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OBJECTIVE: To assess whether level of arterial obstruction determines the effectiveness of SET in patients with IC.BACKGROUND DATA: Guidelines advocate SET before invasive treatment for IC, but early revascularization remains widespread, especially in patients with aortoiliac disease.METHODS: Patients were recruited from 10 Dutch centers between October 2017 and October 2018. Participants received SET first, followed by endovascular or open revascularization in case of insufficient effect. They were grouped according to level of stenosis (aortoiliac, femoropopliteal, multilevel, or rest group with no significant stenosis). Changes from baseline walking performance (maximal and functional walking distance on a treadmill test, 6-minute walk test) and vascular quality of life questionnaire-6 at 3 and 6 months were compared, after multivariate adjustment for possible confounders. Freedom from revascularization was estimated with Kaplan-Meier analysis.RESULTS: Some 267 patients were eligible for analysis (aortoiliac n = 70, 26%; femoropopliteal n = 115, 43%; multilevel n = 69, 26%; rest n = 13, 5%). No between group differences in walking performance or vascular quality of life questionnaire-6 were found. Mean improvement in maximal walking distance after 6 months was 439 m [99% confidence interval (CI) 297-581], 466 m (99% CI 359-574), 353 m (99% CI 210-496), and 403 m (99% CI 58-749), respectively (P = 0.40). Freedom from intervention was 73.9% for aortoiliac disease and 88.6% for femoropopliteal disease (hazard ratio 2.46, 99% CI 0.96 - 6.30, P = 0.013).CONCLUSIONS: Short-term effectiveness of SET for IC is not determined by the location of stenosis. Although aortoiliac disease patients improved walking performance and health-related quality of life similarly compared to other arterial disease level groups, they underwent revascularization more often.

Background: Patient reported outcome measures (PROMs) such as health status (HS) and quality of life (QOL) are frequently used interchangeably while they represent different outcomes. Whether a discrepancy exists in patients with intermittent claudication (IC) in changes over time between HS and QOL is unclear. This study aimed to investigate the strength and the direction of the association between HS and QOL over time in patients with IC that underwent supervised exercise therapy (SET).Material and methods: Patients were part of the ELECT multi-center prospective cohort study. One goal of this study was to obtain data on HS and QOL at different time intervals of patients with IC that underwent SET. HS (VascuQOL-6) and QOL (WHOQOL-BREF) were completed at baseline, 3 months, and 6 months follow up. Pearson's correlation coefficients and the associated common variances (R2) were calculated to measure the strength and the direction of the association between HS and QOL in changes between baseline and follow-up moments.Results: In total, 177 patients were included in data analyses. Only changes in physical QOL and overall QOL had a small correlation with changes over time in HS, at both 3- and 6 months follow up (respectively R2=.14; P < 0.001 and R2 = 0.12; P < 0.001 for physical QOL and R2 = 0.18; P < 0.001 and R2 = 0.13; P < 0.001 for overall QOL).Conclusions:This study showed that HS and QOL provide different outcomes in patients with IC that underwent SET. Future studies should be aware of these differences before PROMs are being incorporated as an outcome measure in clinical studies.

Background: Intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI) are both associated with a decreased health status and possibly quality of life (QOL). A better understanding of the differences in QOL between patients with IC and CLTI could be of additional value in shared decision-making. The aim of this study was to compare the QOL at baseline between patients with IC and patients with CLTI.Methods: The study population was based on 2 study cohorts, 1 cohort consisted of patients with IC (ELECT registry) and the other cohort of patients with CLTI (KOP-study). Patients with an age of ≥70 years were included. QOL at baseline was measured by the WHOQOL-BREF questionnaire. Nonresponders were excluded from data analyses. Student's t-tests and analysis of covariance (ANCOVA) analyses were used to compare QOL between the 2 groups. Outcomes of the ANCOVA analyses were expressed as estimated marginal means.Results: In total, 308 patients were included, 115 patients with IC and 193 patients with CLTI. Patients with CLTI were older (median age 80 years vs. 75 years, P < 0.001) and had more comorbidities. Patients with IC had a statistically significant higher QOL regarding physical health (mean 13.7 [standard deviation (SD) 2.3] vs. 10.8 [SD 2.8], P < 0.001), psychological health (mean 15.3 [SD 2.1] vs. 14.1 [SD 2.4], P < 0.001), environment (mean 16.3 [SD 2.4] vs. 15.5 [SD 2.0], P < 0.002), and the overall domain (mean 3.5 [SD 0.7] vs. 3.1 [SD 0.9], P < 0.001). After correcting for the confounding effect of age and sex, patients with IC still had a statistically significant higher QOL in the physical, psychological, environment, and overall domain.Conclusions: Patients with IC had a significantly higher QOL in the physical, psychological, environment, and overall domains of the WHOQOL-BREF questionnaire compared with patients with CLTI. This underlines the importance of strategies that reduce disease progression as disease progression is associated with a decrease in QOL.

