needing CEA combined with CABG/VR could improve postoperative results.
FP 1.4
Central aortic augmentation index is associated with obstructive and aneurysmatic patterns of aorto-peripheral vascular disease M. Beckmann1, M. Kohler2, V. Jacomella2, Z. Rancic2, M. Lachat2, B. Amann-Vesti2, M. Husmann2 (1St.Gallen, 2Zurich)
Objective: Elevated central hemodynamic parameters for arterial stiffness such as the central augmentation index (cAIx) has been reported to be an independent predictor for cardiovascular events. Aim: To assess and compare cAIx in patients with a known high-risk profile such as peripheral arterial disease (PAD) and abdominal aortic aneurysm (AAA). Methods: Central AIx was assessed by radial applanation tonometry (Sphygmocor) in a total of 187 patients at a tertiary referral center: 130 patients had PAD only, 21 patients had AAA only and 36 patients had both AAA and PAD. Differences in cAIx measurements between the three groups were tested by non-parametric tests followed by computation of a z-score and multivariate linear regression analysis to establish an association with obstructive or aneurysmatic patterns of vascular disease. Results: Mean cAIx was 29.8±8.3 with higher values in female (n=55) 34.7±6.,4 and older patients (>80years, n=22) 33.5±7.4. Intergroup comparison with z-score computation revealed a significant difference (p=0.006, H0: z-score(AAA or AAA&PAD)=z-score (PAD); p=0.0484, H0: z- score(AAA)=z-score(PAD or AAA&PAD)) in cAIx between patients with AAA (26.1±9.3), patients with both AAA and PAD (28.0±8.7) and patients with PAD alone (30.9 ±7.9). Female PAD patients (n=48) showed highest cAIx with 35.0±6.3. After adjustment for confounders, cAIx was significantly lower in patients with AAA, higher in patients with both AAA and PAD and highest in patients with PAD only (β=0.066, [95% CI, 0.0008 to 0.13], p=0.047). Conclusion: Non-invasive assessment of arterial stiffness in high-risk profile patients indicates that elevated central augmentation indeces are associated with PAD and AAA. To our knowledge, this is the first comparison of cAIx measurements for PAD and AAA patients revealing significantly higher cAIx for patients with obstructive arterial disease. FP 1.5
Endovascular infrarenal aortic aneurysm repair using the Anaconda system: lessons learned in a consecutive series of 75 cases A. Zollikofer, T. Wyss, G. Heller, M. Furrer (Chur)
Objective: Despite controversial long-term results there is a steady increase in endovascular repair of abdominal aortic aneurysm (EVAR). The aim of this study is to report our personal experience with a modular, repositionable endograft system including mid-term follow-up results. Methods: From 2008-2012 data from EVAR patients using the Anaconda® (Vascutek-Terumo) system were prospectively collected. An analysis of technical feasibility, in-hospital course and clinical and radiological mid-term follow-up in a single institution was performed. Results: 75 consecutive patients were enrolled in the study protocol. Two intraoperative conversions to open procedure had to be performed in the early period (technical success rate 97%) and two early postoperative complications (graft stenosis, graft occlusion) occurred resulting in a 30-day morbidity of 5%. In-hospital mortality was zero. Complications during follow-up period had to be treated in seven patients (9%) (one endoleak type III, two graft occlusions and four arterio-arterial embolic complications). Since 2011, we now recommend a dual platelet anti-aggregation regimen during the
first three months after the intervention. Since then, none of the treated patients had a thrombo- embolic event. Conclusion: Despite an expected learning curve, technical success was high and the rate of complications seems to be acceptable, with special regard to the zero mortality. The incidence and the means of prevention of thrombo-embolic complications in the intermediate and long-term follow-up should be included in all EVAR protocols because this might be a relevant contributor of complications. Peripheral Arterial Diseases FP 2.1 Percutaneous transluminal angioplasty (PTA) is a good solution for for the treatment of infra- inguinal bypass stenosis. S. Popeskou, S. Déglise, C. Dubuis, F. Saucy, S. Engelberger, L. Mazzolai, J.-M. Corpataux (Lausanne) Objective: In this endovascular era, infra-inguinal venous bypass is still the gold standard treatment for long femoral artery occlusions or after PTA failure. However, about 50% of bypasses fail during the first year due to stenosis. It has been demonstrated that routine bypasses surveillance by Doppler US is mandatory to achieve good patency rates. However, optimal treatment for infra-inguinal bypass stenosis is not clearly established. PTA has gained acceptance in initial management of graft stenosis but its role is still unclear especially with regards to the rate of recurrence. The aim of this study is to evaluate the treatment of infra-inguinal bypass stenosis by PTA. Methods: Data from patients who underwent transluminal angioplasty for treatment of infra-inguinal bypass stenosis between 2008 and 2012 was reviewed and analysed. Mean time from bypass was 18 months (range 3-54). A detailed analysis of the PTA procedure was undertaken, with emphasing on stenosis location, type and size of balloons and stents as well as success, recurrence and complications rates. Graft patency was also evaluated. Results: During the study period, 102 grafts stenosis were treated in 90 patients. Mean age was 77 years old (range 58-98) and two third of patients were men. The majority of bypasses were venous conduits (90%). Proximal anastomosis site was the femoral artery in 82% and distal anastomosis was the popliteal artery in 47% or a distal artery in the remaining 53%. First angioplasty was performed after a mean follow-up time of 10 months. There were a total of 175 initial stenosis and 35 recurrent ones. Eleven complications occurred which had to be treated surgically. At the end of the follow-up period, patency rate was 84%. Conclusion: Transluminal angioplasty to treat infra-inguinal bypass stenosis seems to be safe and effective. The need for stenting is rare. Complications and stenosis recurrence rates were low. However, due to progression of atherosclerosis and intimail hyperplasia development, there is a need for multiple interventions to ensure satisfactory patency rate in these bypasses
FP 2.2
Percutaneous Intentional Luminal Assisted Recanalization (PILAR) of challenging peripheral chronic total occlusions using a high frequency vibrational device F. Glauser1, A. Chouiter2, Y. Lachenal1, A. Jouannic1, F. Doenz1, S. D. Qanadli1 (1Lausanne, 2Neuchâtel)
Objective: Recanalization of chronic total occlusions (CTO) is a technically challenging procedure especially in case of in-stent and/or pre-stent CTO and heavily calcified CTO. The aim of this study was to assess the safety and the efficacy of a high frequency vibrational device (Crosser) in such situations Methods: Forty-four patients, with a mean age of 64 years, were treated with the Crosser device. Eighty-four percent of the patients had intermittent claudication. Sixteen percent of the patients were Fontaine stage III or IV. CTOs were in iliac (24%), femoro-popliteal (69%) or tibial arteries (7%). Fifty-eight percent of patients had heavy calcified CTOs. Twenty-eight percent of patients had in-stent or pre-stent CTO. The Crosser device consists of a crossing device based on high frequency mechanical vibrations. Primary technical success was the ability to cross CTO using the Crosser device. Safety endpoints were thromboembolisms and perforations related to the device on procedure. A 3 month follow-up was obtained for all patients. Results: Technical success rate recanalization was 90%. The mean recanalized length was 156 mm and the mean Crosser use time was 3.2 minutes. The Crosser achieved intra-luminal intended recanalization in 60 %. There were no adverse events related to the Crosser device. Recanalized vessels were treated with angioplasty/stents. Clinical success was 91% at 3 months follow-up. Conclusion: The Crosser device is safe and shows promising results in challenging cases such as heavily calcified lesions and in-stent or pre-stent CTOs. FP 2.3
Endovascular angioplasty of the isolated obstruction of internal iliac artery for buttock claudication A. Chouiter1, L. Lu1, F. Doenz2, S. D. Qanadli2 (1Neuchâtel, 2Lausanne)
Objective: Vascular obstruction of the internal iliac artery is common in patients with peripheral arterial disease. However, rarely the lesion is isolated and responsible for buttock claudication. The aim of this study is to report clinical results of symptomatic isolated internal iliac obstruction (IIIO) treated with percutaneous angioplasty. Methods: From September 2010 to April 2012, we retrospectively reviewed our series of eighteen patients with buttock claudication treated with angioplasty for the IIIO. Demographics, technical success, clinical outcome and complications are presented. Results: A total of nineteen arteries were treated. Seventeen patients were treated by unilateral recanalization of the internal iliac artery and one patient necessitated a bilateral angioplasty. Only one patient was treated with balloon angioplasty alone, all the others were treated with stent implantation. There was 100% technical success and no complication observed. All patients presented a successful clinical outcome with the relief of the symptoms at 3, 6 and 12 months follow-up. Conclusion: Percutaneous endovascular treatment of IIIO is a safe and effective procedure. Patient selection however is mandatory. Larger series and long term follow up are required to clearly define the role and the benefit of the procedure. FP 2.4
