BACKGROUND:The purpose of this study is to better define the clinical relevance of aneurysms affecting collateral vessels in patients with celiac artery (CA) occlusive disease. METHODS:True pancreaticoduodenal artery (PDA) and gastroduodenal artery (GDA) aneurysms associated with CA stenoses or occlusions reported from 1970 to 2010 in the English literature and similar cases treated at the University of Michigan were reviewed. Clinical presentations and differing treatment modalities were documented and analyzed. RESULTS:One hundred twenty-five patients having CA occlusive disease exhibited true arterial aneurysms affecting the PDA (105 patients), GDA (10 patients), or both PDA and GDA and their branches (10 patients). Aneurysm size averaged 2.1 cm. Included were 110 patients culled from the literature and 15 treated by the authors. The mean age of patients in this series was 59 years and there was no gender predilection. Aneurysms were asymptomatic in 26%. Abdominal pain affected 54% of the patients, including all who experienced rupture. Rupture occurred in 48 patients of whom 15 were hemodynamically unstable, including 6 who died. Surgical interventions included endovascular embolization (39), aneurysmectomy alone (25), and aneurysmectomy with arterial reconstruction (20). Salutary outcomes occurred in 91% of the cases. Open surgical procedures have remained constant, but were equaled by endovascular interventions in 1996, with the latter having increased 3-fold in the past 15 years. CONCLUSIONS:PDA and GDA aneurysms associated with CA occlusive disease carry a high risk of nonfatal rupture, warranting early treatment. Endovascular and open interventions may be successfully undertaken with minimal risks in treating these uncommon aneurysms.

Background: Risk factors and outcomes after iliofemoral complications after thoracic aortic endovascular repair remain poorly characterized. This study was performed to characterize factors influencing perioperative iliofemoral complications during thoracic aortic endovascular repair.Methods: All patients undergoing transfemoral thoracic aortic endovascular repair since 2005 with adequate preoperative aortoiliac 3-dimensional imaging (n = 126) were identified. Assessment of imaging was blinded with regard to occurrence of iliofemoral complications, defined as anything other than successful transfemoral device delivery and primary closure of an arteriotomy.Results: The complication rate was 12% (n = 15). Univariate analysis identified that female gender, preoperative ankle-brachial index, average and minimal iliac diameters, diameter difference between iliac artery and sheath size, and iliac morphology score (calculated by combining iliac tortuosity, calcification, and vessel diameter) were associated with iliofemoral complications (all P < .05). Multivariate analysis identified the (1) difference between average iliac diameter and sheath size (P = .014), (2) iliac artery morphology score (P = .033), and (3) ankle-brachial index (P = .012) as independent predictors for iliofemoral complications. Early mortality was higher in those with complications (13.3% vs 1.8%, P = .069). Four-year freedom from limb loss, claudication, or revascularization was 97.9%. Iliofemoral complications reduced late survival primarily as a result of increased mortality within the first year (P = .047).Conclusions: Thoracic aortic endovascular repair can be performed safely via a transfemoral approach. Alternative access in patients with high preoperative iliac artery morphology scores and device delivery size requirements over the native iliofemoral size may reduce iliofemoral complications. If early complications occur, prompt repair results in low rates of ischemic limb complications at late follow-up.

Background: Postoperative care of open abdominal aortic surgery (OAAS) traditionally involves the intensive care unit (ICU). We hypothesized that in patients without an indication for postoperative ICU admission, admission to a specialized vascular floor unit (hemodynamic monitoring, 2:1 nursing) offers cost savings to both payer and institution without compromising care.Methods: The electronic medical record was used to collect perioperative data for patients who underwent OAAS between July 2007 and July 2011. The university's cost accounting system provided information on revenue, total margin, and professional billing. Patients with ICU indications (spinal drain, Swan-Ganz monitoring, vasopressors, intubation, or blood product resuscitation) were excluded. Comparative cost and outcome analysis was performed on vascular ward and ICU admissions using the Fisher's exact test for dichotomous categorical variables and the Student's t-test for continuous variables. Long-term survival comparison was calculated using Kaplan-Meier survival estimates.Results: One hundred thirty of 215 patients were included for analysis (85 excluded, 51 floor, 79 ICU). Perioperative data amongst the floor and ICU cohorts were similar. Day of operation professional billing fees were comparable (ICU $13,365 vs. floor $12,626; P = 0.18); however, postoperative professional fees were significantly higher in the ICU cohort (ICU $3,258 vs. floor $2,101; P = 0.001) primarily because of intensivist billing. The hospital generated an average of 8.7% more revenue from the ICU cohort (ICU $37,770 vs. floor $34,756; P = 0.023). This was offset by greater expenses in the ICU cohort (ICU $30,756 vs. floor $25,144; P = 0.02), yielding a hospital profit margin of 107.5% favoring floor admission (ICU $2,858 vs. floor $5,931; P = 0.19). Duration of stay was similar (ICU 8.0 days vs. floor 7.8 days; P = 0.86). Kaplan-Meier survival analysis was not significantly different between cohorts (ICU 10.1%, median follow-up, 1,070 days vs. floor 0%, median follow-up, 405 days; P = 0.13).Conclusions: Postoperative admission to the ICU is not always necessary after OAAS. Specialized vascular floors offer a financial savings to both payer and institution, which allows for simultaneous cost containment while preserving quality outcomes.

