Perspectives in Vascular Surgery and Endovascular Therapy recent issues

Phlebolymphemeda: Usually Unrecognized, Often Poorly Treated

Bunke, N., Brown, K., Bergan, J. — Fri, 18 Sep 2009 04:22:51 PDT

Phlebolymphedema is a condition of mixed venous and lymphatic insufficiency. It is usually not recognized and it is usually not treated. The lymphatic and venous systems are intimately interrelated. In the presence of venous hypertension, which is characteristic of most venous disorders, the increase in lymphatic flow becomes much greater than the lymph transport capacity. The diagnosis of phlebolymphedema is based on a detailed history and physical examination. Patients with phlebolymphedema have skin changes of venous insufficiency, which are easy to recognize. Treatment for chronic phlebolymphedema consists of treating the venous abnormality and watching regression of the lymphatic problem.

The ESCHAR Trial: Should It Change Practice?

Wright, D. D. I. — Fri, 18 Sep 2009 04:22:51 PDT

Introduction: Most leg ulcers are caused by venous disease, the most common cause of venous hypertension being superficial vein incompetence. The ESCHAR trial tested the value of superficial vein surgery combined with compression in the healing and recurrence of venous leg ulcers compared with compression alone. Methods: A total of 500 patients with chronic venous leg ulcers, or recently healed ulcers, were randomized to superficial vein surgery and compression or compression alone. Vein surgery was saphenofemoral ligation and great saphenous stripping and phlebectomy or saphenopopliteal ligation and phlebectomy. Results: Ulcer healing was virtually identical between the 2 groups at 65% at 24 weeks; subgroup analysis failed to show a benefit for surgery to promote ulcer healing. Ulcer recurrence rate was halved in those that underwent surgery regardless of the presence of deep vein incompetence. Conclusion: Superficial vein surgery should be considered in all leg ulcer sufferers to reduce ulcer recurrence rather than accelerate ulcer healing.

Endovenous Laser Ablation: Strategies for Treating Multilevel Disease

Markovic, J. N., Shortell, C. K. — Fri, 18 Sep 2009 04:22:51 PDT

Since its introduction in 1999 and FDA approval in 2002, endovenous laser ablation has been widely accepted to effectively treat superficial venous reflux, with minimal side effects. Anatomically, any combination of superficial, perforator and deep venous disease can result in various stages of chronic venous insufficiency. In general, when multiple levels of venous disease are involved the manifestations of venous insufficiency increase in severity. Given that one patient with significant reflux in deep system will have no resultant symptoms, while another patient may progress to an active ulceration from a saphenous reflux alone, individual treatment strategies in the patient with multilevel reflux disease should be based on a thorough clinical and duplex evaluation to determine their specific anatomy and pathology. A basic understanding of mechanism of laser-tissue interaction, venous pathophysiology and the relationship of deep to superficial reflux disease assists in refining procedural techniques and strategies.

Update on Radiofrequency Ablation

Markovic, J. N., Shortell, C. K. — Fri, 18 Sep 2009 04:22:51 PDT

The two currently available methods to achieve ablation of incompetent veins using radiofrequency energy are radiofrequency ablation (VNUS Closure Plus^tm) and radiofrequency powered segmental ablation (VNUS Closure Fast^tm). Both treatment modalities expose vascular endothelium to high-frequency alternating current. This results in contraction of venous wall collagen with subsequent fibrotic endoluminal obliteration which eliminates hydrostatic and hydrodynamic pressures as the main hemodynamic mechanisms for varicosities. Radiofrequency segmental ablation has become available relatively recently, but increasing amount of clinical data and patient’s satisfaction support this technique as a reasonable therapy for superficial reflux disease. Although initial experience with Closure Fasttm catheter documented substantially decreased average procedural time, little postoperative discomfort and short-term occlusion rates that approximated 100%, larger clinical trials are needed before this modification of traditional radiofrequency ablation can be accurately evaluated in the treatment of superficial reflux disease.

