Kalra, Manju

Background Aortic syndromes (ASs), including aortic dissection, intramural hematoma, and penetrating aortic ulcer, carry significant acute and long-term morbidity and mortality. However, the contemporary incidence and outcomes of AS are unknown. Methods and Results We used the Rochester Epidemiology Project record linkage system to identify all Olmsted County, MN, residents with AS (1995–2015). Diagnostic imaging, medical records, and death certificates were reviewed to confirm the diagnosis and AS subtype. Age- and sex-adjusted incidence rates were estimated using annual county-level census data. Survival for patients with AS was compared with age- and sex-matched controls using Cox regression to adjust for comorbid conditions. We identified 133 patients with AS (77, aortic dissection; 21, intramural hematoma; and 35, penetrating aortic ulcer). Average age was 71.8 years (SD=14.1), and 57% were men. The age- and sex-adjusted incidence was 7.7 per 100 000 person-years, was higher for men than women (10.2 versus 5.7 per 100 000 person-years), and increased with age. Among subtypes, the incidence of aortic dissection was highest (4.4 per 100 000 person-years), whereas the incidence of penetrating aortic ulcer and intramural hematoma was lower (2.1 and 1.2 per 100 000 person-years). Overall, the incidence of AS was stable over time ( P trend=0.33), although the incidence of penetrating aortic ulcer seemed to increase from 0.6 to 2.6 per 100 000 person-years ( P =0.008) with variability over the study interval. Patients with AS had more than twice the mortality rate at 5, 10, and 20 years when compared with population-based controls (5-, 10-, and 20-year mortality 39%, 57%, and 91% versus 18%, 41%, and 66%; overall adjusted mortality hazards ratio=2.1; P <0.001). Survival was lower than expected up to 90 days after AS diagnosis and did not differ significantly by subtype or by 5-year strata of diagnosis. Conclusions Overall, the incidence of aortic dissection and intramural hematoma has remained stable since 1995, despite the decline noted for other cardiovascular disease. AS confers increased early and long-term mortality that has not changed. These data highlight the need to improve long-term care to impact the prognosis of this patient group.

Abstract Background Chronic Coxiella burnetii infections such as vertebral osteomyelitis caused by contiguous spread from an infected abdominal aortic graft or aneurysm have been rarely reported and are associated with significant morbidity and mortality. Methods We present the first four reported US acquired cases of Coxiella burnetii vertebral osteomyelitis caused by contiguous spread from an infected abdominal aortic graft or aneurysm. Results Presenting symptoms included progressive back pain, malaise, and weight loss with recent or remote animal exposure. Typical imaging findings demonstrated a peri-aortic collection with extension to the paraspinal muscles and vertebrae. Antibiotic regimens included doxycycline with either hydroxychloroquine or a quinolone for at least 2 years or as chronic suppression. Conclusions C. burnetii vertebral osteomyelitis is rare and can occur by contiguous spread from an abdominal aneurysm or vascular graft infection. It should be suspected in patients where pre-antibiotic cultures are negative with animal/farming exposure.

Background Klippel–Trenaunay syndrome (KTS) is a mixed mesenchymal malformation characterised by varicose veins, venous and capillary malformations, and hypertrophy of soft tissue and bone. The purpose of this study was to evaluate the surgical outcomes in KTS patients to provide standards for comparison with endovenous therapy. Methods The clinical data of consecutive patient with KTS who underwent open venous surgical treatment between January 1987 and December 2008 were reviewed. Demographics, clinical presentation, operative data, and clinical outcomes were recorded. Follow-up information was obtained from the medical records, mailed questionnaires and phone calls. Descriptive statistics, the Kaplan–Meier method and Log-rank statistics were used where appropriate. Results Twenty-seven females and 22 males, (mean age 26.5 years, range 7.7–55.8) were included in this study. All had varicose veins, 36 (73%) had limb hypertrophy, and 33 (67%) had capillary malformations, with two of three clinical features present in all. The most frequent symptom was pain (N = 43, 88%). Forty-nine patients underwent operations on 53 limbs. Stripping of the GSV, small and accessory saphenous and lateral embryonic veins was performed in 17 (32%), 10 (19%), 9 (17%), and 15 (28%) limbs, respectively. Two patients developed deep vein thrombosis, one had pulmonary embolism (PE), and one patient had peroneal nerve palsy. Freedom from disabling pain at 1, 3 and 5 years was 95%, 77% and 59%, respectively, and freedom from secondary procedures was 78% at 3 years, and 74% at 5 years. At the last follow-up visit, the venous clinical severity score had decreased from 9.48 ± 3.27 to 6.07 ± 3.20 (P < 0.001). Conclusions In selected symptomatic patients with KT syndrome, open surgical treatment is safe and durable. Three-fourths of the patients remain free of disabling pain at five years, but secondary procedures are required in one-fourth of the patients. These data can serve as standards for comparison of endovenous therapy for KT syndrome.

