Percutaneous Endovascular Therapy Research Articles

Percutaneous Endovascular Therapy of Blunt Trauma Related Renal Artery Thrombosis

Percutaneous Endovascular Therapy of Blunt Trauma Related Renal Artery Thrombosis

Predicting Suitable Percutaneous Endovascular Arterial Embolization for Traumatic Abdominopelvic Injuries: A Retrospective Cohort Study.

PurposeThis study evaluated the pre-procedural attributes of trauma patients to determine their suitability to undergo Percutaneous Endovascular Arterial Embolization (PEAE), and the current state of endovascular repair as an option for trauma-related injuries in traumatic abdominopelvic arterial injuries was explored.Patients and MethodsWe retrospectively evaluated the charts of 638 adults with traumatic abdominopelvic injuries treated from March 2011 to February 2021, extensively reviewing their pre-operative indices, pre-operative optimization requirements, and multi-modality imaging records.ResultsIn total, 235 patients (30.63%) were “hemodynamically unstable” on admission, mainly due to hypotension (n=437 [68.5%]). Additionally, laboratory-defined acquired coagulopathies and inherited bleeding disorders were found in 268 patients (42.01%). The computerized tomography bleeding protocol was performed on 408 (63.94%) patients. Percutaneous endovascular therapy by arterial embolization was performed on 146 patients. The mean number of requested pre-intervention blood units for trauma patients significantly exceeded the number of units transfused post-intervention (P<0.0005). Apart from hemodynamics (ie heart rate, mean blood pressure); hemoglobin, and lactic acid levels were independently associated indices of PEAE outcomes (p <0.01).ConclusionDespite the recommendations from the Society of Interventional Radiology on endovascular intervention for trauma and bleeding risk, 36.84% of study patients had hemodynamic instability and other unfeasible parameters that would limit the option of minimally invasive procedures. Early recognition and consideration of suitable treatment options is essential for optimizing patient outcomes. It is imperative that standardized algorithms and management protocols based on available resources be developed.

TCT-160 Preprocedural Predictors of Late All-Cause Mortality Following Percutaneous Endovascular Therapy for Peripheral Arterial Disease: A Systematic Review and Meta-Analysis of Hazard Ratios

TCT-160 Preprocedural Predictors of Late All-Cause Mortality Following Percutaneous Endovascular Therapy for Peripheral Arterial Disease: A Systematic Review and Meta-Analysis of Hazard Ratios

Persisterende zwelling na enkelartroscopie: pseudoaneurysma van de arteria tibialis anterior als zeldzame complicatie

Persistent swelling after ankle arthroscopy: pseudoaneurysm of the anterior tibial artery as a rare complication A patient was admitted to a geriatric rehabilitation ward following a septic arthritis for which she received an antibiotic treatment and arthroscopic irrigation. She had a normal kidney function and received a prophylactic dose of enoxaparin for the prevention of a deep venous thrombosis (DVT). During the hospitalization, a progressive, painless swelling of the ankle was seen. The ultrasonography showed a pseudoaneurysm of the anterior tibial artery measuring 4.2 cm by 4 cm by 1.7 cm. Following the surgical consultation, compression therapy was started. The follow-up ultrasonography after 4 weeks showed absence of flow in the pseudoaneurysm. A pseudoaneurysm is a rare complication (0.008%) of foot and ankle surgery. Risk factors are malnutrition, immunosuppression, diabetes mellitus and trauma or infection. Abnormal coagulation may contribute to the development of a pseudoaneurysm. The diagnosis is mostly based on clinical clues, confirmed by means of color-flow Doppler imaging. The treatment options include non-surgical methods (external compression, ultrasound-guided compression and ultrasound-guided thrombin injections), percutaneous endovascular therapy (coil, stenting) or surgical ligation with an aneurysmectomy and an arterial reconstruction. Although pseudoaneurysms are a rare complication, their possibility should be considered in the period following the commencement of mobilization and weight-bearing after ankle surgery, especially if risk factors are present.

