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Objective: Since the first description of the median arcuate ligament syndrome (MALS), the existence for the syndrome and the efficacy of treatment for it have been questioned. Methods: A systematic review conforming to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was conducted, with a broader view on treatment for MALS including any kind of coeliac artery release, coeliac plexus resection, and coeliac plexus blockage, irrespective of age. Online databases were used to identify papers published between 1963 and July 2021. The inclusion criteria were abdominal symptoms, proof of MALS on imaging, and articles reporting at least three patients. Primary outcomes were symptom relief and quality of life (QoL). Results: Thirty-eight studies describing 880 adult patients and six studies describing 195 paediatric patients were included. The majority of the adult studies reported symptom relief of more than 70% from three to 228 months after treatment. Two adult studies showed an improved QoL after treatment. Half of the paediatric studies reported symptom relief of more than 70% from six to 62 months after laparoscopic coeliac artery release, and four studies reported an improved QoL. Thirty-five (92%) adult studies and five (83%) paediatric studies scored a high or unclear risk of bias for the majority of the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) items. The meaning of coeliac plexus resection or blockage could not be substantiated. Conclusion: This systematic review suggests a sustainable symptom relief of more than 70% after treatment for MALS in the majority of adult and paediatric studies; however, owing to the heterogeneity of the inclusion criteria and outcome parameters, the risk of bias was high and a formal meta-analysis could not be performed. To improve care for patients with MALS the next steps would be to deal with reporting standards, outcome definitions, and consensus descriptions of the intervention(s), after which an appropriate randomised controlled trial should be performed.

Objective Patients with intermittent claudication (IC) are initially treated with supervised exercise therapy (SET), as advised by national and international guidelines. Dutch health insurance companies and the Dutch National Health Care Institute suggested an 87% compliance rate with these guidelines in the Netherlands in 2017 and judged this to be undesirably low. The aim of this study was to evaluate compliance with IC guidelines and to elaborate on the reasons for deviating from them (practice variation) in a large teaching hospital. Methods A retrospective single centre cohort study was conducted at a large teaching hospital in the Netherlands. In total, 420 patients with newly diagnosed IC between 1 January 2017 and 31 December 2018 were analysed. Data included risk profiles and prescribed therapies. Results For all 420 included patients, the compliance rate with the guidelines for SET was 80.5%. The rate of adequately motivated and defensible practice variation was 15.7%; the rate of unjustified practice variation was 3.8%. Meaningful care was seen in 96.2% of cases. Conclusion Deviation from IC guidelines was found in 19.5% of patients. Almost three quarters of this deviation can be explained by the decision to provide personalised, meaningful care.

“Mesenteric arterial thrombosis? Here we call it cemetery thrombosis” (trombosis cementerico in Spanish), said the moderator at a meeting discussing this topic in Cartagena, Colombia. That metaphor, unfortunately, is still justified worldwide.

In patients with median arcuate ligament (MAL) syndrome (MALS), external compression of the coeliac artery (CA) by the MAL causes chronic disabling postprandial abdominal pain, weight loss, and, consequently, lethargy and social deprivation. 1 ,2 The majority of patients with MALS will experience a long medical journey before a diagnosis of MALS is considered, resulting in a substantial burden of disease and high healthcare and societal costs.

In peripheral arterial disease the tissue microcirculation becomes impaired, ultimately resulting in chronic limb threatening ischaemia (CLTI) in 5% of cases. 1 CLTI prognosis is poor unless successful revascularisation is performed. 2 Endovascular and hybrid revascularisation procedures are performed under fluoroscopic and angiographic guidance to visualise the per-operative impact on the macrocirculation. Unfortunately, both lack the ability to visualise the impact on microcirculation, while restoring the microcirculation plays a pivotal role in CLTI. 3 By introducing additional per-operative assessment of the microcirculation, the impact of revascularisation on the microcirculation can be assessed in real time. This allows the surgical team to extend or adjust the revascularisation procedure in a timely manner, improving (prediction of) the clinical outcome.