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.

Objective/Background: The Dutch College of General Practitioners' guideline on peripheral arterial disease (PAD) provides clear recommendations on the management of PAD. An ankle brachial index (ABI) measurement, prescription of antiplatelet drugs and statins, and supervised exercise therapy (SET) for intermittent claudication (IC) are advised. The aims of this study were to determine the adherence of general practitioners (GPs) to their own guideline on PAD and to evaluate the reliability of primary care ABI measurements. Methods: This was a cross-sectional study. All patients suspected of having symptomatic PAD who were referred by GPs to a large hospital in 2015 were evaluated regarding three of the guideline criteria: (i) ABI measurement; (ii) prescription of secondary prevention; (iii) initiation of SET. ABI values obtained in primary care and the hospital's vascular laboratory were compared using correlation coefficients and regression analysis. An abnormal ABI was defined as a value =.9). Results: Of 308 potential patients with new onset PAD, 58% (n = 178) had undergone ABI measurement prior to referral. A modest correlation between ABI values obtained in primary care and the vascular laboratory was found (r = .63, p < .001). Furthermore, a moderate reliability was calculated (intraclass correlation coefficient 0.60, 95% confidence interval 0.49-0.69, p < .001). Of the new patients with an abnormal ABI, 59% used antiplatelet drugs and 55% used statins. A referral for SET was initiated by a GP in 10% of new PAD patients with IC symptoms. Conclusions: Adherence by Dutch GPs to their own society's PAD guideline has room for improvement. The reliability of ABI measurements is suboptimal, whereas rates of prescription of secondary prevention and initiation of SET as primary treatment for IC need upgrading. (C) 2018 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

IntroductionDespite guideline recommendations advocating conservative management before invasive treatment in intermittent claudication, early revascularisation remains widespread in patients with favourable anatomy. The aim of the Effect of Disease Level on Outcomes of Supervised Exercise in Intermittent Claudication Registry is to determine the effect of the location of stenosis on the outcomes of supervised exercise in patients with intermittent claudication due to peripheral arterial disease.Methods and analysisThis multicentre prospective cohort study aims to enrol 320 patients in 10 vascular centres across the Netherlands. All patients diagnosed with intermittent claudication (peripheral arterial disease: Fontaine II/Rutherford 1–3), who are considered candidates for supervised exercise therapy by their own physicians are appropriate to participate. Participants will receive standard care, meaning supervised exercise therapy first, with endovascular or open revascularisation in case of insufficient effect (at the discretion of patient and vascular surgeon). For the primary objectives, patients are grouped according to anatomical characteristics of disease (aortoiliac, femoropopliteal or multilevel disease) as apparent on the preferred imaging modality in the participating centre (either duplex, CT angiography or magnetic resonance angiography). Changes in walking performance (treadmill tests, 6 min walk test) and quality of life (QoL; Vascular QoL Questionnaire-6, WHO QoL Questionnaire-Bref) will be compared between groups, after multivariate adjustment for possible confounders. Freedom from revascularisation and major adverse cardiovascular disease events, and attainment of the treatment goal between anatomical groups will be compared using Kaplan-Meier survival curves.Ethics and disseminationThis study has been exempted from formal medical ethical approval by the Medical Research Ethics Committees United ‘MEC-U’ (W17.071). Results are intended for publication in peer-reviewed journals and for presentation to stakeholders nationally and internationally.Trial registration numberNTR7332; Pre-results.