Foam Sclerotherapy: Techniques and Uses

Bunke, N., Brown, K., Bergan, J. — Fri, 18 Sep 2009 04:22:51 PDT

Sclerosant foam has been increasing in use in recent times. It has certain advantages over liquid sclerosants and is quite safe to use, despite the fact that there are adverse events that have been reported. The history of sclerosant foam goes back in time many years. Tessari developed the current method of creating sclerosant foam in 2001, and his technique has been modified. In our experience, the sclerosant foam has totally replaced other methods of treating venous insufficiency, and the results of treatment are superior to other methods. It is apparent that treatment of a variety of venous disorders can be accomplished using foam sclerotherapy. Our experience and that of others has shown that there are early advantages in the use of foam in the management of varicose veins compared with surgery and other methods.

What Is New in Duplex Scanning of the Venous System?

Zygmunt, J. — Sat, 01 Jun 2002 00:00:00 PDT

The diagnosis and treatment of chronic venous disease has undergone a quantum leap forward in recent decades. In many ways, the venous system is now considered more complex than the arterial system. This is a result of the advances in understanding due to improvements in duplex ultrasound equipment, diagnostic techniques, and communication standards as they relate to findings in anatomy, pathology, and hemodynamics. Currently, it is self-evident that duplex ultrasound has become the gold standard for diagnosis of the venous system providing anatomic and functional information. Mapping techniques, understanding of superficial reflux, and other factors that affect duplex ultrasound findings are presented. These factors and techniques can affect diagnostic results and therefore have significant impact on the planning and approach to treatment of primary and recurrent venous insufficiency.

Progress in MR Imaging of the Venous System

Spritzer, C. E. — Sat, 01 Jun 2002 00:00:00 PDT

This article reviews the utility of magnetic resonance imaging (MRI)/magnetic resonance venography (MRV) in the assessment of common venous problems. There is a brief synopsis of current MRI/MRV techniques used for such purposes. This is followed by a review of application of these techniques to specific diagnoses. In short, MRV is quite useful for assessing venous pathology.

Nutcracker Syndrome: When Should It Be Treated and How?

Menard, M. T. — Sat, 01 Jun 2002 00:00:00 PDT

Nutcracker syndrome refers to compression of the left renal vein by the superior mesenteric artery and aorta. Patients typically present with left flank pain and associated symptoms of pelvic congestion. Hematuria is frequently present, and vulvar or lower extremity varices are seen in a subset of patients. Clinical suspicion of the syndrome is confirmed by duplex scanning, computerized tomography, or magnetic resonance imaging. Documentation of a hemodynamically significant pressure gradient across the point of compression during venographic assessment in patients with appropriate symptom severity is important prior to undertaking treatment. A variety of surgical procedures have been described to achieve venous decompression, the most popular being that of transposition of the left renal vein to the more distal inferior vena cava. Long-term data on the success of surgical treatment is scarce. More recently, endovascular stenting of the left renal vein has been used.

Anticoagulation Strategies for Venous Thromboembolism

Peterson, D., Harward, S., Lawson, J. H. — Sat, 01 Jun 2002 00:00:00 PDT

Venous thromboembolism (VTE) continues to be a major source of morbidity and mortality in the United States with an estimated incidence of greater than 600 000 clinically evident cases each year. It results in more than 200 000 deaths per year and is thought to be the number one cause of preventable in-hospital deaths. This review presents the history, pathophysiology, diagnostic considerations, and treatment options for VTE.

Vascular Malformations: An Update

Fri, 18 Sep 2009 04:22:51 PDT

Vascular malformations occur as a result of an arrest in the development of the vascular system. The modified Hamburg classification distinguishes arterial, venous, arteriovenous, capillary, lymphatic, and mixed vascular malformations. Each malformation is further subdivided based on anatomy and on the time when arrest in development of the embryogenesis occurred; malformations can be truncular or extratruncular. Progress in the last decade in management has been significant because of improvements in open surgical procedures and perfection of percutaneous and hybrid endovascular interventions and devices, such as balloons, stents, and stent-grafts. There has been increasing use of embolization for the treatment of malformations with coils, other particles, glue, or with endovascular placement of occlusive plugs. Absolute alcohol, detergent liquids, or foam have been used for sclerotherapy with improved efficacy. The agents are delivered percutaneously or through a catheter placed either into the feeding arteries or the draining veins. This review aims to aid vascular and endovascular specialists in staying familiar with vascular malformations. These specialists need to be able to evaluate the patients, perform treatment if appropriate, or refer complex cases to multidisciplinary vascular malformation clinics and vascular centers.