Objectives The dynamic endovascular environment of stent grafts may influence long term outcome after endovascular aneurysm repair (EVAR). The sealing and fixation of a stent graft to the aortic wall is challenged at every heartbeat, yet knowledge of the cardiac induced dynamics of stent grafts is sparse. Understanding the stent–artery interaction is crucial for device development and may aid the prediction of failure in the individual patient. The aim of this work was to establish quantitative stent graft motion in multiphasic electrocardiogram (ECG) gated computed tomography (CT) by image registration and segmentation techniques. Methods Experimental validation was performed by evaluating a series of ECG gated CT scans of a stent graft moving at different amplitudes of displacement at different virtual heart rates using a motion generating device with synchronised ECG triggering. The methodology was further tested on clinical data of patients treated with EVAR devices with different stent graft designs. Displacement during the cardiac cycle was analysed for points on the fixating stent rings, the branches or fenestrations, and the spine. Results Errors for the amplitude of displacement measured in vitro at individual points on the wire frame were at most 0.3 mm. In situ cardiac induced displacement of the devices was found to differ per location and also depended on the type of stent graft. Displacement during the cardiac cycle was greatest in a fenestrated device and smallest in a chimney graft sac anchoring endosystem, with maximum displacement varying from 0.0 to 1.4 mm. There was no substantial displacement measurable in the spine. Conclusions A novel methodology to quantify and visualise stent graft motion in multiphasic ECG gated CT has been validated in vitro and tested in vivo. This methodology enables further exploration of in situ motion of different stent grafts and branch stents and their interaction with native vessels.

Introduction: Over the past decade, primary percutaneous mesenteric artery stenting (PMAS) has become an alternative to open revascularisation for treatment of mesenteric ischaemia. Institutes have presented favourable short-term outcomes after PMAS, but there is a lack of data on long-term stent patency. Methods: One hundred and forty-one patients treated by PMAS for acute and chronic mesenteric ischaemia over an 8 year period were studied. Anatomical success was assessed by duplex ultrasound and/or CT angiography. A stenosis >= 70% was considered to be a failure. Results: Eighty-six coeliac arteries (CA) and 99 superior mesenteric arteries (SMA) were treated with PMAS in 141 patients. Nine CAs (10%) and 30 SMAs (30%) were occluded at the time of treatment. Median follow-up was 32 months (IQR 20-46). The overall primary patency rate at 12 and 60 months was 77.0% and 45.0%. The overall primary assisted patency rate was 90.3% and 69.8%. Overall secondary patency was 98.3% and 93.6%. Conclusion: This study shows excellent long-term secondary patencies after PMAS, comparable with published data on long-term patencies after open surgical revascularisation. (C) 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Objectives To compare expanded polytetrafluoroethylene (ePTFE) prosthesis and collagen-impregnated knitted polyester (Dacron) for above-knee (AK) femoro-popliteal bypass grafts. Design A prospective multicentre randomised clinical trial. Patients and Methods Between 1992 and 1996, 228 AK femoro-popliteal bypass grafts were randomly allocated to either an ePTFE ( n =114) or a Dacron ( n =114) vascular graft (6mm in diameter). Patients were eligible for inclusion if presenting with disabling claudication, rest pain or tissue loss. Follow-up was performed and included clinical examination and duplex ultrasonography at all scheduled intervals. All patients were treated with warfarin. The main end-point of this study was primary patency of the bypass graft at 2, 5 and 10 years after implantation. Secondary end-points were mortality, primary assisted patency and secondary patency. Cumulative patency rates were calculated with life-table analysis and with log-rank test. Results After 5 years, the primary, primary assisted and secondary patency rates were 36% (confidence interval (CI): 26–46%), 46% (CI: 36–56%) and 51% (CI: 41–61%) for ePTFE and 52% (CI: 42–62%) ( p =0.04), 66% (CI: 56–76%) ( p =0.01) and 70% (CI: 60–80%) ( p =0.01) for Dacron, respectively. After ten years these rates were respectively 28% (CI:18-38%), 31% (CI:19-43%) and 35% (CI: 23-47%) for ePTFE and 28% (CI: 18-38%), 49% (CI: 37-61%) and 49% (CI: 37-61%) for Dacron. Conclusion During prolonged follow-up (10 years), Dacron femoro-popliteal bypass grafts have superior patency compared to those of ePTFE grafts. Dacron is the graft material of choice if the saphenous vein is not available.

