Duplex Examination Research Articles

Inflammatory markers in patients with internal carotid artery stenosis.

IntroductionAvailable reports underline the significance of the inflammatory process in the development, progression and destabilisation of atherosclerotic plaques in the internal carotid artery (ICA). The aim of this study was to evaluate the relationship between the degree of ICA stenosis, ultrasound plaque morphology and serum concentration of selected inflammatory markers.Material and methodsSixty-five patients with ICA stenosis > 50% (39 symptomatic) and 30 healthy volunteers were enrolled in the study. Clinical, neurological examination and laboratory evaluation (leucocyte count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), fibrinogen, tumour necrosis factor-α (TNF-α), interleukins (1β, 6 and 10), anti-cytomegalovirus IgG antibody titre) were performed. Stenosis grade ≥ 70%, ulcerations on the plaque surface and a hypoechoic (or predominantly hypoechoic) structure of the plaque, obtained by colour-coded duplex examination, were accepted as the characteristics of unstable stenoses.ResultsUnstable ultrasound features of ICA stenosis were found significantly more often in symptomatic than in asymptomatic patients (71.79% vs. 30.71% for stenosis degree ≥ 70%, p = 0.001 and 61.23% vs. 38.46% for unstable plaque morphology, p = 0.01). Patients with ICA stenosis had significantly higher serum concentrations of interleukin-6, fibrinogen, ESR and higher CRP values than the individuals from the control group (p = 0.001, p = 0.009, p = 0.036, p = 0.009 respectively). Patients with unstable plaques structure had significantly higher concentrations of TNF-α, interleukin-6, fibrinogen, higher number of leukocytes, monocytes and higher CRP values than patients with stable plaques (p = 0.008, p = 0.049, p = 0.012, p = 0.0002, p = 0.006, p = 0.0003 respectively). No significant differences in above-mentioned parameters between the groups with stenosis < 70% and ≥ 70% were found.ConclusionsThere is a relationship between the activity of the selected inflammatory markers in serum and atherosclerotic unstable internal carotid artery stenosis. There is no relationship between serum concentration of inflammatory markers and degree of carotid artery stenosis.

Pelvic Venous Reflux is a Major Contributory Cause of Recurrent Varicose Veins in more than a Quarter of Women.

Background Leg varicose veins are associated with pelvic venous reflux in approximately 20% of women who have had children. However, most venous units do not routinely look for pelvic venous reflux or treat it. We aimed to investigate what proportion of patients with recurrent varicose veins and a history of open surgery have pelvic venous reflux as a major contributing cause of their recurrence. Methods A retrospective study was performed of all patients referred in the previous year with recurrent varicose veins or venous reflux disease who had previously had open surgery performed elsewhere. All patients had routine lower limb venous duplex ultrasonography, and those found to have reflux of pelvic origin underwent transvaginal duplex ultrasonography. Each case was assessed by a consultant vascular surgeon, and the major cause (or causes, if more than one) of the recurrent varicose veins was noted. Results A total of 109 patients with recurrent varicose veins in 172 legs were analyzed (mean age, 53.9 years; female-to-male ratio, 97:12). Patients were divided into four groups: group 1, all patients; group 2, female patients; group 3, female patients with children; and group 4, female patients with children who had not had hysterectomy. Pelvic venous reflux was found to be a major contributing cause of recurrent varicose veins in 44 of 172 legs (25.6%). This rose to 43 of 154 legs (27.9%) in group 2, 40 of 131 legs (30.5%) in group 3, and 37 of 111 legs (33.3%) in group 4. Conclusions Pelvic venous reflux is a major contributing cause of recurrent varicose veins after open surgery that has rarely been reported previously. In view of this finding, we suggest that a duplex ultrasound protocol, incorporating a transvaginal duplex examination of the ovarian and internal iliac veins, be adopted for the investigation of pelvic venous reflux in female patients presenting with symptomatic leg varicose veins with duplex-observed reflux entering the leg vein pattern from the pelvis. In the event that it is found, we suggest that treatment and resolution of this source of venous reflux be considered before any intervention for the leg varicose veins, surgical or otherwise.

