Introduction - Endovascular aortic repair (EVAR) is an expert task. A mastery learning approach is warranted. To date no validated assessment tools of competence in EVAR exist. The primary aims were to develop evaluation documents for learning progress and skill acquisition for A) stent graft sizing and selection1, and B) operator's procedural competence in EVAR2. Methods - A) The test for EVAR stent graft planning was developed based on a literature review. An international cross sectional study examined evidence of validity for the assessment. Consultants (N=22) from radiology and vascular surgery with varying experience in EVAR planning (novices, intermediates, and experts) were presented with computed tomography angiography from three patients. Test scores were based on z-scores using the anatomical measurements and graft choices of the experts as reference. B) A Delphi panel of international EVAR experts was established (N=32, vascular surgery (N=21) and radiology (N=11)). Iterative Delphi rounds were executed. The first round was based on triangulation of a literature review, stent graft instructions for use, and interviews with experts. The panellists rated the importance of competence assessment items on a five point Likert scale. Consensus was defined as 80% of the panel rating an item four or five in the primary round and 90% in subsequent. Consensus on the final assessment tool was defined as Cronbach's alpha >0.8 after a minimum of three rounds. Results - A) The stent planning test demonstrated reliable results (ICC=0.83, p < 0.001) and high internal consistency (Cronbach's α= 0.91, p < 0.001). Overall, experts performed significantly better than novices and intermediates (p < 0.002 and p < 0.005, respectively). The anatomical sub-test discriminated significantly between experts and novices (Mann Whitney U, p = 0.002), experts and intermediates (p = 0.010), and novices and intermediates (p = 0.036). In the stent selection sub-test experts performed significantly better than both novices and intermediates (p = 0.002 and p = 0.007), but no difference was found between novices and intermediates (p = 1). B) Delphi study: Three rounds of surveys were conducted with a completion rate of 100% in the first two rounds and 91% in round three. The expert panel reached consensus on seven pivotal assessment items, Cronbach's alpha=0.82. The resulting rating scale, EVARATE, covers key elements in EVAR competency. Each assessment item has well defined grades with explicit anchors from unacceptable to superior performance on a five point Likert scale. Conclusion - This study presented a standardised and objective assessment tool of competence in EVAR supported by strong validity evidence. A novel seven-item rating scale for assessment of operator's competence was developed, based on international expert consensus. These tests of EVAR competence hold promise for teaching novel operators at entry to practise. References1.Strøm M, Lönn L, Bech B et al. Assessment of competence in EVAR stent graft sizing and selection. EJVES 2017 (accepted for publication)2.Strøm M, Lönn L, Bech B et al. Assessment of competence in EVAR procedures - A novel rating scale developed by the Delphi technique. EJVES 2017 (accepted for publication)

Background Provoked gluteal claudication is a known risk after endovascular aortic repair (EVAR). Lowered gluteal muscle oxygenation (SgmO2) may be demonstrated by near-infrared spectroscopy (NIRS). Purpose To evaluate NIRS-determined SgmO2 in EVAR patients. Material and Methods NIRS-determined SgmO2 was used in an observational study design (n = 17). From the ambulatory setting, seven EVAR patients were included with reported gluteal claudication from medical records. In 10 patients scheduled for EVAR, SgmO2 was measured before and after the procedure. NIRS sensors were applied bilaterally on the gluteal region. Treadmill walking (12% incline, 2.4 km/h) was introduced to stress gluteal muscles. Results A reduced SgmO2 with regional side difference ( P < 0.05) was noted in all 10 patients following EVAR and four reported gluteal claudication. In patients with gluteal claudication (n = 7), treadmill decreased SgmO2. The time to recover the SgmO2 was prolonged for tissue exposed to occluded hypogastric artery (median = 512 s, range = 73–1207 s vs. median = 137, range = 0–643 s; P = 0.046). Conclusions EVAR affects gluteal muscle oxygenation. NIRS could be used to assess whether gluteal claudication is related to lowered SgmO2.