Proximal claudication is secondary to ischemia caused by peripheral artery disease (PAD), whereas proximal pseudo-claudication is secondary to other disease processes such as hip arthritis, spinal stenosis, neuropathy, and so forth. The differentiation between the two can be challenging. Exercise transcutaneous oxygen pressure measurement (exercise-TcPO 2 ) allows noninvasive detection of flow-reducing lesions in the proximal arteries and tributaries of the lower extremity arterial tree. We present the first case report in the United States using an exercise-TcPO 2 algorithm. A 71-year-old diabetic patient with proximal left-sided and right-calf claudication with indeterminate ankle-brachial indices underwent an exercise-TcPO 2 study before and after endovascular intervention. Four TcPO 2 probes were placed: one at chest level (reference probe), one on each buttock, and one on the symptomatic calf. The Delta from Resting Oxygen Pressure (DROP) index was calculated at each probe site using a previously validated protocol. Proximal left- and right-calf ischemia were confirmed by the initial exercise-TcPO 2 , and, after endovascular treatment of the left iliac artery lesion, improvements in proximal exercise-TcPO 2 values were found. These data suggest that exercise-TcPO 2 can be useful in PAD evaluation in patients with non-compressible arteries and/or proximal claudication.

Endovascular reconstruction has become the standard treatment of chronic obstruction of large veins. Stenting is done with increasing frequency to treat iliac venous obstructions, with or without associated inferior vena caval or femoral vein occlusions. Open reconstruction with venous bypass is performed today in patients who fail attempts at venous stenting or who are not candidates for endovascular reconstructions. Patients with primary or secondary malignancies invading the vena cava undergo open caval reconstruction at the time of tumour excision. Open venous reconstructions are still preferred in patients with large vein injuries due to blunt or penetrating trauma or in those who suffer iatrogenic venous injuries. Hybrid reconstruction can be performed with endophlebectomy of the common femoral or femoral veins combined with iliofemoral stenting.

Intraluminal thrombus adjunct to internal carotid artery plaque is a rare finding on traditional diagnostic imaging. Prompt diagnosis is important as it carries a high risk of recurrent stroke. We describe 2 symptomatic patients with severe stenosis on duplex scanning and internal carotid artery thrombus (ICAT) identified on subsequent computed tomographic angiography. Histology of the surgical specimen confirmed the composition predicted by computed tomography. Computed tomographic angiography can provide accurate diagnosis and characterization of internal carotid thrombus and lead to prompt therapeutic intervention.

Objective: Endoleaks are critical complications of endovascular abdominal aortic aneurysm repair (EVAR). This study sought to determine the frequency and nature of intraoperative endoleaks and their impact on postoperative endoleak-related events. Methods: A retrospective chart review was performed of all patients who underwent EVAR at our institution. The impact of intraoperative endoleaks on postoperative endoleak rates and endoleak-related reintervention rates were assessed. Results: From December 18, 1996, to May 21, 2003, 241 patients underwent EVAR. An endoleak was observed during 126 (52.3%) procedures. Type I endoleaks were observed in 63 (26.1%) cases: 35 proximal and 31 distal endoleaks (3 cases at both attachments). Angioplasty, additional cuff placement, or stenting corrected 59 (89.4%) of these endoleaks. A total of 71 type II intraoperative endoleaks (29.5%) and 8 type IV endoleaks (3.3%) were observed without any attempted corrective maneuvers. Ten type III endoleaks (4.2%) occurred but all resolved with angioplasty or additional cuff placement. In all, 86 (35.7%) endoleaks persisted on completion angiogram. Patients with a type I or type II intraoperative endoleak were more likely to have an endoleak at 1.5 years (31.4% vs. 21.6%, P = .018). Reinterventions were required more often after an intraoperative type I endoleak (10% vs. 4%, P = .003). Patients with intraoperative endoleaks demonstrated a trend toward less postoperative aneurysm diameter reduction at 2 years (43.8% vs. 74.5%, P = .104). Conclusion: The presence of a type I or a type II endoleak during EVAR significantly increases the likelihood of a postoperative endoleak and should prompt a high degree of suspicion during follow-up.