Background A hybrid operating theater (HOT) enables optimal image quality, improved ergonomics, and excellent sterility for complex endovascular and hybrid procedures. We hypothesize that the commissioning of a new HOT involves a learning curve. It is unclear how steep the learning curve of these advanced HOTs is. The main purpose of this research was to evaluate radiation exposure parameters in a new HOT for a team of vascular surgeons experienced with infrarenal endovascular aneurysm repair (EVAR) procedures in a conventional operating room with a mobile C-arm. In addition, a comparison of the dose-area product (DAP) achieved in this study and in the literature was made. Methods Before commissioning of the HOT, four vascular surgeons completed a comprehensive HOT training program. From the commissioning of the HOT, clinical and procedural data for all consecutive acute and elective patients treated with EVAR were retrospectively collected for a period of 18 months (January 2016-June 2017). A literature review was conducted of the dose-area product in EVAR procedures performed with a dedicated fixed system or mobile C-arm to analyze how this study performed compared with the literature. Results In the 18-month study period, 77 patients were treated with EVAR (59 electively and 18 acutely), from whom the data were obtained. There was no significant change in radiation exposure parameters over time. From the commissioning of the HOT, EVAR procedures were performed with radiation exposure parameters similar to those of studies found in experienced vascular centers using fixed systems. Conclusions Concerning radiation exposure parameters, the commissioning of a new HOT was not accompanied by a learning curve. Radiation exposure parameters achieved in this study were similar to those of studies from experienced and dedicated vascular centers.

Objectives: The impact of postoperative complications after Major Abdominal Surgery (MAS) is substantial, especially when socio-economical aspects are taken into account. This systematic review focuses on the effects of preoperative exercise therapy (PEXT) on physical fitness prior to MAS, length of hospital admission and postoperative complications in patients eligible for MAS, and on what is known about the most effective kind of exercise regime. Methods: A systematic search identified randomised controlled trials on exercise therapy and pulmonary physiotherapy prior to MAS. The methodological quality of the included studies was rated using the 'Delphi List For Quality Assessment of Randomised Clinical Trials'. The level of agreement between the two reviewers was estimated with Cohen's kappa. Results: A total of 6 studies were included, whose methodological quality ranged from moderate to good. Cohen's kappa was 0.90. Three studies reported on improving physical fitness prior to MAS with the aid of PEXT. Two studies reported on the effect of training on postoperative complications, showing contradictory results. Three studies focused on the effect of preoperative chest physiotherapy on postoperative lung function parameters after MAS. While the effects seem positive, the optimal training regime is still unclear. Conclusion: Preoperative exercise therapy might be effective in improving the physical fitness of patients prior to major abdominal surgery, and preoperative chest physiotherapy seems effective in reducing pulmonary complications. However consensus on training method is lacking. Future research should focus on the method and effect of PEXT before high-risk surgical procedures. (C) 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

The aim of the paper is to prospectively describe early and mid-term outcomes for emergency endovascular aneurysm repair (eEVAR) versus open surgery in acute abdominal aortic aneurysms (aAAAs), both unruptured (symptomatic) and ruptured. We enrolled all consecutive patients treated for aAAA at our center between April 2002 and April 2008. The main outcome parameters were 30-day, 6- and 12-month mortality (all-cause and aneurysm-related). Two hundred forty patients were enrolled in the study. In the unruptured aAAA group ( n = 111), 47 (42%) underwent eEVAR. The 30-day, 6- and 12-month mortality rates were 6, 13 and 15% in the eEVAR group versus 11% (NS), 13% (NS) and 16% (NS) in the open group, respectively. In the ruptured aAAA group ( n = 129), 25 (19%) underwent eEVAR (mortality rates: 20, 28 and 36%, respectively) compared with 104 (81%) patients who underwent open surgery (mortality rates: 45% ( P = 0.021), 60% ( P = 0.004) and 63% ( P = 0.014), respectively). In conclusion, the present study showed a reduced 30-day, 6- and 12-month mortality of eEVAR compared with open surgery in all patients with aAAA, mainly due to a lower mortality in the ruptured aAAA group. Late aneurysm-related mortality occurred only in the eEVAR group.