Massive Vertebral Destruction Associated With Chronic Rupture of Infrarenal Aortic Aneurysm

Case report and review of literature. To highlight the specific features of a rare, life-threatening, clinical picture. Vertebral erosion (VE) is rarely associated with contained rupture of an abdominal aortic aneurysm. The involvement of radicular nerves can mimic a discus hernia syndrome; eventually vertebral erosion induces isolated lower back pain. These features often lead to a delayed or wrong diagnosis of a life-threatening condition. Forty-two complete similar case reports have been published in the English literature since 1962. The most prevalent symptoms are low back pain and neurological signs due to compression of radicular nerves. A 73-year-old man presented to Vascular Surgery department complaining of continuous pain in the lumbar region during the previous 6 months. The duplex examination revealed a huge infrarenal aortic aneurysm with an undefined posterior wall. Spiral CT and MR scan confirmed the aneurysm and a scalloping of the second and third lumbar vertebral bodies. A double-team intervention, vascular and orthopedic, consisted in aneurysm graft replacement; vertebral bodies excision and anterior and posterior spinal stabilization. Postoperatively the patient experienced reversible respiratory and renal failure and was discharged home in good health after 30 days. The presence of aortic abdominal aneurysm is always to be considered in the evaluation of an elderly patient complaining lower back pain or lower limb neuropathy of recent onset, especially in the presence of a degenerative process of the spine.

Perioperative Arteriovenous Fistula and Pseudoaneurysm After Plantar Fascia Release: Diagnosis and Intervention

Acquired arteriovenous fistulas are historically attributed to penetrating injuries, most commonly to the extremities. However, iatrogenic arteriovenous fistulas are becoming more prevalent. We discuss the case of a patient presenting with an acquired arteriovenous fistula and pseudoaneurysm after a plantar fascia release of the foot. A healthy 50-year-old white man presented with a 6-month history of swelling, numbness, and pain in his right foot. The patient previously underwent right foot surgery for recurrent, severe plantar fasciitis. Postoperatively, he underwent two hematoma drainage attempts in the office, each time aspirating syringes of blood without resolution of symptoms and recurrent swelling. He subsequently presented to vascular surgery for evaluation. On physical examination, a bruit was auscultated on the medial plantar aspect of the right foot. In addition, the foot demonstrated signs of swelling and venous congestion. An arterial duplex revealed a large pseudoaneurysm (Fig 1, Fig 2). The patient was subsequently scheduled for an arteriogram and intervention. The arteriogram revealed a pseudoaneurysm and arteriovenous fistula, which correlated with the duplex examination. The plantar branch of the posterior tibial artery containing the abnormality was selected with a 0.018-inch catheter. Coil embolization of the feeding artery was performed in combination with direct thrombin injections under ultrasound guidance. At the end of the procedure, minimal flow was demonstrated and the foot was wrapped with a pressure dressing.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) The patient was seen back on postoperative day 5 with a repeat duplex. The right foot duplex revealed no evidence of residual flow within the pseudoaneurysm. The patient reports he is ambulating without difficulty, and the swelling, numbness, and pain have resolved. He was released to perform normal activity. Traditional treatment of acquired arteriovenous fistula requires open operative repair. More commonly, an endovascular approach can be safe and effective in the treatment of acquired arteriovenous fistulas and pseudoaneurysms involving the foot.

Alterations of baroreflex sensitivity after carotid endarterectomy according to the preoperative carotid plaque echogenicity

Baroreflex sensitivity is lower in patients with echogenic carotid plaques compared with patients with echolucent ones. The purpose of our study was to compare the baroreflex function after carotid endarterectomy (CEA) between patients with different plaque echogenicity. Spontaneous baroreflex sensitivity (sBRS), heart rate, and systolic and diastolic arterial pressure were calculated in 51 patients with a severe carotid stenosis (70%-99%) 24 hours before CEA, as well as 24 and 48 hours after CEA. Carotid plaque echogenicity was graded from 1 to 4 according to Gray-Weale classification, after duplex examination, and the patients were divided into two groups: the echolucent (grade 1 or 2) and the echogenic (grade 3 or 4). The postoperative mean systolic arterial pressure values in all 51 patients at 24 and 48 hours (143.2 and 135.5 mm Hg, respectively) were found to be significantly increased compared with the preoperative value (132.5 mm Hg; x2=32, P<.001). Mean sBRS value, in all patients, was significantly reduced postoperatively to 2.1 ms mm Hg(-1), from the mean preoperative value, 3.7 ms mm Hg(-1), independently of plaque echogenicity. Twenty patients (39%) were included in the echolucent group and 31 (61%) in the echogenic. The two groups had significant differences in two parameters: the rate of diabetes mellitus and the rate of symptomatic plaques. After adjusting the two groups for these differences, we found that the preoperative difference in sBRS between the two groups (F[1,51]=11, P<.003) was eliminated 24 and 48 hours after CEA (F[1,51]=.007, P<.9 and F[1,51]=.4, P<.5 for 24 and 48 hours, respectively). Before the removal of carotid atheroma, baroreflex sensitivity, which is a well established cardiovascular risk factor, seems to be affected by carotid plaque echogenicity. However, CEA has as a result a similar baroreflex response in all patients, regardless of plaque echogenicity, implying no association of plaque morphology and postoperative baroreflex sensitivity.