Between 1986 and 2005, 22 patients (mean age, 14.7 years; range, 3-21) with renal hypertension underwent renal artery revascularization for 28 lesions, 23 with open repair (OR) and 5 with percutaneous transluminal renal angioplasty (PTRA). Thirty-day morbidity was 17% (4/23). Hypertension was cured in 13 (57%), improved in 8 (38%), and unchanged in 1 (5%). Renal function worsened in 1. At a mean follow-up of 4.9 years, 1-year patency rate was 94% and maintained for 5 years. Hypertension at 1 year was cured in 6 of 14 patients (43%; OR, 4; PTRA, 2) and improved in 8 (57%; OR, 7; PTRA, 1); hypertension at 5 years was cured in 50% and improved in 50%. Renal function remained unchanged in all patients who were followed. The authors conclude that both OR and PTRA benefit pediatric patients. PTRA for selected patients may be promising as a first line treatment or as a bridge to definitive OR in children with small arteries.

Previous results following subfascial endoscopic perforator vein surgery were reported to be worse in post-thrombotic syndrome than in limbs with primary valvular incompetence. This report comprises a larger patient cohort with longer follow-up. The goal of this study was to determine if subfascial endoscopic perforator vein surgery is justified in patients with postthrombotic venous insufficiency. The clinical data of 91 consecutive patients who underwent subfascial endoscopic perforator vein surgery with or without superficial reflux ablation over a 7-year period from May 1993 to June 2000 were retrospectively analyzed. Fifty-four females and 37 males (median age, 53 years; range, 20-77) underwent 103 subfascial endoscopic perforator vein surgery procedures. Forty-two limbs were classified as C6 (active ulcer), 34 as C5 (healed ulcer), and 24 as C4 (lipodermatosclerosis). Thirty procedures were performed in post-thrombotic limbs. Concomitant superficial reflux ablation was performed in 74 limbs (72%); saphenous vein stripping had been previously performed in 29 (28%). Deep venous incompetence was present in 89% of limbs; 13% had venous outflow obstruction on plethysmography. Cumulative ulcer healing in post-thrombotic limbs was not significantly different from limbs with primary valvular incompetence; 30-, 60-, and 90-day healing rates were 44%, 72%, and 72% vs 39%, 70%, and 87%, respectively (p = 0.35). On univariate analysis, the presence of ulcer greater than 2 cm in diameter was associated with delayed ulcer healing (p = 0.02). Cumulative ulcer recurrence in all limbs was 4%, 20%, and 27% at 1, 3, and 5 years, respectively. Ulcer recurrence in post-thrombotic limbs was higher than in limbs with primary valvular incompetence at 1, 3, and 5 years; 16%, 47%, and 56% vs 0%, 8%, and 15%, respectively (p = 0.001). Recurrent ulcers were small, superficial, and easier to heal. Clinical improvement was significant even in post-thrombotic limbs; median clinical score decreased from 9.5 to 3 (p=0.001), and median outcome score was +2 (mean 1.9; range, -I to 3). Median clinical score in patients with primary valvular incompetence improved from 6 to 1.5 (p = 0.0001). Subfascial endoscopic perforator vein surgery with superficial reflux ablation promoted ulcer healing, improved clinical outcome, and resulted in a low long-term ulcer recurrence rate in limbs with primary valvular incompetence. Despite good clinical outcome in post-thrombotic limbs, ulcer recurrence was high. These results imply that the role of subfascial endoscopic perforator vein surgery with superficial reflux ablation in patients with post-thrombotic limbs continues to be controversial.