Objective The reported mortality reduction of emergency endovascular aneurysm repair (eEVAR) compared with open repair in patients with a ruptured abdominal aortic aneurysm (rAAA), as observed in observational studies, might be flawed by selection bias based on anatomical suitability for eEVAR. In the present study, we compared mortality in EVAR suitable versus non-EVAR-suitable patients with a ruptured AAA who were all treated with conventional open repair. Materials and Methods In all patients presenting with a suspected rAAA, computed tomography angiography (CTA) scanning was performed. All consecutive patients with a confirmed rAAA on preoperative CTA scan and treated with open repair between April 2002 and April 2008 were included. Anatomical suitability for eEVAR was determined by two blinded independent reviewers. Outcomes evaluated were mortality (intra-operative, 30-day, and 6-month), morbidity, complications requiring re-intervention and length of hospital stay. Results A total of 107 consecutive patients presented with a rAAA and underwent preoperative CTA scanning. In 25 patients, eEVAR was performed. In the 82 patients who underwent open repair, CTA showed an EVAR-suitable rAAA in 33 patients (41.8%) and a non-EVAR-suitable rAAA in 49 patients. Thirty-day and 6-month mortality rate was 15/33 (45.5%; 95% confidence interval (CI) 28.1–63.7) and 18/33 (54.5%; 95% CI 36.4–71.9) in the EVAR-suitable group versus 24/49 (49.0%; 95% CI 34.4–63.7) (P = 0.75) and 29/49 (59.2%; 95% CI 44.2–73.0) (P = 0.68) in the non-EVAR-suitable group, respectively. Conclusions The present study suggests that anatomical suitability for EVAR is not associated with lower early and midterm mortality in patients treated with open ruptured AAA repair. Therefore, the reported reduction in mortality between eEVAR and open repair is unlikely due to selection bias based on anatomical AAA configuration.

Measurement of the ankle—brachial index (ABI) can provide important information about the presence of subclinical atherosclerosis. Performing the ABI in the overall population is not feasible, but it can be used in a selected population. A simple prediction rule could be of much use to estimate the risk of an abnormal ABI. This was designed as an observational study in the setting of 955 general practices in The Netherlands. A total of 7454 patients aged ≥ 55 years presenting with at least one vascular risk factor (smoking, hypertension, diabetes, and hypercholesterolemia) and no complaints of intermittent claudication were included. Patients were selected by the general practitioner during visiting hours and from medical records. Main outcome measures included the prevalence of PAD, defined as an ABI below 0.9, which was related to vascular risk factors using regression analyses on which the PREVALENT clinical prediction model was developed. The overall prevalence of PAD was 18.4%. Since the treatment of individuals with a history of coronary heart disease and cerebrovascular disease will not be influenced by the finding of asymptomatic PAD, these individuals were not taken into account for the development of the clinical prediction model. Analyses showed a significantly increased risk for PAD with increasing age, smoking, and hypertension. The clinical prediction model giving risk factor points per factor (age: 1 point per 5 years starting at 55 years; ever smoked: 2 points; currently smoking: 7 points; and hypertension: 3 points), showed a proportional increase of the PAD prevalence with each increasing risk profile (range: 7.0—40.6%). In conclusion, based on the PREVALENT clinical prediction model, the general practitioner is able to identify a high-risk population in which measurement of ABI is useful.

Objective Many studies have been published regarding the influence of smoking on the incidence and prevalence of peripheral arterial disease (PAD). A systematic review was performed to establish the magnitude of the effect of smoking on the development of PAD, and a possible dose-response relationship. Methods English-language articles were reviewed by 2 observers using a standardized form, and were summarized in tabular form. Data were extracted by 2 independent observers. Where possible, outcome data, expressed in terms of prevalence or incidence, were recalculated as odds ratio or relative risk, with never-smokers as the reference group, or if this was not available the nonsmoker group. Most studies did not provide primary data. Therefore the weighted means were reported as a summary estimate, provided that a funnel plot between sample size and observed effect size made publication bias unlikely. Results Sixteen articles describing 17 studies were included in the analysis. Four of the studies were prospective, and 13 were cross-sectional. The prevalence of symptomatic PAD was increased 2.3-fold in current smokers. Even in former smokers the prevalence was substantially increased by a factor of 2.6. A clear dose-response relationship, with a strong increase in risk for PAD in heavy smokers was observed. In countries where approximately 30% of the population are smokers, 50% of PAD can be attributed to smoking. Conclusions Smoking is a potent risk factor for symptomatic PAD, with an important and consistent dose-response relationship. With the persistence of high risk for PAD in former smokers, tobacco control programs should continue to advocate smoking cessation, but focus even more on preventing future generations from ever starting to smoke.

