Retro hepatic IVC injuries (RHVCI) are extremely rare and lethal. The open surgical technique of treating these injuries is a master skill which is not available for most surgeons taking care of these patients. The endovascular trauma management (EVTM) application dictates a new approach in some cases based on applying arterial treatment concepts to the venous trauma cases. We hereby describe a novel technique in which the known chimney technique, often used to treat juxta renal abdominal aortic aneurysm, was used to prevent iatrogenic Budd Chiary which might have been caused by hepatic veins drainage occlusion by a Stent Graft (SG) that was inserted to treat RHVCI. Care should be taken to prevent secondary cardiac injury by long SG.

Background: Arterialization of the foot veins in patients with ischemic foot usually result in excessive foot edema, wound infection, venous gangrene, long hospitalization duration, and a high rate of amputation. We herein present an improved method of foot revascularization via the superficial venous system by in situ reverse arterialization (ISRA) of the foot venous bed, leaving the distal saphenous side branches open. Methods: A 69-year-old patient with toe wet gangrene and end-stage peripheral vascular disease with absence of foot target arteries underwent ISRA procedure, using the great saphenous vein, which was anastomosed end-to-side to the proximal superficial femoral artery. Only proximal saphenous tributaries were ligated until arterial flow reached the pedal superficial veins. Results: Postoperatively, the foot regained normal pulsation over the superficial venous system. The patient did not experience foot edema. On-table subtraction angiography demonstrated arterial flow through the long saphenous and dorsal foot veins, with returned venous flow through the anterior and posterior tibial veins. Methoxyisobutylisonitrile scan conducted 4 weeks postoperatively demonstrated positive oxygen uptake of the pedal muscles, which was absent before surgery. Electron microscopy of the muscles at the level of the transmetatarsal amputation demonstrated regeneration of muscle tissue with mitosis 6 weeks postoperatively. During 1,000 days of follow-up postsurgery, the flow was reduced and the transcutaneous pO(2) level of the foot increased up to 76 mm Hg. Conclusions: This new modified surgical technique of ISRA, in which only proximal saphenous tributaries were ligated in order to prevent high systemic pressure in the foot venous low pressure system, resulted in increased levels of transcutaneous pO(2) and reduced flow, leading to full recovery of the ischemic foot.

OBJECTIVE:In this study we report our experience in the management of Splenic Artery Aneurysm (SAA), diagnosed during pregnancy. STUDY DESIGN:The current manuscript describes three different events, treated in out our department, involving SAAs diagnosed during pregnancy. Each case presents an unusual course and a unique clinical challenge. RESULTS:The first case is of a 25 week's gestation twin pregnancy with ruptured SAA ending in maternal and fetal death. Another case of SAA rupture presented at 27 week's gestation with consequent emergency cesarean section and splenectomy. In the last case, two SAAs were incidentally diagnosed at 25 weeks' singleton gestation. The patient was managed conservatively and delivered by an elective cesarean section at 34 weeks followed by postpartum angiographic embolization of the aneurysms. CONCLUSIONS:Health care providers and especially obstetricians should be aware of the diagnosis of ruptured SAA in a pregnant woman with abdominal discomfort and hemodynamic deterioration. In addition, once an asymptomatic pregnant patient is diagnosed with a SAA, conservative surveillance may be allowed.

Objective: In this study, we present a novel approach for inducing vasoconstriction by pulsed electrical treatment delivered via endovascular electrodes, which can be used in cases where external access to the vessel is limited. Methods: Using computer simulations, we optimized various geometries of endovascular electrodes to maximize the induced electric field on the arterial wall. Using the optimal configuration parameters, we investigated endovascular induced vasoconstriction in both the carotid and femoral sheep arteries. Results: Endovascular electrodes induced robust vasoconstriction in the carotid artery of sheep, showing gradual recovery following treatment. Moreover, the obtained vasoconstriction was accompanied by a seven-fold decrease in blood loss for 100% constriction, compared with no treatment (6 ml versus 42 ml, p < 0.001). The femoral artery was less amenable to the electrical treatment, which we hypothesize results from the reduced density of the sympathetic system's innervation of the adventitia of the sheep femoral artery, as was validated by immunohistochemical analysis. Finally, treatment safety was validated through arterial histological studies, in which no adverse effect was observed, and through computer modeling, which depicted a negligible temperature increase. Significance: These results are an important step toward developing a novel approach for inducing reversible and controlled vasoconstriction in arteries that are remote from access.

Penetrating thoracic aortic injuries are very rare, comprising only 1% of all thoracic vascular injuries and 13% of penetrating injuries to the thoracic aorta [1,2]. These injuries are usually fatal on the scene and have a very high mortality rate, 55%, even among the few who are alive when they arrive at the emergency room (ER) [3]. Most patients who reach the ER are in shock due to intrathoracic hemorrhage and as such should be transferred immediately to the operating room (OR). However, most trauma patients around the world are treated in hospitals which lack cardiac and vascular surgeons who are familiar with this complicated area of the aorta. Endovascular treatment, either as temporary bleeding control or as a definitive measure, seems a promising option. We hereby report a case of a patient with several stab wounds, to the thoracic inlet, with proximal descending aortic injury. The clinical course and therapeutic dilemmas are discussed.