Office-Based Vascular Lab: Is It Worth the Effort?

Ashraf Mansour, M., Zwolak, R. M. — Mon, 20 Apr 2009 04:21:02 PDT

The vascular laboratory is an essential part of any contemporary clinical vascular practice. The prototype of the vascular laboratory consisted mainly of instruments designed to understand the hemodynamics of the vascular tree. Earlier versions also played important roles in clinical research. Currently, sophisticated imaging equipments enable clinicians to evaluate the whole range of arterial and venous diseases in the outpatient setting. Both patients and physicians have found this to be very practical and convenient. Furthermore, income generated from performing diagnostic tests in the vascular laboratory helps support a variety of clinical activities and research. However, recent cost-cutting measures by medical insurance carriers are threatening the viability of office-based vascular laboratories.

EVAR for the Treatment of Ruptured AAA

Morasch, M. D. — Mon, 20 Apr 2009 04:21:02 PDT

Endovascular repair (EVAR) for ruptured abdominal aortic aneurysm (AAA) has been held out as a safer, less invasive alternative to open surgery with the potential to significantly reduce in-hospital mortality. Despite the inherent biases that accompany comparison of the 2 treatment modalities, there appears to be a clear role for EVAR for select patients in select centers. To successfully treat patients with ruptured AAA both open and endovascular modalities should be available and clear protocols using a team approach must be developed.

Commentary on "EVAR for the Treatment of Ruptured AAA"

Faizer, R. — Mon, 20 Apr 2009 04:21:02 PDT

Fenestrated Grafts or Debranching Procedures for Complex Abdominal Aortic Aneurysms

Wilderman, M., Sanchez, L. A. — Mon, 20 Apr 2009 04:21:02 PDT

Over the past 15 years, endovascular aneurysm repair of abdominal aortic aneurysms has become widely accepted as a means of treating aneurysms located in the infrarenal portion of the aorta. It has been estimated that 30% to 40% of patients with abdominal aortic aneurysms are not candidates for endovascular repair using the current commercially available devices. The primary limitation has been unfavorable anatomy most often associated with the proximal aortic neck. Although the morbidity and mortality of open pararenal or suprarenal aneurysms has improved, many patients will not tolerate open surgery. Therefore, other techniques need to be employed. This article looks at 2 other techniques to treat complex pararenal, juxtarenal, or thoracoabdominal aneurysms, one being the use of fenestrated devices and the other being visceral artery debranching followed by endovascular grafting. Multiple series are reviewed, and the outcomes are analyzed.

Commentary on "Fenestrated Grafts or Debranching Procedures for Complex Abdominal Aortic Aneurysms"

Lyden, S. P., Sanchez, L. A. — Mon, 20 Apr 2009 04:21:02 PDT

Update on Venous Procedures Performed in the Office Setting

Carr, S. C. — Mon, 20 Apr 2009 04:21:02 PDT

Treatment for chronic venous disease has evolved from hospital-based surgical procedures to minimally invasive office-based office procedures that provide shorter recovery periods, less postprocedural discomfort, and quicker return to normal activities. A specialty venous clinic, separate from the arterial practice, with a specialized professional health care team, provides a comfortable setting in which patients can have access to the most up-to-date treatment options. Sclerotherapy treatment for telangectasias, reticular veins, tributary varicosities, insufficient truncal veins, and incompetent perforating veins is a common therapy that is well suited for the office setting. Most office-based minimally invasive venous procedures require little or no sedation. Tumescent anesthesia is safe and effective for ambulatory phlebectomy and endovenous ablation procedures. A calm, inviting atmosphere, confident and professional health care team, and prompt access to care will improve patient satisfaction and result in a successful, growing venous practice.