Popliteal artery recanalization using SUPERA stent: A retrospective study A. Chouiter1, L. Lu1, S. D. Qanadli2, M. Öksüz1 (1Neuchâtel, 2Lausanne)
Objective: The aim of this study was to evaluate efficacy, safety, and midterm patency of a popliteal artery recanalization with implantation of a self-expanding interwoven nitinol stent in patients with intermittent claudication or chronic critical limb ischemia. Methods: From April 2010 to March 2012, twenty-five patients were treated for atherosclerotic disease of the popliteal artery (total occlusion in 36% of patients) with implantation of a SUPERA stent because of elastic recoil, residual stenosis, or flow-limiting dissection after percutaneous transluminal angioplasty. The patients were followed for up to 12 months by Doppler ultrasound examinations, ankle-brachial index and assessments of Leriche and Fontaine class. Results: Technical success was achieved in 100% of procedures. Primary patency rate was 80% at 12 months. Four in-stent restenosis were successfully dilated by drug eluting balloon. One occlusion occurred, leading to an amputation in a patient with extensive disease in arteries bellow the knee inducing high resistance outflow. Conclusion: Percutaneous endovascular treatment of atherosclerotic disease of the popliteal artery with implantation of a SUPERA stent is a safe and clinically effective procedure. FP 2.5
Evaluation of ankle-brachial index measurements performed by medical students A. Alatri, L. Calanca, M. Monti, L. Mazzolai (Lausanne)
Objective: Ankle-brachial index (ABI) is a relatively simple, inexpensive, and non-invasive test used by angiologists for diagnosis of peripheral artery disease (PAD). ABI is also a predictor of cardiovascular (CV) events and mortality in PAD patients. ABI measurements performed by angiologists show good accuracy and reproducibility with a sensitivity and specificity of 89-95% and 95-100%, respectively. ABI measurement could be a valuable tool to be used by general practitioners (GPs) and internal medicine physicians for patient screening and CV morbidity evaluation. In the present study we evaluated accuracy of ABI measurements, performed in hospitalized patients, by sixth-year medical students after a short training period. Methods: Consecutive hospitalized patients (> 60 years) with at least one CV risk factor (diabetes, hypertension, dyslipidemia, previous cardiac- or cerebro-vascular disease myocardial, active or past smoking) were recruited. ABI's were measured according to standard method (highest ankle systolic pressure over highest humeral systolic pressure) using a hand held Doppler probe. ABI values were calculated separately for each limb. All participating students received a short training period (3 hours) by an experimented angiologist before study start. Sensitivity, specificity, positive predictive value (VPP), negative predictive value (NPV), and Kappa test were calculated according to results obtained in patients with or without PAD (as assessed by the angiologist). Results: Fifty-nine consecutive patients (27 women) were recruited. In 2 patients, for technical reasons (leg ulcers), ABI was calculated in only one leg therefore, a total of 116 ABI's were available for analysis. According to the reference group ABI results were: normal (0.91-1.40) in 62.1% of cases, abnormal (>1.40) in 18.1%, mild PAD (0.90-0.71) in 7.8%, moderate PAD (0.70-0.51) in 10.3%, and severe PAD (<=0.50) in 1.7% of cases). Overall, sensitivity, specificity, VPP and VPN were 75.0%, 87.5%, 78.6% and 85.1%, respectively. Resulting kappa test was of 0.4565 (moderate agreement). In 5 cases, students were not able to determine ABI. Among CV risk factor, only blood pressure was significantly higher in PAD (p<0.001) compared to non-PAD patients. Conclusion: ABI measurements require well trained personnel and a short training period is not sufficient to guarantee adequate accuracy and reproducibility.
Venous Diseases
FP 3.1
Thromboembolic complications in patients with Inflammatory Bowel Disease: results from Swiss IBD Cohort Study A. Alatri, A. Schoepfer, N. Fournier, L. Calanca, L. Mazzolai (Lausanne)
Objective: Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is associated with a high risk of venous thromboembolic complications (VTC) such as deep vein thrombosis (DVT) and pulmonary embolism (PE). Aims of study is to assess VTC prevalence in IBD patients and to identify associated risk factors. Methods: Data from patients enrolled in the Swiss IBD Cohort Study (SIBDCS) were analyzed. Since 2006 the SIBDCS collects data on a large sample of IBD patients from hospitals and private practices across Switzerland. For the present study, data from CD patients and UC patients were analysed separately. Results: At the time of our analysis, 90/2284 (3.94%) IBD patients suffered from VTC; of these, 45/1324 (3.4% overall; 2.42% with DVT, 1.51% with PE) had CD, and 45/960 (4.7% overall; 3.23% with DVT, 2.40% with PE) presented with UC. In CD patients, median disease duration was 12 years in the VTC group compared to 8 years in CD patients group without VTC (p=0.001). A history of IBD-related intestinal surgery was identified more frequently in the CD population with VTC compared to the one without IBD-related intestinal surgery (53.3% vs. 35.8%, p=0.016). No differences among the two groups were observed for perianal surgery (26.7% vs. 19.2%, p=0.216) or for disease location (p=0.596). In UC patients, disease duration was slightly longer in the VTC group compared to the one without VTC (median 7 years vs 6 years, p=0.053). UC-related intestinal surgery was more frequently encountered in the VTC group compared to the one without VTC (22.2% vs. 5.0%, p<0.001). Similarly to CD patients, no difference was found regarding perianal surgery (4.4% vs. 2.0%, p=0.240). UC patients with VTC were found more frequently to suffer from pancolitis compared to UC patients without VTC (53.3% vs 40.3%, p=0.003). IBD treatment, including immunomodulators and anti-TNF agents, was similar in patients with and without VTC both for CD and UC. Conclusion: IBD is associated with an important number of VTC. Thromboembolic complications were more prevalent in UC patients compared to CD ones. Intestinal surgery was an important VTC risk factor in both UC and CD patients. Disease duration was identified as a significant VTC risk factor in CD patients whereas pancolitis appeared a significant VTC risk factor in UC patients. FP 3.2
Diurnal changes of lower leg volume in obese and non-obese subjects R. P. Engelberger, A. Indermühle, F. Baumann, J. Fahrni, I. Baumgartner, T. Willenberg (Bern)
Objective: Obesity is an accepted risk factor for chronic venous disease. However, the mechanisms behind this association are poorly understood. Aim of the present study was to test the hypothesis that obese subjects without any objective venous disease have a higher diurnal leg volume increase compared to non-obese subjects. Methods: In this prospective cohort study including obese (BMI >=30 kg/m^2) and non-obese (BMI <=25 kg/m^2) subjects without venous insufficiency, lower leg volume was assessed by optoelectronic volumetry in the morning and in the evening. All subjects underwent duplex ultrasound and light reflection rheography (venous pump power and venous refill time, VRT) to investigate lower
extremity venous function. Between the morning and evening visit a pedometer was carried to assess the daily number of footsteps. A backward multivariable linear regression model was used to determine factors associated with diurnal lower leg volume increase. Results: 42 limbs in 24 obese subjects and 29 limbs in 15 non-obese subjects were analyzed. Obese subjects had larger common femoral vein diameters (17.1±2.4 mm vs. 15.5±2.4 mm, P<.01) and slower peak, mean and minimal velocities (25.1±10.6 cm/s vs. 44.3±14.3 cm/s; 6.8±2.4 cm/s vs. 12.7±5.6 cm/s; -0.2±6.4 cm/s vs. -6.3±11.9 cm/s; P<.01 for all) than non-obese subjects. VRT was shorter in obese subjects (40.5±15.0 s vs. 51.0±12.1 s, P<.01) and decreased significantly in the course of the day only in obese subjects (P<.01). Obesity, male gender, CEAP class, total time between the two visits, and difference between morning and evening VRT were positively associated with higher lower leg volume increase; morning VRT and the total number of footsteps showed a negative association (P<.04 for all). Conclusion: Obesity was found to be independently related to higher diurnal leg volume increase. One potential mechanism is a progressive failure of venous valve function in the course of the day in obese subjects. FP 3.3
Sural nerve injury following stripping of the small saphenous vein - is this complication avoidable? H. J. Hermanns (Lucerne)
