Search

Objectives The VascuQol is a questionnaire for health related quality of life (HRQL) in patients with intermittent claudication (IC), and is frequently used to evaluate treatment effects. Yet, the interpretation of change in score on a questionnaire is not always obvious. The minimally important difference (MID) represents the smallest change in score on a questionnaire that is considered relevant by patients. This study aims to determine the MID for the VascuQol sumscore and its different domains for patients with IC. Methods A total of 118 participants were recruited from the SUPER study, a multicenter randomized controlled trial comparing angioplasty with supervised exercise therapy for alleviation of IC due to an iliac artery stenosis or occlusion. All patients completed the VascuQol and the Short Form 36 (SF-36) questionnaires at baseline and after 12 months of follow up. Two anchor based methods for MID calculation were applied. Two anchors were used: six global rating of change questions aimed at the VascuQol sumscore and subscales and the health transition item of the SF-36, both recorded at 12 months of follow up. Results The MID for the VascuQol sumscore ranged between 1.19 and 1.66 for improvement and 0.08 and 0.41 for deterioration. For the pain domain, MID values ranged from 1.48 to 1.91 for improvement and 0.19 to 0.34 for deterioration. Finally, for the activities domain MID values ranging from 1.55 to 2.2 and from 0.12 to 0.26 for improvement and deterioration were found, respectively. Since the correlations between the anchors and the symptom, social and emotional subscales were below the threshold of 0.3, the MID was not calculated for these subscales. Conclusions The range of MID values found in this study is an indication of the smallest change score on the VascuQol questionnaire score that is considered relevant by patients with IC. They may help to better interpret trial results and set treatment goals. [ABSTRACT FROM AUTHOR]

Objective To compare the midterm re-intervention and survival rates after EVAR and OR for ruptured abdominal aortic aneurysms (RAAA). Methods Observational cohort study including all consecutive RAAA patients between 2004 and 2011 in 10 hospitals in the Amsterdam ambulance region. The primary end point was re-interventions within 5 years of the primary intervention. The secondary end point was death. The outcomes were estimated by survival analyses, compared using the logrank test, and subsequently adjusted for possible confounders using Cox proportional hazard models. Re-interventions were estimated in all patients and in patients who survived their hospital stay. Results Of 467 patients with a RAAA, 73 were treated by EVAR and 394 by OR. Five years after the primary intervention, the rates of freedom from re-intervention were 55% for EVAR (26/73, 95% CI: 41–69%) and 60% for OR (130/394, 95% CI: 55–66%) ( p = .96). After adjustment for age, sex, comorbidity, and pre-operative hemodynamic stability, the risk of re-intervention was similar (HR 1.01, 95% CI: 0.65–1.55). The survival rates were 36% for EVAR (45/73, 95% CI: 24–47%) and 38% for OR (235/394, 95% CI: 33–43%) ( p = .83). In 297 patients who survived their hospital stay, the rates of freedom from re-intervention were 66% for EVAR (15/54, 95% CI: 52–81%) and 90% for OR (20/243, 95% CI: 86–95%) ( p < .01). After adjustment for age and sex, the risk of re-intervention was higher after EVAR (HR 0.27, 95% CI: 0.14–0.52). Conclusions Five years after the primary intervention, endovascular and open repair for ruptured abdominal aortic aneurysm resulted in similar re-intervention and survival rates. However, in patients who survived their hospital stay the re-intervention rate was higher for EVAR than for OR. [ABSTRACT FROM AUTHOR]