Distal embolization during percutaneous revascularization of the lower extremity arteries.

Background: Percutaneous endovascular therapy is nowadays the leading treatment option for patients with symptomatic peripheral arterial disease, but it can be complicated with distal embolization (DE). Patients and methods: We retrospectively analyzed 2054 endovascular revascularization interventions performed in patients with disabling claudication or chronic critical limb ischemia in the Catheterisation Laboratory of the Department of Vascular Diseases, University Medical Centre Ljubljana between January 2014 and December 2018. Lesions were treated by balloon angioplasty and/or stent implantation, without atherectomy. Results: The overall incidence of DE was 0.9%. DE was more frequent in females than males (1.6% vs 0.5%, p=0.011), in the absence of antiplatelet treatment prior to intervention compared to previous antiplatelet treatment (2.1% vs 0.6%, p=0.005) and in femoropopliteal stenting compared to angioplasty without stenting (2.2% vs 0.8%, p=0.037). DE was successfully managed with percutaneous aspiration, in combination with angioplasty when necessary, in 84% of cases. In remaining 16% of patients, DE was managed with surgical thromboembolectomy. Conclusions: The incidence of DE during endovascular revascularization of chronic atherosclerotic lesions in lower limb arteries without use of atherectomy was low. DE was more frequent in women, in patients without prior antiplatelet treatment and in femoropopliteal stenting. The majority of DE was successfully managed percutaneously.

Endovascular tibial arteries revascularization and its outcome on wound healing with split-thickness skin grafts for limb salvage in patients with below-the-knee vascular disease

Background Continuous and rapid advancement in percutaneous endovascular therapy has led to a significant increase in its use as a primary option for revascularization replacing surgical bypass, and it has become a standard treatment for critical limb ischemia (CLI). Clinical success of percutaneous revascularization has been mostly judged by patency rate and limb salvage, but there is paucity of reports on the outcomes of the wound. We present a retrospective study of immediate angiographic and 6-month clinical outcome of patients who underwent endovascular recanalization of tibial arteries for CLI followed by surgical debridement and wound reconstruction with split-thickness skin graft (STSG) for patients with grade 2 ulcer according to the Wound, Ischemia, foot Infection score. Patients and methods Between January 2016 and April 2017, 47 consecutive adult patients with CLI who underwent endovascular recanalization of infra-popliteal arteries due to more than 50% stenosis or chronic total occlusion with grade 2 chronic wound that was reconstructed using STSG and who had a clinical follow-up of at least 6 months were selected for analysis. Results Forty-seven patients underwent endovascular reconstruction. Forty (85.1%) patients underwent only balloon angioplasty and remaining seven (14.9%) underwent additional bailout stenting for proximal tibioperoneal or anterior tibial arteries. Twenty-eight (59.6%) patients had multiple vessel recanalization, while 19 (40.4%) patients had single vessel recanalization. Linear flow to the foot was achieved in at least one artery, mostly the anterior tibial artery in 32 (68.1%) patients postrevascularization. Successful wound healing occurred in 37 (80.4%) patients, 24 (64.9%) of them underwent wound covering with STSG with graft uptake in 20 (83.3%) patients. Limb salvage was achieved in 41 (89.1%) patients at a 6-month follow-up. Conclusion Endovascular recanalization of tibial arteries is an effective procedure for the treatment of CLI. STSG can be considered a reliable option for achieving wound healing in diabetic foot patients after successful revascularization and proper wound debridement. Normal outflow with at least one of the three infra-popliteal vessels being patent is essential for adequate healing and graft taking.

Percutaneous endovascular therapy for symptomatic chronic total occlusion of the left subclavian artery.