Objective: Sural nerve injury, caused by stripping of the small saphenous vein (SSV) is described as a “minor complication” in varicose vein surgery. The reason for this damage is probably the close anatomical relationship of nerve and vein in the calf region. In spite of a sufficient vascular result after operation, injuries of the nerve may be a permanent problem for the patient. Therefore we investigated nerve injuries by a detailed neurological examination and analyzed the influence of quality of life (modified QL-questionnaire). Methods: The study design was a retrospective analysis of 646 SSV-Stripping operations ( period: 2005-2011; Venous and Wound Care Center Krefeld, Germany). The follow-up examination of all patients after three months included a clinical and neurological examination, followed by duplex scan. Patients with sural nerve injury were invited to an additional detailed examination one year after surgery and their quality of life was graded by questionnaire. The relationship of the nerve damage to the direction of stripping, length of stripping, size of buttons (thread technique) and weight of patients will be pointed out. Results: At the first follow-up examination (3 months) 44 (6,8 %) of 646 patients suffered from a lack of neurological sensitivity. 35 of them were investigated a second time one year after diagnosis. 13 patients (2%) were classified as a clear damage of the sural nerve with an affected skin area of 165 cm2 in median (4,5-470 cm2). 7 patients (1%) suffered from non-specific neurological problems, not related to the sural nerve innervation-area, while 11 patients were healthy and free of symptoms. In conclusion, our rate of nerve injury is 2%. In comparison to all patients, the sural group had an increased body weight and the stripping procedure included in 77% the complete SSV (Hach III). In spite of nerve damage 73% assessed their quality of life as good up to excellent. Only one female patient (9%) still has serious problems. Conclusion: The injury of sural nerve is more frequent in overweight patient and stripping procedure up to the ankle region (Hach III). Only 2% of our patients are burdened by this complication after SSV surgery. Compared with other studies this problem only occured in rare cases, but is not avoidable. In spite of irreparable nerve damage, quality of life and well-being is not really influenced. FP 3.4
Comparative effects of forced running exercise and angiotensin II receptor blocker telmisartan on angiotensin II-induced atherosclerosis J. Szostak1, M. Pellegrin1, K. Bouzourène1, J.-F. Aubert1, A. Berthelot2, J. Nussberger1, P. Laurant3, L. Mazzolai1 (1Lausanne, 2Besançon, 3Avignon)
Objective: Exercise training and angiotensin (Ang) II type 1 receptor (AT1r) blockers are effective therapies in reducing atherosclerosis in patients and animal models. However, few studies have directly compared these two treatments on experimental atherosclerosis. Therefore the purpose of this study was to determine the relative effects of forced running exercise and telmisartan on Ang II- dependent atherosclerosis using a mouse model. Methods: Mouse model of Ang II-induced atherosclerosis and vulnerable plaques was generated in hypercholesterolemic ApoE-/- mice by clipping left renal artery (2-kidney 1-clip [2K1C] renovascular hypertension model). 2K1C ApoE-/- mice were randomized into three groups: forced treadmill running (60 min/day, 5 days/week at a moderate intensity) (F-RUN), telmisartan treatment (25 mg/kg/day in drinking water) (TELM), and non-exercised and non-treated control (CONT). The protocol lasted 5 weeks. Mean blood pressure (MBP), plasma cholesterol and renin concentration (PRC), atherosclerotic plaque size and phenotype as well as aortic mRNA expression of AT1r, AT2r, PPAR-alpha, PPAR-gamma, PPAR-delta, CD11c (pro-inflammatory M1 macrophage marker), CD206 (anti-inflammatory M2 macrophage marker), IL-2 (pro-inflammatory Th1 marker), and IL-13 (anti- inflammatory Th2 marker) were determined at the end of the study. Results: As expected, MBP was significantly reduced, and PRC significantly increased in TELM. F- RUN did not change MBP and PRC. Plasma cholesterol concentrations were similar between groups. TELM significantly reduced atherosclerotic plaque size (-50%) but not F-RUN. Compared to CONT, both TELM and F-RUN showed a more stable plaque phenotype. Neither F-RUN nor TELM affected AT1r or AT2r expression. F-RUN significantly upregulated PPARs expression. TELM significantly reduced expression ratio of IL-2 to IL-13. No change was observed in CD11c and CD206 expression among groups. Conclusion: Forced running exercise and telmisartan are equally effective in preventing Ang II- mediated plaque vulnerability. Anti-atherosclerotic effects of these two interventions seem to be mediated by distinct mechanisms: Forced running stimulates PPARs expression whereas telmisartan modulates Th1/Th2 response toward a less inflammatory state in arterial wall. FP 3.5
Use of nitrogen oxide/oxygen during endovenous treatment of varicose veins T. O. Meier, V. Jacomella, B. Amann-Vesti (Zurich)
Objective: Tumescent anaesthesia (TA) is an important but sometimes very painful step in the procedure of endovenous thermal ablation of incompetent veins. The aim of the study was to examine whether the use of nitrogen oxide/oxygen (N20/O2) reduces pain during the application of TA. Methods: Prospective analysis of consecutive patients undergoing endovenous laser ablation (EVLA) of incompetent saphenous veins either with TA under the analgo-sedation with nitrous oxide/oxygen inhalation (N2O/O2-group) or TA alone (controls). Patients were asked to fill-in a questionnaire immediately after the intervention to assess satisfaction with the intervention and pain-levels during different steps of the intervention (0= not at all, 10 = very much). Adverse events during the treatment were monitored. Results: Between January 2011 and March 2013, 62 patients were included: 31 patients (14 men) in the NO2/O2 group with a mean age of 44years (23-72) and 31 controls (9 men), mean age 48years (31-69). In the NO2/O2 group a significantly lower pain score was noted (2.45 points, range 0-6) compared to the controls (4.3 points, range 1-9, p<0.001). 64.5% of the patients were perfectly satisfied with the NO2/O2-Inhalation, 32% found the inhalation acceptable, and 80% would undergo the procedure with NO2/O2 again. Only 4 patients receiving NO2/O2 complained of adverse effects such as unpleasant loss of control (2 patients), headache (1 patient) and dizziness (1 patient). Conclusion: This is the first report about the use of NO2/O2 during the application of TA for EVLA. N2O/O2 is a safe and effective method to reduce pain during the application of tumescent anaesthesia for EVLA Arterial Aneurysm P10
Interaction between widening diameter of abdominal aorta and cardiovascular risk factors and atherosclerosis burden F. Glauser, L. Mazzolai, R. Darioli, M. Depairon (Lausanne)
Objective: The aim of this study was to investigate influence of traditional cardiovascular risk factors (CVRF) and subclinical atherosclerosis (ATS) burden on early stages of abdominal aortic diameter (AAD) widening among adults. Methods: 2,052 consecutive patients (P) (39 % women), mean age 52 ± 13 years, were prospectively screened for CVRF, ATS, and AAD. B-mode ultrasound was used to evaluate the largest AAD and to detect carotid and femoral atherosclerotic plaques. Results: Mean AAD was 15.2 ± 2.8 mm. Atherosclerotic plaques were detected in 71 % of patients. Significant univariate correlation between AAD, traditional CVRF, and ABS was found. However, multiple regression analysis showed that only seven of them were significantly but weakly correlated with AAD (R² = 0.27, p < 0.001). On the other hand, a multivariate logistic analysis was used to evaluate CVRF impact on enlarged AAD ≥25 mm (EAAD) as compared to those with AAD <25 mm. These factors did not account for more than 30 % of interaction (R² = 0.30, p = 0.001). Furthermore, despite a large proportion of patients with high number of CVRF, and subclinical ATS, rate of patients with AAD ≥25 mm was low (1 %) and scattered regardless their CHD risk score or ATS burden. Conclusion: These results suggest that, although some traditional CVRF and presence of ATS are associated with early stages of EAAD, other determinants still need to be identified for a better understanding of abdominal aortic aneurysm pathogenesis. P11
Paraincisional subcutaneous infusion of ropivacaine after open abdominal vascular surgery shows significant advantages L. Chaykovska1, D. Mayer1, R. Tunesi1, Z. Rancic1, F. Veith1, 2, M. Lachat1 (1Zurich, 2New York)
Objective: Opiates are widely used for postoperative pain relief. Unfortunately, their side effects, such as inhibited gastrointestinal motility and respiratory depression may compromise or delay postoperative recovery after laparotomy. We used paraincisional subcutaneous 0.25% ropivacaine infusion to improve pain relief and decrease postoperative morphine consumption in patients after open surgery for aortic aneurysm. Methods: A retrospective single center study including 58 patients treated by open surgery for aortic aneurysm between October 2006 and June 2012. Overall, 28 patients (control group) received standard postoperative pain management including opiates and 30 patients (pain catheter (PC) group ) were treated with paraincisional continuous local analgesia with 0.25 % ropivacaine administrated via bilateral subcutaneous catheters along with additional on-demand opiates administration. Results: Demographic data as well as peri- and postoperative outcomes were comparable between the groups during the first 5 days after surgery. Patients of the PC group received significantly less morphine, although the patients in both groups reported a similar pain relief. Wound healing disorders or catheter associated subcutaneous infection were not observed in any patient of the study cohort.