Objective/Background Arterial calcification may render the ankle-brachial index (ABI) unreliable in diabetic patients. Although guidelines recommend the toe-brachial index (TBI) for patients with falsely elevated ABI arbitrarily defined as an ABI > 1.4, arterial calcification is also common among diabetic patients with an ABI ≤ 1.4. This could result in a “falsely normalized” ABI and under-diagnosis of peripheral arterial disease (PAD). We investigated whether diabetes invalidates the ABI as opposed to the TBI, and if the TBI may therefore be more suitable for detecting PAD in diabetic patients. Methods The difference between ABI and TBI was compared between diabetic and non-diabetic patients with an ABI ≤ 1.4 referred to the vascular laboratory. A Bland–Altman plot was constructed to assess whether ABI–TBI differences were dependent on the magnitude of the measurements. Subgroup analyses were performed for patients with a normal ABI, and for patients with critical ischemia. Results The population comprised 161 diabetic (252 limbs) and 160 non-diabetic (253 limbs) patients (mean age 67). Median ABIs (0.79 vs. 0.80) were similar, while median TBI was 0.07 higher in diabetics ( p = 0.024). The ABI–TBI difference in diabetics and non-diabetics was similar (0.32 vs. 0.35; p = .084), and was also similar for patients with a normal ABI. Moreover, ABI–TBI differences in diabetic- and non-diabetic patients overlapped, irrespective of the magnitude of the measurements. Diabetes was not associated with larger differences between ankle and toe pressures (mean difference −0.9 mmHg, 95% confidence interval −15 to 13 mmHg) among patients with critical ischemia. Conclusion No evidence was found that the TBI may overcome the potentially invalidated ABI in diabetic patients with an ABI ≤ 1.4. ABI and TBI are strongly associated, and this relationship is not influenced by diabetes. Therefore, the TBI does not allow for earlier detection of ischemia in diabetes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate 1 to 48 month follow-up outcomes of different endovascular treatment strategies in below-the-knee (BTK) arterial segments in critical limb ischemia (CLI) patients. Methods: Medline and Embase were searched (last searched on 5 November 2013) for studies of randomized controlled trials comparing either balloon angioplasty (PTA) or drug-eluting balloon (DEB) with optional bailout stenting, or primary stenting using a bare stent (BS) or drug-eluting stent (DES) to one another. Methodological quality of each trial was assessed using a Cochrane Collaboration's tool, and quality of evidence was assessed using the GRADE system. Outcomes assessed were wound healing, quality of life, change in Rutherford classification, amputation, death, target lesion revascularization (TLR), bypass, binary restenosis, late lumen loss, stenosis grade, and event-free survival with follow-up periods of at least 1 month. Results: Twelve trials including 1145 patients were identified, with 90% of patients having CLI. Six BS versus PTA and two DES versus PTA trials showed low-quality evidence of equal efficacy. One trial, comparing DEB with PTA, showed moderate-quality evidence of improved wound healing (RR 1.28; 95% CI: 1.05 to 1.56; p = .01), improvement in Rutherford classification (RR 1.32; 95% CI: 1.08 to 1.60; p = .008), and lower TLR (RR 0.41; 95% CI 0.23 to 0.74; p = .002) and binary restenosis (RR 0.36; 95% CI 0.24 to 0.54; p < .0001) in diabetic patients after 12 months. Amputation and death rate did not differ significantly. For DES versus BS, most trials showed equal efficacy between strategies. Conclusion: Based on low- to moderate-quality evidence, PTA with optional bailout stenting using BS should remain the preferred strategy in treating CLI patients with BTK arterial lesions. Before other strategies can be implemented, larger and high-quality RCTs assessing clinically relevant outcomes are needed. [Copyright &y& Elsevier]

Objective: To evaluate 1 to 36 month follow-up outcomes of different endovascular treatment strategies in above-the-knee (ATK) arterial segments in patients with intermittent claudication (IC) and critical limb ischemia (CLI). Methods: Studies indexed in Medline and Embase from 1980 to November 2013 of randomized controlled trials comparing balloon angioplasty (PTA) or drug-eluting balloon (DEB) with optional bailout stenting, or primary stenting using a bare stent (BS) or drug-eluting stent (DES) to one another were included. Methodological quality of each trial was assessed using the Cochrane Collaboration tool, and quality of evidence was assessed using the GRADE system. Outcomes assessed were quality of life, walking capacity evaluated by treadmill or questionnaire, change in Rutherford classification, target lesion revascularization (TLR), bypass, binary restenosis, late lumen loss, stenosis grade, amputation, death, major adverse cardiac events, or event-free survival with follow-up periods of at least 1 month. Results: Twenty-three trials including 3314 patients in total were identified. Eighty-five per cent patients had IC and 15% CLI. Fifteen trials showed no systematic benefit of BS over PTA. One trial comparing DES and PTA reported no significant differences in walking capacity or Rutherford classification. Four trials showed a beneficial effect on TLR rate, but not on Rutherford classification of DEB compared with PTA. In four trials DES did not systematically perform better than BS. Conclusion: In general, performing PTA with optional bailout stenting for ATK lesions is the preferred strategy in patients with IC. For CLI, more studies are needed for recommending an optimal treatment strategy. [Copyright &y& Elsevier]