Commentary on "Update on Venous Procedures Performed in the Office Setting"

Golan, J., Carr, S. C. — Mon, 20 Apr 2009 04:21:02 PDT

Femoral Arterial Access Management for Endovascular Aortic Aneurysm Repair: Evolution and Outcome

Shafique, S., Murphy, M. P., Sawchuk, A. P., Cikrit, D., Dalsing, M. C. — Mon, 20 Apr 2009 04:21:02 PDT

Endovascular repair of abdominal and thoracic aortic aneurysms (AAAs and TAAs, respectively) has become the standard of care for anatomically appropriate patients. All the devices developed to date for endograft repair of AAAs and TAAs are deployed through relatively large (12F to 24F) sheaths. Traditionally, this access has required arterial exposure with open cut down, but with the development of suture-mediated arterial closure devices and decreasing profile of delivery sheaths of endografts, there is an increasing trend toward percutaneous endovascular repair of aortic aneurysms. This is an effective and safe approach in a select group of patients. Ultrasound guidance ensures that access is obtained proximal to the common femoral artery bifurcation. The procedure should be performed in a sterile operating room environment, and the physicians performing endovascular repair should be experienced in open arterial exposure, should the closure device fail to close the arteriotomy.

Commentary on "Femoral Arterial Access Management for Endovascular Aortic Aneurysm Repair: Evolution and Outcome"

Peterson, B. G., Shafique, S. — Mon, 20 Apr 2009 04:21:02 PDT

Dialysis Access Steal Syndromes

Lemmon, G. W., Murphy, M. P. — Mon, 20 Apr 2009 04:21:02 PDT

Dialysis-associated steal syndromes remain a vexing problem for the busy vascular access surgeon. Those factors associated with ischemia include the elderly, diabetic, female, preexisting cardiac disease and brachial anastomosis, and previous ipsilateral access. A constellation of symptoms and findings based on underlying arterial disease and flow characteristics are necessary to provide prompt diagnosis and initiate treatment. Although a digital brachial index (DBI) >1 and transcutaneous oxygen tension (TCPO₂ ) measurements >60 mm Hg accurately predict a patient not at risk, no DBI or TCPO2 levels below that accurately predict if a patient will develop dialysis-associated ischemia. The goal of the vascular access surgeon is to provide prompt recognition and treatment of the disorder to maximize both limb salvage and access salvage. Continuation of angio access in the same extremity can be accomplished in most individuals.

Commentary on "Dialysis Access Steal Syndromes"

Howard, T. C. — Mon, 20 Apr 2009 04:21:02 PDT

Techniques to Enhance Arteriovenous Fistula Maturation

McLafferty, R. B. — Mon, 20 Apr 2009 04:21:02 PDT

Maturation of an arteriovenous fistula remains an elusive step in obtaining a good functional hemodialysis access outcome. Considerable variability in the performance of access procedures exists between surgical practices that are not necessarily well justified. Herein, a brief overview of techniques is presented to help in maximize the potential for maturing an arteriovenous fistula. These include arm vein preservation, arm vein duplex mapping, branch ligation, staged transposition/ superficialization, and comprehensive follow-up and intervention program. Although definitive data may be lacking to show effectiveness in all areas reviewed, recommendations are made to help surgeons in working toward higher maturation rates. Further opportunities avail to developing clinical practice guidelines so as to give all end stage renal disease patients the best clinical experience.

Commentary on "Techniques to Enhance Arteriovenous Fistula Maturation"

Schneider, J. R., McLafferty, R. B. — Mon, 20 Apr 2009 04:21:02 PDT

Endovascular Abdominal Aortic Aneurysm Repair Versus Open Repair: Why and Why Not?

Mon, 20 Apr 2009 04:21:02 PDT

Randomized clinical trials have documented clinical equipoise when comparing endovascular abdominal aortic aneurysm repair (EVAR) with open aneurysm repair (OAR). Studies using large administrative databases in the United States have documented a trend whereby the majority of patients undergoing elective abdominal aortic aneurysm (AAA) repair in the United States are being repaired using endovascular techniques. However, few specific guidelines, outside of anatomic criteria for EVAR, exist to aid the physician in determining which approach is best for the individual patient. Variables to be considered in order to determine which approach is best for the patient who requires an AAA repair include age and comorbidities, arterial anatomy, and provider characteristics.

Commentary on "Endovascular Abdominal Aortic Aneurysm Repair Versus Open Repair: Why and Why Not?"