Background: Chronic occlusion of the femoral or the proximal popliteal vein responsible for venous obstruction and the constellation of clinical sequelae that ensue remains a surgical challenge that carries notable patient morbidity. Sapheno-popliteal bypass (SPB) remains a surgical reconstructive option for select patients that demonstrate patency of the popliteal vein, great saphenous vein, saphenofemoral junction, and iliac veins. We sought to analyze our single-institution experience with this technique.Methods: A retrospective review of a single-center experience with SPB was performed. Preoperative risk factors and indications for intervention (ie, venous claudication, ulceration) were identified. Duration of follow-up and endpoints, including clinical improvement, wound healing, patency, and limb loss were assessed. A Kaplan-Meier analysis for primary and secondary patency was performed.Results: Seventeen patients underwent SPB for chronic lower extremity venous obstruction between July 1988 and August 2011. Median age at operation was 41 years (range, 23-69 years). There was a male predominance noted (n = 12; 71%). All patients had chronic edema and venous claudication. Five patients (29%) had evidence of venous ulceration preoperatively. Eight patients (47%) underwent a preceding venous intervention (ie, iliac stenting or venous thrombolysis). Three patients had a concomitant arteriovenous fistula, created at the time of bypass to enhance in-flow; three patients underwent concomitant femoral-femoral venous bypass. Four patients (24%) experienced hematoma post-operatively that required operative evacuation; in two patients, compression from this hematoma resulted in early graft occlusion. After a median follow-up of 103 months (range, 3-271 months), 82% of patients experienced near or complete resolution of venous claudication. Three of the five patients with venous ulceration healed their wounds (67%). Of the 16 patients that underwent Duplex scan follow-up, primary patency after a median follow-up of 103 months was 56%, primary-assisted patency was 69%, and secondary patency was 75%. One patient required amputation approximately 21 years after SPB and there were no deaths. This secondary patency rate exceeds previously published patency rates.Conclusions: SPB may be indicated for certain patients with chronic venous stasis disease secondary to femoral venous obstruction that have failed other standard therapies. SPB remains a satisfactory and reliable procedure that produces clinical improvement in a selected group of patients and should be considered in a contemporary venous surgical practice.

Marjolin's ulcer is an aggressive form of squamous cell carcinoma that develops over time from chronic wounds and scars, including burns and chronic venous stasis ulcers. The incidence of malignant transformation is low, resulting in a delay in diagnosis and increased morbidity and mortality in these patients. We report a case of Marjolin's ulcer that was incidentally found after limb amputation for chronic venous stasis ulcer along with a comprehensive literature review on the etiology, diagnosis, and treatment of this disease.