Objective/background The impact of post-operative complications in abdominal aortic aneurysm (AAA) surgery is substantial, and increases with age and concomitant co-morbidities. This systematic review focuses on the possible effects of pre-operative exercise therapy (PET) in patients with AAA on post-operative complications, aerobic capacity, physical fitness, and recovery. Methods A systematic search on PET prior to AAA surgery was conducted. The methodological quality of the included studies was rated using the Physiotherapy Evidence Database scale. The agreement between the reviewers was assessed with Cohen's kappa. Results Five studies were included, with a methodological quality ranging from moderate to good. Cohen's kappa was 0.79. Three studies focused on patients with an AAA (without indication for surgical repair) with physical fitness as the outcome measure. One study focused on PET in patients awaiting AAA surgery and one study focused on the effects of PET on post-operative complications, length of stay, and recovery. Conclusion PET has beneficial effects on various physical fitness variables of patients with an AAA. Whether this leads to less complications or faster recovery remains unclear. In view of the large impact of post-operative complications, it is valuable to explore the possible benefits of a PET program in AAA surgery.

Purpose To give an overview of the etiology and diagnostic process of superficial temporal artery pseudoaneurysms and to evaluate different treatment modalities. Basic methods PubMed was used for searching multiple databases for relevant clinical studies. Principal findings A total of 62 studies were included, harboring 82 patients. Surgical excision is the most frequently described treatment, but less invasive treatment modalities as coiling and thrombin injections are gaining popularity. Surgical treatment was successful in all cases (67/67). Endovascular treatment was successful in 69% (9/13); the five cases treated with thrombin injection were all successful. Complementary, a description of our experience with thrombin injection is given. Conclusions Limited evidence of minimal invasive treatment for superficial temporal artery pseudoaneurysm is available. Based on this review combined with our limited experience, we suggest thrombin injections to be considered as the future primary treatment modality. In the case of unsuccessful exclusion of the aneurysm, surgical excision can be performed.

Introduction Sudden thrombosis of an abdominal aortic aneurysm is a rare condition with a high mortality rate. Report We present a patient with acute neurological deficits in both legs based on a thrombosis of a nine centimetre infrarenal abdominal aortic aneurysm. Successful iliac thrombectomy with aortic tube graft reconstruction was performed. Discussion Sudden thrombosis of an abdominal aortic aneurysm is a rare condition, but should be taken into consideration in patients with acute neurological deficits of the lower extremities. Prompt diagnosis and surgical management can lead to a successful outcome. A review of the literature is presented.

Objectives. To improve the use of the ankle-brachial index (ABI) measurement, and management of patients with peripheral arterial disease (PAD) a combined training, targeting GPs and practice assistants (PAs) was developed. To measure the effect of the combined training on the management of patients with PAD, a cross-sectional study was performed. Methods. Fifty consecutive patients referred by GPs to a vascular surgery out-patient clinic were analysed. Six months after the training an additional fifty patients were included. In all patients the ABI measurement, risk factor management, and treatment as performed by the GP, prior to referral, were analysed. Results. The measurement of the ABI significantly increased from 10% before the training to 53% after the training (GPs with training: 83%, GPs without training: 35%; P: 0.001). The referral of patients with actual PAD significantly increased from 32% before the training to 70% after the training (GPs with training: 83%, GPs without training: 59%; P: 0.05). The presence and treatment of risk factors did not differ between the groups. Conclusions. Within the limitations of a before and after study the combined training of GPs and PAs appears to be an effective method to increase ABI measurements and significantly improve adequate diagnostics