Jacobs, D. L., Upchurch, G. R. — Mon, 20 Apr 2009 04:21:03 PDT

Guest Editorial

Ascher, E. — Wed, 17 Dec 2008 19:38:43 PST

Office-Based Surgery for Vascular Surgeons

Patel, N., Hingorani, A., Ascher, E. — Wed, 17 Dec 2008 19:38:43 PST

Office-based procedures have witnessed a veritable explosion with more than 10 million procedures being performed in the United States yearly. This is partially because of improvements in technology that allow these procedures to be performed safely in the office. However, as the number of procedures has increased, the reports of significant morbidity and mortality that have been appearing in the media have captured the public's attention. Until recently, this new and growing field has been largely unregulated. This is changing nationwide. The authors review the new regulations in New York State as a model of the future of this rapidly evolving field and their effect on vascular surgery office procedures.

Commentary on "Office-Based Surgery for Vascular Surgeons"

Dardik, A. — Wed, 17 Dec 2008 19:38:43 PST

Setting Up an Outpatient Imaging Center: Adding Computed Tomographic Angiography, Magnetic Resonance Angiography and an Outpatient Angiography Suite to Surgeon-Run Vascular Laboratories

Samson, R. H. — Wed, 17 Dec 2008 19:38:43 PST

Computed tomographic angiography, magnetic resonance angiography and diagnostic arteriography are all vascular diagnostic tools that should be included in modern vascular diagnostic laboratories. Before undertaking the establishment of such a facility, the vascular specialist or group needs to ensure safe patient care and the ability to provide such diagnostic tests and procedures without incurring a financial loss. This article will detail one method of setting up such a facility and suggest some other approaches. It will also introduce some of the issues that may change the political landscape in the Unites States of America, which may make such arrangements more complex in that country.

Commentary on "Setting up an Outpatient Imaging Center: Adding Computed Tomographic Angiography, Magnetic Resonance Angiography, and an Outpatient Angiography Suite to Surgeon-Run Vascular Laboratories"

Darling, R. C. — Wed, 17 Dec 2008 19:38:43 PST

New Office-Based Vascular Interventions

Marks, N., Hingorani, A., Ascher, E. — Wed, 17 Dec 2008 19:38:43 PST

Objective: Following contemporary trend, various vascular interventions being performed in the office. We describe our office experience with radiofrequency ablation (RFA) of incompetent perforating veins (IPV) and duplex-guided balloon angioplasties of failing/nonmaturing arterio-venous fistulas (AVF). Duplex-guided balloon angioplasties of AVF: Eighteen patients with 20 failing arterio-venous (AV) fistulas underwent office duplex-guided balloon angioplasties. Thirteen procedures (65%) were on non-maturing fistulas and the remaining 7 (35%) - in dialyzed patients. Sheath insertion, wire and balloon passage and inflation were guided by duplex only. RFA of IPVs: We performed 25 radiofrequency ablations of 49 IPVs. Early follow-up scan confirmed total occlusion of 45 (92%) treated IPVs. Patients gender, CEAP class, perforator diameter or GSV patency did not correlate with current procedure failure. Conclusion: Excellent duplex imaging quality and technical advances in endovascular tools allowed us safely perform AVF balloon angioplasties and RFA of IPVs in the office.

Commentary on "Office-Based Vascular Interventions": Is It a Step Forward?

Ricotta, J. J. — Wed, 17 Dec 2008 19:38:43 PST

Ambulatory Phlebectomy in the Office

Almeida, J. I., Raines, J. K. — Wed, 17 Dec 2008 19:38:43 PST

Ambulatory phlebectomy is a minor, office-based surgical procedure designed to remove varicose veins. It is a perfect complement to endovenous thermal ablation of the saphenous vein. With this combination, patients can expect all varicose veins to vanish following a 1-hour procedure that employs only local anesthesia in the comfort of a physician's office. Advantages of office-based surgery are ease of scheduling for doctors and patients, less paperwork, elimination of travel time, and cost containment for the health care system. Furthermore, a procedure that is performed by the same staff daily is more streamlined and safe.