The treatment of vascular injuries remains a significant challenge of modern trauma care. This is particularly true of injuries at challenging anatomic locations or that are complex in nature. The mortality rates from these injuries can be high, despite recent progress in application of damage control management concepts. Developments of endovascular techniques have introduced new alternatives to traditional open repair strategies that may prove useful in the setting of complex vascular injury. The concept of endovascular and hybrid trauma management (EVTM) gains experience which allows replacing traditional principles of open vascular management in selected cases. Endovascular modalities, specifically intra-vascular balloon occlusion, offer a novel strategy that may be of particular use in these situations. Our present case presentation outlines an example of successful utilization of this approach and affords an opportunity to review a simplified approach using endovascular balloons as proximal and distal control measures, in order to limit the challenges represented by more extensive anatomic exposures in a victim of trauma.

Background The possibility of coronary steal through an arteriovenous fistula (AVF) in hemodialysis (HD) patients with coronary artery bypass grafts (CABGs) using an ipsilateral internal thoracic artery (ITA) has been suggested. In order to define the significance of such a possibility, we analyzed cardiac events and mortality risk in patients in relation to AVF flow. Methods A retrospective cohort study was performed on prevalent HD patients from a single center. The outcomes included a first cardiac event, cardiac death and death from any cause. Results The group consisted of 23 chronic HD patients having ITA CABG and upper extremity AV access, 12 patients had an ipsilateral and 11 patients had a contralateral location of ITA CABG and an upper extremity AV access. The mean follow-up period was for 37.0 months. Multivariable Cox proportional-hazards regression analysis of risk of death from any cause in relation to AV access flow showed no increased risk, neither in the group with ipsilateral location of ITA grafts and dialysis accesses (adjusted HR, 3.047 [95% CI, 0.996 to 1.000], p = 0.081), nor in the group with contralateral location of both shunts (adjusted HR, 0.173 [95% CI, 0.997 to 1.002], p = 0.678). There was no significant correlation between AV access blood flow and the risk of first cardiac event as well as cardiac death in either study group. Conclusions In this study on HD patients having ipsilateral ITA CABG and AVF, fistula flow rate was not found to be associated with mortality or cardiac risk.

Objectives A high prevalence (10%) of vascular trauma (VT) was previously described in terror-related trauma as compared with non–terror-related trauma (1%), in a civilian setting. No data regarding outcome of VT casualties of improvised explosive device (IED) explosions, in civilian settings, are available. The aim of the current study is to present the prognosis of civilian casualties of IED explosions with and without VT. Methods A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from September 2000 to December 2005 who were victims of explosions were included. These patients were subdivided into patients with VT (n = 109) and non-VT (NVT) (n = 1,152). Both groups were analyzed according to mechanism of trauma, type and severity of injury, and treatment. Results Of 1,261 explosion casualties, there were 109 VT victims (8.6%). Patients with VT tended to be more complex, with a higher injury severity score (ISS): 17.4% with ISS 16 to 24 as compared with only 10.5%. In the group of critically injured patients (ISS, 25–75), 51.4% had VT compared with only 15.5% of the NVT patients. As such, a heavy share of hospitals’ resources were used—trauma bay admission (62.4%), operating rooms (91.7%), and intensive care unit beds (55.1%). The percentage of VT patients who were admitted for more than 15 days was 2.3 times higher than that observed among the NVT patients. Lower-extremity VT injuries were the most prevalent. Although many resources are being invested in treating this group of patients, their mortality rate is approximately five times more than NVT (22.9% vs. 4.9%). Conclusions Vascular trauma casualties of IED explosions are more complex and have poorer prognosis. Their higher ISS markedly increases the hospital’s resource utilization, and as such, it should be taken into consideration either upon the primary evacuation from the scene or when secondary modulation is needed in order to reduce the burden of the hospitals receiving the casualties. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level V.

