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Concept: Femoral artery

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BACKGROUND: Iliac artery atherosclerotic disease may cause intermittent claudication and critical limb ischemia. It can lead to serious complications such as infection, amputation and even death. Revascularization relieves symptoms and prevents these complications. Historically, open surgical repair, in the form of endarterectomy or bypass, was used. Over the last decade, endovascular repair has become the first choice of treatment for iliac arterial occlusive disease. No definitive consensus has emerged about the best endovascular strategy and which type of stent, if any, to use. However, in more advanced disease, that is, long or multiple stenoses or occlusions, literature is most supportive of primary stenting with a balloon-expandable stent in the common iliac artery [1]. Recently, a PTFE-covered balloon-expandable stent (Advanta V12, Atrium Medical Inc., Hudson, NH, USA) has been introduced for the iliac artery. Covering stents with PTFE has been shown to lead to less neo-intimal hyperplasia and this might lower restenosis rates [2-4]. However, only one RCT, of mediocre quality has been published on this stent in the common iliac artery [5,6]. Our hypothesis is that covered balloon-expandable stents lead to better results when compared to uncovered balloon-expandable stents. METHODS: This is a prospective, randomized, controlled, double-blind, multi-center trial. The study population consists of human volunteers aged over 18 years, with symptomatic advanced atherosclerotic disease of the common iliac artery, defined as stenoses longer than 3 cm and occlusions. A total of 174 patients will be included.The control group will undergo endovascular dilatation or revascularization of the common iliac artery, followed by placement of one or more uncovered balloon-expandable stents. The study group will undergo the same treatment, however one or more PTFE-covered balloon-expandable stents will be placed. When necessary, the aorta, external iliac artery, common femoral artery, superficial femoral artery and deep femoral artery will be treated, using the standard treatment.The primary endpoint is absence of binary restenosis rate. Secondary endpoints are reocclusion rate, target-lesion revascularization rate, clinical success, procedural success, hemodynamic success, major amputation rate, complication rate and mortality rate. Main study parameters are age, gender, relevant co-morbidity, and several patient, disease and procedure-related parameters.Trial registrationDutch Trial Register, NTR3381.

Concepts: Atherosclerosis, Stent, Femoral artery, Arteries of the lower limb, External iliac artery, Internal iliac artery, Arteries of the abdomen, Common iliac artery

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Introduction: In this study the angiogenetic effect of sintered 45S5 Bioglass® was quantitatively assessed for the first time in the arteriovenous loop model. Materials and Methods: An arteriovenous loop was created by interposition of a venous graft from the contralateral side between the femoral artery and vein in the medial thigh of 8 rats. The loop was placed in a teflon isolation chamber and was embedded in a sintered 45S5 Bioglass® granula matrix filled with fibrin gel. Specimens were investigated three weeks postoperatively by means of micro-computed tomography, histological and morphometrical techniques. Results: All animals tolerated the operations well. At 3 weeks both, micro-computed tomography and histology demonstrated a dense network of newly formed vessels originating from the AV loop. All constructs were filled with cell-rich, highly vascularised connective tissue around the vascular axis. Analysis of vessel diameter revealed constant small vessel diameters indicating immature new vessel sprouts. Conclusion: This study shows for the first time axial vascularization of a sintered 45S5 Bioglass® granula matrix. After three weeks the newly generated vascular network already interfused most parts of the scaffolds and showed signs of immaturity. The intrinsic type of vascularisation allows transplantation of the entire construct using the AV loop pedicle.

Concepts: Blood, Blood vessel, Histology, Artery, Vein, Circle, Femoral artery, Deep vein

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OBJECTIVE: Endografts represent a relatively new treatment modality for occlusive disease of the superficial femoral artery, with promising results. However, endografts may occlude collateral arteries, which may affect outcome in case of failure. The purpose of this study was to analyze the clinical outcome of failed endografts in patients with superficial femoral artery occlusive disease. METHODS: All patients treated with one or more polytetrafluorethylene-covered stents between November 2001 and December 2011 were prospectively included in a database. Patients with a failure of the endograft were retrospectively analyzed. Clinical and hemodynamic parameters were assessed before the initial procedure and at the time of failure. Outcome of secondary procedures was analyzed. RESULTS: Among the 341 patients who were treated during the study period, 49 (14.4%) failed during follow-up. Mean (standard deviation) Rutherford category at failure did not differ from the category as scored before the initial procedure (3.1 [1.3] vs 3.3 [0.6]; P = .33). Forty-three percent of patients (n = 21) presented with the same Rutherford category as before the initial procedure, 37% (n = 18) with an improved category, and 20% (n = 10) with a deteriorated category. The ankle-brachial index was significantly lower at the time of failure (0.66 [0.19] vs 0.45 [0.19[; P <.002). Seventy-six percent of patients with a failure needed secondary surgery, of which 25% were below knee. The 1-year primary, primary-assisted, and secondary patency rates of secondary bypasses were 55.1%, 62.3%, and 77.7%, respectively. The amputation rate was 4.1% (n = 2). CONCLUSIONS: Failure of endografts is not associated with a deterioration in clinical state and is related to a low amputation rate. The hypothesis that covered stents do not affect options for secondary reconstructions could not be confirmed, as 25% of patients with a failure underwent a below-knee bypass. Secondary surgical bypasses are correlated with poor patency. The amputation rate after failure is low.