Endovenous Laser Ablation of Incompetent Perforating Veins with 1470 nm, 400 μm Radial Fiber

To evaluate the efficacy of endovenous laser ablation (EVLA) of incompetent perforating veins (IPVs) with 1470 nm laser with 400 μm radial fiber. EVLA for perforating veins can be performed with insignificant postprocedural morbidity. This allows treatment to be offered to elderly patients with comorbidities that would preclude anesthesia for surgical treatment or subfascial endoscopic perforator surgery (SEPS). A total of 24 perforating veins in 16 limbs of 13 patients were treated between July 2010 and December 2011 in our clinic. Follow-up duplex scans were performed at 1 week and 1, 3, 6, and 12 months after the procedure, to determine the treatment outcome. Of the 23 treated IPVs, 20 (86.9%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 174 J (range 105-236 J). Four of five ulcers had healed after 8 weeks in clinical-etiology-anatomy-pathophysiology (CEAP) C6 group. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. All components of the Venous Clinical Severity Score (VCSS) demonstrated significant improvements at each postprocedural visit (p<0.001 for all), except for pigmentation and compression, which exhibited variation throughout the follow-up period. Especially in the case of liposclerotic or ulcerated skin in the affected region, EVLA of IPVs with 1470 nm diode laser is highly effective and safe, and appears to be feasible. Additionally, repeat treatment can easily be performed should recurrence of IPVs arise.

Internal Carotid Occlusion in a Newborn

The vascular laboratory was called to the neonatal intensive care unit to perform a carotid duplex examination on a 2-day-old infant. This term female newborn was delivered via caesarian because of labor that failed to progress. There were no significant maternal risk factors. On day 2, the infant was noted to have seizures. Magnetic resonance imaging of the brain demonstrated a large left hemispheric infarct with a midline shift. The findings of an echocardiogram were normal. The carotid system was evaluated by the use of a “hockey stick” 15–7 MHz linear array transducer. The common, external, and internal carotid arteries were well visualized bilaterally, as well as the vertebral and subclavian arteries. The right side was normal. The left common carotid artery signal was high resistance and a drumbeat, high resistance signal was noted at the origin of the internal carotid artery. The internal carotid artery appeared to be filled with soft echoes, and no signal was detected within the internal carotid artery beyond the origin. The infant was then transferred to Children's hospital for further evaluation and possible tissue plasminogen activator treatment. Neonatal cerebral infarction has been reported to be present in 1 in 4,000 full-term infants. Neonatal cerebral infarct was found in 12% of infants who developed neonatal seizures. Newborns with arterial ischemic stroke usually present with seizures. Primary risk factors for arterial ischemic stroke include cardiac disease, perinatal complications, and other acute illnesses, including dehydration and prothrombotic disorders. Mortality rates after arterial ischemic stroke in newborns are less than 10%. In many cases, the outcome is normal. Duplex imaging of the carotid vessels is feasible in neonates and can provide the treating physician with valuable diagnostic information.