Commentary on "Ambulatory Phlebectomy in the Office"

Lawrence, P. F. — Wed, 17 Dec 2008 19:38:43 PST

Laser Ablation of Cutaneous Leg Veins

Almeida, J. I., Raines, J. K. — Wed, 17 Dec 2008 19:38:43 PST

Patients presenting with lower-extremity telangiectasias, commonly known as spider veins, are a frequent presentation for vascular surgeons. The use of lasers in the treatment of lower-extremity spider veins has gained increased popularity during the past 5 years. This technology, driven by consumer demand, has been effective in treating vessels that are refractory to sclerotherapy treatment, vessels that arise from telangiectatic matting, and in patients who experience a phobia to needles. One laser wavelength per machine limits what the practitioner can do. That is, each type of vein responds best to a specific wavelength. Light skin is more forgiving to complications than dark skin. The devices are a complement to good sclerotherapy, not a substitute.

Commentary on "Laser Ablation of Cutaneous Leg Veins"

Elias, S. — Wed, 17 Dec 2008 19:38:43 PST

Commentary on "Laser Ablation of Cutaneous Leg Veins"

Padberg, F. — Wed, 17 Dec 2008 19:38:43 PST

Endovenous Ablation of the Saphenous Vein

Kalra, M., Gloviczki, P. — Wed, 17 Dec 2008 19:38:43 PST

The introduction of the minimally invasive, endovenous thermal techniques of superficial reflux ablation have revolutionized the treatment of varicose veins in the last 8 years. The ease of performance even in an office setting, reduced discomfort, and quicker return to normal activity have resulted in universally superior patient acceptance and have made these endovenous procedures the mainstay of present treatment of varicose veins. With encouraging early and mid-term results, future developments in this field must mandate standardization of technical aspects, follow-up imaging, and reporting. The significance of reflux in the great saphenous vein stump, of reflux-free recanalization of a segment of the vein, and their potential for causing recurrent varicose veins remains unknown. The incidence of groin neovascularization and its significance needs to be determined. Ultrasound-guided foam sclerotherapy is also emerging as a competitor to other endovenous techniques and is particularly useful in superficial and tortuous veins not ideally suited for endovenous thermal ablation, as well as recanalized segments of ablated veins.

Commentary on "Endovenous Ablation of the Saphenous Vein"

Rockman, C. B. — Wed, 17 Dec 2008 19:38:43 PST

Anand, Yusuf, Xie, et al. The Warfarin Antiplatelet Vascular Evaluation Trial Investigators. Oral anticoagulation and antiplatelet therapy and peripheral arterial disease. N Engl J Med. 2007;357:217-227

Huber, T. S. — Wed, 17 Dec 2008 19:38:43 PST

available at http://www.ncbi.nlm.nih.gov/ pubmed/17634457

Prinssen, Buskens, de Jong, et al. Cost-Effectiveness of Conventional and Endovascular Repair of Abdominal Aortic Aneurysms: Results of a Clinical Trial. J Vasc Surg. 2007;46:883-890

Sternbergh, C. — Wed, 17 Dec 2008 19:38:43 PST

available at http://eclips.consult.com/eclips/ article/Surgery/S0090-3671(08)79272-3

Pawaskar M, Satiani B, Balkrishnan R, Starr JE. Economic evaluation of carotid artery stenting versus carotid endarterectomy for the treatment of carotid artery stenosis. J Am Coll Surg. 2007;205:413-419

Sharafuddin, M. J., Kresowik, T. F. — Wed, 17 Dec 2008 19:38:43 PST

available at http://www.ncbi.nlm.nih.gov/ pubmed/17765157

Lam RC, Shah S, Faries PL, McKinsey JF, Kent KC, Morrissey NJ. Incidence and clinical significance of distal embolization during percutaneous interventions involving the superficial femoral artery. J Vasc Surg. 2007;46:1155-1159

Mix, J. W., Stevens, S. L. — Wed, 17 Dec 2008 19:38:43 PST

available at http://www.ncbi.nlm.nih.gov/ pubmed/18154991

Carotid Artery Angioplasty and Stenting: Where Do We Stand?

Oderich, G. S., Faries, P. — Thu, 16 Oct 2008 21:42:47 PDT

Current Indications for Carotid Angioplasty and Stenting

Chaer, R. A., Makaroun, M. S. — Thu, 16 Oct 2008 21:42:47 PDT

Carotid angioplasty and stenting has been established as a minimally invasive alternative to endarterectomy for patients with significant extracranial carotid occlusive disease. Its indications, however, continue to evolve, as more controlled data from large clinical trials are being accumulated. The purpose of this article is to review the current evidence supporting the application of carotid angioplasty and stenting in certain subsets of patients and the relative contraindications for its use.

