Objectives: Endovascular aneurysm repair (EVAR) has enabled the treatment of aneurysmal disease in those of significantly advanced age. Although there have been positive experiences documented in the literature, the feasibility of EVAR in octogenarians and nonagenarians as a demographic are still largely unknown. We report a single-center experience with EVAR in octogenarians and nonagenarians. Methods: Cases of EVAR in octogenarians and nonagenarians were identified retrospectively at our center over 5 years using a prospectively maintained database. Results: Seventeen patients undergoing EVAR at our institution were reviewed; this included 14 octogenarians and 3 nonagenarians. Of these, 94% were male, with a mean age of 86.6 (81–98) years and a mean aneurysm diameter of 7.6 cm. The average number of comorbidities in our cohort was 2.6. Perioperative morbidity was 35.3% and consisted of hospital-acquired pneumonia, ischemic bowel, and one return to theater for bleeding from the access site. 30-day mortality was 17.6% (n = 3), with 2 of these patients undergoing repair for a ruptured AAA. Mean survival in those surviving 30 days was 27.8 months (39 days–51 months). Conclusion: EVAR in octogenarians and nonagenarians is feasible with good technical outcomes and acceptable perioperative morbidity and mortality.

Aneurysmal disease can occur in any vessel in the body and occur most commonly the aorta, cerebral and popliteal arteries; however, aneurysms of the digital artery remain a rare presentation. They form an important differential diagnosis in any patient presenting with a mass in the hand. This report presents the case of a 64-year-old man with a true aneurysm of the common palmar digital artery who underwent successful repair, following excision and end to end anastomosis. Only 21 cases of true digital artery aneurysm have been reported; we review the literature pertaining to the diagnosis and management of digital artery aneurysms since they were first described by Baruch et al in 1977.

Endovascular graft infection is a rare but challenging complication that requires a tailored approach to remove the infected graft and restore the arterial circulation combined with long-term antibiotic therapy. We present a case surgically treated with explant of the graft and reconstruction of the thoracoabdominal aorta. Microbiological investigation revealed growth of Neisseria meningitidis, which is extremely rare in this location, and to our knowledge, has not been previously published in the literature.

The prevalence of abdominal aortic aneurysms (AAA) in the nonagenarian and centenarian populations is set to increase. Endovascular aneurysm repair (EVAR) has been shown to be achievable with excellent outcomes in carefully selected nonagenarians. However, experience with centenarians is limited.We report the case of a 100-year-old who presented with a tender 8-cm AAA and successfully underwent EVAR. This report describes the second case of AAA repair in a centenarian in the literature and the first reported EVAR in this demographic. The patient survived for 2 years after the procedure,was free of EVAR or aneurysm-related complications. Furthermore, we present a systematic review of the existing literature and insights pertaining to outcomes in nonagenarians undergoing EVAR.

Introduction: There is a need to improve outcomes and care in the perioperative period amongst patients who are having major lower limb amputations. The aim of this audit was to determine adherence to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommended standards for the management of patients undergoing major lower limb amputations.

Peripheral Arterial Disease (PAD) is a cause of significant morbidity and mortality in the Western world. Risk factor modification and endovascular and surgical revascularisation are the main treatment options at present. However, a significant number of patients still require major amputation. There is evidence that nitric oxide (NO) and its endogenous inhibitor asymmetric dimethylarginine (ADMA) play significant roles in the pathophysiology of PAD. This paper reviews experimental work implicating the ADMA-DDAH-NO pathway in PAD, focussing on both the vascular dysfunction and effects within the ischaemic muscle, and examines the potential of manipulating this pathway as a novel adjunct therapy in PAD.

Erythropoietin (EPO) has tissue-protective properties, but it increases the risk of thromboembolism by raising the haemoglobin concentration. New generation of EPO derivatives is tissue protective without the haematopoietic side effects. Preclinical studies have demonstrated their effectiveness and safety. This paper summarizes the development in EPO derivatives with emphasis on their potential use in critical limb ischaemia.