OBJECTIVES:A high prevalence (10%) of vascular trauma (VT) was previously described in terror-related trauma as compared with non-terror-related trauma (1%), in a civilian setting. No data regarding outcome of VT casualties of improvised explosive device (IED) explosions, in civilian settings, are available. The aim of the current study is to present the prognosis of civilian casualties of IED explosions with and without VT.METHODS:A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from September 2000 to December 2005 who were victims of explosions were included. These patients were subdivided into patients with VT (n = 109) and non-VT (NVT) (n = 1,152). Both groups were analyzed according to mechanism of trauma, type and severity of injury, and treatment.RESULTS:Of 1,261 explosion casualties, there were 109 VT victims (8.6%). Patients with VT tended to be more complex, with a higher injury severity score (ISS): 17.4% with ISS 16 to 24 as compared with only 10.5%. In the group of critically injured patients (ISS, 25-75), 51.4% had VT compared with only 15.5% of the NVT patients. As such, a heavy share of hospitals' resources were used-trauma bay admission (62.4%), operating rooms (91.7%), and intensive care unit beds (55.1%). The percentage of VT patients who were admitted for more than 15 days was 2.3 times higher than that observed among the NVT patients. Lower-extremity VT injuries were the most prevalent. Although many resources are being invested in treating this group of patients, their mortality rate is approximately five times more than NVT (22.9% vs. 4.9%).CONCLUSIONS:Vascular trauma casualties of IED explosions are more complex and have poorer prognosis. Their higher ISS markedly increases the hospital's resource utilization, and as such, it should be taken into consideration either upon the primary evacuation from the scene or when secondary modulation is needed in order to reduce the burden of the hospitals receiving the casualties.LEVEL OF EVIDENCE:Prognostic/epidemiologic study, level V.

BACKGROUND:Extremity injuries, which accounts for 20% of all battlefield injuries, result in 7-9% of deaths during military activity. Silicone tourniquets were used, by the Israeli Defense Force (IDF) soldiers, for upper extremity and calf injuries, while thigh injuries were treated by an improvised "Russian" tourniquet (IRT). This is the first study, performed in the IDF, comparing the IRT with Combat Application Tourniquets (CAT) and Special Operations Force Tactical Tourniquets (SOFTT). 23 operators from the Israeli Naval Unit (Shayetet 13) were divided into two groups according to their medical training (11 operators trained as first-responders; 12 operators as medics). Repetitive applications of the three tourniquets over the thigh and upper arm, and self-application of the CAT and SOFTT over the dominant extremity were performed using dry and wet tourniquets (828 individual placements) with efficacy recorded. Cessation of distal arterial flow (palpation; Doppler ultrasound) confirmed success, while failure was considered in the advent of arterial flow or tourniquet instability. Satisfaction questionnaires were filled by the operators.RESULTS:CAT and SOFTT were found to be superior to the IRT, in occluding arterial blood flow to the extremities (22%, 23% and 38%, respectively, failure rate). The application was quicker for the CAT and SOFTT as compared to the IRT (18, 26, 52 seconds, respectively). Wet tourniquets neither prolonged application nor did they increase failure rates. Similarly, medics didn't have any advantage over non-medic operators. No findings indicated superiority of CAT and SOFTT over one another, despite operators' preference of CAT.CONCLUSIONS:CAT and SOFTT offer an effective alternative to the IRT in stopping blood flow to extremities. No difference was observed between medics and non-medic operators. Thus, the CAT was elected as the preferred tourniquet by our unit and it is being used by all the operators.

OBJECTIVES:Extensive literature exists about military trauma as opposed to the very limited literature regarding terror-related civilian trauma. However, terror-related vascular trauma (VT), as a unique type of injury, is yet to be addressed.METHODS:A retrospective analysis of the Israeli National Trauma Registry was performed. All patients in the registry from 09/2000 to 12/2005 were included. The subgroup of patients with documented VT (N = 1,545) was analyzed and further subdivided into those suffering from terror-related vascular trauma (TVT) and non-terror-related vascular trauma (NTVT). Both groups were analyzed according to mechanism of trauma, type and severity of injury and treatment.RESULTS:Out of 2,446 terror-related trauma admissions, 243 sustained TVT (9.9%) compared to 1302 VT patients from non-terror trauma (1.1%). TVT injuries tend to be more complex and most patients were operated on. Intensive care unit admissions and hospital length of stay was higher in the TVT group. Penetrating trauma was the prominent cause of injury among the TVT group. TVT group had a higher proportion of patients with severe injuries (ISS ≥ 16) and mortality. Thorax injuries were more frequent in the TVT group. Extremity injuries were the most prevalent vascular injuries in both groups; however NTVT group had more upper extremity injuries, while the TVT group had significantly much lower extremity injuries.CONCLUSION:Vascular injuries are remarkably more common among terror attack victims than among non-terror trauma victims and the injuries of terror casualties tend to be more complex. The presence of a vascular surgeon will ensure a comprehensive clinical care.

Screening for asymptomatic carotid artery stenosis (CAS) is highly controversial Many surgeons routinely screen their patients for carotid disease prior to major operations, yet the benefit of such practice was never demonstrated. The treatment of symptomatic patients has not changed much during the last twenty years, since the publication of the North American Symptomatic Carotid Endarterectomy Trial (NASCET). However, in contrast, the Asymptomatic Carotid Atherosclerosis Study (ACAS) and the Asymptomatic Carotid Surgery Trial (ACST) failed to get the same acceptance among the multidisciplinary group treating CAS.The prevalence of asymptomatic 60-99% carotid artery stenosis among the general population is about 1%. Neither ACAS nor ACST showed that stenosis severity was associated with increasing stroke risk. The 'realpolitik' is that mass interventions in asymptomatic patients will probably only ever prevent about 1% of all strokes. This is even truer regarding patients scheduLed for major operation, in which the incidence of stroke is less than 1%. Moreover the current evidence in the literature suggests that the best medicaL treatment (BMT) results in 0.5% strokes per year, better than resuLts which can be offered by surgery. According to the current evidence, it seems that asymptomatic carotid artery screening should be discontinued, since it is a major waste of resources.