High serum concentration of ropivacaine was detected in two patients (6%) with end stage renal disease, who developed temporary neurologic symptoms. This was successfully treated by reduction of the ropivacaine dosage. Length of ICU stay was significantly shorter in the PC group (2 (0 – 23) vs. 4.5 (0 – 32) ICU days, *p=0.04). Conclusion: This is the first report about paraincisional subcutaneous catheters for analgesia after laparotomy. This series shows that continuous paraincisional subcutaneous infusion of 0.25 % ropivacaine after open surgery for aortic aneurysm repair is feasible and safe. However patients with renal failure caution regarding dosage is mandatory. This technique allows sustained pain relief with significant reduction of opiate requirement and faster recovery after surgery. P13
Case report - splenic rupture after endovascular aneurysm repair of the infrarenal abdominal aorta - spontaneous or iatrogenic G. Meier-Fiorese, I. Schwegler, C. Berthold (Zurich)
Objective: Since its introduction in the 1990s, endovascular repair of abdominal aortic aneurysms using stent graft devices has been established as an alternative method for aneurysm repair. By doing more and more aneurysm repair this way, knowledge about complications and source of defects is growing. We present a case of a splenic rupture following an EVAR procedure. A complication which has never been published before, as far as we know. Methods: The 68 year old patient consulted his family doctor because of unspecific abdominal symptoms. An abdominal ultrasound examination was performed, which showed an abdominal aortic aneurysm of about 40 mm diameter. To confirm this result a contrast enhanced CT scan was obtained. The CT scan showed a 40 mm aneurysm of the infrarenal aorta and a 40 mm aneurysm of the right arteria iliaca communis. Both aneurysms were suitable for EVAR. First step was the embolisation of the right internal iliac artery. Three weeks later we performed an unremarkable EVAR procedure under general anesthesia. Routine CT scan on the first post operative day showed correctly placed stent graft without endoleak and retrospectively a normal spleen without any lesion. Results: On the second postoperative day, general condition of the patient got worse with signs of haemodynamic instability. With the strong suspicion of retroperitoneal bleeding, a CT scan was performed, that showed a large hematoma within the spleen and a lot of bloody ascites in the abdominal cavity. An urgent laparotomy was indicated, the diagnosis was confirmed and a splenectomy was performed. The hospital stay was afterwords uneventful. The patient recovered soon and left the hospital on the 9th day after splenectomy. Surveillance CT scan, done after one and three months stayed unremarkable. Conclusion: The reason for this „spontaneous“ splenic rupture remains unclear. During the EVAR procedure we administered 5000IE liquemin and after the operation the patient was given Clexane 20 sc. together with Aspirin cardio 100 mg. There was no suspicion for a coagulation disorder. A trauma of the patient was not reported. The examination of the specimen showed a central rupture of the spleen and a large intracapsular hematoma, but no indication as to the ethiology.
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EVAR Solution in an infective aortitis: an open discussion L. Mezzetto, L. Giovannacci, R. Rosso (Lugano)
Objective: Aortitis has been defined as a distinct entity of the acute aortic syndrome. It shows a poor natural history with rupture rates in up to 40% and urgent surgical repair is commonly warranted. Patients usually are elderly with multiple co-morbidities and therefore sometimes unfit for surgery. In this report we presented an emergent EVAR treatment for a severe infective aortitis, in a patient unfit for conventional open approach. Methods: a 65-years-old man presented to the emergency department with sudden severe lumbar pain and severe inflammatory syndrome (Temperature 38.5°C, PCR 187mg/L, PCT 0.56mcg/L). A CT- scan conducted emergently showed an infra-renal aortitis with a penetrating ulcer, impending for rupture. Two months before, the patient underwent neck radiotherapy for lymph nodes metastasis of a squamous cell carcinoma with unknown primary origin. That procedure was complicated by neck abscess, subsequently resolved. Results: straight tubular (Endurant - Medtronic) endovascular repair was conducted urgently. Lumbar pain immediately resolved but the patient developed a septic shock requiring an ICU stay. The blood coultures showed S. aureus growth and a specific antibiotic therapy was immediately introduced. Fever and inflammatory syndrome rapidly regressed and the patient was discharge in optimal medical conditions after one month. Long-term antibiotic therapy has been maintained. Comparision between 1-month and 3-month CT-PET showed a clear reduction in patological perigraft captation; the patient remained asymptomatic with normal leucocite count and normal CRP. Conclusion: Infectious aortitis has to be considered a vascular emergency for the impending risk of rupture. Open surgical repair continues to be the gold standard treatment. On the other hand, in cases of emergency in patient unfit for surgery, EVAR and long term antibiotic therapy has been proposed as an alternative approach. Data published in the literature is limited but,, singular case reports with good outcome, like this one, offer the opportunity to open an interesting discussion. P18
Perigraft seroma after open abdominal aortic aneurysm repair with Dacron graft: a rare presentation B. Hummel1, C. Rouden2, C. Zeisel1, W. Nagel1 (1St.Gallen, 2Basel)
Objective: Perigraft seroma (PGS) is a known but rare complication after conventional abdominal aortic aneurysm (AAA) repair. It’s defined as a sterile fluid collection, confined within a nonsecretory fibrous pseudomembrane surrounding a vascular graft. Most of the described cases in the literature are associated to PTFE (polytetrafluoroethylene) graft. Methods: A 60-year-old man underwent an uneventful open repair of an asymptomatic 6.2 cm infrarenal AA with a 18x9mm Silver-Dacron aorto-biiliacal bifurcated graft. A computed tomography (CT-scan) 3 months later revealed a 6.4cm clear fluid collection adjacent to the right distal anastomosis. No haematoma or bleeding and no sign of inflammation or infection could be seen. As the patient was completely asymptomatic and had no sign of infection, a conservative treatment was initiated. 2 months later the patient returned complaining of pain in the right iliac fossa and a painful hernia of the midline scar. No relevant change of the fluid collection could be observed on the CT- scan and color Duplex ultrasonography. To rule out infection, a needle aspiration of the perigraft fluid collection was performed under CT-scan. Clear serous fluid was withdrawn. Culture results were
positive for Staphylococcus capitis. Although contamination was likely, infection could not be ruled out. All remaining laboratory tests were normal. A surgical revision was decided. Results: At surgery, no signs of prosthetic infection could be detected. The right iliac retroperitoneal sac was incised longitudinally. Citrine liquid under pressure and some viscous gel like substance were evacuated. The prosthesis showed locally no sign of incorporation. After sac resection and debridement, an omentopexy was performed. Microscopic examination of intraoperative material revealed fibrinous tissue with unspecific lymphocytic inflammatory infiltrate. No bacterial growth could be proved. A CT-scan 3 and 5 months later showed no signs of recurrence. Conclusion: The origin of PGS remains unclear. Possible aetiologies such as low grade infection, immunologic reaction to graft material, trans-graft passage of fluid or increased activation of fibrinolytic cascade are discussed. Small and asymptomatic PGS may be followed closely. In symptomatic patients an intervention combining resection of PGS sac, endarterectomy of the remaining membrane and omentoplasty should be considered. P23
Symptomatic false aneurysm of the left cubital artery - a case report A. S. Wenning, K. T. Mouton, W. G. Mouton (Thun)
Objective: False and true aneurysms of the cubital artery are rare. We present a case of a false cubital artery aneurysm taking an unusual course. Methods: Seventeen years ago, a now 50 year old male patient had a 10 m fall off a scaffolding resulting in (only) a fracture to the right elbow requiring osteosynthesis. At that time, contrast was injected in the left cubital vein, this being the only time the left cubital vein was ever punctured. Two years ago an aneurysm was discovered in the left cubital artery and demonstrated by angiography to be 4.5 cm in length and 1.6 cm in diameter. The size increased rapidly within one month to a length of 6 cm and a diameter of 2 cm, with increasing pain. Intra-operatively the aneurysm had the appearance of a true aneurysm. It was resected and a reconstruction was performed with a reversed great saphenous vein interposition. Results: Histology showed a false cubital artery aneurysm. There was fresh and older thrombus in the lumen and arterial wall. No media-dissection was observed. Duplex sonographic follow-up to date shows a patent venous reconstruction without stenosis. Conclusion: False aneurysms of the cubital artery are rare and can be caused by accidental puncture of the artery instead of the vein. In our case the delay is extraordinarily long and the cause of the sudden onset of the increase in size is unclear.