Percutaneous endovascular therapy is an accepted and preferred procedure for symptomatic subclavian artery disease. However, the technical feasibility and effectiveness of treating chronic total occlusion of the subclavian artery with this approach is uncertain. We aimed to evaluate the initial and mid-term results of endovascular therapy for patients with symptomatic chronic total occlusion of the left subclavian artery. Consecutive patients who underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery between January 2010 and February 2014 were included. Overall, 16 patients (10 male, 6 female; mean age 56 ± 13 years) underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery. 6 (37.5%) had arm claudication, 8 (50.0%) had vertebrobasilar insufficiency and 2 (12.5%) had coronary steal. 18 balloon-expandable stents were implanted in 15 patients. Central luminal passage was not achieved in one patient because of the subintimal position of the guidewire (procedural success rate 93.8%). There were no procedure-related complications. Mean preprocedural and postprocedural systolic blood pressure differences between the upper extremities were 37 ± 13 (range 25-60) mmHg and 11 ± 9 (range 5-38) mmHg, respectively; the improvement was statistically significant. Outpatient follow-up revealed one asymptomatic restenosis at two years. The patency rate at two years was 93.3%. Balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery is safe and effective, with good acute success rate and mid-term patency. Prospective randomised studies on larger patient populations would provide more precise results.

Aorto-renal Bifurcation Stenting in a Juvenile Non-specific Aorto-Arteritis: case report

Takayasu Arteritis (TA) is a granulomatous inflammation of unknown aetiology affecting the aorta and its major branches with usual affliction among patients younger than 50 years and rarely among children. We present a 7-years old boy referred for evaluation of hypertension. He had a significant blood pressure difference between right arm, left arm and lower limbs. Computed tomography imaging of thorax and abdomen showed stenosis of left subclavian artery, left renal artery and juxtareanl aorta which was subsequently confirmed on aortogram. He underwent percutaneous endovascular therapy with aorto-renal bifurcation stenting with reduction of blood pressure and gradient. Renal angioplasty with stenting remains a challenging procedure in patients with tight ostial lesion, and juxtarenal aortic involvement in lieu of precise stent placement and avoiding side branch occlusion.

Aorto-renal bifurcation stenting in a juvenile non-specific aorto-arteritis: case report

Takayasu Arteritis (TA) is a granulomatous inflammation of unknown aetiology affecting the aorta and its major branches with usual affliction among patients younger than 50 years and rarely among children. We present a 7-years old boy referred for evaluation of hypertension. He had a significant blood pressure difference between right arm, left arm and lower limbs. Computed tomography imaging of thorax and abdomen showed stenosis of left subclavian artery, left renal artery and juxtarenal aorta which was subsequently confirmed on aortogram. He underwent percutaneous endovascular therapy with aorto-renal bifurcation stenting with reduction of blood pressure and gradient. Renal angioplasty with stenting remains a challenging procedure in patients with tight ostial lesion, and juxtarenal aortic involvement in lieu of precise stent placement and avoiding side branch occlusion.

Accuracy and safety of CO2 digital subtraction angiography during endovascular treatment of symptomatic peripheral artery occlusive disease. A prospective study on Egyptian patients