Groin infection after vascular reconstruction is one of the most severe complications, necessitating aggressive surgical therapy. Maintaining limb perfusion along with removal of an infected graft sometimes requires an unorthodox surgical solution. We describe such an unorthodox surgical approach, in which a new graft was routed from the infrarenal aorta to the anterior tibial artery through the iliac bone wing.

HomeStrokeVol. 44, No. 4Why Calls for More Routine Carotid Stenting Are Currently Inappropriate Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBWhy Calls for More Routine Carotid Stenting Are Currently InappropriateAn International, Multispecialty, Expert Review and Position Statement Anne L. Abbott, MD, PhD, FRACP, Mark A. Adelman, MD, Andrei V. Alexandrov, MD, P. Alan Barber, PhD, MBChB, FRACP, Henry J.M. Barnett, CC, MD, Jonathan Beard, FRCS, ChM, MEd, Peter Bell, FRCS, MD, DSC, KBE, Martin Björck, MD, PhD, David Blacker, MD, FRACP, Leo H. Bonati, MD, Martin M. Brown, MD, FRCP, Clifford J. Buckley, MD, FACS, Richard P. Cambria, MD, John E. Castaldo, MD, Anthony J. Comerota, MD, FACS, RVT, E. Sander ConnollyJr, MD, Ronald L. Dalman, MD, FACS, Alun H. Davies, MA, DM, FRCS, FHEA, FEBVS, FACPh, Hans-Henning Eckstein, MD, PhD, Rishad Faruqi, MD, FRCS (Eng), FRCS (Ed), FACS, Thomas E. Feasby, MD, Gustav Fraedrich, MD, Peter Gloviczki, MD, Graeme J. Hankey, MD, FRACP, Robert E. Harbaugh, MD, FAANS, FACS, Eitan Heldenberg, MD, Michael G. Hennerici, MD, Michael D. Hill, MD, MSc, FRCPC, Timothy J. Kleinig, PhD FRACP, MBBS (Hons), BA, Dimitri P. Mikhailidis, BSc, MSc, MD, FRSPH, FCP, FFPM, FRCP, FRCPath, Wesley S. Moore, MD, Ross Naylor, MD, FRCS, Andrew Nicolaides, MS, FRCS, PhD (Hon), Kosmas I. Paraskevas, MD, PhD, David M. Pelz, MD, FRCPC, James W. Prichard, MD, Grant Purdie, MD, FRACP, Jean-Baptiste Ricco, MD, PhD, Peter A. Ringleb, MD, PhD, Thomas Riles, MD, Peter M. Rothwell, MD, PhD, FRCP, FMedSci, Peter Sandercock, MA, DM, FRCPE, FMedSci, Henrik Sillesen, MD, DMSc, J. David Spence, BA, MBA, MD, FRCPC, FCAHS, Francesco Spinelli, MD, Jonathon Sturm, MBChB, PhD, Aaron Tan, MD, FRACP, Ankur Thapar, BSc, MBBS, MRCS, Frank J. Veith, MD, Tissa Wijeratne, MD, FRACP and Wei Zhou, MD Anne L. AbbottAnne L. Abbott From the School of Public Health and Preventive Medicine, The Alfred Centre, Monash University, Melbourne, Australia (A.L.A.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.A.); Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (A.L.A.); Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY (M.A.A.); Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL (A.V.A.); Department of Medicine, Centre for Brain Research, University of Auckland, Auckland, New Zealand (A.B.); Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada (H.J.M.B.); Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom (J.B.); University of Leicester, University of Leicester Hospitals, Leicester, United Kingdom (P.B.); Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden (M.B.); Neurology Department, Sir Charles Gairdner Hospital, Perth, Australia (D.B.); Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (L.B.); UCL Institute of Neurology, The National Hospital, Queen Square, London, United Kingdom (M.M.B.); Texas A&M Health Sciences Center College of Medicine, Scott and White Health Care Systems, Central Texas Veterans Health Care System, Temple, TX (C.J.B.); Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.P.C.); Neurology Division, USF College of Medicine, Lehigh Valley Health Network, Allentown, PA (J.E.C.); Jobst Vascular Institute, The Toledo Hospital, Toledo, OH (A.J.C.); Department of Neurological Surgery, Columbia University, New York, NY (E.S.C.); Divisions of Vascular Surgery and Cardiovascular Health (Quality and Outcomes), Stanford University, Stanford, CA (R.L.D.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom (A.H.D.); Department for Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen, Universität München, München, Germany (H.-H.E.); Stanford University, Stanford, CA (R.F.); University of California, San Francisco, CA (R.F.); Department of Vascular and Endovascular Surgery, Kaiser Permanente Medical Center, Santa Clara, CA (R.F.); Department of Clinical Neurosciences Faculty of Medicine, University of Calgary, Calgary, Canada (T.E.F.); Department of Vascular Surgery, Medical University, Innsbruck, Austria (G.F.); Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (P.G.); Neurology Department, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.); Penn State Institute of the Neurosciences, Penn State University, Hershey, PA (R.E.H.); Department of Vascular Surgery, Assaf Harofeh Medical Center, Zerifin, Israel (E.H.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.H.); Neurologische Universitätsklinik, Universitätsmedizin Mannheim, UMM; University of Heidelberg, Mannheim, Germany (M.G.H.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (M.D.H.); Neurology Department, Royal Adelaide and Lyell McEwin Hospitals, Adelaide, Australia (T.J.K.); Department of Medicine, University of Adelaide, Adelaide, Australia (T.J.K.); Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London, London, United Kingdom (D.P.M.); Division of Vascular Surgery, UCLA, Los Angeles, CA (W.S.M.); Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom (R.N.); Department of Vascular Surgery, Imperial College, London, Vascular Non-invasive Diagnostic Centre, London, United Kingdom (A.N.); Red Cross Hospital, Athens, Greece (K.I.P.); Medical Imaging and Clinical Neurological Sciences, University of Western Ontario, London, ON, Canada (D.M.P.); Neurology Department, Yale Medical School, New Haven, CT (J.W.P.); Neurology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia (G.P., A.T.); Vascular Surgery Service, University of Poitiers, Poitiers, France (J-B.R.); Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.A.R.); Division of Vascular Surgery, New York University School of Medicine, New York, NY (T.R.); Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom (P.M.R.); Division of Clinical Neuroscience, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (H.S.); Neurology and Clinical Pharmacology, University of Western Ontario, London, ON, Canada (J.D.S.