Beilage: 197.pdf Peripheral Arterial Diseases
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Assisted recanalization of in-stent chronic total occlusions using a high frequency vibrational device F. Glauser1, A. Chouiter2, Y. Lachenal1, A. Jouannic1, F. Doenz1, S. D. Qanadli1 (1Lausanne, 2Neuchâtel)
Objective: Recanalization of in-stent and/or pre-stent total and chronic occlusions is a technically challenging procedure. The aim of this study was to assess the safety and the efficacy of a high frequency vibrational device for in-stent CTO treatment. Methods: Eight patients with mean age 68 years were treated. One patient was Fontaine IV stage while 7 had intermittent claudication. All patients had in-stent chronic total occlusion of the superficial femoral artery (SFA) documented by CT or angiography and 4 patients had additional pre-stent occlusion. The Crosser device consists of a crossing device based on high frequency mechanical vibrations. Primary technical success was the ability to cross CTO using the Crosser device. Safety endpoints were thromboembolisms and perforations related to the device. A 3 month follow-up was obtained for all patients. Results: The technical success rate for Crosser recanalization was 100%. The mean recanalized length was 180 mm and the mean Crosser activation time was 5 minutes. The Crosser achieved intra-luminal intended recanalization in 86%. There were no adverse events related to the Crosser device. Recanalized vessels were treated with angioplasty/stents. Clinical success was 100% at 3 months follow-up. Conclusion: The Crosser device is safe and shows promising results in challenging cases such as in- stent CTO. Further evaluations, however, are needed to better select patients for such device. P4
Forced treadmill running versus voluntary wheel running versus forced swimming for the treatment of experimental peripheral artery disease M. Pellegrin, K. Bouzourène, J-F. Aubert, C. Poitry-Yamate, V. Mlynarik, R. Gruetter, L. Mazzolai (Lausanne)
Objective: Supervised exercise training is a first-line therapy for peripheral arterial disease (PAD) management. However, types of exercise providing optimal clinical benefits remain unclear. We therefore compared the effects of three exercise training on walking performance in a mouse model of PAD and investigated potential underlying mechanisms. Methods: Unilateral hindlimb ischemia was induced in atherosclerotic ApoE-/- mice by common iliac artery ligation. One week post-ischemia, mice were randomized into four groups: control sedentary (SED), forced treadmill running (F-RUN), voluntary wheel running (V-RUN), and forced swimming exercise (F-SWI). The protocol lasted 4 weeks. Daily physical activity and maximal walking capacity were estimated using a 24 hours free running and incremental forced running tests. Ischemic hindlimb perfusion and oxygenation were quantified using Laser Doppler imaging and transcutaneous O2 pressure measurements. Arteriogenesis was evaluated in ischemic gastrocnemius muscle using immunohistochemical staining for α-smooth muscle actin and real time-PCR analysis to determine vascular endothelial growth factor (VEGF), hypoxia-inducible factor-1 (HIF-1) and Angiopoeitin2 (ANG2) mRNA expression. Ischemic hindlimb muscle glucose uptake was assessed by 18F- fluorodeoxyglucose positron emission tomography imaging. Atherosclerotic plaque size was quantified at the aortic sinus level by histological techniques. Results: F-RUN and V-RUN, but not F-SWIM, significantly improved daily physical activity. Maximal walking capacity significantly increased following V-RUN only. Exercise training did not accelerate spontaneous recovery of ischemic hindlimb perfusion and oxygenation. Arterioles number as well as mRNA levels of VEGF, HIF-1 and ANG2 in ischemic gastrocnemius did not significantly differ between the four groups. Ischemic hindlimb glucose uptake significantly decreased in SED over time and after F-SWIM, but not following F-RUN and V-RUN. Atherosclerotic plaque size was significantly reduced with F-RUN and V-RUN. Conclusion: Forced and voluntary running are equally effective in improving daily physical performance whereas only voluntary running improves maximal walking performance in our mouse model. Positive mechanisms may involve prevention of hindlimb glucose uptake impairment and inhibition of atherosclerosis development. P5
Renal auto-transplantation implanted on Omnilow II bioprothesis to treat vascular infection after ureteral necrosis S. Engelberger, S. Déglise, T. Holzer, C. Dubuis, F. Saucy, J.-M. Corpataux (Lausanne)
Objective: Iatrogenic ureteral injuries in aortic surgery has an incidence of 0.5 to 1%. If not discovered and treated promptly, it may be associated with severe complications, such as prosthetic vascular graft infection. The goal when dealing with ureteral lesions is to avoid nephrectomy and to ensure adequate sealing of the ureter. Various treatments exist, such as double J tube placement, ureteral reimplantation, transureterostomy, or even ureteroileostomy, with diverse morbidity rates. We report the first case of renal auto-transplantation implanted on a bioprothesis to treat aorto-iliac graft infection due to ureteral necrosis. Methods: A 69 year-old male patient with an aorto-biiliac bypass graft performed in 1997 presented with false anevrysms at the distal anastomoses. On one side, a stent graft was implanted to cover it with previous embolization of the internal iliac artery. In order to maintain hypogastric perfusion on the other side, surgery was mandatory. The iliac limb was reimplanted on the internal iliac artery with excision of the anevrysm and a short prosthetic bypass to the external iliac artery was added. In the immediate post-operatory period, a necrosis of the left ureter was diagnosed and treated with external drainage and JJ tube placement in the left ureter. Due to secondary infection of the external iliac prosthesis, the patient was re-operated. The short bypass was removed and replaced by an Omniflow II bioprosthesis between the left iliac prosthetic limb and the common femoral artery. Due to substantial ureteral necrosis, it was decided to perform a renal auto-transplantation in the left iliac fossa with arterial implantation on the bioprosthesis. Long-term antibiotherapy was carried out, based on the microbial flora detected Results: The postoperative time was uneventful except for an ileus requiring laparotomy. At 1 month, the renal function was normal. No vascular complications occurred, all reconstructions remained patent and the patient was asymptomatic. After 12 weeks of antibiotherapy, no signs of recurrence of infection were observed. Conclusion: To our knowledge, it is the first report of renal autotransplantation performed on the bioprosthesis Omniflow II. This technique shoud be considered as a salvage procedure but it can avoid nephrectomy in cases of ureteral necrosis. P7
Safety and efficacy of the CELT ACD and vascular closing device for percutaneous closure of arterial femoral access S. Archontaki, F. Glauser, Y. Lachenal, F. Doenz, R. Meuli, S. D. Qanadli (Lausanne)
Objective: To evaluate the efficacy and safety of the Celt ACD device for percutaneous femoral artery closure in unselected patients. Methods: Thirty patients who underwent percutaneous closure of femoral arterial access after endovascular procedures were included in this study. Twenty eight had retrograde access and two
antegrade access. Patients had received intra-arterial heparin (2500 to 5000 IU) during the intervention and were under ASA. All patients underwent Doppler US in the 2 hours following the intervention and at 1 and 3 months. Results: The closing device deployed successfully in 29 patients. In one patient with antegrade access, the device couldn’t be advanced through the introducer sheath. Hemostasis was immediately achieved in all implanted devices. Two patients had minor immediate complications (1 small hematoma, 1 focal dissection above the puncture site). No delayed complication occurred in the 25 patients who underwent a follow-up study after 1 and 3 months. Conclusion: Percutaneous femoral artery closure with Celt ADC device is easy and safe procedure with a low rate of major and minor complications P9