Objective. The technical and clinical outcome of endovascular revascularization was analyzed in patients with suspicion of chronic splanchnic syndrome (CSS). Methods. Medical history, duplex, angiography and exercise gastric tonometry suggested CSS in 97 patients. Twenty-seven of them were treated endovascular (one patient had 3-vessel, 12 patients had 2-vessels, 14 patients had 1-vessel CSS). Five patients received previous splanchnic revascularization. Twenty-three patients (85%) had severe co-morbidity: cardiac, pulmonary or cachexia. Endovascular treatment consisted of percutaneous transluminal angiography (PTA) of the coeliac artery (CA) or superior mesenteric artery (SMA) in three and primary balloon expandable stenting in 24 patients (13 CA and 10 SMA solitary, two CA and SMA both, 31 splanchnic arteries in total). Results. Three patients showed procedure related complications (11%). Mean follow-up was 19, range 2–76 months. Two patients died during follow up, both not procedure or CSS related. Five patients had no improvement of symptoms, without evidence of re- or residual stenosis. The primary clinical success was 67%, secondary clinical success was 81%. The primary patency was 81% and secondary patency was 100%. Conclusion. Endovascular treatment of CSS has a reasonable outcome. It is an alternative to operative treatment, especially in patients with high co-morbidity or limited life expectancy.

Introduction: Open repair of ruptured abdominal aortic aneurysm (rAAA) still has a high mortality. Endovascular aortic repair (EVAR) may be the way to improve survival rates. However, it is not clear how many patients with rAAA will be suitable for acute EVAR. Methods: Between October 2000 and April 2002 all patients with acute symptomatic or ruptured AAA were assessed for EVAR on an intention-to-treat basis with emergency computed tomographic angiography (CTA). Patient and logistic characteristics were analysed. We used two commercially available aorto uni-iliac devices with a maximum proximal diameter of 28 and 34 mm. Results: Five out of 26 patients were excluded for CTA and EVAR because of severe and persistent hypotension (3 pts) or logistic reasons (2 pts, both eligible). Twelve patients were found not eligible for EVAR due to unsuitable infrarenal aortic neck length (3 pts), neck diameter (1 pt) or a combination of both (8 pts). The remaining six patients were treated with EVAR. After 6 months no graft failure or aneurysm related deaths were recorded in the EVAR group. Conclusion: A total of 28% of patients with symptomatic or ruptured AAA was treated with EVAR. A potential 42% of patients could have been suitable for EVAR, if the correct devices had been in stock and all patients had been properly assessed.

formed. The arterial splanchnic circulation was normal but there was complete thrombosis of all veins in the mesentery of the small intestine including the central splanchnic veins. The entire small intestine was cyanotic, consistent with severe ischaemia, but no part of the intestine was necrotic and no resection was performed. In the IC-unit a hyperdynamic circulation was pursued with fluid challenge and dobutamine inotropic support guided by pulmonary artery pressure monitoring (cardiac index > 4.0 1/min/m2). Vasodilatation was achieved with ketanserin (4 rag/ h). Oxygen delivery (DO2) and oxygen consumption (VO2) were calculated using the standard formulae. In addition the patient was heparinised (APTT 60-90 s). Total parenteral feeding was started. Second and third look laparotomies were performed after 16 and 48 h. The severely compromised venous circulation of the small intestine appeared to be significantly improved.