Commentary on "Current Indications for Carotid Angioplasty and Stenting"

Lumsden, A. B., Davies, M. — Thu, 16 Oct 2008 21:42:47 PDT

Carotid Artery Stenting: Technical Issues and Role of Operators' Experience

Verzini, F., De Rango, P., Parlani, G., Panuccio, G., Cao, P. — Thu, 16 Oct 2008 21:42:47 PDT

Major criticism of randomized clinical trials comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA) focused on the incomplete learning curve of interventionists and the inadequate and outdated technology employed, which might have contributed to the high stroke and death rates in the CAS arm. The effect of the learning curve related to technical expertise and patient selection strongly influences the results of CAS. Due to the devastating potential complications when compared with other endovascular minimally invasive procedures, CAS requires a more strict analysis of operator training and outcome, because improvement in the learning curve is accompanied by a comparative reduction in complication rates. Today, there is a general agreement that requirements for training in CAS are higher than in other fields. In contrast to many endovascular peripheral arterial interventions, CAS represents a more challenging procedure because it involves complex catheter-based skills. Training experience attempts to sensibly reduce strokes that may occur during the unprotected phases of catheterization/approach to the target vessel and the protected phase of ballooning/stenting and cerebral protection device retrieval. Mandatory training, familiarity with the indications and contraindications, and knowledge of the technology and devices are paramount for the success of CAS, and preprocedure, intraprocedure, and postprocedure patient management is essential for reducing morbidity and mortality. These prerequisites are essential to allow CAS to be accepted as a potential alternative to CEA.

Carotid Artery Stenting: Technical Issues and Role of Operators' Experience

Clair, D. G. — Thu, 16 Oct 2008 21:42:47 PDT

Embolization During Carotid Angioplasty and Stenting : What Is the Optimal Method for Detecting Embolic Debris and Its Sequelae?

DeRubertis, B. G. — Thu, 16 Oct 2008 21:42:47 PDT

Although the initial randomized trials evaluating the efficacy of carotid angioplasty and stenting (CAS) relative to carotid endarterectomy (CEA) were favorable for CAS, more recent trials have not been universally supportive and have instead highlighted the fact that patient selection may be the key to reducing poor outcomes following percutaneous carotid intervention. Because adverse neurologic events of sufficient severity to be detected by neurologic exam are rare, it is helpful to have more sensitive surrogates of neurologic outcome, such as neurocognitive testing, transcranial Doppler, diffusion-weighted magnetic resonance imaging, and particulate analysis of captured embolic debris. These techniques allow for the evaluation of embolic phenomenon and its sequelae during CAS, which is likely responsible for the majority of adverse neurologic outcomes with this new modality. By correlating the data gathered by these techniques with the perioperative patient, lesion, or device characteristics in those undergoing CAS, one may ultimately be able to better identify and avoid percutaneous treatment in patients who are at heightened risk of embolic phenomenon and adverse clinical outcomes.

Commentary on "Embolization During Carotid Angioplasty and Stenting: What Is the Optimal Method for Detecting Embolic Debris and Its Sequelae?"

Bassiouny, H. — Thu, 16 Oct 2008 21:42:47 PDT

The Impact of Embolic Protection Device and Stent Design on the Outcome of CAS

Bosiers, M., Deloose, K., Verbist, J., Peeters, P. — Thu, 16 Oct 2008 21:42:47 PDT

The importance of angioplasty and stenting in the treatment of carotid artery disease cannot be underestimated. Successful carotid stenting does not only depend on the operator's skills and experience but also on an adequate selection of cerebral protection devices, and carotid stents can help avoid neurological complications. A broad spectrum of carotid devices is currently on the market, and because each of them has its own advantages and disadvantages, it is virtually impossible to claim that one specific device is the best. The individual characteristics of each specific protection system or stent may make it an attractive choice in one circumstance but render it a less desirable option in other situations. The applicability depends primarily on the arterial anatomy and the specific details of the lesion being treated. But certainly, personal preferences and familiarity with a specific device may legitimately influence the decision to choose one over another.