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, London, ON, Canada (J.D.S.); Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy (F.S.); Neurology Department, Gosford and Wyong Hospitals, University of Newcastle, New South Wales, Australia (J.S.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College, London, London, United Kingdom (A.T.); Division of Vascular Surgery, New York University School of Medicine, Cleveland Clinic, Lerner School of Medicine of Case Western Reserve University, Edward Hebert School of Medicine, University of The Health Sciences, New York (F.J.V.); Neurology Department, Western Hospital, Western Clinical School, University of Melbourne, Melbourne, Australia (T.W.); and Vascular and Endovascular Surgery, Stanford University, Palo Alto VA Health Care System, Stanford, CA (W.Z.). Search for more papers by this author , Mark A. AdelmanMark A. Adelman From the School of Public Health and Preventive Medicine, The Alfred Centre, Monash University, Melbourne, Australia (A.L.A.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.A.); Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (A.L.A.); Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY (M.A.A.); Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL (A.V.A.); Department of Medicine, Centre for Brain Research, University of Auckland, Auckland, New Zealand (A.B.); Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada (H.J.M.B.); Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom (J.B.); University of Leicester, University of Leicester Hospitals, Leicester, United Kingdom (P.B.); Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden (M.B.); Neurology Department, Sir Charles Gairdner Hospital, Perth, Australia (D.B.); Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (L.B.); UCL Institute of Neurology, The National Hospital, Queen Square, London, United Kingdom (M.M.B.); Texas A&M Health Sciences Center College of Medicine, Scott and White Health Care Systems, Central Texas Veterans Health Care System, Temple, TX (C.J.B.); Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.P.C.); Neurology Division, USF College of Medicine, Lehigh Valley Health Network, Allentown, PA (J.E.C.); Jobst Vascular Institute, The Toledo Hospital, Toledo, OH (A.J.C.); Department of Neurological Surgery, Columbia University, New York, NY (E.S.C.); Divisions of Vascular Surgery and Cardiovascular Health (Quality and Outcomes), Stanford University, Stanford, CA (R.L.D.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom (A.H.D.); Department for Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen, Universität München, München, Germany (H.-H.E.); Stanford University, Stanford, CA (R.F.); University of California, San Francisco, CA (R.F.); Department of Vascular and Endovascular Surgery, Kaiser Permanente Medical Center, Santa Clara, CA (R.F.); Department of Clinical Neurosciences Faculty of Medicine, University of Calgary, Calgary, Canada (T.E.F.); Department of Vascular Surgery, Medical University, Innsbruck, Austria (G.F.); Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (P.G.); Neurology Department, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.); Penn State Institute of the Neurosciences, Penn State University, Hershey, PA (R.E.H.); Department of Vascular Surgery, Assaf Harofeh Medical Center, Zerifin, Israel (E.H.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.H.); Neurologische Universitätsklinik, Universitätsmedizin Mannheim, UMM; University of Heidelberg, Mannheim, Germany (M.G.H.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (M.D.H.); Neurology Department, Royal Adelaide and Lyell McEwin Hospitals, Adelaide, Australia (T.J.K.); Department of Medicine, University of Adelaide, Adelaide, Australia (T.J.K.); Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London, London, United Kingdom (D.P.M.); Division of Vascular Surgery, UCLA, Los Angeles, CA (W.S.M.); Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom (R.N.); Department of Vascular Surgery, Imperial College, London, Vascular Non-invasive Diagnostic Centre, London, United Kingdom (A.N.); Red Cross Hospital, Athens, Greece (K.I.P.); Medical Imaging and Clinical Neurological Sciences, University of Western Ontario, London, ON, Canada (D.M.P.); Neurology Department, Yale Medical School, New Haven, CT (J.W.P.); Neurology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia (G.P., A.T.); Vascular Surgery Service, University of Poitiers, Poitiers, France (J-B.R.); Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.A.R.); Division of Vascular Surgery, New York University School of Medicine, New York, NY (T.R.); Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom (P.M.R.); Division of Clinical Neuroscience, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (H.S.); Neurology and Clinical Pharmacology, University of Western Ontario, London, ON, Canada (J.D.S.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, London, ON, Canada (J.D.S.); Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy (F.S.); Neurology Department, Gosford and Wyong Hospitals, University of Newcastle, New South Wales, Australia (J.S.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College, London, London, United Kingdom (A.T.); Division of Vascular Surgery, New York University School of Medicine, Cleveland Clinic, Lerner School of Medicine of Case Western Reserve University, Edward Hebert School of Medicine, University of The Health Sciences, New York (F.J.V.); Neurology Department, Western Hospital, Western Clinical School, University of Melbourne, Melbourne, Australia (T.W.); and Vascular and Endovascular Surgery, Stanford University, Palo Alto VA Health Care System, Stanford, CA (W.Z.). Search for more papers by this author , Andrei V. AlexandrovAndrei V. Alexandrov From the School of Public Health and Preventive Medicine, The Alfred Centre, Monash University, Melbourne, Australia (A.L.A.