Objectives: In patients with a ruptured abdominal aortic aneurysm (RAAA), anatomic suitability for endovascular aneurysm repair (EVAR) depends on aortic neck and iliac artery characteristics. If the aortoiliac anatomy is unsuitable for EVAR (“hostile anatomy”), open repair (OR) is the next option. We hypothesized that the death rate for OR is higher in patients with hostile anatomy than in patients with friendly anatomy. Methods: We conducted an observational cohort study in 279 consecutive patients with an RAAA treated with OR between 2004 and 2011. The primary endpoint was 30-day or in-hospital death. Aortoiliac anatomy (friendly vs. hostile) was determined prospectively by the vascular surgeon and the interventional radiologist treating the patient. A multivariable logistic regression analysis was done to assess the risk of dying in patients with hostile anatomy after adjustment for age, sex, comorbidity, and hemodynamic stability. Results: Aortoiliac anatomy was friendly in 71 patients and hostile in 208 patients. Death rate was 38% (95% confidence interval (CI): 28 to 50%) in patients with friendly anatomy and 30% (95% CI: 24 to 37%) in patients with hostile anatomy (p = .23). After multivariable adjustment, the risk of dying was not higher in patients with hostile anatomy (adjusted odds ratio 0.744, 95% CI 0.394 to 1.404). Conclusion: The death rate after open repair for an RAAA is comparable in patients with friendly and hostile aortoiliac anatomy. [Copyright &y& Elsevier]

Objective: Interpreting whether changes in quality of life (Qol) in patients with peripheral arterial disease (PAD) are not only statistically significant but also clinically relevant, may be difficult. This study introduces the concept of the minimally important difference (MID) to vascular surgeons using Qol outcomes of patients treated for chronic critical limb ischemia (CLI). Methods: The Vascular Quality of Life (VascuQol) questionnaire was recorded at baseline before treatment and after 6 months follow-up in consecutive patients with CLI treated between May 2007 and May 2010. Statistical significance of change in VascuQol score was tested with the Wilcoxon Signed Rank test. The MID for the VascuQol score was determined using a clinical anchor-based method and a distribution-based method. Results: A total of 127 patients with CLI completed the VascuQol after 6 months. The VascuQol sum scores improved from 3.0 (range 1.1–5.9) at baseline to 4.0 (range 1.2–6.7) at 6 months (p < .001). The MID on the VascuQol sumscore indicating a clinically important change determined with the anchor-based method was 0.36, and with the distribution-based method was 0.48. On an individual level, depending on the method of determining the MID, this resulted in 60% to 68% of the patients with an important benefit. Conclusions: Expression of changes in Qol by means of the MID provides better insight into clinically important changes than statistical significance. [Copyright &y& Elsevier]

Objectives: To evaluate the diagnostic accuracy of computed tomography angiography (CTA) in detecting arterial lesions in patients with suspected arterial injury of the upper or lower extremity due to trauma. Methods: A systematic review and meta-analysis was carried out. Medline and Embase were searched on August 13, 2012, for studies comparing CTA with surgery, digital subtraction angiography (DSA), or follow-up, which allowed extraction of data into two-by-two tables. The methodological quality of included studies was assessed using the QUADAS tool. Summary estimates of sensitivity and specificity of CTA in identifying or excluding arterial lesions were obtained using a bivariate model. Results: This review included 11 studies making up a total of 891 trauma patients. The included studies were of moderate methodological quality and at risk of misclassification and verification bias. Some 4.2% of all CTA studies were non-diagnostic. The summary estimates of sensitivity and specificity of CTA were 96.2% (95% CI 93.5–97.8%) and 99.2% (95% CI 96.8–99.8%), respectively. Conclusion: Despite methodological flaws, the excellent estimates of sensitivity and specificity indicate that CTA is an accurate modality for evaluating arterial lesions in patients with extremity trauma and can replace DSA. [Copyright &y& Elsevier]

Abstract: Presented are three cases of volleyball players with ischaemia of the hand due to arterial emboli originating from an injured posterior circumflex humeral artery (PCHA). An operative treatment with ligation of the PCHA was performed in all patients because of the proximity of the occlusion to the axillary artery. After a rehabilitation programme, all patients could return to their previous level of competition. During overhead motion, the PCHA is prone to injury in its position overlying the humeral head and its course through the quadrilateral space. Recognition of the vascular origin of these symptoms in athletes is important to prevent serious ischaemic complications. Signs of ischaemia might be subtle and may be misdiagnosed as musculoskeletal injuries. Therefore, the examining physician must have a high index of suspicion and awareness about these injuries is important. [Copyright &y& Elsevier]