Concepts: Coronary artery bypass surgery, Femoral artery, Femoral vein, External iliac artery, Superficial iliac circumflex artery, Popliteal artery, Femoral triangle

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Venous catheters provide access for hemodialysis (HD) when patients do not have functioning access device. Obstruction of jugular, femoral or even external iliac vessels further depletes options. Subclavian approach is prohibited. Catheterization of inferior vena cava requires specialized equipment and skills.

Concepts: Central venous catheter, Femoral artery, External iliac artery, Inferior vena cava, Deep vein thrombosis, Deep vein, Superior vena cava, External iliac vein

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Objectives. To summarize available evidence regarding stent fracture in the femoropopliteal region. Methods. We searched PubMed, 2000-2011, using MeSH search terms “stents,” “popliteal artery,” and “femoral artery.” Results. We identified 29 original studies reporting 0% to 65% incidence of stent fracture. Fracture-related repeat revascularization could be avoided in the absence of device failure. Recently published data suggest that even a 5% rate of fracture-related reintervention would generate $118.4 million in health care cost in the United States. These excess procedures would also result in major complications and deaths that might have been avoided in the absence of stent fracture. Conclusions. Reported incidence and clinical relevance of femoropopliteal stent fractures vary across studies. Stent fracture may lead to repeat revascularization. These reinterventions create considerable-and potentially avoidable-economic burden for patients and payers. Further, these costs are effectively invisible wherever stent fractures are not systematically documented as the reason for reintervention.

Concepts: Pulse, Femoral artery, Popliteal artery

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Complex lesions within the femoro–popliteal vascular territory, amongst others, include more than 15cm long or heavily calcified occlusions of the superficial femoral artery (SFA) or total occlusions of the popliteal artery (PA). For those Type–C/–D lesions TASC–II recommendations originating from 2007 advocate bypass surgery as the therapy of choice if the patient is a suitable candidate for this. Against the background of evolving endovascular techniques which often allow recanalization of even long and calcified lesions as well as improved patency rates after endovascular treatment ofsuch complex lesions, many vascular specialists go for an endovascular–first approach for the treatment of challenging lesions, last but not least in those patients unfit for surgery or in those lacking an adequate conduit or distal target vessel segment. This review focuses on two important aspects of treating complex femoro–popliteal lesions by an endovascular approach. The first part covers techniques to pass a complex lesion with a guidewire, while the second discusses strategies to improve the outcome of the endovascular reconstruction in terms of patency and clinical success.

Concepts: Pulse, Coronary artery bypass surgery, Femoral artery, Femoral vein, Arteries of the lower limb, External iliac artery, Popliteal artery, Popliteal vein

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Two cases of compartment syndrome of the lower extremities occurring during surgery for gynecological malignancies are reported. In addition to the risk from being in the lithotomy position for over 4 h, these two cases were believed to have been caused by the combined use of a disposable wound retractor and abdominal retractors to secure the operative field. This conclusion is based on the fact that an abrupt increase in partial pressure of end-tidal CO2 (ETCO2) was observed when wound drapes and abdominal retractors were removed approximately 4 h after the start of surgery. Prolonged compression of the external iliac vein by a disposable wound retractor and abdominal retractors is believed to have induced congestion of the lower extremities, eventually resulting in compartment syndrome. To verify this, during subsequent surgeries of the same type, changes in the diameters of femoral arteries and veins when a disposable wound retractor and abdominal retractors were used were monitored using an ultrasound device, and the findings confirmed that changes in vascular diameter do occur.

Concepts: Vein, Femoral artery, Femoral vein, External iliac artery, Deep vein, Veins, Compartment syndrome, Lithotomy position

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To determine the predictors of restenosis, major adverse limb events (MALEs), postoperative death (POD), and all-cause mortality after repeat endovascular treatment of superficial femoral artery (SFA) restenosis.

Concepts: Femoral artery, Femoral vein, External iliac artery, Superficial iliac circumflex artery, Femoral triangle

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Iatrogenic pseudoaneurysms of the femoral artery lead to increased morbidity and mortality, especially when surgical treatment is necessary. Manual compression and thrombin injection are commonly used to occlude the pseudoaneurysms. However, in some cases these treatment options are inapplicable or unsuccessful. We introduce a novel technique to interventionally close pseudoaneurysms.

Concepts: Mortality rate, Intervention, Femoral artery, Femoral vein, External iliac artery, Superficial iliac circumflex artery, Femoral triangle, Art intervention