Background Although supervised exercise therapy is considered to be of significant benefit for people with leg pain (peripheral arterial disease (PAD)), implementing supervised exercise programs (SETs) in daily practice has limitations. This is an update of a review first published in 2006. Objectives The main objective of this review was to provide an accurate overview of studies evaluating the effects of supervised versus non-supervised exercise therapy on maximal walking time or distance on a treadmill for people with intermittent claudication. Search methods For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched September 2012) and CENTRAL (2012, Issue 9). In addition, we handsearched the reference lists of relevant articles for additional trials. No restriction was applied to language of publication. Selection criteria Randomized clinical trials comparing supervised exercise programs with non-supervised exercise programs (defined as walking advice or a structural home-based exercise program) for people with intermittent claudication. Studies with control groups, which did not receive exercise or walking advice or received usual care (maintained normal physical activity), were excluded. Data collection and analysis Two review authors (HJPF and BLWB) independently selected trials and extracted data. Three review authors (HJPF, BLWB, and GJL) assessed trial quality, and this was confirmed by two other review authors (MHP and JAWT). For all continuous outcomes, we extracted the number of participants, the mean differences, and the standard deviation. The 36-Item Short Form Health Survey (SF-36) outcomes were extracted to assess quality of life. Effect sizes were calculated as the difference in treatment normalized with the standard deviation (standardized mean difference) using a fixed-effect model. Main results A total of 14 studies involving a total of 1002 male and female participants with PAD were included in this review. Follow-up ranged from six weeks to 12 months. In general, supervised exercise regimens consisted of three exercise sessions per week. All trials used a treadmill walking test as one of the outcome measures. The overall quality of the included trials was moderate to good, although some trials were small with respect to the number of participants, ranging from 20 to 304. Supervised exercise therapy (SET) showed statistically significant improvement in maximal treadmill walking distance compared with non-supervised exercise therapy regimens, with an overall effect size of 0.69 (95% confidence interval (CI) 0.51 to 0.86) and 0.48 (95% CI 0.32 to 0.64) at three and six months, respectively. This translates to an increase in walking distance of approximately 180 meters that favored the supervised group. SET was still beneficial for maximal and pain-free walking distances at 12 months, but it did not have a significant effect on quality of life parameters. Authors' conclusions SET has statistically significant benefit on treadmill walking distance (maximal and pain-free) compared with non-supervised regimens. However, the clinical relevance of this has not been demonstrated definitively; additional studies are required that focus on quality of life or other disease-specific functional outcomes, such as walking behavior, patient satisfaction, costs, and long-term follow-up. Professionals in the vascular field should make SET available for all patients with intermittent claudication.

Objectives We retrospectively analysed the results of a strategy in which coverage of the internal iliac artery (IIA) during endovascular aneurysm repair (EVAR) was routinely performed without coil embolisation. Methods From January 2010 until May 2012, 32 patients (96.9% men; mean age 73.0 years, range 52–89 years) underwent EVAR with stent grafts extended into the external iliac artery (EIA), all without prior coil embolisation. Aneurysm morphology was determined on preoperative computed tomography (CT) images. During follow-up, patients were interviewed about buttock claudication, and the occurrence of endoleaks and evolution of aneurysm diameter were recorded. Results At baseline, the mid-common iliac artery (CIA) diameter was 33.5 ± 16.8 mm and seven patients presented with ruptured aneurysms. Mean follow-up was 14.3 ± 7.4 months. There were eight deaths, none related to IIA coverage. Buttock claudication occurred in seven (22.6%) patients, which persisted after 6 months in two cases of bilateral IIA coverage. No Type-I or -II endoleaks occurred related to IIA coverage. Aneurysm growth was not observed. Conclusion Endovascular treatment of aortoiliac and iliac aneurysm without pre-emptive coil embolisation of the IIA appears safe and effective. No IIA-related endoleaks or re-interventions occurred in our series. This approach saves operating time, contrast load and costs and may reduce complications. However, a larger population and longer follow-up is required to confirm our findings.

Intermittent claudication (IC) has a high prevalence in the older population and is closely associated with cardiovascular and cerebrovascular disease. High mortality rates are reported due to ongoing atherosclerotic disease. Because of these serious health risks, treatment of IC should address reduction of cardiovascular events (and related morbidity/mortality) and improvement of the poor health-related quality of life (QoL) and functional capacity. In several randomized clinical trials and systematic reviews, supervised exercise therapy (SET) is compared with non-supervised exercise, usual care, placebo, walking advice or vascular interventions. The current evidence supports SET as the primary treatment for IC. SET improves maximum walking distance and health-related QoL with a marginal risk of co-morbidity or mortality. This is also illustrated in contemporary international guidelines. Community-based SET appears to be at least as efficacious as programs provided in a clinical setting. In the Netherlands, a national integrated care network (ClaudicatioNet) providing specialized care for patients with IC is currently being implemented. Besides providing a standardized form of SET, the specialized physical therapists stimulate medication compliance and perform lifestyle coaching. Future research should focus on the influence of co-morbidities on prognosis and effect of SET outcome and the potential beneficial effects of SET combined with a vascular intervention.