HomeCirculationVol. 123, No. 16Aortic Tumor Presenting as Acute Lower Limb Ischemia Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessBrief ReportPDF/EPUBAortic Tumor Presenting as Acute Lower Limb Ischemia Natalia Barry, MB, BS, Janice Tsui, MD, FRCS, Jonathan Dick, MB, BS, Daryll Baker, PhD, FRCS and Sadasivam Selvakumar, FRCS Natalia BarryNatalia Barry From the Vascular Unit, Royal Free Hospital, London (N.B., J.T., J.D., D.B.); and Department of Surgery, Lister Hospital, Stevenage (S.S.), UK. , Janice TsuiJanice Tsui From the Vascular Unit, Royal Free Hospital, London (N.B., J.T., J.D., D.B.); and Department of Surgery, Lister Hospital, Stevenage (S.S.), UK. , Jonathan DickJonathan Dick From the Vascular Unit, Royal Free Hospital, London (N.B., J.T., J.D., D.B.); and Department of Surgery, Lister Hospital, Stevenage (S.S.), UK. , Daryll BakerDaryll Baker From the Vascular Unit, Royal Free Hospital, London (N.B., J.T., J.D., D.B.); and Department of Surgery, Lister Hospital, Stevenage (S.S.), UK. and Sadasivam SelvakumarSadasivam Selvakumar From the Vascular Unit, Royal Free Hospital, London (N.B., J.T., J.D., D.B.); and Department of Surgery, Lister Hospital, Stevenage (S.S.), UK. Originally published26 Apr 2011https://doi.org/10.1161/CIRCULATIONAHA.110.985689Circulation. 2011;123:1785–1787A 47-year-old man presented to his local accident and emergency department with an acutely ischemic left leg. Apart from being a smoker of 30 years, he had no relevant medical or social history. Clinical examination was consistent with femoral embolism with no obvious underlying cause. Examination of the rest of his cardiovascular and respiratory systems was unremarkable. His full blood count, urea, electrolytes, and clotting screen were normal, and ECG showed sinus rhythm with no acute changes.Intravenous heparin infusion was started, and an urgent embolectomy via a popliteal approach was performed with 4-compartment fasciotomies. On-table completion angiography showed restoration of flow to the foot. The retrieved tissue was sent for histological analysis.The patient was then transferred to a vascular unit for further investigations. A transesophageal echocardiogram showed a structurally normal heart, but 2 masses were visible in the descending thoracic aorta (Figure 1 and Movie I in the online-only Data Supplement). A computed tomographic angiogram showed a nonenhancing filling defect in the descending thoracic aorta (Figure 2). Magnetic resonance imaging was performed by a specialist cardiovascular imaging unit to further delineate the mass and revealed a transluminal lesion, extending from 60 mm distal to the left subclavian artery to ≈45 mm above the level of the diaphragm with no surrounding infiltration or other lesions (Figure 3). The appearance suggested an aortic tumor of the descending aorta. Histology of the tissue retrieved at histology was suggestive of myxoma.Download figureDownload PowerPointFigure 1. Transesophageal echocardiographic image shows masses in descending thoracic aorta.Download figureDownload PowerPointFigure 2. Computed tomographic angiogram. Precontrast (A) and postcontrast (B) images show a nonenhancing filling defect in descending thoracic aorta.Download figureDownload PowerPointFigure 3. Magnetic resonance images reveal an irregular mass of the descending thoracic aorta.Surgical resection of the descending thoracic aorta was performed by a joint cardiac and vascular surgical team via a left lateral thoracotomy with left heart bypass. The supradiaphragmatic descending aorta was isolated and cross-clamped below the tumor. Left atrial to left femoral bypass was commenced. The aorta was mobilized and clamped proximally just distal to the origin of the left subclavian artery. The involved segment of aorta was excised, and an 18 mm-Dacron interposition graft was sutured in place (Figures 4 through 6). The patient remained stable throughout surgery and made an uneventful postoperative recovery in the intensive care unit. He was transferred to the ward on day 4 and discharged home on day 9.Download figureDownload PowerPointFigure 4. Aortic tumor before resection, distal to origin of left subclavian artery.Download figureDownload PowerPointFigure 5. Aortic tumor removed, with 18-mm interpositional Dacron graft in place.Download figureDownload PowerPointFigure 6. Aortic tumor specimen.Histology of the surgical specimen confirmed a high-grade undifferentiated sarcoma of the aorta rather than myxoma (Figure 7). The aortic wall was otherwise normal. The patient had 5 cycles of adjuvant chemotherapy, and remains well and tumor free 18 months after completion of treatment.Download figureDownload PowerPointFigure 7. Histological specimen of the aortic tumor showing a tunica intima–based tumor composed of atypical round and spindle-shaped cells set within a myxofibrous stroma. The tumor appears to be demarcated by the tunica media, which is not infiltrated by tumor. Left, Magnification ×4; right, ×40.Although acute limb ischemia is not uncommon, primary aortic tumor as a source of emboli is rarely seen. The prognosis for most primary aortic tumors is poor, and may be improved by prompt diagnosis and treatment. This case highlights the importance of thorough investigation for an underlying cause in patients presenting with acute lower limb ischemia.DisclosuresNone.Footnotes*Drs Barry and Tsui contributed equally to this work.The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/123/16/1785/DC1.Correspondence to Janice Tsui, MD, FRCS, Vascular Unit, Royal Free Hospital, Pond Street, London NW3 2QG, UK. E-mail j.[email protected]ucl.ac.uk Previous Back to top Next FiguresReferencesRelatedDetailsCited By Govsyeyev N, Malgor R, Hoffman C, Harroun N, Sturman E, Al-Musawi M, Malgor E, Jacobs D and Nehler M (2021) A systematic review and meta-analysis of outcomes after acute limb ischemia in patients with cancer, Journal of Vascular Surgery, 10.1016/j.jvs.2021.03.058, 74:3, (1033-1040.e1), Online publication date: 1-Sep-2021. Wang B, Ma D, Cao D and Man X (2019) Huge thrombus in the ascending aorta: a case report and literature review, Journal of Cardiothoracic Surgery, 10.1186/s13019-019-0975-y, 14:1, Online publication date: 1-Dec-2019. Dieter R, Kuzycz G, Dieter R, Gulliver J and Dieter R (2019) Malignant and Benign Aortic Tumors Diseases of the Aorta, 10.1007/978-3-030-11322-3_28, (385-395), . Dieter R, Kuzycz G, DaSilva M, Dieter R, Joudi A and Meyer M (2017) Malignant and Benign Tumor-Induced Critical Limb Ischemia Critical Limb Ischemia, 10.1007/978-3-319-31991-9_29, (323-331), . Rusthoven C, Liu A, Bui M, Schefter T, Elias A, Lu X and Gonzalez R (2014) Sarcomas of the Aorta: A Systematic Review and Pooled Analysis of Published Reports, Annals of Vascular Surgery, 10.1016/j.avsg.2013.07.012, 28:2, (515-525), Online publication date: 1-Feb-2014. Basile C, Mancusi C, Gargiulo P, Perrone Filardi P, Perrino C, Canciello G, Losi M and Esposito G (2021) Aortic thrombosis: the forgotten source of ischemic stroke. A case report and systematic review of the literature, Monaldi Archives for Chest Disease, 10.4081/monaldi.2021.2090 April 26, 2011Vol 123, Issue 16 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.110.985689PMID: 21518992 Originally publishedApril 26, 2011 PDF download Advertisement SubjectsCardiovascular SurgeryComputerized Tomography (CT)