TASC D Femoro-Popliteal Lesions Treated by Endovascular Procedures : A Retrospective Study A. Chouiter, A. Stolz, M. Öksüz, D. Imsand, I. Bruschweiler, R. Wutschert (Neuchâtel)
Objective: The aim of this study was to evaluate efficacy, safety, and midterm patency of endovascular femoro-popliteal recanalization in patients with TASC D arterial lesions inducing chronic critical limb ischemia (CLI) or lifestyle-limiting claudication. Methods: From January 2011 to June 2012, fourteen patients (3 women and 11men) were treated for a TASC D femoro-popliteal artery occlusion. Mean age of patients was 72 years and 10/14 were Leriche and Fontaine class III and IV. Patients were followed at 3, 6 and 12 months by Doppler ultrasound examinations, ankle-brachial index and assessment of Leriche and Fontaine class. Results: Technical success was achieved in 93% of procedures with no intraoperative major complication. Only one recanalisation failed. All the patients were treated with stent implantation. The primary patency rate was 69% at 12 months. Two diffuse in-stent restenosis were successfully dilated by drug eluting balloons. Two patients occluded. Limb salvage rate from major amputation was 100%. Conclusion: Percutaneous endovascular treatment of TASC D femoro-popliteal lesions is a safe and clinically effective procedure. A very close and frequent angiologic control is mandatory to depict restenosis and plan secondary procedures if needed. Larger series and long term follow up are required. P19
Case report - Adventitial cystic disease in connection with the wrist G. Meier-Fiorese, I. Schwegler, B. Helmchen (Zurich)
Objective: Adventitial cystic disease is a rare disease of the arterial wall and can cause symptoms of peripheral artery occlusive disease. The disease was first reported by Atkins and Kelly in 1947 and it occurs more frequently in men in younger and middle age. It is predominantly localized in the Arteria poplitea (85%), the external iliac and femoral arteries. The most common locations are adjacent to joint spaces. We present a case of adventitial cystic disease of the Arteria radialis in relation with the wrist joint to set an example and to discuss varying theories of the etiology. Methods: The case has been documented by MRI, intraoperative pictures and the histologic specimen. Results: The 26-year old patient complained of pain and repetitive tumescence of the forearm following mechanical stress. The MRI study conducted to clarify the complaints showed a perivascular cystic lesion covering the Arteria radialis over a length of 10 cm, reaching from the distal forearm to the basis of the second metacarpal bone.
Due to the discomfort and to prevent a occlusion of the artery in the long term, the indication for resection of the lesion was made. The exarterectomie was carried out easily and with retention of the artery. The formation was removed completely. The histological examination confirmed the diagnosis adventitial cystic diseases and showed that the specimen contained synovial membrane. Conclusion: The etiology of adventitial cystic disease remains uncertain and is still up for debate. Literature describes four theories: mechanical - by repetitive trauma, ganglion - arising from a nearby joint, a systemic disorder and the developmental theory. We apply miscellaneous theories to our case and, will try to prove why we favor one of the theories. P20
The initial experience in the CHUV with the Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) technique T. Holzer, S. Déglise, F. Saucy, S. Engelberger, C. Dubuis, L. Mazzolai, J.-M. Corpataux (Lausanne)
Objective: In cases of aorto-iliac occlusive disease, despite good patency rates, open surgery is associated with post-operative rates of mortality and morbidity of 4 % and 16%, respectively. For these reasons, endovascular therapy associating angioplasty and non-covered stents has progressively supplanted surgery. However, the main limitng factor is the rate of in-stent restenosis due to myointimal hyperplasia. A new endovascular approach consisting in Covered Endovascular Reconstruction of the Aortic Bifurcation (CERAB) using covered stents has been recently developed and we report here our initial experience. Methods: The CERAB technique consists of a reconstruction of the occluded or stenosed aortic bifurcation using Advanta V12 (Atrium) covered stents. It is assumed to be hemodynamically tolerated better with fewer dead spaces, thereby reducing zones of turbulent flow and the risk of intimal hyperplasia. Five patients with a median age of 57 years old have been treated in our Department in the last 2 years using this technique. All had stenosis or occlusion of the distal aorta and iliac bifurcation with Rutherford classes 3 or 4. Results: The immediate technical success was 100%. In the post-operative time, one occlusion of the right leg of a CREAB occurred and necessitated a chimney stent starting in the aorta and finishing in the right common iliac artery. No other complications were observed. The median length of stay was 3 days. All patients received of dual anti-aggregation treatment for 3 months. At follow-up one year later, they were no reoperation. All reconstructions remained patent and the patients were in Rutherford class 1 or 2. No death occurred. Conclusion: Despite the small number of patients treated, the CERAB technique seems to be feasible and effective to treat aorto-iliac occlusive disease. It is safe and presents good results at a short term follow-up. Long term results still have to be investigated and compared with the available data and gold standard techniques. Venous Diseases P2
Deep vein thrombosis of the penis: an unusual but severe complication of prostatic abscess. Case- report and review of the literature L. Calanca, A. Alatri, M. Schaller, A. Sermier, L. Mazzolai (Lausanne)
Objective: Venous thrombosis of the penis has most often been related to the superficial venous system. Thrombosis of penis deep venous system (PDVT) has been rarely reported and must be clearly distinguished because it may cause serious clinical complications. We report the first observation of PDVT associated with infection and we reviewed the other 5 cases already described. Results: A 66-year-old patient, hospitalized for prostatic abscesses and septic shock, presented with a PDVT. Drainage of prostatic abscesses and treatment of septic shock (antimicrobial with piperacillin/tazobactam and support treatments) were immediately undertaken. Patient was also treated with anticoagulant therapy (low-molecular-weight heparin and vitamin K antagonists) for 6 months. Duplex ultrasound showed vein recanalization at the end of the treatment. Local clinical evolution was favorable despite severe initial manifestation presenting with a high probability of major necrotic consequence to the penis. Conclusion: At our knowledge, only five cases have been reported in the literature. Outcome was negative in 3 cases resulting in penis necrosis or persistent erectile dysfunction. PDVT has been associated with Behçet's disease, heterozygous factor V mutation, Henoch-Schonlein purpura, heterozygous factor II mutation, hyperhomocysteinemia, trauma and elevated factor VIII levels. Duplex ultrasound can be used to easily distinguish between superficial and deep venous penile systems. Additionally, it allows analyses of arterial blood flow as well as penile structures. Use of other imaging techniques, such as MRI or CT-scan, provide additional and different information that may be helpful in better targeting a differential diagnosis, in evaluating an associated neoplasia, or in detailing proximal extension of thrombosis. Anticoagulant treatment should avoid potentially serious complications in penile structures drained by the deep venous system, thus hindering thrombosis extension to still patent segments. Additional therapeutic options (i.e. thrombolysis or thrombectomy) may be considered depending on the severity of the clinical picture and according to availability of resources and skilled personnel. Identification and treatment of an underlying cause provoking PDVT should always be looked for. Searching for other prothrombotic conditions must also be undertaken to optimize “anticoagulative treatment” on “anticoagulant duration”.
