Popliteal aneurysm

Popliteal artery aneurysm – endovascular approach

06/17/2015

Red: viabhan results becoming very close to open surgery; patency wise only (leave alone infection, zero a, and overall function. 

Results are found here: http://www.goremedical.com/resources/dam/assets/AP1730EU2_PAA_TrackRecord.FNL.mr.pdf
Secondary patency is 91% in first two years (vs almost 100% in open in best practice centres); then both matches afterwards.
So I would now support endovascular approaches even in fairly youngish (65 yr old) patients. 
lymphoedema

Lymphoedema – a challanging situation

05/28/2015
I have seen three lymphoedema patients today consecutively (and rather randomly booked) in clinic. It is a pretty challanging case that so far has no proper cure for. 
 My advice consists currently of the following components (ref. uptodate May 2015) – 
 1- The term complete decongestive therapy (CDT, also called complex decongestive therapy, complex decongestive physiotherapy, or decongestive lymphatic therapy) refers to an empirically derived, multicomponent technique that is designed to reduce the degree of lymphedema and to maintain the health of the skin and supporting structures [14,21,28]. 
 2- CDT generally consists of a two-phase treatment program that can be used in both adults and children [14,21,28]. Success is dependent in part upon the availability of physicians, nurses, and physical therapists that are trained in these techniques. 
 ●The first phase (treatment phase) includes meticulous skin and nail care to prevent infection, therapeutic exercise, a massage-like technique called manual lymph drainage (MLD), and limb compression using repetitively applied, multilayered padding materials and short-stretch bandages. The patients receive daily therapy five days per week, with circumference and volume measurements weekly to see if improvement is continuing or the patient has plateaued [21]. The usual duration of the first stage is two to four weeks. 
 ●The second phase (maintenance phase) is intended to conserve and optimize the benefit attained in the first phase. It consists of compression garments worn during waking hours and, if necessary, self-compression bandaging at night, skin care, continued exercises, and, as necessary, self-MLD. Limb circumference and volume measurements should be monitored every six months or sooner if necessary [21]. 
3- Efficacy of CDT has been suggested in observational studies, which demonstrated a reduction in limb volume with improved pain, cosmesis, and/or function [35-39]. In these studies, the reduction in limb volume ranged from 33 to 68 percent. However, patient compliance is required for long-term success. In one study, at least 90 percent of the lymphedema reduction was maintained in compliant patients at an average follow-up of nine months, while noncompliant patients lost approximately one-third of the initial benefit [35]. The benefit of CDT was shown in a small phase III trial in which 53 patients with lymphedema after breast cancer treatment were randomly assigned to CDT (lymph drainage, multilayer compression bandaging, elevation, remedial exercise, and skin care) versus standard physiotherapy (bandages, elevation, head-neck and shoulder exercises, and skin care) [40]. The group receiving CDT had a significantly greater improvement in edema as measured by circumferential and volumetric measurements.
bmj smoking

smoking .. best ever study

05/25/2015
Taken from BMJ – how to read a paper.

The world’s most famous cohort study, which won its two original authors a knighthood, was undertaken by Sir Austin Bradford Hill, Sir Richard Doll, and, latterly, Richard Peto. They followed up 40 000 British doctors divided into four cohorts (non-smokers, and light, moderate, and heavy smokers) using both all cause mortality (any death) and cause specific mortality (death from a particular disease) as outcome measures. Publication of their 10 year interim results in 1964, which showed a substantial excess in both lung cancer mortality and all cause mortality in smokers, with a “dose-response” relation (the more you smoke, the worse your chances of getting lung cancer), went a long way to showing that the link between smoking and ill health was causal rather than coincidental.31 The 20 year and 40 year results of this momentous study (which achieved an impressive 94% follow up of those recruited in 1951 and not known to have died) illustrate both the perils of smoking and the strength of evidence that can be obtained from a properly conducted cohort study.32 33

complex EVARs radiation

Are teams performing complex EVARs at higher radiation risk over their heads?