PurposeTo study the efficacy, safety and clinical outcome of carbon dioxide DSA during angioplasty procedures for patients with predominant femoropopliteal segment occlusive lesions, aiming to reduce possible allergic reactions and potential nephrotoxicity. Materials and methodsThe study included eighteen Egyptian patients in a prospective manner, with evidence of predominant femoropopliteal arterial occlusive disease by Duplex study. All the selected patients had borderline renal functions with serum creatinine levels between 1.5 mg/dL and 2 mg/dL. Every patient was scheduled for a percutaneous endovascular therapy during which CO2 DSA and small volume injections of ICM DSA of the diseased segment and distal arterial tree were done. We analyzed our results emphasizing the technical success, CO2 DSA related complications, allergic reactions and intolerance. We also correlated the amount of contrast injected with the serum creatinine levels as well as the degree of opacification of the diseased segment. ResultsWe were able to achieve technical success in 88% of our cases except in two patients who had TASC D lesions. The average fluoroscopy time in our study was about 100 min. There were no CO2 related complications or allergic reactions. Five patients were intolerant to CO2 injection related pains and repeated injections were performed with smaller volumes. The injected mean volume of CO2 was 76.1 mL while the mean volume of ICM used per patient was 24 mL. Most patients showed non-significant rise of serum creatinine levels at both samples. Moreover, the results of the “Good” score & the “Fair” score for the CO2 DSA image quality plotted by the interobserver agreement was about 40% & 33% respectively from the total number of patients included in the study. ConclusionCO2 DSA is a non-nephrotoxic alternative to traditional ICM DSA that could be safely used and well tolerated during endovascular management of lower extremity symptomatic arterial disease. When selectively delivered to the femoropopliteal segment, CO2 provides superior quality images that would cancel or markedly reduce the ICM volume required for prompt visualization and decision making during the revascularization procedure.

Femoropopliteal angioplasty: Short- and mid-term results

Percutaneous endovascular therapy is becoming a primary option for managing femoropopliteal occlusive disease. The purpose of this study was to evaluate the mid-term results of endovascular treatment of femoropopliteal arterial disease. Femoropopliteal percutaneous transluminal angioplasty was performed on 162 consecutive limbs (160 patients) from January 2006 to January 2016. In our study, 87.6% of patients had critical limb ischemia. Lesions were classified as Trans-Atlantic Inter-Society Consensus (TASC) A (43%), B (43%), C (7%), and D (7%). Femoropopliteal interventions included angioplasty only in 70 cases (43.2%), and the remaining 92 (56.8%) received at least one stent. Technical success was achieved in 98.7% of patients, with three deaths and a major morbidity rate of 15%. The actuarial primary patency at 12 and 36 month was 65.4% and 40.2%, respectively, 33 peripheral reinterventions were performed after femoropopliteal axis occlusion, resulting in an actuarial primary limb preservation rate of 94.4 at 12 months. Comparison between angioplasty only and the use of stent show no difference in primary patency (P=0.832) and limb salvage (P=0.67). Negative predictors of primary patency determined by univariate analysis included popliteal location (P<0.001) and TASC D (P<0.001). However, diabetes mellitus (P=0.001) and poor run off (P<0.001) were the principal predictive factors of limb loss. Femoropopliteal angioplasty can be performed with a low morbidity and mortality. Intermediate primary patency is directly related to TASC classification and popliteal localization.

Juvenile Takayasu Arteritis: A case report

Takayasu Arteritis (TA) is rare systemic large vessel chronic inflammatory vasculitis affecting the aorta and its main branches. It was first reported by Mikito Takayasu, a Japanese ophthalmologist. Its etiology is still unknown, however, it has been considered to be of autoimmune origin. TA is more common among young women of childbearing age. It is mostly found in Asia. Takayasu arteritis is rare in children.We present a six years old girl, referred with complaints of low grade fever, headache and dyspnea of 2 months’ duration. She had a significant blood difference between upper and lower extremities on both sides with absent pedal pulses on both sides. She also had anemia and raised ESR. Computed Tomographic imaging showed stenosis of the descending aorta and left subclavian artery. She underwent percutaneous endovascular therapy and blood pressure gradient reduced significantly and pulse volume improved. Her symptoms of headache and breathlessness improved at the time of discharge after the procedure after 48hours.

Catheter-directed thrombolysis in management of postpartum lower limb deep venous thrombosis – A case series

Deep vein thrombosis (DVT) is a major health problem in pregnancy and postpartum period. Catheter-directed thrombolysis (CDT) is safe and effective in the management of symptomatic DVT. Value of CDT in postpartum DVT is not fully evaluated. We describe five patients presenting with acute iliofemoral DVT in their early postpartum period who were treated with mechanical thromboaspiration and CDT. The CDT was done using streptokinase infusion and unfractionated heparin. Percutaneous angioplasty was done in patients with symptomatic residual lesion following thrombolysis. Patients were discharged with oral anticoagulant and compression stockings. This approach was successful in all five cases. Percutaneous endovascular therapy using CDT, mechanical thromboaspiration, and balloon angioplasty is safe and effective in iliofemoral DVT in postpartum period.