Background Screening with ankle-brachial index (ABI) measurement could be clinically relevant to avoid cardiovascular events in subjects with asymptomatic atherosclerosis. To assess the practical impact of guidelines regarding the use of ABI as a screening tool in general practice, the corresponding number needed to screen, including the required time investment, and the feasibility of ABI performance, was assessed. Methods An observational study was performed in the setting of 955 general practices in the Netherlands. Overall, 13,038 subjects of ≥55 years presenting with symptoms of intermittent claudication and/or presenting with ≥ one vascular risk factor were included. Several guidelines recommend the ABI as an additional measurement in selected populations for risk assessment for cardiovascular morbidity. Results Screening of the overall population of ≥50 years results in ≈862 subjects per general practice who should be screened, resulting in a time-requirement of approximately 6 weeks of full time work. Using an existing clinical prediction model, 247 patients per general practice should be screened for PAD by ABI measurement. Conclusion Screening the entire population of ≥50 years will in our opinion not be feasible in general practice. A more rationale and efficient approach might be screening of subsets of the population of ≥55 years based on a clinical prediction model.

The incidence of Abdominal Aortic Aneurysms (AAA) has persistently increased over the past decades (Best et al., 2003). This is partly attributed to increased ageing of the population, improved diagnostic tools and the introduction of screening programmes (Sakalihasan et al., 2005). To date, AAAs are responsible for 1.3% of all deaths among men aged between 65-85 years in developed countries (Sakalihasan et al., 2005). This percentage is probably even higher due to underestimation of AAA related mortality, since AAAs generally exist without symptoms (Acosta et al., 2006). In patients with an identified AAA and abdominal and/or back pain in combination with pain at palpation of the aneurysm (a so called symptomatic AAA), pending rupture of the AAA is assumed. However, evidence for a symptomatic AAA representing pending rupture is lacking (Scott et al., 2005). When rupture occurs, the mortality rate is as high as 80% (Semmens et al., 2000; Veith et al., 2003; Gorham et al., 2004). Forty percent of the patients with a ruptured AAA do not reach the hospital alive (Semmens et al., 2000) and in patients reaching the hospital and undergoing surgery, the mortality rate is approximately 50% (Sayers et al., 1997). Despite progression in surgical techniques, anaesthetical management, vascular prostheses and perioperative care, there is only a gradual decline in operative mortality rate over the past decades (Heller et al., 2000; Bown et al., 2002). In 1991, a new minimally invasive technique was described by Parodi et al. to treat AAA, endovascular aneurysm repair (EVAR) (Parodi et al., 1991). In the elective setting, EVAR showed an absolute and relative mortality risk reduction of approximately 3 and 75%, respectively (Prinssen et al., 2004; EVAR-trial-participants 2005). In the acute setting, emergency EVAR (eEVAR) is a strategy that might allow for improvement in above mentioned poor prognosis. Since 1994 an increasing amount of publications of eEVAR to treat acute AAAs is published. Currently, eEVAR has become an accepted treatment option which is increasingly being performed to treat acute AAA. However, the potential reduction in peri-operative mortality of eEVAR compared to conventional open repair in patients with an acute AAA is still open to debate. in this chapter, we will discuss the role of endovascular AAA repair in patients with a ruptured AAA.

Background Disease severity and functional impairment in patients with intermittent claudication is usually quantified by the measurement of pain-free walking distance (intermittent claudication distance, ICD) and maximal walking distance (absolute claudication distance, ACD). However, the distance at which a patient would prefer to stop because of claudication pain seems a definition that is more correspondent with the actual daily life walking distance. We conducted a study in which the distance a patient prefers to stop was defined as the functional claudication distance (FCD), and estimated the reliability and validity of this measurement. Methods In this clinical validity study we included patients with intermittent claudication, following a supervised exercise therapy program. The first study part consisted of two standardised treadmill tests. During each test ICD, FCD and ACD were determined. Primary endpoint was the reliability as represented by the calculated intra-class correlation coefficients. In the second study part patients performed a standardised treadmill test and filled out the Rand-36 questionnaire. Spearman's rho was calculated to assess validity. Results The intra-class correlation coefficients of ICD, FCD and ACD were 0.940, 0.959, and 0.975 respectively. FCD correlated significantly with five out of nine domains, namely physical function (rho = 0.571), physical role (rho = 0.532), vitality (rho = 0.416), pain (rho = 0.416) and health change (rho = 0.414). Conclusion FCD is a reliable and valid measurement for determining functional capacity in trained patients with intermittent claudication. Furthermore it seems that FCD better reflects the actual functional impairment. In future studies, FCD could be used alongside ICD and ACD.