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.A.); Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (A.L.A.); Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY (M.A.A.); Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL (A.V.A.); Department of Medicine, Centre for Brain Research, University of Auckland, Auckland, New Zealand (A.B.); Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada (H.J.M.B.); Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom (J.B.); University of Leicester, University of Leicester Hospitals, Leicester, United Kingdom (P.B.); Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden (M.B.); Neurology Department, Sir Charles Gairdner Hospital, Perth, Australia (D.B.); Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (L.B.); UCL Institute of Neurology, The National Hospital, Queen Square, London, United Kingdom (M.M.B.); Texas A&M Health Sciences Center College of Medicine, Scott and White Health Care Systems, Central Texas Veterans Health Care System, Temple, TX (C.J.B.); Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.P.C.); Neurology Division, USF College of Medicine, Lehigh Valley Health Network, Allentown, PA (J.E.C.); Jobst Vascular Institute, The Toledo Hospital, Toledo, OH (A.J.C.); Department of Neurological Surgery, Columbia University, New York, NY (E.S.C.); Divisions of Vascular Surgery and Cardiovascular Health (Quality and Outcomes), Stanford University, Stanford, CA (R.L.D.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom (A.H.D.); Department for Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen, Universität München, München, Germany (H.-H.E.); Stanford University, Stanford, CA (R.F.); University of California, San Francisco, CA (R.F.); Department of Vascular and Endovascular Surgery, Kaiser Permanente Medical Center, Santa Clara, CA (R.F.); Department of Clinical Neurosciences Faculty of Medicine, University of Calgary, Calgary, Canada (T.E.F.); Department of Vascular Surgery, Medical University, Innsbruck, Austria (G.F.); Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (P.G.); Neurology Department, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.); Penn State Institute of the Neurosciences, Penn State University, Hershey, PA (R.E.H.); Department of Vascular Surgery, Assaf Harofeh Medical Center, Zerifin, Israel (E.H.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.H.); Neurologische Universitätsklinik, Universitätsmedizin Mannheim, UMM; University of Heidelberg, Mannheim, Germany (M.G.H.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (M.D.H.); Neurology Department, Royal Adelaide and Lyell McEwin Hospitals, Adelaide, Australia (T.J.K.); Department of Medicine, University of Adelaide, Adelaide, Australia (T.J.K.); Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London, London, United Kingdom (D.P.M.); Division of Vascular Surgery, UCLA, Los Angeles, CA (W.S.M.); Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom (R.N.); Department of Vascular Surgery, Imperial College, London, Vascular Non-invasive Diagnostic Centre, London, United Kingdom (A.N.); Red Cross Hospital, Athens, Greece (K.I.P.); Medical Imaging and Clinical Neurological Sciences, University of Western Ontario, London, ON, Canada (D.M.P.); Neurology Department, Yale Medical School, New Haven, CT (J.W.P.); Neurology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia (G.P., A.T.); Vascular Surgery Service, University of Poitiers, Poitiers, France (J-B.R.); Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.A.R.); Division of Vascular Surgery, New York University School of Medicine, New York, NY (T.R.); Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom (P.M.R.); Division of Clinical Neuroscience, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (H.S.); Neurology and Clinical Pharmacology, University of Western Ontario, London, ON, Canada (J.D.S.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, London, ON, Canada (J.D.S.); Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy (F.S.); Neurology Department, Gosford and Wyong Hospitals, University of Newcastle, New South Wales, Australia (J.S.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College, London, London, United Kingdom (A.T.); Division of Vascular Surgery, New York University School of Medicine, Cleveland Clinic, Lerner School of Medicine of Case Western Reserve University, Edward Hebert School of Medicine, University of The Health Sciences, New York (F.J.V.); Neurology Department, Western Hospital, Western Clinical School, University of Melbourne, Melbourne, Australia (T.W.); and Vascular and Endovascular Surgery, Stanford University, Palo Alto VA Health Care System, Stanford, CA (W.Z.). Search for more papers by this author , P. Alan BarberP. Alan Barber From the School of Public Health and Preventive Medicine, The Alfred Centre, Monash University, Melbourne, Australia (A.L.A.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.A.); Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (A.L.A.); Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY (M.A.A.); Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL (A.V.A.); Department of Medicine, Centre for Brain Research, University of Auckland, Auckland, New Zealand (A.B.); Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada (H.J.M.B.); Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom (J.B.); University of Leicester, University of Leicester Hospitals, Leicester, United Kingdom (P.B.); Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden (M.B.); Neurology Department, Sir Charles Gairdner Hospital, Perth, Australia (D.B.); Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (L.B.); UCL Institute of Neurology, The National Hospital, Queen Square, London, United Kingdom (M.M.B.); Texas A&M Health Sciences Center College of Medicine, Scott and White Health Care Systems, Central Texas Veterans Health Care System, Temple, TX (C.J.B.); Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.P.C.); Neurology Division, USF College of Medicine, Lehigh Valley Health Network, Allentown, PA (J.E.C.); Jobst Vascular Institute, The Toledo Hospital, Toledo, OH (A.J.C.); Department of Neurological Surgery, Columbia University, New York, NY (E.S.C.); Divisions of Vascular Surgery and Cardiovascular Health (Quality and Outcomes), Stanford University, Stanford, CA (R.L.D.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom (A.H.D.); Department for Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen, Universität München, München, Germany (H.