04/19/2015
ref:

Angulation of the C-Arm During Complex Endovascular Aortic Procedures Increases Radiation Exposure to the Head

EJVES Apr 2015
  • Head dose was significantly higher in the PO compared with the AO (median 54 μSv [range 24–130 μSv] vs. 15 μSv [range 7–43 μSv], respectively; p = .022), 
  • as was over-lead body dose (median 80 μSv [range 37–163 μSv] vs. 32 μSv [range 6–48 μSv], respectively; p = .003). 
  • Corresponding under-lead doses were similar between operators (median 4 μSv [range 1–17 μSv] vs. 1 μSv [range 1–3 μSv], respectively;p = .222). 
  • Primary operator height, DSA acquisition time in left anterior oblique (LAO) position, and degrees of LAO angulation were independent predictors of PO head dose (p < .05).

the following diagrams explain it all: 



cone beam CT EVAR

Cone Beam Computed Tomography and EVAR

04/19/2015
ref:

Intra-operative Cone Beam Computed Tomography can Help Avoid Reinterventions and Reduce CT Follow up after Infrarenal EVAR

ref: EJVES Apr 2015
Fifty-one patients (44 men) were enrolled in a prospective trial. Patients underwent completion angiography and CBCT during infrarenal EVAR. 

Twelve endoleaks were detected on completion digital subtraction angiography (CA). CBCT detected 4/5 type 1 endoleaks, but only one type 2 endoleak. CTA identified eight type 2 endoleaks and one residual type I endoleak. Two cases of stent compression were seen on CA. CBCT revealed five stent compressions and one kink, which resulted in four intra-operative adjunctive manoeuvres. CTA identified all cases of kinks or compressions that were left untreated. Two of them were corrected later. No additional kinks/compressions were found on CTA. Groin closure consisted of 78 fascia sutures, nine cut downs, and 11 percutaneous sutures. Seven femoral artery pseudoaneurysms (<1 cm) were detected on CTA, but no intervention was needed.

In 1996, three Italian people invented the Cone Beam CT, which went into the US market in 2001. It has become the ‘norm’ in most dental practices, as a simple means of reconstructing the X-Ray easily into 3D. 
 For Interventional Radiology, the patient is positioned offset to the table so that the region of interest is centered in the field of view for the cone beam. A single 200 degree rotation over the region of interest acquires a volumetric data set. The scanning software collects the data and reconstructs it, producing what is termed a digital volume composed of three-dimensionalvoxels of anatomical data that can then be manipulated and visualized with specialized software



atherosclerosis prevention carotid artery disease coronary angiogram

Routine pre-op coronary angio pre- CEA: is it useful?

04/19/2015
ref:

Long-term Results of a Randomized Controlled Trial Analyzing the Role of Systematic Pre-operative Coronary Angiography before Elective Carotid Endarterectomy in Patients with Asymptomatic Coronary Artery Disease

EJVES Apr 2015
The group (from Italy) randomised 426 patients who were candidates for CEA, with no history of CAD, a normal electrocardiogram (ECG), and a normal cardiac ultrasound. In group A (n = 216) all patients underwent coronary angiography before CEA. In group B (n = 210) CEA was performed without coronary angiography. Patients were not blinded for relevant assessments during follow-up. Primary end-point was the occurrence of MI at 3.5 years. The secondary end-point was the overall survival rate. Median length of follow-up was 6.2 years.

The outcome is very interesting: short term results are not much different, but long term ones are significantly different and better for coronary patients. This proves the importance of secondary prevention more than anything! 


complex AAA; FEVAR; BEVAR

A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms

04/11/2015
Ref.