Natural History of Carotid Artery Occlusion

Carotid artery occlusion (CAO) is a risk factor for stroke ipsilateral to the occlusion and puts patients in a high-risk category when contralateral endarterectomy is performed. The purpose of this study was to evaluate the long-term outcomes of patients with internal CAO and to determine risk factors predictive of subsequent neurological event, contralateral carotid intervention, or death. Patients with internal CAO shown by duplex ultrasonography were retrospectively identified and followed between January 2002 and June 2010 (follow-up: 1-101 months, mean: 52 months) at a tertiary care hospital. All had multiple duplex examinations available for review. Chi-square analysis was used to determine risk factors for neurologic event, contralateral intervention, or all-cause morality. Multivariate Cox proportional hazard analysis was conducted using univariate risk factors with P values <0.1. Survival was estimated using the Kaplan-Meier method (P < 0.05 significant). Eighty patients with internal CAO were identified and available for analysis. On initial encounter, 30 (38%) were symptomatic, with 26 (87%) having symptoms referable to the side of the occluded internal carotid artery. During follow-up, seven (9%) had a neurologic event, of which six (86%) were referable to the occluded side; 14 (18%) patients underwent a contralateral operation. Nineteen (24%) patients died during the period of study. Although numerous variables of multivessel disease were significant with χ(2) analysis, there was no significant risk factor associated with neurologic event on multivariate analysis. However, the development of a hemodynamically significant stenosis (>50%) or occlusion of the external carotid artery (ECA) ipsilateral to the occlusion on follow-up (P < 0.027) was associated with increased risk of death. Kaplan-Meier analysis showed 7-year survival for patients with ECA disease at follow-up was significantly worse (16.2% ± 10.3% [n = 21] vs. 79% ± 8.7% [n = 59]; P < 0.00001). Frequently, patients present with neurological symptoms referable to the side of the internal CAO. Eighty-six percent of neurologic events that occur in follow-up are attributable to the side of the occluded carotid, indicating that the occluded side continues to contribute to neurologic morbidity over time. Multivariate analysis revealed no single factor to be predictive of subsequent neurologic events. With significant risk of death in patients found to have ipsilateral ECA stenosis during follow-up, it seems reasonable to continue surveillance of the occluded carotid.

The Role of Ultrasound to Identify Nonthrombotic Lower Extremity Pathology

Accreditation in peripheral venous testing can be obtained based on femoropopliteal duplex ultrasound evaluation, and many laboratories limit their examination to this segment only. This simplified protocol detects acute femoropopliteal deep venous thrombosis (DVT) but misses calf vein DVT, superficial venous thrombosis, chronic DVT, venous reflux, and other nonvenous findings potentially responsible for pateints' presenting conditions. A protocol limited to the femoropopliteal segment results in additional unnecessary testing and can create patient dissatisfaction. We evaluated the differences in the diagnosis between a limited femoropopliteal vs a complete approach to the venous ultrasound evaluation of the lower extremities in patients examined in an outpatient vascular laboratory. A database with the complete ultrasound examinations of the lower extremity, including the common femoral, deep femoral, popliteal, tibial and peroneal veins, calf musclar veins, and great and small saphenous veins, performed in 1208 consecutive patients from July 2009 to February 2010 was queried. Of the 1208 patients, acute femoropopliteal DVT was found in 20 (1.66%), acute infrapopliteal DVT in 36 (2.98%), chronic femoropopliteal DVT in 42 (48%), and superficial thrombophlebitis of the lower extremities in 84 (6.95%). In addition, deep venous insufficiency (>500 milliseconds) was found in 385 (31.87%) and superficial venous insufficiency in 212 (17.55%). A mass was found in 64 (5.3%), comprising 10 cysts, four hematomas, 46 solid masses, and three aneurysms. Limited femoropopliteal ultrasound examination for acute DVT would have only detected a small percentage of the positive findings. These data suggest that the duplex examination can be used to further delineate the cause of outpatients' symptoms compared with the limited protocol.

Commentary on ‘Aortomonoiliac Endografting after Failed Endovascular Aneurysm Repair: Indications and Long-term Results’

All vascular surgeons/radiologists are aware of the higher rate and the implied costs of re-intervention after EVAR1: with peripheral angioplasty, for instance, given that these are smaller amounts often mean that these costs are swept under the carpet. With EVAR and the associated higher costs of both procedure and device, this becomes a significant issue. Furthermore, all is fine when things are going well, but it is of course in the nature of medicine for things to get complicated, particularly in this group of patients who by default come with a host of co-morbidities; the real issue is then with getting problems fixed with minimal disruption, i.e. an endovascular problem should ideally have an endovascular solution. This is especially so with the authors indicating a high mortality with open conversions, indicated in a sense in their own cohort with a V-POSSUM score exceeding 11%. There are several points to examine: firstly, the premise of the paper itself. The authors present salvage AMI-redoEVAR for mostly type I or type III endoleaks, and no one would debate the issue with the need to deal with these and an increasing sac, though, as referenced, even endotension has been treated as such. Importantly this has also shown up shortcomings with older devices, and certainly if the fabric in one Vanguard device disintegrated, how many more are there waiting for the same to happen? Secondly, follow-up. In the UK repeated outpatient follow-up post-EVAR simply does not occur; this would likely upset the balance in new-to-follow-up ratios, a criterion that is closely performance managed. Yes, pulse examination can pick out reduction in pulses, but reliable duplex examination can interrogate the flow aspects in any case. I understand this has now been modified. The ESVS guidelines for EVAR surveillance would be a useful reference in this regard.2 Thirdly, access still remains an issue even the second time around as indicated by the one failure, even though the authors