Predictors of Medium-term Patency in Percutaneous Endovascular Therapy of Femoro-popliteal Lesions

BackgroundThe objective is to study the medium-term results of angioplasty and stenting in the femoro-popliteal sector in patients with critical limb ischemia (CLI), and identify angiographic predictive factors of primary patency. Patients and methodsRetrospective review of 98 patients with critical ischemia and angiographic lesions characterized as TASC A=13 (14%), B=38 (40%), C=24 (25%) or D=20 (21%). A total of 106 angioplasties and primary self-expanding stents (mean length of stent coverage of 19cm) were performed between January 2006 and January 2011. ResultsThe immediate results of patency, limb salvage and survival were 95, 96 and 96%, respectively. Primary patency at 1 and 2 years was 54 and 38%, respectively. Twenty-seven cases (25%) required endovascular iterative procedures, providing an assisted patency at 1 and 2 years of 72 and 60%, and a secondary patency of 80 and 67%. A lower primary patency was observed (log rank) when stent length was >20cm (P<.001), popliteal artery was involved (P=.004), and in TASC C and D lesions (P=.04). In multivariate analysis (Cox), only stent length >20cm was an independent negative predictor for primary patency (HR=5.7, P<.001). The limb salvage at 1 and 2 years was 83 and 81%, respectively. ConclusionsAngioplasty with stent in the femoro-popliteal sector is a safe technique, but with significantly lower permeability results in injuries that require stent coverage of more than 20cm. In these cases, vein bypass surgery should be the procedure of choice.

Covered stent implantation for anastomotic pseudoaneurysm of innominate artery post total aortic arch replacement

A 59-year-old man presented with back pain that lasted 2 h. Computed tomography revealed acute type A dissection. Emergent total aortic arch replacement was performed on the same day. In 2 weeks later, CT angiography (CTA) showed the aneurysm of his innominate artery. Endovascular repair using covered stent by transbrachial artery approach was successfully performed. CTA at 8 months showed that pseudoaneurysm was excluded. The patient had no symptoms and no other complications were seen. Percutaneous endovascular therapy can be applied for high-risk patient of suprathoracic open surgery.

Lumbar artery pseudoaneurysm as a late complication of osteomyelitis with vertebral body destruction

We report the case of a 79-year-old patient whose acute back pain revealed a 9-cm nonruptured lumbar artery pseudoaneurysm occurring 5 years after a vertebral body osteomyelitis that induced a significant vertebral destruction. She underwent an urgent percutaneous selective arterial embolization. Lumbar artery false aneurysm should, thus, be suspected as a possible etiology of any new painful symptoms in patients suffering from a chronic vertebral destructive disease.

Endovascular Repair of Blunt Extremity Arterial Injury: Case Report

Surgical revascularization is the standard treatment of complex blunt traumatic extremity vascular injuries. Limb salvage may be improved with minimally invasive endovascular therapies because of the ability to perform diagnostic and therapeutic intervention simultaneously. Two cases of acute limb-threatening arterial injuries successfully treated with percutaneous endovascular therapy are reported. A skier suffered hemodynamic instability after shoulder reduction. An axillary arterial injury was suspected and confirmed with angiography. A covered stent successfully controlled the hemorrhage. A morbidly obese female sustained anterior dislocation of her left knee 7 years previously requiring repair. She developed recurrent knee dislocation with acute leg ischemia. Emergent fixation was performed followed by percutaneous angiography. Short segment thrombosis of the popliteal was noted. Wire recanalization of the thrombosed artery and stent placement restored 3-vessel runoff. Endovascular therapy can offer faster, easier access to the extremity vascular injury facilitating revascularization and avoiding long incisions and dissections.