A propensity-matched comparison of outcomes for fenestrated endovascular aneurysm repair and open surgical repair of complex abdominal aortic aneurysms
EJVES Apr 2015
These figures are shockingly true, and has to be always taken into account when a patient is offered a FEVAR, especially our octogenarians. 
Raux et al.11 compared F-EVAR with open surgery in patients with complex AAA in two large volume centres: In this study, 
  • F-EVAR had higher 30 day mortality rates (9.5% vs. 2%), 
  • higher procedural complications (24% vs. 7%) 
  • and graft related complications (30% vs. 2%) than open surgery.

The authors conceded that “the learning curve of the endovascular technique was likely to be responsible in part for the adverse outcomes observed in the F-EVAR cohort”

The WINDOWS multicentre French Registry reported outcomes in 268 patients who received F-EVAR or B-EVAR for juxtarenal AAA (group 1), suprarenal AAA and TAAA Type IV (group 2), and TAAA Type I, II, III (group 3).15 In hospital mortality was 6.5% for group 1 patients, 14.3% for group 2, and 21.4% for group 3.

This paper suggests that more complex aortic endovascular procedures (especially branched repair of TAAAs) should be focused within higher volume institutions that can provide all treatment options, have experience in dealing with technically challenging intra-operative problems and where multidisciplinary cooperation is such that the choice of treatment is not influenced by specialty, political, or financial aspects.

I personally fully agree .. the amount of complex parameters involved in the treatment of those patients is huge … and require a lot of experience and high level thinking/planning… as well as a relaxed time in the sub-sub-sub specialty in vascular surgery …. for best outcome to be achieved,. 



FEA rupture risk

Finite Element Analysis and Rupture risk

03/09/2015
Source: EJVES Mar2015

Finite Element Analysis in Asymptomatic, Symptomatic, and Ruptured Abdominal Aortic Aneurysms: In Search of New Rupture Risk Predictors

This is another interesting addition to the family of predictions for ruptured aneurysm. The strength of it is mainly in its derivation from real life cases and physiologic parameters, ending up in certain immediate outcome (symptomatic, symptomatic, or rupture). And yes, we are more well equipped with info if we have the FEA available with the CTA simultaneously. The problems remains in two things: the lack of adoption of such analysis by surgeons and radiologists (this is the approach of mechanical engineers anyway); and the funding (this article has one declared conflict of interest: one author is the owner/developer of the software he is claiming to work better for us) … yet again, there is no question that the future will ONLY be in such level of analysis, not in the simplified outdated one from the 1990s!!! The new generation has moved to iPhones, Maya software, adobe, smart watches, and smart cars … the technology has doubles 16 (that’s SIXTEEN) times since 1990 (as per Moore law) … so new ideas are now VERY much welcomed!!
here are few interesting findings from the paper: (images are copyrighted to EJVES exclusively). 
1- note how PWRRI is significantly different in 1st vs 3rd group, even after allowing for such large CI. The PWS is also different and less widely distributed; but only for 1st vs 3rd group. 
2- Note how in a case of 5.5cm, the PWS can range from 0.1 to 1.0, giving a risk of rupture from minimum to imminent! That’s dangerous indeed!! WHICH PATIENT OF OURS will rupture while we are preparing him/her to undergo a procedure! See my post on estimated risk of rupture, where more specific biomechanical factors (that are calculable by simple mathematics) gives more info on the risk of rupture compared to simple diameter measurements. 
CAR. registry carotid artery aneurysm

Extracranial Carotid Artery Aneurysm (ECAA) registry – use this oppurtunity

03/08/2015
ref:

Extracranial Carotid Artery Aneurysm: Optimal Treatment Approach – 

  • J.C. Welleweerd, 
  • G.J. de Borst, , 
  • on behalf of 
  • the Carotid Aneurysm Registry Project Group

  • EJVES Mar 2015
  • This is an online registry to enter all such rare cases into one database and allow for a proper assessment of best diagnosis and treatment. 
  • I think it is quite useful and certainly attractive to join once one have a case like this!

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