Objective. Smoking is the major risk factor associated with the development and progression of peripheral arterial disease (PAD). To establish the best estimate of the effect of smoking, smoking cessation, and the dose-response relationship on the patency of lower extremity bypass grafts, we performed a systematic review. Methods. A search of medical articles and reviews relating to the influence of smoking on the patency of arterial reconstructive grafts in patients with PAD was made. Studies considered for inclusion were those that evaluated the influence of smoking on the primary, secondary, or cumulative patency rates of arterial reconstructive surgery in the lower extremities in patients with PAD. Primary data were used to calculate summary estimates with standard meta-analysis techniques. Results. The 29 eligible studies included 4 randomized clinical trials, 12 prospective studies', and 13 retrospective studies. The effect of smoking on graft patency in the randomized clinical trials and other prospective studies had a 3.09-fold (2.34 to 4.08; P

Background Exercise therapy (ET) is the main conservative and proven effective treatment of patients with intermittent claudication. Currently, the most frequent exercise prescription is a single 'go home and walk' advise, without supervision or follow-up. There is no evidence to support the efficacy of this advise and compliance is known to be low. Therefore, a systematic approach was used to guarantee quality and standardisation of treatment, optimal guideline adherence and improved of inter-professional communication between vascular surgeons and physiotherapists. In this preliminary report we would like to outline the steps taken for the development and implementation of the Network Exercise Therapy Parkstad Methods In October 2003 all 59 regional physiotherapy practices were invited to attend a symposium regarding ET in a physiotherapeutic setting. Attending physiotherapists interested in providing ET and willing to follow a certified course on ET, were asked to register. Three tastkgroups were formed to accomplish the set targets: Exercise therapy education, Exercise therapy implementation and continuity, and Inter-professional communication in the Parkstad region. Results In total 27 physiotherapists, from 22 different practices followed the educational program and are now trained and accredited to provide ET according to the guideline of the Royal Dutch Society for Physiotherapy. A web-based database wasdesigned to contain information on disease specific items provided by the vascular surgery department, and aspects with respect to ET registered by the physiotherapist. The information is regularly updated and available online. Access tothe database is restricted to vascular surgeons and physiotherapists in the network. The secondary purpose of the database is to register essential benchmark data for future analysis of ET in a physiotherapeutic setting in the Netherlands and to enable physiotherapists continuous feedback on patient performance. A triage system was developed to detect patients with a compromised cardiac history. This group receives ET at the in-hospital department of revalidation with the possibility of immediate consultation of a cardiologist in case of cardiac complications or even CPR. Conclusion The Network Exercise Therapy Parkstad of supervised ET is the first initiative in the Netherlands to provide ET close to the patient's home environment. With the implementation of supervised ET in an outpatient physiotherapeutic setting for all eligible patients with symptomatic PAD, the access to care has been improved. A web-based communication system provides physiotherapists and vascular surgeons with all the necessary and continues updated patient information. Future research, currently in progress, will investigate the therapeutic benefits and cost-effectiveness of exercise therapy in a physiotherapeutic setting.

Objective. To determine critical issues for future awareness programmes on peripheral arterial disease (PAD).Design. National Dutch survey.Materials and methods. A representative sample of 1294 members of the general population, and 281 patients with PAD from the Capi@home database were administered a questionnaire concerning awareness of PAD.Results. The response rate was 81% for the general population and 78% for patients with PAD. The familiarity with PAD terminology and symptoms amongst the general population was low. Few patients (20%) were aware that PAD was a disease of arteries. Amongst both the general population and the patient populations, PAD risk factors identification was low: hypertension (4% versus 0%); hypercholesterolaemia (9% versus 12%), diabetes (2% versus 8%), and smoking (27% versus 52%). Knowledge was moderate in both populations about treatment with exercise, but low for smoking cessation. The general population was unaware of the central role of general practitioners in the treatment of PAD.Conclusions. The awareness of symptoms, risk factors, and treatment options for PAD is low. Both population and patients needed only minimal information to relate PAD to other atherosclerotic diseases. Based on the results of this survey the Dutch Platform of Peripheral Arterial Disease together with the Dutch Heart Foundation are initiating the first awareness campaign on atherosclerosis.