Open surgery for atherosclerotic chronic mesenteric ischemia

This study was undertaken to document the results of our current practice of open mesenteric revascularization to enable comparison with the recent trend of percutaneous endovascular therapy for the treatment of chronic mesenteric ischemia. Patients were identified via operation code data as well ongoing audit data from 1992 until 2006. Only patients with a history of chronic mesenteric ischemia secondary to atherosclerosis for 3 months or longer were included in the study. Follow-up data have been collected prospectively and include clinical examination and history, as well as graft surveillance consisting of mesenteric duplex ultrasonography, computed tomography, and/or angiography every 6 months for 3 years and then yearly thereafter. Thirty-nine consecutive patients underwent 41 open revascularization procedures for chronic mesenteric ischemia, comprising 67 bypass grafts. The mean patient age was 65 years (range, 45-85 years), and 44% (n = 17) were male. Symptoms were present on average for 11 months (range, 4-48 months) before treatment. The average weight loss was 11.4 kg, and three patients (7.6%) also had evidence of ischemic enteritis. There was one perioperative death, thus giving a perioperative mortality rate of 2.5%. Perioperative morbidity occurred in five patients (12.2%). Primary graft patency was 92% at 5 years. Seven patients died during follow-up, which ranged from 4 to 161 months (mean, 39 months)-one (2.5%) from mesenteric ischemia. Two (5%) other patients have had recurrent mesenteric ischemic symptoms. Open surgical mesenteric revascularization by bypass grafting for atherosclerotic-induced chronic mesenteric ischemia can be performed with low mortality and morbidity and provides excellent long-term primary patency rates and symptom-free outcomes. Pending more data on the acute and long-term results of endovascular techniques, open mesenteric revascularization remains the gold standard for most patients with chronic mesenteric ischemia.

Intermediate results of percutaneous endovascular therapy of femoropopliteal occlusive disease: A contemporary series

Percutaneous endovascular therapy is becoming a primary option for managing infrainguinal occlusive disease. This study examined the results of femoropopliteal percutaneous transluminal angioplasty (PTA) with intermediate (mean, 24 months) follow-up in a contemporary series of patients presenting with critical limb ischemia or claudication. Femoropopliteal PTA was performed on 238 consecutive limbs (208 patients) from January 2002 to July 2004. Study end points, including primary patency, assisted patency, and limb salvage (Society of Vascular Surgery reporting standards), were assessed by Kaplan-Meier life-table analysis, and factors predictive of hemodynamic or clinical failure, or both, were evaluated by univariate and multivariate methods. Clinical and demographic features included a mean age, 72 years; male (62%); critical limb ischemia (46%); diabetes mellitus (49%); and renal insufficiency (creatinine >or= 1.5 mg/dL) (29%). Lesions were classified as TransAtlantic Inter-Society Consensus (TASC) A (11%), B (43%), C (41%), and D (5%). PTA was confined to the femoropopliteal segment in 77 patients (33%), and 161 (67%) underwent concurrent interventions in other anatomic locations. Femoropopliteal interventions included angioplasty only in 183 (78%), and the remaining 53 (22%) received at least one stent. Technical success was achieved in 97% of patients, with no deaths and a major morbidity rate of 3%. The 36-month actuarial primary patency was 54.3%, and assisted patency was 92.6% (37 peripheral reinterventions), resulting in a limb preservation rate of 95.4% in all patients regardless of clinical presentation. Interval conversion to bypass surgery occurred in 19 patients (8%). Comparison between critical limb ischemia and claudication revealed a primary patency of 40.8% vs 64.8%, assisted patency of 93.8% vs 92.6%, and limb salvage of 89.7% vs 100%, respectively. Negative predictors of primary patency determined by multivariate analysis included history of congestive heart failure (P = .02) and TASC C/D (P = .02). However, further evaluation of TASC C/D vs A/B revealed an assisted patency of 89.7% vs 94.3% (P = .37) and limb salvage of 94.3% vs 96.4% (P = .58). Femoropopliteal PTA can be performed with a low perioperative morbidity and mortality. Intermediate primary patency is directly related to TASC classification. Although secondary intervention is often necessary to maintain patency in TASC C/D lesions, these data suggest that it would be appropriate to use PTA as initial therapy for chronic femoropopliteal occlusive disease regardless of clinical classification at presentation or TASC category of lesion severity.