13th Annual meeting of the European Venous Forum, Thursday 28 June–Saturday 30 June 2012, Florence, Italy A prospective study comparing ultrasonography and angiography for the diagnosis of chronic cerebrospinal venous insufficiency M Simka, T Ludyga, M Kazibudzki, P Latacz and P Janas Euromedic Specialist Clinics, Department of Vascular & Endovascular Surgery, Katowice, Poland Objectives: This study was aimed at testing the diagnostic accuracy of current sonographic criteria of chronic cerebrospinal venous insufficiency (CCSVI). In addition, we tried to identify alternative sonographic parameters associated with impaired outflow in the internal jugular veins. Method: Firstly, the findings of Doppler sonography were compared with the results of reference test: catheter venography. There were assessed 116 internal jugular veins and vertebral veins in 58 patients with associated multiple sclerosis. We evaluated our findings in the context of current sonographic criteria, proposed by Zamboni, and new criteria: by expert panel of the International Society for Neurovascular Disease (ISNVD). Secondly, we assessed 41 different sonographic variables, also those not mentioned in the current criteria (such as flow direction, peak flow velocity, cross-sectional area and diameter of the vein) in 115 patients. These parameters were also compared with venographic findings. Results: We found that although sonographic patterns suggesting outflow abnormalities were very common in multiple sclerosis patients: e.g. at least one positive Zamboni’s criterion was found in 92.2% of the assessed veins, their diagnostic accuracy was limited. For example, positive and negative predictive values of one positive Zamboni’s criteria were 79.4% and 33.3%, and of at least two positive criteria: 81.8% and 21.7%. Accuracy of ISNVD criteria was not much better. Multivariate regression analysis of 41 sonographic parameters revealed some variables that were associated with increased prevalence of venographic abnormalities: no flow detected in all three segments of internal jugular vein in upright position, peak flow velocity in the upper and middle segments in upright position less than 24 cm/second, and in lower segment less than 88 cm/second, peak flow velocity in the upper segment in supine position less than 24 cm/second, and cross-sectional area of the upper segment in the supine position less than 8 mm. However, even using these parameters we were unable to create a reliable set of criteria. Of note, many variables used by the current CCSVI sonographic protocols were not proven to be associated with increased prevalence of venographic pathology, for example: reduced or bidirectional flow in the vertebral veins. Conclusions: Our research is showing a clear gap in the understanding of haemodynamics in this particular venous territory. Consequently, more research is needed to improve diagnostic accuracy of Doppler sonography for the diagnosis of CCSVI. It is also possible that in this territory catheter venography is a tarnished ‘gold standard’ and that some abnormalities (e.g. compression of the vein by adjacent muscles) show only on sonography. Perhaps, a multimodal approach is required to evaluate these veins properly. Role of duplex ultrasound in chronic cerebrospinal venous insufficiency: a single centre experience with 711 patients A Al-Muzaini*, H Safar† and T Sinan‡ *Vascular Imaging Service; Vascular Surgery Service; Interventional Vascular Radiology Department, Mubarak Al-Kabeer

Varicose veins are an early manifestation of chronic venous insufficiency. Although the risk factors associated with varicose veins are well described, the basic pathophysiology leading to venous valvular incompetence, and thus, varicosities are less well known. However, cosmetics aside, the leg fatigue and heaviness that is associated with chronic venous insufficiency in the presence of varicose veins can be disabling. The treatment of superficial vein reflux has evolved in the past 10 years making open surgical ligation and stripping of the great saphenous vein largely a historic procedure. Endovenous ablation using catheter-based techniques achieve vein closure with minimal surgical risk. In the same sense, removal of varicosities associated with superficial reflux has also evolved. Traditionally, varicose veins were removed with multiple stab incisions and hook phlebectomy. The introduction of transilluminated-powered phlebectomy has allowed for removal of large clusters of varicose veins using fewer ...

Since first described by Parodi in 1991, endovascular aortic repair (EVAR) has progressively and dramatically changed the approach to treating abdominal aortic aneurysm (AAA) disease.1 Whereas historically developed to treat patients unfit for open repair, EVAR now represents the primary paradigm by which most infrarenal AAAs are managed. This paradigm shift has occurred in the setting of long-term clinical uncertainty and increased expense, largely secondary to the costs of the endograft itself. EVAR is currently performed by multiple interventional and surgical specialties. Outcomes are associated with lower in-hospital mortality rates compared with open repair, often permitting successful discharge of patients within 24 hours. Because the market share of EVAR has increased, the endograft industry has also seen tremendous growth and development. Cross-sectional imaging with 3-dimensional reconstructions has become paramount to the appropriate and timely management of aortic aneurysms. At present, even in the setting of aortic rupture, EVAR is preferred because it has been associated with lower mortality rates compared with open repair. Despite the rampant increase in EVAR, not all patients are anatomic candidates for EVAR as defined by industry-issued instructions for use. Therefore, alternative treatment strategies, such as altering endografts with fenestrations or sidearm grafts, snorkeling stent grafts alongside endografts, or performing hybrid debranching procedures with open bypasses to the viscerals and renals followed by endografting have been developed. Although the data supporting EVAR as the primary treatment option for infrarenal AAA is robust, its superiority over open repair can be questioned until the long-term outcomes (>10 years) from landmark randomized controlled trials begin to surface. Parenthetically, the indications for EVAR seem to be increasing because clinical equipoise remains ambiguous and fewer trainees are required to perform open AAA repair. Although early use of EVAR was primarily at centers of excellence, currently it has become the most …