Hyoid-related internal carotid artery dissection

A 30-year-old man without cardiovascular risk factors presented, after 1 week of right-sided anterior neck pain, with acute left hemiplegia immediately after heavy weight lifting (i.e., removing large boxes filled with books with the head in mid-position without rotation). There was no recent history of head or cervical trauma. Brain MRI showed an acute infarction in the right middle cerebral artery territory. Carotid duplex examination revealed a high degree of stenosis of the right internal carotid artery, which was confirmed by CT angiography showing a segmental tapered narrowing of the right internal carotid artery located just lateral of the greater horn of hyoid bone, in the absence of atheromatous plaques (Fig. 1). Fat-saturated T1 MRI showed the presence of an intramural hematoma in the right internal carotid artery. A diagnosis of carotid dissection, in absence of clear head/ cervical trauma was made, and anticoagulation treatment was started. CT angiography also showed a 90-mm-long bilateral elongated styloid process (Fig. 1). However, the tip of the elongated styloid process was located at 9.1 mm of the right internal carotid artery, and the smallest distance between the body of the elongated styloid process and the right internal carotid artery was 3.5 mm, making impingement of the carotid artery by the styloid process, even with head rotation or flexion, unlikely. Another abnormality was noticed on CT angiography, consisting of an elongated hyoid bone resulting in a extremely reduced distance of 1.6 mm between the anterior tubercle of the transverse process of the third cervical vertebra and the greater horn of the hyoid bone (Figs. 1, 2). Three months later, CT angiography revealed complete recanalization of the right internal carotid artery (with a diameter of 4.5 mm at the level of the greater horn of the hyoid bone), now located medial of the greater horn of the hyoid bone (Fig. 2). Carotid duplex examination showed normal velocities, in the absence of changes in velocities after head rotation. We hypothesized that intermittent change in position of the internal carotid artery (diameter 4.5 mm) through the small space (1.6 mm) between the third cervical vertebra and the hyoid bone may have provoked the arterial dissection, although carotid injury due to the elongated styloid bone could not be excluded. In a vast portion of patients with carotid dissection, there is no clear history of head or cervical trauma. The exact cause of these, so-called spontaneous, dissections is unclear. Recently, certain anatomic characteristics of the styloid process (i.e., the length and the proximity to the carotid artery) have been reported as potential risks factors for carotid dissection [1]. The stylohyoid complex consists of the styloid process, the stylohyoid ligament, and hyoid bone. Pathological conditions (called the stylohyoid complex syndrome) associated with these structures, which can include an elongated styloid process, ossified stylohyoid ligament, elongated hyoid bone, or combinations of several of these conditions (like in our patient with both elongated styloid process and elongated hyoid bone) can cause cervical and pharyngeal symptoms, probably related to irritation of the structures around this complex (including the carotid arteries and the cranial nerves VII, IX, and X) [2]. D. Renard (&) Department of Neurology, CHU Nimes, Hopital Caremeau, Place du Pr Debre, 30029 Nimes Cedex 4, France e-mail: dimitrirenard@hotmail.com

Comparison of vein valve function following pharmacomechanical thrombolysis versus simple catheter-directed thrombolysis for iliofemoral deep vein thrombosis

Successful catheter-directed thrombolysis (CDT) for iliofemoral deep vein thrombosis (IFDVT) reduces post-thrombotic morbidity and is a suggested treatment option by the American College of Chest Physicians for patients with IFDVT. Pharmacomechanical thrombolysis (PMT) is also suggested to shorten treatment time and reduce the dose of plasminogen activator. However, concern remains that mechanical devices might damage vein valves. The purpose of this study is to examine whether PMT adversely affects venous valve function compared to CDT alone in IFDVT patients treated with catheter-based techniques. Sixty-nine limbs in 54 patients (39 unilateral, 15 bilateral) who underwent catheter-based treatment for IFDVT form the basis of this study. Lytic success and degree of residual obstruction were analyzed by reviewing postprocedural phlebograms. All patients underwent bilateral postprocedure duplex to evaluate patency and valve function. Phlebograms and venous duplex examinations were interpreted in a blinded fashion. Limbs were analyzed based on the method of treatment: CDT alone (n = 20), PMT using rheolytic thrombolysis (n = 14), and isolated pharmacomechanical thrombolysis (n = 35). The validated outcome measures were compared between the treatment groups. Sixty-nine limbs underwent CDT with or without PMT. The average patient age was 47 years (range, 16-78). Venous duplex was performed 44.4 months (mean) post-treatment. Of the limbs treated with CDT with drip technique, 65% demonstrated reflux vs 53% treated with PMT (P = .42). There was no difference in long-term valve function between patients treated with rheolytic and isolated pharmacomechanical thrombolysis. In the bilateral group, 87% (13/15) demonstrated reflux in at least one limb. In the unilateral group, 64% (25/39) had reflux in their treated limb and 36% (14/39) in their contralateral limb. There was no correlation effect of residual venous obstruction on valve function, although few patients had >50% residual obstruction. In patients undergoing catheter-based intervention for IFDVT, PMT does not adversely affect valve function compared with CDT alone. A higher than expected number of patients had reflux in their uninvolved limb.