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Giant symptomatic aneurysm of the inferior vena cava: a case report U. Wenger, V. Makaloski, M. Czerny, J. Schmidli (Bern)
Objective: Inferior vena cava aneurysm is a rare entity with less than fifty reported cases worldwide. This aneurysm can be asymptomatic or presents with severe clinical complications such as thrombosis, pulmonary embolism or rupture. We present a case of giant symptomatic inferior vena cava aneurysm with abdominal pain, pulmonary and visceral embolisms. Methods: Sixteen-year old female presented in regional hospital with acute chest pain and nausea after a syncope in the toilet. She also experienced moderate abdominal pain in the upper abdomen for several weeks. Emergency CT-scan diagnosed an aneurysm of the inferior vena cava 13 x 11 x 7 cm and multiple infarctions of both kidneys and spleen. The patient was immediately transferred to our institution and operated on urgently due to the acute abdominal pain with increased risk of rupture. Results: The aneurysm sac was resected and the ventral defect in the wall of vena cava was reconstructed with a bovine patch plasty. Intraoperative transoesophageal echocardiography showed a right heart strain and a patent foramen ovale with left-right shunt. During the initial postoperative course, due to deterioration of respiration and the need for reintubation, a new CT-scan of the chest was performed, showing massive pulmonary embolism with occlusion of the left pulmonary artery,
the right upper lobe artery and several peripheral emboli. On the same day, an open bilateral embolectomy of the pulmonary arteries and primary closure of the patent foramen ovale was performed. Oral anticoagulation was started as soon as the patient recovered from both operations. She developed a liver big hematoma under anticoagulation, which was the reason for the prolonged abdominal pain. There was no need for further surgical intervention. She was discharged on day 19 with normal renal and liver function. Conclusion: Treatment of asymptomatic aneurysms of the inferior vena cava is highly controversial. Surgical treatment of symptomatic aneurysms consisting of complete or partial resection is recommended. In our case, the giant aneurysm hosted a huge amount of thrombus followed by massive pulmonary embolism and peripheral visceral embolisation because of a patent foramen ovale. P8
Prospective randomized trial to compare two different insertion techniques for peripherally inserted central catheter: interim results F. Glauser, Y. Lachenal, S. Archontaki, A. Jouannic, F. Doenz, S. D. Qanadli (Lausanne)
Objective: Peripherally inserted central catheter (PICC) is increasingly used to provide access to central veins. It has led to the development of a bedside technique for placement of PICC, which could result in tip malposition. The aim of our study is to compare a bedside PICC placement to a fluoroscopically guided PICC with specific regards to tip position. Methods: One hundred fifty patients are randomized to either bedside placement or fluoroscopically guided PICC insertion. All procedures are done by the same interventional team and include a post- procedural chest radiography to assess catheter tip position. Depending on the International Guidelines for optimal tip position, patients are classified in three groups: optimal, non-optimal not needing repositioning, non-optimal requiring additional repositioning procedures. Results: In the interim analysis, all intended PICCs placement were done. In the bedside PICC group, 20% of patients were classified as suboptimal tip position and 5% needed repositioning. In the fluoroscopic group, all the catheter tips were located at the lower third of the SVC or at the caval-atrial junction. Conclusion: Our preliminary results suggest that tip malposition is relatively frequent with bedside placement of PICC despite procedures realized by experienced interventional radiologists. P12
Implanted central venous catheter dysfunction: value of endovascular stripping and repositioning D. Rhyner, F. Glauser, Y. Lachenal, F. Doenz, A. Jouannic, S. D. Qanadli (Lausanne)
Objective: To analyze the efficacy and safety of endovascular stripping (ES) and repositioning procedures for implanted central venous catheter (ICVC) dysfunction. Methods: 95 consecutive patients (mean age, 62 years) with ICVC dysfunction were included. ICVC was implanted for chemotherapy in 90.5% of patients. ICVC dysfunction was clinically suspected and confirmed by injection of iodinated contrast material. In 11 patients the dysfunction was associated to thrombus formation that needed anticoagulation therapy and in 84 patients the dysfunction was related to fibrin sheath formation. Primary malposition was seen in 35 patients and secondary malposition in 15 patients. In 69% of patients, persistent dysfunction after conservative treatment, including heparin and in situ thrombolysis, was observed. These patients were considered for ES. The procedure
consisted of introducing a snare catheter with a loop via the common femoral vein under local anesthesia. If necessary catheter tip repositioning was performed. Results: Technical success of ES was achieved in 95.5 %. In 8 patients repositioning maneuver was conducted, mostly concerning catheter tips stuck in the brachiocephalic (5%), right (2%) or left (5%) subclavian vein. There were no immediate complications. No thromboembolic event was observed. Conclusion: Our findings underline the safety and efficacy of ES of ICVC dysfunction. P16
Inferior vena cava occlusion due to cava filter: the surgical approach still has a place T. Holzer, S. Déglise, S. Engelberger, F. Saucy, F. Glauser, S. D. Qanadli, J.-M. Corpataux (Lausanne)
Objective: Nowadays, inferior vena cava (IVC) filter is a commonly used device and indications were expanded to patients at risk of deep venous thrombosis who cannot be prophylactically anticoagulated. Retrievable filters were designed to provide temporary protection but many of them are left in place. Complications, especially perforation or migration are described. Some degree of thrombus inside the filter has been reported to be present in about 20% of cases but less of 1% of patients presented with total occlusion of the IVC. Therefore, the experience of management of such cases is really limited and controversial. Methods: We report the case of a 59 years old patient with a temporary IVC filter in April 2012 due to massive bilateral pulmonary embolism (PE). The oral anticoagulation was stopped after 6 months but the filter was never removed. Six months later, the patient presented swelling of both legs, with lumbar pain and bilateral venous claudication. A CT scan showed an occluded IVC starting in the filter and involving the iliac, femoral, popliteal and tibial veins. Moreover, a large thrombus burden was seen above the filter. The patient was highly symptomatic, leading to an aggressive strategy. Due to the risk of PE, the IVC was temporary occluded at the suprarenal level with a percutaneous balloon inserted through the right internal jugular vein. Surgical thrombectomies of femoro-popliteal and iliac veins were performed through a median laparotomy and inguinotomies. Thrombus extraction and filter removal were achieved through a cavotomy. Results: The intervention was well tolerated without signs of PE. A post-operative duplex ultrasound showed a partial recanalisation of the IVC and right ilio-femoral veins. At 1 month, the patient was asymptomatic and the swelling almost completely disappeared. Conclusion: Due to the paucity of the reports in the literature concerning the management of IVC filter thrombosis, no guidelines exist. The endovascular approach is the first choice nowadays, associating mechanical and pharmacological thrombus removal. Technical success rates of 80% have been reported. However, in cases of long and bilateral occlusion or when there is a free-floating thrombus above the filter, this therapy is associated with more risk of complications or failure. Therefore, the surgery still has a place with the advantage of filter removing. Varia
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Improved bleeding control and hemodynamic stability after embolization in unstable polytrauma patients J. Aguet, P. Bize, R. Duran, N. Demartines, A. Denys (Lausanne)