Since first described by Parodi in 1991, endovascular aortic repair (EVAR) has progressively and dramatically changed the approach to treating abdominal aortic aneurysm (AAA) disease. Whereas historically developed to treat patients unfit for open repair, EVAR now represents the primary paradigm by which most infrarenal AAAs are managed. This paradigm shift has occurred in the setting of long-term clinical uncertainty and increased expense, largely secondary to the costs of the endograft itself. EVAR is currently performed by multiple interventional and surgical specialties. Outcomes are associated with lower in-hospital mortality rates compared with open repair, often permitting successful discharge of patients within 24 hours. Because the market share of EVAR has increased, the endograft industry has also seen tremendous growth and development. Cross-sectional imaging with 3-dimensional reconstructions has become paramount to the appropriate and timely management of aortic aneurysms. At present, even in the setting of aortic rupture, EVAR is preferred because it has been associated with lower mortality rates compared with open repair. Despite the rampant increase in EVAR, not all patients are anatomic candidates for EVAR as defined by industry-issued instructions for use. Therefore, alternative treatment strategies, such as altering endografts with fenestrations or sidearm grafts, snorkeling stent grafts alongside endografts, or performing hybrid debranching procedures with open bypasses to the viscerals and renals followed by endografting have been developed. Although the data supporting EVAR as the primary treatment option for infrarenal AAA is robust, its superiority over open repair can be questioned until the long-term outcomes (>10 years) from landmark randomized controlled trials begin to surface. Parenthetically, the indications for EVAR seem to be increasing because clinical equipoise remains ambiguous and fewer trainees are required to perform open AAA repair. Although early use of EVAR was primarily at centers of excellence, currently it has become the most common manner for AAA repair. This review will reflect on the landmark trials which have validated the use of EVAR. Data supporting the use of aortic endografts from the 4 primary manufacturers [Medtronic Inc (Minneapolis, MN), W.L Gore and Associates (Flagstaff, AZ), Cook Medical Inc (Bloomington, IN), and Endologix (Irvine, CA)] who have obtained Food and Drug Administration (FDA) approval will be summarized. The literature supporting the use of branched or fenestrated endografts for use in the management of pararenal and thoracoabdominal aortic aneurysms (TAAA) will be reviewed. Finally, we will discuss products in the endograft pipeline, as well as the expanding indications for EVAR.

Chronic occlusion of the femoral or the proximal popliteal vein responsible for venous insufficiency and the constellation of clinical sequelae that ensue remains a surgical challenge that carries notable patient morbidity and the threat of potential limb loss. Saphenopopliteal bypass remains a surgical reconstructive option for select patients that demonstrate patency of the popliteal vein, greater saphenous vein, saphenofemoral junction and pelvic veins. We sought to analyze our single-institution experience with this technique. A retrospective review of a single-center experience with saphenopopliteal transposition was performed. Preoperative risk factors and indications for intervention (ie: symptomatology including tissue loss) were identified. Duration of follow-up and end-points including clinical improvement, wound healing, patency and limb loss were assessed. A Kaplan-Meier analysis for patency was performed. Seventeen patients underwent a saphenopopliteal bypass for chronic lower extremity venous obstruction between July, 1988 and August, 2011. Median age at operation was 40 years (range, 23-69 years). There was a male predominance noted (N=12; 71%). All patients suffered from chronic edema and venous claudication. Six patients (35%) had evidence of venous ulceration preoperatively. Seven patients (41%) underwent a preceding venous intervention (ie: iliac stenting or venous thrombolysis). Three patients had a concomitant arteriovenous fistula created to enhance in-flow; two patients underwent concomitant femoral-femoral venous bypass. Five patients (29%) experienced hematoma postoperatively that required operative evacuation; in two patients compression from this hematoma resulted in early graft occlusion. After a median follow-up of 85 months (range, 2-236), 82% of patients experienced symptom improvement or near-complete symptom resolution. Four of the six patients with venous ulceration healed their wounds (67%). Of the sixteen patients that underwent Duplex follow-up, primary patency was 68.7% and secondary patency was 75%. (Fig) One patient required amputation and there were no deaths. This secondary patency rate exceeds any previously published patency rate. Saphenopopliteal bypass is indicated for chronic venous stasis disease secondary to deep venous obstruction at the thigh. This venous reconstruction option remains a satisfactory and reliable procedure that produces clinical improvement in a selected group of patients and should be considered in a contemporary venous surgical practice.