Abstract: Introduction: Treatment of intermittent claudication (IC) due to peripheral arterial disease (PAD) is aimed at improving walking distance and includes secondary prevention of cardiovascular disease. Both supervised exercise therapy (SET) and percutaneous transluminal angioplasty (PTA) have proven to be effective in increasing maximum and pain-free walking distance in IC. However, the optimal treatment strategy in patients with IC due to iliac artery stenosis or occlusion remains unclear. Objective: To compare the (cost-) effectiveness of initial PTA versus initial SET in patients with disabling IC due to an iliac artery obstruction. Design: In a multicentre randomised controlled trial 400 consecutive patients with IC will be randomly assigned to PTA (with additional stent placement on indication) or SET. Primary outcomes are maximum walking distance and health-related quality of life measured using the disease-specific VascuQol instrument after 1 year. Secondary outcomes are pain-free walking distance, functional status, generic quality of life, complications related to each of the interventions, additional interventions, treatment failures and costs (cost-effectiveness and cost-utility) after 1 year. Conclusion and implications: Based on the results of this proposed large study well-founded adjustments of existing guidelines on the treatment of iliac artery occlusive disease can be implemented (Clinical Trials.gov NCT01385774; Nederlands Trial Register NTR2776). [Copyright &y& Elsevier]

Abstract: Rupture of a thoraco-abdominal aortic aneurysm (TAAA) is usually lethal. Patients with contained ruptures, who reach the hospital, have traditionally been subjected to open reconstructive surgery. However, especially in older patients, open surgery has a high mortality and morbidity rate. Visceral hybrid procedures (VHPs) can provide an alternative in this high-risk patient group. We present a literature review of VHPs with a focus on acute TAAAs. [Copyright &y& Elsevier]

Purpose: To assess interobserver and intraobserver agreement on presence of rupture and determining suitability for endovascular repair (EVAR) on CT angiography (CTA) of patients with a suspected ruptured abdominal aortic aneurysm (RAAA). Methods: For the Amsterdam Acute Aneurysm study, a randomised multicenter trial (ISRCTN66212637), we register all patients with suspected RAAA in the Amsterdam region. For the current analysis 51 consecutive patients were included from this prospective database. Pre operative CT scans were assessed twice with a six-week interval by three vascular surgeons and two interventional radiologists. Variables recorded were presence of rupture, diameter and length of the infrarenal aortic neck, diameters of both iliac arteries and final judgement on anatomical suitability for EVAR. Kappa values for dichotomous outcomes were calculated as a measure of agreement above chance. Continuous outcomes were investigated by calculating the intraclass correlation coefficient (ICC) and by Bland-Altman plots. Results: For presence of rupture group kappa was 0.59 (CI: 0.42–0.77). The group kappa of suitability for EVAR was 0.38 (CI: 0.24–0.51). The ICC for diameter and length of the infrarenal aortic neck and diameters of left and right iliac arteries were 0.40 (CI: 0.26–0.56), 0.47 (CI: 0.32–0.62), 0.61 (CI: 0.48–0.74) and 0.35 (CI: 0.21–0.50) respectively. The Bland-Altman plots confirmed the large variation among observers. Intraobserver kappa ranged from 0.57–0.78 for presence of rupture and 0.40–0.80 for suitability for EVAR. Conclusion: Moderate interobserver agreement was found for presence of rupture and fair agreement for suitability for EVAR. Intraobserver agreement ranged from moderate to almost perfect. Based on this data, optimization of the protocol is mandatory to identify uniform measuring techniques of well defined anatomical criteria for endovascular repair of ruptured aneurysms. [Copyright &y& Elsevier]

Abstract: Rupture of a thoraco-abdominal aortic aneurysm (TAAA) is usually lethal. Patients with contained ruptures, who reach the hospital, have traditionally been subjected to open reconstructive surgery. However, especially in older patients, open surgery has a high mortality and morbidity rate. We describe a case of an 82-year-old man with a contained rupture of a Crawford type IV TAAA, whom we successfully treated with endovascular exclusion after visceral and renal re-vascularisation (a visceral hybrid procedure (VHP)). [Copyright &y& Elsevier]

A technique is described in which by subintimal recanalization it is possible to create a percutaneous distal bypass to the foot. This technique might offer new opportunities for patients with non-healing ulcers which are technically and/or medically inoperable. [Copyright &y& Elsevier]

Abstract: Percutaneous closure devices are now often used for closure of the femoral puncture site after percutaneous vascular interventions. We describe a case were an accidental puncture in the aortic arch during placement of a central venous catheter is successfully closed with a closure device. [Copyright &y& Elsevier]

Abstract: Introduction: Subintimal angioplasty is a well-recognised treatment method for stenosis and occlusions in peripheral arterial occlusive disease. In patients with extensive atherosclerosis, large pelvic collateral networks may signify concomitant mesenterial artery disease. Case report: We describe a patient in whom a percutaneous subintimal angioplasty of the external iliac artery was complicated by acute bowel ischaemia due to occlusion of important mesenteric collaterals. After urgent bypass surgery, the patient made a full recovery. Conclusion: This report emphasises the importance of recognising mesenteric collateral formation from the iliac arteries in endovascular procedures, as the mesenterial vascularisation may depend heavily on it. [Copyright &y& Elsevier]