Book review

This text is a compilation of the presentations from the Twenty-ninth Annual Vascular Symposium held by the Division of Vascular Surgery, Feinberg School of Medicine at Northwestern University. The aims of the Symposium and this book are to review advances and provide an overall coverage of the practice of vascular surgery. The work of almost 100 authors is presented in 44 chapters organized into 13 sections. The topics covered include basic considerations, government issues, noninvasive tests, carotid surgery, carotid stents, infrainguinal arterial reconstructions, percutaneous endovascular therapy, aortic aneurysm, aortic endovascular grafts, upper-extremity ischemia, hemodialysis access, vascular trauma, and venous problems. The authors of each chapter are recognized experts. The chapters address controversies and “hot topics” rather than giving an overall coverage of the issue for most topics. The topic selections are somewhat eclectic but certainly relevant to the practicing vascular surgeon. Each chapter is well organized and clearly presented. The editors have done well to avoid repetition despite some overlap in topics. Although there are many well-presented line drawings and tables, the reproduction of these and some of the photographs and images is of rather poor quality. The cited references in each chapter are well chosen for the most part; unfortunately, some chapters have no references within the past 5 years. In keeping with the present state of vascular surgery, much of the book relates to endovascular procedures. The chapter “Pathology of Stents and Stent Endografts” gives a brief but comprehensive overview of important information that should be known to all who use these devices. The reference list is extensive and up-to-date. The section on carotid interventions is brief and incomplete but gives a “snapshot” of issues that are rapidly evolving. These include some tips and techniques, an introduction to cerebral protective devices, and some limited results and discussion of the ongoing trials. Aortic surgery and endografting are covered in sections that reflect the more mature nature of this material. There are excellent reviews of endoleak management, surgical conversion, and fenestrated and branched grafts. These chapters are adequately detailed and well referenced. Other chapters on thoracic and abdominal aneurysms are complementary to this material. A thoughtful chapter on “Guidelines for Treatment of AAA” brings together many well-tried concepts with up-to-date trials and treatment comparisons to provide a measured approach to decision making. All practitioners, regardless of practice preferences, should be aware of this material. Included in the chapters on venous management are reviews of venous ablation, assessment of the swollen limb, and venous disease in obesity. Although there is little new in these chapters, they do serve as a reminder of management approaches to these common but sometimes challenging disorders. The chapter on “New Concepts in the Management of DVT” is a well-organized overview of newer medications and approaches presented in a concise, readable, well-referenced form. The chapters on renal dialysis complications, including hand ischemia, and the DOQI targets are useful reviews with practice implications for anyone practicing in this area. The section on noninvasive testing presents a comparison of portable ultrasound machines for aortic screening; unfortunately, it is not comprehensive, and with rapidly changing technology, is becoming dated. The review of infrainguinal graft surveillance is thorough and well referenced and should be well known to vascular surgeons. A protocol for carotid screening is presented and will be useful in discussions of the relevance of this to patient and social issues. The chapter on three-dimensional ultrasound presents a variety of material of interest but, thus far, limited clinical relevance. This text provides an accessible resource for quick updates on many areas of vascular surgery. Although it cannot be considered as a comprehensive textbook, its authors and editors have produced a useful volume of updates and reminders for any vascular specialist.