European journal of vascular surgery最新文献

The implantation of an aortic bifurcation graft (ABG) for treatment of occlusive (OD) and aneurysmal (AD) aortoiliac disease is a standard technique with good long-term results and a relatively low incidence of complications. In a retrospective review of our patients from 1964 to 1993 only 36/1520 patients were identified who required reoperation at the proximal aortic anastomosis after ABG. Indications were graft occlusion (15/36) and graft stenoses (2/36), refractory to graft thrombectomy, proximal aortic anastomotic aneurysms (11/36) or graft infection (8/36). Graft occlusion or stenosis most frequently led to aortic reoperation in the OD-group (53.5%), recurrent aneurysmal disease (37.5%) and graft infection (37.5%) were the dominant indications in the AD-group. Mean time interval to reoperation was shorter in cases of graft infection (35 ± 33 months) as compared with graft stenosis (66 ±58 months), graft occlusion (86 ± 49 months) or aortic anastomotic aneurysms (152 ± 90 months). Of the reoperations, 92% were done electively, 8% as emergency procedures. The perioperative course was uneventful in 67% of patients. Overall mortality rate after elective revisional surgery was 3% but reached 66% in emergencies. Postoperative morbidity and mortality was related to preoperative morbidity and the urgency of surgery, not with the mode of aortic intervention nor indication.

Screening for abdominal aortic aneurysm has been offered to 13 000 patients. An overall compliance of 76% (range 51–99%) has been achieved. For those with an initial aortic diameter between 29 mm and 45 mm serial ultrasound scans are offered to monitor aortic change. Of the 302 cases followed up by repeated scans, 93 have had more than 5 scans (mean of 7 scans) over a mean time period of 32.1 months (range 15–63 months). The rate of change of all these aneurysms has been calculated using all data points and robust linear regression. It has been possible to postulate an algorithm for aortic growth. The influence of measurement precision and ultrasound quality assurance on the rescan interval is demonstrated and it is suggested that 2 years is a suitable rescan interval for aortas with diameter less than 40 mm.

The elastic properties of newly implanted in situ (IS, n = 11) and reversed (RV, n = 21) saphenous grafts were studied with the use of Vessel Wall Doppler Tracking. From diameter, diameter change and simultaneously recorded pulse pressure, distensibility coefficient (DC) representing the intrinsic elastic properties and compliance coefficient (CC), a parameter of haemodynamic capacity, were calculated. In order to obtain a mechanical profile, the parameters were assessed at defined sites down the graft and native arterial system. In the RV group the reversal of the grafts resulted in a difference in diameter around the proximal anastomoses (7.4 vs. 4.3 mm, p < 0.01) and from proximal to distal (4.3 vs. 5.9 mm, p < 0.01) in the grafts; around the distal anastomoses no differences in diameter were observed. Due to the natural taper of the in situ grafts, diameter decreased from proximal to distal in the grafts (4.5 vs. 3.2 mm, p < 0.05) and no size differences were found around the anastomoses. In the RV group a decrease in DC was observed from proximal to distal in the grafts; whereas in the IS group no change in DC was found from proximal to distal in the grafts but a decrease in DC was observed around the distal anastomoses. In the RV group, a decrease in CC at the proximal anastomoses was observed (0.25 vs. 0.09 mm² /kPa, p < 0.01). In the IS group no change in CC was observed around the proximal anastomoses and distal anastomoses. However, a decrease of this parameter from proximal to distal in the grafts was found (0.07 vs. 0.04 mm² /kPa, p < 0.05). These results demonstrate that the elastic properties of newly inserted human saphenous vein grafts are comparable with native artery elastic properties. In contrast to the in situ technique, a mismatch in haemodynamic capacity is apparent round the proximal anastomoses using the reversed technique, indicating haemodynamic benefit at the proximal anastomoses of in situ grafts. An important decrease in haemodynamic capacity is present in in situ grafts, whereas this parameter remains stable in reversed grafts, suggesting intrinsic haemodynamic advantage in reversed grafts.

Redundant length of the cervical part of the internal carotid artery (ICA) is a clear angiographic entity although the clinical significance is uncertain. Transcranial Doppler sonography (TCD) examinations were performed on 15 patients with 23 elongated ICAs. The recordings were obtained with the use of flat 2 MHz probe from the middle cerebral artery (MCA) and the intracranial part of ICA at rest and in eight possible extreme positions of head and neck rotation. The mean blood flow velocity in the intracranial part of the ICA obtained in the neutral position was 50.1 ± 8.3 cm s⁻¹ and after head and neck rotations was 49.8 ± 9.5 cm s⁻¹. The mean blood flow velocity in the MCA was 55.8 ± 6.7 cm s⁻¹ and did not change significantly after head and neck movements (54.9 ± 7.6 cm s⁻¹). Analysis of 368 one minute recordings from all possible head positions showed no significant changes of blood flow velocity. Rotation of the head and neck has no significant influence on intracranial blood flow velocity in the presence of carotid artery elongation.

Standard assessment of aortoiliac obstructive disease (AIOD) includes arteriography preferably supplemented with femoral artery pressure (FAP) measurements. This study investigated the value of Duplex scanning in classifying AIOD and compared the outcome of Duplex scanning with clinical decision making. One-hundred-and-fifty-three aortoiliac segments of 87 patients were prospectively examined by Duplex scanning, arteriography, and FAP measurements to establish the presence or absence of significant AIOD. The results of these tests were compared to each other and to the subsequent vascular interventions and their success rates. Excellent agreement (kappa 0.82) was found between Duplex scanning and arteriography. The agreement between Duplex scanning and FAP measurements was much lower (kappa 0.52). The correlation between the performed treatment and the assessment of AIOD by Duplex scanning or arteriography was good, whereas the FAP results correlated only moderately with the performed treatment. Endovascular or operative treatment was actually performed in only 63% of the aortoiliac segments with an abnormal FAP test (success rate 80%). Aortoiliac segments with significant AIOD according to arteriography or Duplex scanning were treated invasively in 86% (success rate 81%) and 82% (success rate 80%), respectively. In conclusion, Duplex scanning can replace arteriography as a screening tool for the identification of treatable aortoiliac lesions whereas the value of FAP measurements in the decision making process is limited.

Abdominal aortic aneurysm (AAA) is a common disease of the elderly exhibiting a complex aetiology. In a survey of 82 Irish aneurysm patients, compared to 79 age- and sex-matched control subjects, we have investigated a number of potential biochemical and molecular genetic markers which are amenable to analysis from blood specimens and which might have predictive value for AAA. No significant differences were observed between patients and control subjects in relation to serum lipids, leucocyte elastase activity or serum a₁-antitrypsin concentration. We have used the polymerase chain reaction to screen the patient and control groups in search of disease-associated genetic variation on chromosome 16, particularly in the region of the Cholesteryl Ester Transfer Protein (CETP) gene. Although variation in allele frequencies was detected between patients and controls at the four marker loci studied, no significant gene-disease associations were detected. The absence of gene-disease associations in our study may indicate that the genetic component in the aetiology of AAA in Ireland differs from that in the UK. Alternatively, it may indicate that the high degree of polymorphism at microsatellite loci may make them unsuitable as markers for the study of gene-disease associations in moderately sized populations. We therefore conclude that the biochemical and molecular genetic markers which we have examined are of no predictive value, and that ultrasonography remains the screening modality of choice for abdominal aortic aneurysm.