Objective: To determine prognostic factors and evaluate outcome of transcatheter arterial embolization in severely injured and hemodynamically unstable patients with multicompartmental bleeding. Methods: Between June 2000 and May 2008, 36 consecutive patients treated with transcatheter arterial embolization for major retroperitoneal bleeding associated with at least one additional source of bleeding were retrospectively reviewed. Mean Injury Severity Score (ISS) was 49.4 +/- 15.8. Univariate and multivariate analyses were performed to identify parameters associated with embolization failure, need for additional surgery to control bleeding and fatal outcome at 30 days. Results: Embolization was technically successful in 35 of 36 patients (97.2%) and resulted in immediate and sustained (>= 24 h) hemodynamic improvement in 29 patients (80.5%). Additional hemostatic surgery was required after embolization in 6 patients (16.6%). 15 patients (41.6%) died within 30 days. Failure to restore hemodynamic stability was correlated with the hourly rate of packed red blood cells administration (P = 0.014), fresh frozen plasma administration (FFP; P = 0.031), and systolic blood pressure (SBP) immediately before embolization (P = 0.002). The need for additional surgery was correlated with hourly rate of FFP administration immediately before embolization (P = 0.0002) and hemodynamic instability (P = 0.003). Death was correlated with initial Glasgow Coma Scale score at admission (P = 0.001), ISS (P = 0.014), New Injury Severity Score (P = 0.016), number of injuries (P = 0.012), SBP before embolization (P = 0.042), need for vasopressive drugs before embolization (P = 0.037), and hemodynamic status (P = 0.0004). Conclusion: In hemodynamically unstable patients, transcatheter arterial embolization allows effective control of bleeding and improves hemodynamic stability. Immediate survival is related to hemodynamic condition before embolization, and 30-day mortality is mainly related to associated brain trauma P14
Advanta V12 : a suitable alternative for the treatment of traumatic aortic injuries S. Engelberger, S. Déglise, T. Holzer, F. Saucy, F. Doenz, J.-M. Corpataux (Lausanne)
Objective: Blunt traumatic abdominal aortic injuries often affect young adults and children with small vessel diameters. The abdominal aorta is injured in less than 20% of all traumatic aortic lesions. Endovascular treatment options gain popularity given the low postoperative morbidity and good short term results. Small vessel diameter may limit the use of ‘off the shelf’ stent grafts. This case report shows a possible treatment option in this setting. Methods: We report the case of a 20 years old male treated in an emergency setting after a motor vehicle accident. He presented a laceration of the abdominal aorta with partial avulsion of a lumbar artery at the level of L2-3 and contained bleeding. Given the diameter of the abdominal aorta of 12 mm, a 12mm and a 16 mm PTFE covered stent (Advanta V12®) have been used for the endovascular coverage of the lesion. Results: The immediate success was complete. There was no postoperative complications with full recovery. At 6 months, the stents were patent and the hematoma totally disappeared. Short term follow up showed no complications. Conclusion: Lumbar artery avulsion is a possible mechanism of aortic injury, especially in cases of blunt trauma. PTFE covered stents (Advanta V12®) are available in smaller diameters than conventional aortic stent grafts and hence can be used for the endovascular treatment of blunt injuries of a small diameter infrarenal aorta. P15
Bleeding from an unusual cause C. Jeanneret-Gris, S. Brunner (Bruderholz)
Objective: The following case report shall demonstrate a rare, but not to be missed , cause of hemorrhagic diathesis. Methods: We present a 49 year old patient, who was admitted to the hospital with severe bruising and a large hematoma in the right thigh without recalling a previous trauma. The bleeding was so severe, that the patient's blood pressure declined and tranfusion was necessary. Further investigations revealed, that the patient nurished himself only with pasta, potatoes and lactose free milk. He never ate fruit, vegetables or meat. Results: The laboratory tests revealed a low hemoglobin, but normal white blood cell - and normal thrombocyte count. The INR and the liver enzymes were within normal limits. The Von Willberand factor was normal. The vitamin C level was far bellow normal values (see table 1), the vitamin B complex level was decreased as well. On clinical examination, we found extended hematomas of the right leg, a gingival hyperplasia and corkscrew shaped hairs. After substitution of vitamin C, the hematoma resolved. The hemoglobin level rose from 109 to 117 g/l under the additional substitution of vitamin B-complex. Table 1 Value Reference range Vitamin C 0.7 mg/l 2-20 mg/l Vitamin B 1 62 nmol/l 67-200 nmol/l Vitamin B 12 85 pmol/l 100-430 pmol/l Conclusion: As a consequence of a very unbalanced diet, the patient presented symptoms of a severe deficiency of vitamin C, also called scurvy or sailor's disease.The symptoms can be mistaken as a small vessel - vasculitis. The "trial" of hemorrhagic diathesis (hematoma, petechiae), gingival hyperplasia and corkscrew shaped hair is characteristic in vitamin C deficiency. After substitution of vitamin C, the hematomas resolved and the haemoglobin level was stable after the transfusion of erythrocyte concentrates and the substitution of vitamin B-complex. Nowadays, we should include "eating habits" in the patient's history assessment. The knowledge of the symptoms of this rare deficiency is crucial for further treatment.
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In situ cryopreserved homograft revascularization for an atypical presentation L. Mezzetto, L. Giovannacci, R. Rosso (Lugano)
Objective: Although relatively rare, aortic graft infections continues to be one of the foremost challenges in vascular surgery. They are associated with high morbidity and mortality rates and they warrant a high index of suspicion by the vascular surgeon. The diagnosis may be difficult and the cause is unclear. Different treatments have been proposed: in situ cryopreserved homograft revascularization appears to be an effective method. Methods: A 52-years-old man from Bosnia presented to the emergency department with a 12-hour history of moderate epigastric pain, with nausea, diarrhea and mild inflammatory syndrome (leucocyte count 16.9 x10E9/L and PCR 17mg/L). Two years before he had undergone on aorto-biliac
revascularization for elective infra-renal aortic aneurysm. A CT-scan showed a duodenitis and a thick tissue plane between duodenum and aortic graft, without any other pathologic signs. The gastro- duodenoscopy was negative. Abdominal pain resolved spontaneously in 24 hours. Upon suspicion of atypical graft infection, a CT-Pet scan was conducted which showed a clear pathological distribution along the aorto-iliac graft. Results: Patient underwent a transperitoneal in situ aorto-bisiliac revascularization with cryopreserved aortic homograft. Periprosthetic fluid was found but all bacteriological samples were negative. Post- operative period was characterized by a mild transient elevation of cardiac enzymes, treated conservatively. No other surgical complications occurred. The patient was discharged after two weeks, in very good clinical conditions. An oral broad-spectrum antibiotic therapy was conducted for three months and then a CT scan was performed: correct revascularization and no signs of infections were documented. Up to this day, the patient continues to be completely asymptomatic. Conclusion: Aortic graft infection can be subtle, making the diagnosis very difficult; this must be the first suspicion in a patient with unclear abdominal signs and symptoms after an aortic revascularization. In situ cryopreserved homograft approach can be considered a good therapeutical option. P22
Hedonistic chemical embolisation, spectrum of therapy S. Kolloczek1, I. Schwegler2 (1Bülach, 2Zurich)
Objective: Venous complications due to intravenous drug use, mostly affect the lower extremity. Ischemia, as a result of accidental intaarterial injections, occur more frequently in the upper extremity. Usually these patients present late and therefore immediate therapy must be initiated to prevent amputation of the limb. So far there are some case reports, however there are no treatment guidelines. The therapy ranges from conservative to operative therapy regimes. Often the treatment consists of intra arterial vasodilatation, heparin i.v., dexametason and sometimes localized lysis. Thrombectomy on the other hand, is not often used as a therapy. The purpose of this summary is to provide an overview of treatment options, based on three cases, that support starting therapy immediately. Methods: Three cases are presented with varying severity and different therapy approaches of ischemia. Prior to the emergency, two of the three patients studied presented with the cardinal symptoms of burning pain distal to the injection site, followed by discoloration of the skin and sensory disturbance immediately after injection. The third patient was hospitalized for another reason and the discomfort due to accidental arterial injection was an incidental finding. Results: Severe pain in the limb in i.v. drug abuser suggests an ischemic event. Depending on the degree of damage wait-and-see attitude is legitimate. A proposed immediate response is to initiate a therapy with heparin to avoid further growth of the thrombus, followed by steroids, thrombolysis and vasodilator medication. Thrombectomy is also a promising intervention. Conclusion: Based on our case studies it can be shown that despite more than 12 hours of ischemic history, a thrombectomy with localized lysis after accidental intra arterial drug injection can successfully be performed.
Függelék A monasztikus rendek történetéhez lásd King, Peter, A mona -1. MAGYARORSZÁGI FÉRFI SZERZETESRENDEK chizmus Nyugaton. A monasztikus szerzetesség története a latinegyházban, Szent István Társulat, Budapest 2007. Benedettini Confederati – Congregazione Benedettina di Ungheria – Magyar Bencés Kongregáció Az Annuario Pontificio 2008 szerint a férfi szerzetesköz