Pulmonary Embolism Averted

A 55-year-old morbidly obese male (body mass index 54) underwent placement of a prophylactic inferior vena cava (IVC) filter before a laparoscopic sleeve gastrectomy. Preoperative lower extremity venous duplex examination was negative for deep vein thrombosis. He was discharged home on postoperative day 3 after the bariatric procedure and had an uneventful recovery. Approximately 7 weeks later, he underwent an attempt at IVC filter retrieval. A repeat lower extremity venous duplex examination at that time was again negative for deep vein thrombosis. Cavography at the time of attempted retrieval demonstrated thrombus adherent to and trapped in the middle of the IVC filter, with a flow void that extended to the level of the hepatic veins (Figure 1A; online-only Data Supplement Movie IA). The filter retrieval was aborted, …

Improved perioperative neurological monitoring of coronary artery bypass graft patients reduces the incidence of postoperative delirium: the Haga Brain Care Strategy

Postoperative delirium is a major cause of morbidity and mortality after cardiovascular surgery. Risk factors for postoperative delirium include poor cerebral haemodynamics and perioperative cerebral desaturations. Our aim was to reduce the postoperative delirium rate by using a new prevention strategy called the Haga Brain Care Strategy. This study evaluates the efficacy of the implementation of the Haga Brain Care Strategy to reduce the postoperative delirium rate after elective coronary artery bypass graft (CABG) procedures. The primary endpoint was the postoperative delirium rate, and the secondary endpoint was the length of stay in the intensive care unit. The Haga Brain Care Strategy consisted of the conventional screening protocol for delirium with the addition of preoperative transcranial Doppler examinations, perioperative cerebral oximetry, modified Rankin score, delirium risk score and (if indicated) duplex examination of the carotid arteries. In case of poor preoperative haemodynamics, the cerebral blood flow was optionally optimized by angioplasty or the patient was operated on under mild hypothermic conditions. Perioperative cerebral desaturations >20% outside the normal range resulted in intervention to restore cerebral oxygenation. Cerebral oximetry was discontinued when patients regained consciousness. Patients undergoing elective CABG procedures in 2010 were compared with patients scheduled for coronary bypass graft procedures in 2009 who had not been exposed to additional Haga Brain Care Strategy assessment. A total of 233 and 409 patients were included in 2009 and 2010, respectively. The number of patients subjected in 2010 to transcranial Doppler examinations, cerebral oximetry or both (Haga Brain Care Strategy) were 262 (64.1%), 201 (49.1%) and 139 (34.0%), respectively. The overall rate of postoperative delirium decreased from 31 (13.3%) in 2009 to 30 (7.3%) in 2010 (P = 0.019). A binary logistic regression model showed that the Haga Brain Care Strategy was an independent predictor of a reduced risk of developing a postoperative delirium (odd ratio = 0.37, P = 0.021). With the implementation of the Haga Brain Care Strategy in 2010, a reduction of the incidence of postoperative delirium in patients undergoing elective CABG procedures was observed. In addition, the length of stay in the intensive care unit showed an overall tendency to decline. The limited number of observations and the current study design do not allow a full evaluation of the Haga Brain Care Strategy but the data support the idea that a sophisticated preoperative assessment of cerebral haemodynamics and perioperative monitoring of cerebral oximetry reduce the incidence of the postoperative delirium in CABG surgery.