-H.E.); Stanford University, Stanford, CA (R.F.); University of California, San Francisco, CA (R.F.); Department of Vascular and Endovascular Surgery, Kaiser Permanente Medical Center, Santa Clara, CA (R.F.); Department of Clinical Neurosciences Faculty of Medicine, University of Calgary, Calgary, Canada (T.E.F.); Department of Vascular Surgery, Medical University, Innsbruck, Austria (G.F.); Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (P.G.); Neurology Department, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.); Penn State Institute of the Neurosciences, Penn State University, Hershey, PA (R.E.H.); Department of Vascular Surgery, Assaf Harofeh Medical Center, Zerifin, Israel (E.H.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.H.); Neurologische Universitätsklinik, Universitätsmedizin Mannheim, UMM; University of Heidelberg, Mannheim, Germany (M.G.H.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (M.D.H.); Neurology Department, Royal Adelaide and Lyell McEwin Hospitals, Adelaide, Australia (T.J.K.); Department of Medicine, University of Adelaide, Adelaide, Australia (T.J.K.); Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London, London, United Kingdom (D.P.M.); Division of Vascular Surgery, UCLA, Los Angeles, CA (W.S.M.); Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom (R.N.); Department of Vascular Surgery, Imperial College, London, Vascular Non-invasive Diagnostic Centre, London, United Kingdom (A.N.); Red Cross Hospital, Athens, Greece (K.I.P.); Medical Imaging and Clinical Neurological Sciences, University of Western Ontario, London, ON, Canada (D.M.P.); Neurology Department, Yale Medical School, New Haven, CT (J.W.P.); Neurology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia (G.P., A.T.); Vascular Surgery Service, University of Poitiers, Poitiers, France (J-B.R.); Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany (P.A.R.); Division of Vascular Surgery, New York University School of Medicine, New York, NY (T.R.); Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom (P.M.R.); Division of Clinical Neuroscience, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom (P.S.); Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (H.S.); Neurology and Clinical Pharmacology, University of Western Ontario, London, ON, Canada (J.D.S.); Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, London, ON, Canada (J.D.S.); Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy (F.S.); Neurology Department, Gosford and Wyong Hospitals, University of Newcastle, New South Wales, Australia (J.S.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College, London, London, United Kingdom (A.T.); Division of Vascular Surgery, New York University School of Medicine, Cleveland Clinic, Lerner School of Medicine of Case Western Reserve University, Edward Hebert School of Medicine, University of The Health Sciences, New York (F.J.V.); Neurology Department, Western Hospital, Western Clinical School, University of Melbourne, Melbourne, Australia (T.W.); and Vascular and Endovascular Surgery, Stanford University, Palo Alto VA Health Care System, Stanford, CA (W.Z.). Search for more papers by this author , Henry J.M. BarnettHenry J.M. Barnett From the School of Public Health and Preventive Medicine, The Alfred Centre, Monash University, Melbourne, Australia (A.L.A.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (A.L.A.); Florey Institute of Neuroscience and Mental Health, Melbourne, Australia (A.L.A.); Division of Vascular and Endovascular Surgery, New York University Langone Medical Center, New York, NY (M.A.A.); Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL (A.V.A.); Department of Medicine, Centre for Brain Research, University of Auckland, Auckland, New Zealand (A.B.); Clinical Neurological Sciences, Division of Neurology, University of Western Ontario, London, Canada (H.J.M.B.); Sheffield Vascular Institute, Northern General Hospital, Sheffield, United Kingdom (J.B.); University of Leicester, University of Leicester Hospitals, Leicester, United Kingdom (P.B.); Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden (M.B.); Neurology Department, Sir Charles Gairdner Hospital, Perth, Australia (D.B.); Department of Neurology and Stroke Unit, University Hospital Basel, Basel, Switzerland (L.B.); UCL Institute of Neurology, The National Hospital, Queen Square, London, United Kingdom (M.M.B.); Texas A&M Health Sciences Center College of Medicine, Scott and White Health Care Systems, Central Texas Veterans Health Care System, Temple, TX (C.J.B.); Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (R.P.C.); Neurology Division, USF College of Medicine, Lehigh Valley Health Network, Allentown, PA (J.E.C.); Jobst Vascular Institute, The Toledo Hospital, Toledo, OH (A.J.C.); Department of Neurological Surgery, Columbia University, New York, NY (E.S.C.); Divisions of Vascular Surgery and Cardiovascular Health (Quality and Outcomes), Stanford University, Stanford, CA (R.L.D.); Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom (A.H.D.); Department for Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen, Universität München, München, Germany (H.-H.E.); Stanford University, Stanford, CA (R.F.); University of California, San Francisco, CA (R.F.); Department of Vascular and Endovascular Surgery, Kaiser Permanente Medical Center, Santa Clara, CA (R.F.); Department of Clinical Neurosciences Faculty of Medicine, University of Calgary, Calgary, Canada (T.E.F.); Department of Vascular Surgery, Medical University, Innsbruck, Austria (G.F.); Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN (P.G.); Neurology Department, Royal Perth Hospital, University of Western Australia, Perth, Australia (G.J.H.); Penn State Institute of the Neurosciences, Penn State University, Hershey, PA (R.E.H.); Department of Vascular Surgery, Assaf Harofeh Medical Center, Zerifin, Israel (E.H.); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (E.H.); Neurologische Universitätsklinik, Universitätsmedizin Mannheim, UMM; University of Heidelberg, Mannheim, Germany (M.G.H.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada (M.D.H.); Neurology Department, Royal Adelaide and Lyell McEwin Hospitals, Adelaide, Australia (T.J.K.); Department of Medicine, University of Adelaide, Adelaide, Australia (T.J.K.); Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London, London, United Kingdom (D.P.M.); Division of Vascular Surgery, UCLA, Los Angeles, CA (W.S.M.); Vascular Surgery Group, Division of Cardiovascular Sciences, Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom (R.N.); Department of Vascular Surgery, Imperial College, London, Vascular Non-invasive Diagnostic Centre, Lond