Background Exercise walking has improved walking capacity in patients with intermittent claudication without affecting the macrocirculation reflected in ankle pressures. We wanted to investigate microcirculation in the skin related to exercise walking by using Micro-Lightguide Spectrophotometry (O2C). Materials and Methods Twenty-eight patients with intermittent claudication—bilateral in 17—were included in a 12 weeks of structured home-based exercise program. The pain-free and maximal walking distances were determined on a treadmill. Saturation and flow, monitored by O2C, were examined immediately before and after the treadmill test. O2C examination took place before as well as after completion of the exercise program. Ankle–brachial index was obtained before treadmill testing. Results As expected, walking performance improved significantly without affecting ankle pressures. Neither oxygen saturation nor flow, assessed at 2 mm depth, was affected following a 12 weeks of exercise program. We observed a significant decrease in oxygen saturation and flow upon treadmill testing in the both limbs in patients with bilateral peripheral arterial disease (PAD). In contrast, the treadmill test elicited no changes in the opposite and asymptomatic limb in patients with only unilateral PAD. Conclusion The findings suggest that O2C may be used to study microcirculatory changes. However, it is best suited for the study of phenomena resulting in major changes as it eliminates some inherent variability.

The purpose was to evaluate endovascular aortic repair (EVAR) patients with known gluteal claudication using near infrared spectroscopy (NIRS), and secondly to assess the hemodynamic consequences of occluding one internal iliac artery (IIA) during EVAR. EVAR interventions with occlusion of one IIA were examined. Gluteal claudicants were recruited from the outpatient clinic at their annual EVAR control (Group A; n=7) and a second cohort was collected consecutively and prospectively before and after the intervention (Group B; n=10). A treadmill test (12% incline, 2.4 km/h) with NIRS (INVOS-5100) sensors applied bilaterally on the gluteal regions was performed. NIRS was used to asses muscle oxygenation. NIRS data was divided into baseline, exercise and recovery values. Recovery times and absolute NIRS values (oxygenation) from the two gluteal sides were compared. Mean recovery times (group A) of the occluded and patent sides were 512 sec [73-1207] and 137 sec [0-643] (p=0.046) respectively. Using 240 seconds (suggested by literature) as cut-off the sensitivity and specificity were both 71% for finding the occluded IIA. Group B revealed similar oxygenation level of the two gluteal regions pre EVAR. Post EVAR an overall absolute reduction of the oxygenation were noted and a significant difference in the recovery values of the two gluteal sides (p<0.05). In this explorative study NIRS does show relevant changes of the oxygenation on the gluteal region following occlusion of an IIA in groups of patients. But given the lack of statistical power the efficacy of diagnostic use in individual patients has yet to be proven.

Objectives: The aims of this study were to investigate the validity evidence for a novel procedure specific assessment tool of competence in endovascular aortic repair (EVAR) and to establish a pass/fail level for the assessment. Methods: Computed tomography angiography data of a 55 mm in diameter infrarenal aortic aneurysm was implemented into an endovascular simulator. Twenty-three physicians with varying EVAR experiences were video-recorded when performing a standard EVAR procedure on the simulator. Two experienced EVAR operators assessed the participants using the novel rating scale, "EndoVascular Aortic Repair Assessment of Technical Expertise" (EVARATE). Validity was studied according to the framework endorsed by the American Educational Research Association. Results: The EVARATE scale had a high internal consistency (Cronbach's alpha = .90). The inter-rater reliability was acceptable (Intraclass Correlation Coefficient = .68, p = .005). Specific EVAR experience correlated significantly with the EVARATE score (Spearman's rho = .62, p = .002), but general endovascular experience did not. Consequence analysis showed that the EVARATE assessment could distinguish novices from intermediates (p < .01) and from experts (p < .001). A pass/fail score was determined using the contrasting groups' method. Conclusion: This paper presents the initial validity evidence for a novel procedure specific assessment tool, EVARATE, for operator competence in endovascular aortic repair investigated in a simulated setting. The assessment tool can be used to provide structured formative feedback to trainees. (C) 2018 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