Intercostal artery pseudoaneurysm: a rare complication of transaortic transcatheter aortic valve implantation

In this case report, we present an 86-year old patient with an intercostal pseudoaneurysm after transaortic transcatheter aortic valve implantation (TAVI). This new technique of a transaortic approach is considered a possible alternative to the more usual transfemoral, trans-subclavian or transapical access site, mainly in patients with extensive peripheral arterial disease. A mini-thoracotomy or mini-sternotomy is needed to access the ascending aorta. The patient presented with a painless but progressive pulsatile mass right parasternally, 3 months after the procedure. An intercostal pseudoaneurysm was diagnosed with duplex examination and chest CT. Successful treatment with an ultrasound-guided injection of thrombin resulted in a complete obliteration of the pseudoaneurysm. Only nine reported cases of intercostal pseudoaneurysms have been reported worldwide, and this is the first case in a patient who underwent a transaortic TAVI. Since the transaortic access is used more frequently, it is important to report on possible complications of this new technique.

Further Evidence of the Clinical, Hormonal, and Genetic Heterogeneity of Klinefelter Syndrome: A Study of 216 Infertile Egyptian Patients

This study aims to provide further insight into the phenotypic heterogeneity of Klinefelter syndrome (KS) by presenting clinical, hormonal, and genetic data from a large series of Egyptian infertile patients with KS. A retrospective case series of KS patients was studied over a period from January 2003 to April 2010. All patients underwent a complete history and physical examination; color duplex examination; semen analysis; measurement of total testosterone (T), follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), and prolactin (PRL); and chromosomal typing. Mosaic KS diagnosis was confirmed by fluorescence in situ hybridization. The series included 216 KS patients (198 nonmosaic, 16 mosaic, and 2 KS variants). Typical clinical signs of hypoandrogenism were observed in 86% of patients. Gynecomastia affected 20.8% of the patients. Eunuchoidal body proportions, with arm span exceeding height and lower segment length exceeding upper segment length, were detected in 43.9% and 64.4% of the patients, respectively. In all patients, a reduction in testicular size and azoospermia were detected. Normal levels of T, FSH, LH, E2, and PRL were detected in 44.5%, 3.7%, 3.3%, 93.5%, and 91.2% of patients, respectively. Differences were not significant between patients with classic KS and those with mosaic KS in terms of the frequency of clinical signs of hypoandrogenism, gynecomastia, low T concentrations, or high concentrations of FSH, LH, E2, and PRL (all P > .05). The results of the current study emphasize the heterogeneous clinical, hormonal, and genetic phenotype of infertile KS patients. Our findings support the usefulness of cytogenetic studies in infertile patients showing small testicular size and azoospermia, regardless of the presence of other clinical or endocrine findings.

Anomalous Vascular Blood Flow in the Presence of Right-Sided Aortic Arch

The congenital anomaly of right-sided aortic arch is often associated with aberration or isolation of the aorta's branch vessels. We report a case in which a carotid duplex examination revealed alterations in vascular flow patterns which led to the diagnosis of a right-sided aortic arch.

Case Series of Subclavian Artery Aneurysms in the Noninvasive Vascular Laboratory

Introduction Subclavian artery aneurysm (SAA) is an uncommon entity, and there is little information in the vascular ultrasound literature regarding this disorder. Methods Query of a single-center noninvasive vascular laboratory database for all duplex examinations performed from January 1, 2000, to December 31, 2009 with a diagnosis of SAA. Medical records, archived ultrasound images, and correlative imaging studies were reviewed. Result A total of 12 patients with SAA were identified. Median age 56 years (range, 24–86 years), 58% male. The etiology of SAA was as follows: atherosclerosis (3/12), thoracic outlet syndrome (TOS; 3/12), connective tissue disorder (3/12), trauma (2/12), and vasculitis (1/12). All patients with SAA not caused by TOS had additional peripheral arterial or aortic aneurysm(s) previously or subsequently documented on imaging studies. Ten patients had symptoms at the time of diagnosis, most commonly arm and neck pain, arm claudication, and neurological findings. Aneurysms were equally distributed between right and left sides. The majority of SAA (9/12) were located at the origin or proximal subclavian artery; 3 were dissecting aneurysms. The median aneurysm maximal diameter was 2.35 cm (range, 1.5–6.4 cm), and the median contiguous normal artery diameter was 0.85 cm. Three patients had significant velocity shifts noted within the aneurysm. Vertebral artery flow was abnormal in one-third of SAA (4/12). Marked tortuosity of either internal carotid artery was a common related finding among these patients (6/12). Correlative computed tomography scan was available for 5 patients. A total of 75% of subjects in this series underwent open or endovascular aneurysm repair, whereas the remaining patients were followed with no intervention. Conclusion Duplex ultrasound is a useful tool for diagnosis and characterization of subclavian artery aneurysms. Among patients with SAA who have no evidence of TOS, careful evaluation for co-existent aortic and peripheral aneurysms is critical.