The relationship between CEAP class and Venous Clinical Severity Score (VCSS) change following great saphenous vein ablation (GSVa) is under reported. We further defined this relationship in patients including those with severe chronic venous disease (CVD) and the obese. We reviewed our prospectively collected venous procedural database from January 2007 to October 2010 for patients who had undergone GSVa (± phlebectomies). A CEAP class 5 or 6 designated severe CVD. VCSS were obtained preoperatively and at the 1st, 2nd, and 3rd follow up visits. 265 limbs in 216 patients underwent GSVa. (Table 1) Follow up was done at a mean of 7.5, 102.7, and 242.6 days postoperatively. A significant association between CEAP class and a declining VCSS following GSVa was seen, such that more severe CVD does not improve to the same degree as less severe CVD.(Fig 1) A direct correlation between increasing BMI and higher VCSS by a coefficient of .053 was demonstrated. (p < .001).Table 1Patient DemographicsCEAP 2CEAP 3CEAP 4CEAP 5 and 6p valueNUMBER OF LIMBS1111092916N/AMALE:FEMALE28:8722:8713:165:11.036MEAN AGE49.6752.4954.7953.19.094MEAN BMI28.9229.6032.8235.41.01RFA:EVLT59:5140:6910:1913:3.001PHLEBETOMIES n(%)66 (59%)32 (29%)8 (28%)2 (13%)<.001BMI - Body Mass Index (kg/m2); RFA - Radiofrequency Ablation; EVLT - Endovenous Laser Treatment Open table in a new tab BMI - Body Mass Index (kg/m2); RFA - Radiofrequency Ablation; EVLT - Endovenous Laser Treatment Although all groups improved, the degree of improvement was influenced by BMI and CEAP class. Realistic outcomes must be considered when counseling patients.

Objective: The combination of D-dimer and Wells score can exclude, but not confirm, the diagnosis of deep venous thrombosis (DVT). Since thrombosis and inflammation are interrelated, we evaluated the combination of soluble P-selectin (sPsel) with other inflammatory biomarkers for the diagnosis of DVT. Methods: Sixty-two positive and one hundred and sixteen patients with negative DVT, by duplex scan, were prospectively evaluated for sPsel, D-dimer, C-reactive protein (CRP), microparticles (MPs; total, leukocyte, and platelet-derived and tissue factor positive microparticles), and clinical Wells score. Results: Biomarkers and clinical scores that differentiated DVT positives from negatives were sPsel (87.3 vs 53.4 ng/mL, P < .0001), D-dimer (5.8 vs 2.1 mg/ L, P < .0001), CRP (2.1 vs 0.8 μg/mL, P < .0005), and Wells score (3.2 vs 2.0, P < .0001). For MP analysis, platelet-derived MPs were found to differentiate DVT from negatives. Using multivariable logistic regression, a combination of sPsel and Wells score could establish the diagnosis of DVT (cut point ≥90 ng/mL + Wells ≥2), with a specificity of 96% and positive predictive value (PPV) of 100%, and could exclude DVT diagnosis (cut point ≤60 ng/mL and Wells <2) with a sensitivity of 99%, a specificity of 33%, and a negative predictive value (NPV) of 96%. Conclusion: This study establishes a biomarker and clinical profile combination that can both confirm and exclude the diagnosis of DVT.