Cerebral hyperperfusion syndrome (CHPS) is a rare, complication of carotid artery revascularization. Acute retinal hemorrhage is a very rare entity previously described as a manifestation of CHPS following carotid artery stenting (CAS), but to the best of our knowledge, not yet described as a complication of carotid surgery. An Ascending Aorta to bilateral Carotid bypass was performed in a 35-year-old woman with active Takayasu arteritis and 95% symptomatic stenosis of both common carotid arteries. Severe retinal hemorrhage appeared on the second post operative day combined with high blood pressure, brain edema on CT scan and grand mal seizures. It seems that fundoscopic examination following carotid revascularization of tight can be helpful in identifying those patients who develop symptoms suggesting of CHPS.

Lymphedema is the "neglected vascular disease". A lot has been written about arterial and venous pathologies but our knowledge, as physicians, about the pathophysiology on the one hand and about the treatment, on the other hand, is scarce. Lymphedema is subdivided into primary and secondary disease. The primary lymphedema is further subdivided to congenital, praecox and tarda. Conservative treatment is the first line of therapy. Surgery has not been proven as a good solution for this disease, and furthermore, even when operations are being conducted, conservative treatment should be continued on a daily basis. It seems that further research about this "forgotten disease" should be designed in order to improve the treatment of these complicated patients.