Introduction renal arteries. The proximal neck of the aneurysm was 24 mm long and 23 mm wide, without thrombus or Endoluminal repair of infrarenal aneurysms of the calcifications, and consequently fit for endovascular abdominal aorta is still controversial. Much unfixation (Fig. 2). Preoperative kidney function was certainty continues to exist about its proper application normal (urea: 5.5 mmol/l and creatinine: 91 lmol/l). and its success and reliability. The patient was operated on under epidural anWe report two cases with different types of anaesthesia. An AneuRx 26/15/165 aortoiliac stent graft eurysms of the infrarenal abdominal aorta, in which was placed transfemorally, followed by a 16/115 iliac there is, in our view, a clear preference for endoluminal contralateral leg and two iliac extensions of 15/55 right exclusion of the aneurysm. and 16/55 left (Medtronic AVE, California, U.S.A.). Occlusion time of the aorta was 5.5 minutes, fluoroscopy time was 27 min, blood loss was 200 ml, and skin-to-skin time was 105 min. The postoperative course was uneventful, except for Cases a grade I wound infection of the right groin. The abdominal aorta was not painful on palpation any A 56-year-old man presented with a 2-week history more. The patient was fully ambulatory the day after of a progressive pain in the back and abdomen. The surgery. Postoperative kidney function remained norpatient was known to have an infrarenal aneurysm of mal (urea: 6.3 mmol/l and creatinine: 128 lmol/l). CT the abdominal aorta (diameter 40 mm) and a horseshoe scan and duplex scanning of the abdomen, on diskidney. On physical examination, the aorta was paincharge (fifth postoperative day) and after 12 months, ful. Pulsations in the femoral arteries existed. The showed no evidence of endoleak and a normal (horseankle–brachial index was 1.01 at the right and 1.00 at shoe) kidney function (Fig. 1B). The aneurysm size the left side. Preoperative work-up consisted of a spiral was decreased to 43 mm. computed tomography (CT) scan and an intra-arterial An 83-year-old man, who had recovered from a abdominal angiogram and resulted in an aneurysm of pneumococcal sepsis 6 months ago, was referred to the abdominal aorta with a largest diameter of 49 mm, our hospital with an asymptomatic saccular aneurysm expanding in the common iliac arteries. There was no of the infrarenal abdominal aorta with a diameter of significant angulation of the aortic neck, or iliac ar55 mm. Preoperative work-up consisted of spiral CT teries. The inferior mesenteric artery was occluded scan and intra-arterial abdominal angiogram, which and both the internal iliac arteries were patent. Both resulted in a saccular aneurysm with a largest diameter renal arteries divide high up, next to the superior of 60 mm. On spiral CT there was no evidence of aorta mesenteric artery (Fig. 1A). There were no aberrant wall infection. The erythrocyte sedimentation rate (ESR) was 20 mm/h. Therefore, an active mycotic aneurysm was unlikely. The inferior mesenteric artery ∗ Please address all correspondence to: R. H. Geelkerken, Deas well as both the iliac arteries were patent. There partment of Vascular Surgery, Medisch Spectrum Twente, P.O. Box: 50 000, 7500 KA Enschede, The Netherlands. was no significant angulation of the aortic neck, or

Introduction entire vessel is imaged and the most optimal Doppler sample is assessed. The transducer is then repositioned Currently, duplex ultrasound (US) is the preferred in a transverse plane until the ‘‘seagull sign’’, representing both the common hepatic and splenic arteries diagnostic modality for the evaluation of obstructive disease of both the arterial and venous system of the in a single image, is obtained. Further adaptation of transducer and ultrasound beam is usually necessary extremities, the extracranial vessels, the aorta and the iliac vessels. However, the role of duplex US in the to obtain an angle of