Objective: Although duplex ultrasound is the standard for the diagnosis of lower extremity deep venous thrombosis (LE-DVT), imaging is not always available. The use of D-dimer can exclude (high-sensitivity), but not rule in (low specificity) LE-DVT. Previously, we demonstrated that soluble P-selectin (sP-sel) in combination with the Wells score, establishes the diagnosis of LE-DVT with a specificity of 96% and a positive predictive value of 100%. In order to validate our previous results, we applied the model to a separate but similar patient cohort. Additionally, we analyzed the role of biomarkers for diagnosing upper extremity DVT (UE-DVT).Methods: Between April 2009 and March 2012, all patients presenting for a duplex ultrasound exam with concern of DVT were screened. Demographics, clinical data, D-dimer, sP-sel, C-reactive protein, a disintegrin and metalloproteinase with a thrombospondin type 1 motif; member 13, and von Wile brand factor levels were prospectively collected in 279 patients (234 LE-DVT, 45 UE-DVT). Continuous and categorical variables among patients with DVT were compared with patients without DVT. The diagnostic sensitivity, specificity, positive predictive value, and negative predictive value were then calculated using our previously derived cut points to rule in or exclude DVT.Results: Among 234 patients evaluated for LE-DVT, 112 (48%) patients had a confirmed LE-DVT with significant differences in all biomarkers. When Wells score >= 2, sP-sel could rule in LE-DVT with a specificity of 97.5% and a positive predictive value of 91%, which was more accurate than Wells score >= 2 and D-dimer (specificity, 65%; positive predictive value, 69%). When Wells score was <2, D-dimer was superior to sP-sel for excluding the diagnosis of LE-DVT (sensitivity, 98%; negative predictive value, 95% vs sensitivity, 91%; negative predictive value, 79%). The use of additional biomarkers did not increase accuracy. Had imaging not been available, we could have correctly ruled in or ruled out LE-DVT in 29% (67/234) of patients. The use of sP-sel in UE-DVT was nondiagnostic.Conclusions: We demonstrate that when Wells score sP-sel is an excellent biomarker to rule in LE-DVT. Different from our previous study, D-dimer and a Wells score <2 was most sensitive at excluding a diagnosis of LE-DVT. Combined, Wells score, sP-sel, and D-dimer can both rule in and exclude LE-DVT in approximately one-third of patients.

The combination of D-dimer and Wells score can exclude, but not confirm, the diagnosis of suspected deep venous thrombosis (DVT). Since thrombosis and inflammation are interrelated, this study sought to determine if a combination of inflammatory biomarkers and clinical scores could establish the diagnosis. 152 patients presenting with suspected DVT, 44 positive and 108 negative by duplex scan, and 30 healthy controls were prospectively evaluated for soluble P-selectin (sPsel), D-dimer, C-reactive protein (CRP), microparticles (MP) and Wells score. Biomarkers and characteristics that discriminated DVT positives from negatives were sPsel (94.1 vs 53.1 ng/mL, p < 0.01), D-dimer (5.8 vs 2.1, p < 0.01), CRP (1.91 vs 0.83 μg/mL, p < 0.05) and Wells score (3.3 vs 2.0, p < 0.01). MP were not found to be significant in the study. Results, using logistic regression are shown on the table.Tabled 1Logistic regression resultsVariablesROCp-value (regression)SensitivitySpecificityPPVNPVD-dimer (≥400 ng/mL)0.59<0.0191.7%35%31.7%95.6%Wells score (≥2)0.63<0.0127.3%85.2%34%79%sPsel (≤35 ng/mL)0.77<0.0193.3%14.8%31.5%85.7%sPsel (≥115 ng/mL)0.66<0.0133%98.1%93.3%78.1%sPsel + Wells (≤35 ng/mL + <2)0.82<0.0195.8%48.8%30%100%sPsel + Wells (≥115 ng/mL + ≥2)0.82<0.0120.8%98.8%100%78%Of 152 patients, 44 negatives presented sPsel≤35 ng/mL and Wells<2 and 14 positives had sPsel≥115 ng/mL and Wells≥2. Open table in a new tab Of 152 patients, 44 negatives presented sPsel≤35 ng/mL and Wells<2 and 14 positives had sPsel≥115 ng/mL and Wells≥2. sPsel + Wells can establish the diagnosis of DVT (≥115 ng/mL + ≥2), with specificity = 93.8% and PPV = 100%, and can exclude the diagnosis (≤35 ng/mL + <2) with sensitivity = 95.8% and NPV = 100%. Based on our data, 38% (58/152) could potentially be diagnosed with DVT without the need of imaging exams.

Paraganglionic tumors are rare. A germline mutation responsible for a familial pattern of paragangliomas (PGLs) has been identified on the genes encoding for the subunits of succinate dehydrogenase (SDH). Manifestations of those with a succinate dehydrogenase subunit C (SDHC) germline mutation have been almost exclusively reported as single head and neck paragangliomas (HNPGLs). We present a 32-year-old man with a familial SDHC mutation who manifests synchronous PGLs of the carotid body and the thoracic aortopulmonary window. To our knowledge, this is the first report of such a presentation for this mutation. (J Vase Surg 2011;53:805-7.)