There is a need to develop alternative treatment strategies for the 30% of patients with critical leg ischemia (CLI) for whom conventional modes of revascularization fail. The efficacy erythropoietin (EPO) in this regard has been verified in preclinical models. Erythropoietin receptors are expressed in the human skeletal muscle and possibly, upregulated in CLI. Furthermore, EPO induces angiogenesis and prevents apoptosis in the ischemic skeletal muscle. The use of EPO in conjunction with autologous bone marrow cells or gene-induced angiogenesis with vascular endothelial growth factor may be more effective in inducing angiogenesis and protecting the critically ischemic leg than EPO alone. The recently synthesized nonhemopoietic derivatives of EPO (eg, asialo erythropoietin and carbamylated erythropoietin) allow higher doses to be administered to achieve tissue protective effects, without an unwanted increase in hematocrit. This may allow translation of preclinical studies into clinical trials.

BACKGROUND In 2001, in the US, 23% of haemodialysis patients were dialysing through tunnelled venous catheters (TVCs), and in the UK (2006) there were 28% of prevalent patients using catheters. It is unlikely that numbers will significantly decrease. We present the results of a prospective audit of the survival of 812 TVCs placed in 492 patients at our institution over a 6-year period (comprising 212 048 patient catheter days or 7068 patient catheter months of follow-up). Four different designs of catheter were studied: Split-Cath III (Medcomp), HemoSplit (Bard), Tesio twin catheter (Medcomp) and Permcath (Quinton). METHODS We used Kaplan-Meier survival analysis with log-rank test, to compare the effect of different parameters on catheter survival. The relative importance of significant parameters was determined by Cox regression analysis. RESULTS We have shown a significant catheter survival advantage of first catheters over second and subsequent insertions, of right internal jugular site over left internal jugular and thereafter over femoral site, and of non-diabetic over diabetic patients. Patient age, sex and operator (physician in ward-based procedure room under ultrasound control or surgeon in operating theatre under fluoroscopic assistance) did not significantly affect survival. The Permcath design demonstrated inferior survival in all but first catheter insertions in catheter-naïve patients. The HemoSplit and Tesio twin catheter designs demonstrated best survival overall. By Cox proportional hazard modelling the design and the position of the TVC seemed to be the most significant independent survival factors. CONCLUSIONS Clinicians need accurate data regarding catheter survival, mode of insertion and design, to inform practice.