Commentary on "The Impact of Embolic Protection Device and Stent Design on the Outcome of CAS"

Wholey, M. H. — Thu, 16 Oct 2008 21:42:47 PDT

Flow Reversal for Cerebral Protection in Carotid Artery Stenting: A Review

Kelso, R., Clair, D. G. — Thu, 16 Oct 2008 21:42:47 PDT

Carotid artery stenting has established itself as a valid treatment option for carotid stenosis. Many neuroprotective devices have been developed to minimize the risk of embolic events and stroke. Of the devices available today, flow reversal is unique in its conceptual similarity to carotid endarterectomy shunting techniques that maintain cerebral flow. This review focuses on the technical aspects, results, advantages, and disadvantages of carotid flow reversal for embolic protection during carotid artery stenting.

Commentary on "Flow Reversal for Cerebral Protection in Carotid Artery Stenting: A Review"

Parodi, J. — Thu, 16 Oct 2008 21:42:47 PDT

Hemodynamic Changes Associated With Carotid Artery Interventions

Thu, 16 Oct 2008 21:42:47 PDT

Carotid artery interventions can be associated with adverse hemodynamic changes, including bradycardia and hypotension. These hemodynamic changes are believed to be caused by direct stimulation of the carotid sinus baroreceptors, mimicking normal physiological response to rises in blood pressure. During open carotid surgery, these hemodynamic changes can be controlled by direct injection of medications that block fast voltage gated sodium channels in the neuron cell membrane, thus preventing depolarization of the presynaptic neuron in the carotid sinus. This form of control is difficult or impossible during percutaneous carotid interventions because direct access to the carotid artery and carotid sinus is not available. This discussion focuses on the cause, effects, and possible treatments for the hemodynamic changes associated with carotid artery stenting procedures.

Commentary on "Hemodynamic Changes Associated With Carotid Artery Interventions"

Wei Zhou, — Thu, 16 Oct 2008 21:42:47 PDT

A Review of the Trials Comparing Carotid Endarterectomy and Carotid Angioplasty and Stenting

Ricotta, J. J., Malgor, R. D. — Thu, 16 Oct 2008 21:42:47 PDT

In the last decade, carotid artery angioplasty and stenting (CAS) has gained popularity as an alternative to carotid endarterectomy (CEA) for the treatment of carotid stenosis, particularly in patients who are at high operative risk. CAS offers the advantage of being a less invasive procedure, potentially minimizing the risks of wound complications and cranial nerve injury, which may translate into shorter length of hospitalization and less resource utilization. Since the advent of CAS, several randomized controlled trials and carotid stent registry trials have been conducted comparing the outcomes of CEA with those of CAS for the treatment of carotid stenosis in both symptomatic and asymptomatic patients. This review will summarize the results of randomized controlled trials (CAVATAS, WALLSTENT, SAPPHIRE, EVA-3S, SPACE, and CaRESS) as well as pivotal carotid registry studies (ARCHeR, BEACH, CAPTURE, CASES-PMS, CREATE, and CABernET) intended to evaluate the safety and efficacy of CEA and CAS in treatment of carotid stenosis. In addition, it will provide a preview of the current ongoing and future trials examining the safety, applicability, and indications of CAS and CEA (CREST, CAVATAS-2, ACT 1, and TACIT).

Commentary on "A Review of the Trials Comparing Carotid Endarterectomy and Carotid Angioplasty and Stenting"

Oderich, G. S. — Thu, 16 Oct 2008 21:42:47 PDT

Disparities in the treatment and outcomes of vascular disease in Hispanic patients. J Vasc Surg. 2007;46:971-978

Brothers, T. E. — Thu, 16 Oct 2008 21:42:47 PDT

Idraparinux versus standard therapy for venous thromboembolic disease. N Engl J Med. 2007;1094-1104

Stone, W. M., Money, S. R. — Thu, 16 Oct 2008 21:42:47 PDT

Gaps in public knowledge of peripheral arterial disease: The first national PAD public awareness survey. Circulation. 2007;116:2086-2094

Taylor, S. M. — Thu, 16 Oct 2008 21:42:47 PDT

Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N Engl J Med. 2007;357:349-359

Farber, M. A. — Thu, 16 Oct 2008 21:42:47 PDT