ABSTRACTObjectivesTo study the effect of red blood cell (RBC) storage duration on long‐term mortality in patients undergoing cardiac intervention.BackgroundRBCs undergo numerous structural and functional changes during storage. Observational studies have assessed the association between RBC storage duration and patient outcomes with conflicting results.MethodsBetween January 2006 and December 2014, 82 408 patients underwent coronary angiography. Of these, 1856 patients received one to four RBC units within 30 days after this procedure. Patients were allocated according to length of RBC storage duration: short‐term (≤11 days), intermediate (IM)‐term (12–23 days) and long‐term (≥24 days). The study endpoints were 30‐day and long‐term all‐cause mortality.ResultsA total of 4168 RBC units were given to 1856 patients. The mean RBC storage duration was 8.5 ± 2.1, 17.7 ± 3.4 and 29.9 ± 3.4 days in the short‐term, IM‐term and long‐term storage groups, respectively. There was no difference in baseline characteristics between the groups. The long‐term storage group received significantly more units (2.4 ± 1.0 units) as compared to the short‐term (2.0 ± 1.0 units; P < 0.001) and IM‐term storage group (2.2 ± 1.0 units; P < 0.01). In the survival analysis, there was no significant difference in all‐cause mortality between the groups (log‐rank: 0.509 for 30‐days mortality; 0.493 for 5‐year mortality). Additional stratified analysis demonstrated no association between RBC storage duration and long‐term mortality.ConclusionThis study did not find an association between RBC storage duration and 30‐days or long‐term mortality in patients undergoing cardiac intervention.

Objective/Background: To develop a procedure specific global rating scale for assessment of operator competence in endovascular aortic repair (EVAR).Methods: A Delphi approach was used to achieve expert consensus. A panel of 32 international experts (median 300 EVAR procedures, range 200-3000) from vascular surgery (n = 21) and radiology (n = 11) was established. The first Delphi round was based on a review of endovascular skills assessment papers, stent graft instructions for use, and structured interviews. It led to a primary pool of 83 items that were formulated as global rating scale items with tentative anchors. Iterative Delphi rounds were executed. The panellists rated the importance of each item on a 5 point Likert scale. Consensus was defined as 80% of the panel rating an item 4 or 5 in the primary round and 90% in subsequent rounds. Consensus on the final assessment tool was defined as Cronbach's alpha > .8 after a minimum of three rounds.Results: Thirty-two of 35 invited experts participated. Three rounds of surveys were completed with a completion rate of 100% in the first two rounds and 91% in round three. The 83 primary assessment items were supplemented with five items suggested by the panel and reduced to seven pivotal assessment items that reached consensus, Cronbach's alpha = 0.82. The seven item rating scale covers key elements of competence in EVAR stent placement and deployment. Each item has well defined grades with explicit anchors at unacceptable, acceptable, and superior performance on a 5 point Likert scale.Conclusion: The Delphi methodology allowed for international consensus on a new procedure specific global rating scale for assessment of competence in EVAR. The resulting scale, EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE), represents key elements in the procedure. EVARATE constitutes an assessment tool for providing structured feedback to endovascular operators in training. (C) 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

OBJECTIVES AND BACKGROUND:Practical skills training in vascular surgery is facing challenges because of an increased number of endovascular procedures and fewer open procedures, as well as a move away from the traditional principle of "learning by doing." This change has established simulation as a cornerstone in providing trainees with the necessary skills and competences. However, the development of simulation based programs often evolves based on available resources and equipment, reflecting convenience rather than a systematic educational plan. The objective of the present study was to perform a national needs assessment to identify the technical procedures that should be integrated in a simulation based curriculum.DESIGN AND METHODS:A national needs assessment using a Delphi process was initiated by engaging 33 predefined key persons in vascular surgery. Round 1 was a brainstorming phase to identify technical procedures that vascular surgeons should learn. Round 2 was a survey that used a needs assessment formula to explore the frequency of procedures, the number of surgeons performing each procedure, risk and/or discomfort, and feasibility for simulation based training. Round 3 involved elimination and ranking of procedures.RESULTS:The response rate for round 1 was 70%, with 36 procedures identified. Round 2 had a 76% response rate and resulted in a preliminary prioritised list after exploring the need for simulation based training. Round 3 had an 85% response rate; 17 procedures were eliminated, resulting in a final prioritised list of 19 technical procedures.CONCLUSION:A national needs assessment using a standardised Delphi method identified a list of procedures that are highly suitable and may provide the basis for future simulation based training programs for vascular surgeons in training.