Invited commentary

This meticulous evaluation of the repeatability and reproducibility of venous duplex imaging by a distinguished group of investigators represents the first phase of the Investigating Venous Evaluation and Standardization of Testing (INVEST) study, the program initiated by the American Venous Forum to develop reporting standards for diagnostic venous studies. Given the extraordinarily widespread use of venous duplex imaging and its critical role in the diagnosis and treatment of chronic venous insufficiency, such standardization is vital for the clinical and research missions associated with this disease. All duplex examinations, as we know from our arterial experience, are highly operator dependant, and thus, establishment of their reliability is essential. On the arterial side, this has largely been accomplished through the application of standard methodologies to perform and report studies and validation by comparison with arteriography. The current study is the first step in such an effort for venous noninvasive diagnosis. It should be noted at the outset that this study is not designed to evaluate the accuracy of venous duplex imaging, but only its repeatability and reproducibility and the factors that can affect these end points. The key findings of this study were that the greatest repeatability was achieved when scans were performed in the morning with the individual standing, and that use of the shorter 0.5-second cut point improved agreement between interpretations of reflux (not validity). In addition, education by standardized training of technologists and the application of a single examination protocol improved reproducibility. This rigorously conducted study is a strong first step in the process of standardizing venous duplex imaging. From it we have learned that adhering to a standard protocol matters more than factors that cannot be controlled, that experience and precision matter, and that studies performed by different individuals in different laboratories on different patients can be compared in a meaningful way when standardization is applied. These important observations allow us to take the next steps in the process, which will involve formalizing performance and reporting standards and creating the expectation that they will be adhered to. Despite the accomplishments of this study in determining the repeatability and reproducibility of venous duplex imaging, there remains an important but unanswered question yet to be addressed: What is the validity of venous duplex imaging? This may prove quite challenging because we lack a gold standard, such as carotid arteriography, for comparison, but most certainly merits our further investigation. Multicenter assessment of venous reflux by duplex ultrasoundJournal of Vascular SurgeryVol. 55Issue 2PreviewThis prospective multicenter investigation was conducted to define the repeatability of duplex-based identification of venous reflux and the relative effect of key parameters on the reproducibility of the test. Full-Text PDF Open Archive

PolytetraOuoroethylene patch saphenoplasty: Is it effective against recurrent varicose veins?

Background: Recurrent varicose veins after surgery (REVAS) are a common, complex and costly problem. The possibilities for recurrent varicose veins after correctly ligated SFJ may be due to: dilatation of preexisting venous tributaries from the common femoral vein (CFV) or formation of new veins as a result of angiogenic stimulation termed neovascularisation. Interposition of a prosthetic implant covering the saphenous stump has been called ''patch saphenoplasty. The aim of the present study is to evaluate the use of polytetrajluroethylene (PTFE) patch sutured over the saphenofemoraljunction (PTFE saphenoplasty) to reduce the incidence of recurrent varicose veins. Patients and methods: This study was conducted in General and Vascular Surgery Unit at Mansoura University hospital between March 2007 and November 2010.Patients were included ifthey had varicose veins from the CEAP clinical classification: C 2-5; recurrent varicose veins and isolated short saphenous vein varicosity were excluded. 320 patients (368 limbs) were eligible for the study; The patients were randomized into two groups; group L flush ligation of the GSV was performed at the SFJ without using any technique to contain possible postoperative neovasculorization; group IL underwent PTFE saphenoplasty (rectangular piece (2 x 3cm) of PTFE was sutured on the saphenous stump). Results: Both groups were comparable as regard patients' characteristics.The global incidence of early postoperative complications was higher in-group II than group I (9.4% vs. 3.8%) (PO.OOJ). Two months postoperative clinical and duplex examination revealed no clinical recurrence or neovascularization at the site of SFJ ligation in both groups.One-year postoperative clinical examination revealed recurrent thigh varicosities in 15/187 limbs in-group I (8 %) and in 8/181 limbs (4.4 %) in-group II. By duplex examination neovascularization occurred in 37/187 (19.7%) limbs in-group I (22 limbs grade 2 & 15 limbs grade 3) but in-group II neovascularization occurred in 19/181(10.5%) limbs (11 limbs grade 2 & 8 limbs grade). (P 0.001) Conclusion: Interposition of PTFE implant at the level of the ligated saphenofemoral stump significally reduces the incidences of clinical recurrence and neovascularization