Objectives and background: The aims of this study were to develop a test of competence in endovascular aortic repair (EVAR) stent graft sizing and selection; to examine the test for evidence of validity; and to explore the experience required for the task.Methods: The test was developed based on a literature review resulting in 22 anatomical assessment points and a graft selection. Validity evidence was explored in an international cross sectional study. Twenty-two consultants with varying levels of experience in the field (novices, intermediates, and experts) were presented with computed tomography angiography of the aortic vessels from three patients. Test scores were based on summed z-scores using the anatomical measurements and graft choices of the experts as a reference. A proficiency score was established using the contrasting groups standard setting method.Results: The assessment was shown to be reliable with an intraclass correlation coefficient of 0.83 (p < .001) and high internal consistency with a Cronbach's alpha of .91 (p < .001). Mann Whitney U test showed that experts performed significantly better than novices and intermediates (p < .002 and p < .005, respectively). Regarding anatomical measurements, Mann Whitney U test could discriminate between experts and novices (p = .002), between experts and intermediates (p = .010), and between novices and intermediates (p = .036). In stent selection the experts performed significantly better than both the novices and the intermediates (p = .002 and p = .007, respectively), while there was no significant difference between the two non-expert groups (p = 1). A credible passing standard with appropriate consequences was established using the contrasting groups methods.Conclusion: This study presents a standardised and objective assessment tool of competence in vessel analysis and stent graft selection for endovascular aortic repair. This was supported by strong validity evidence with good internal consistency and discriminatory ability. The tool may be used to facilitate training and certification of future endovascular specialists. (C) 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Background Vascular access complications after coronary angiography (CAG) and percutaneous coronary intervention (PCI) are known to increase morbidity, prolong hospitalization and raise hospital costs. Therefore, risk factor identification and improvement of safety strategies for vascular management are important. We aimed to assess the incidence of major vascular complications related to femoral access, and to identify potential risk factors. Methods Over a period of six years, 23,870 index procedures (CAG) were performed in two centres, prospectively entered in the database and retrospectively analysed. Data was obtained from the Eastern Danish Heart Registry and cross-matched with data from the Danish Vascular Registry. Index procedures were defined as the first trans-femoral procedure. Demographic, procedural and mortality data, as well as information on access complications requiring surgery within 30 days were collected. Mortality data were collected for minimum 12 months. Results We identified 130 (0.54%) access complications requiring surgery; 65 pseudoaneurysms (0.28%), 46 arterial occlusions (0.19%), 15 hematomas (nine groin and six retroperitoneal hematomas) (0.06%), and 4 arterial dissections (0.02%). Risk factors for complications were left sided femoral access (OR 4.11 [2.29–7.37] p < 0.001), peripheral arterial disease (PAD) (OR 2.42 [1.48–3.94] p < 0.0001) and female sex (OR 2.22 [1.51–3.24] p < 0.0001). Conclusion Vascular complications related to femoral access in coronary diagnostic and interventional procedures are low (0.54%). Risk factors were left sided access, PAD, and female sex.

The median arcuate ligament syndrome (MALS) is a rare entity and poorly described in the Danish literature, which makes the exact prevalence difficult to estimate. It is more often among women, typically younger and less cardiovascular stigmatized as compared to the usual patients suffering intestinal ischemia. It is believed that the median arcuate ligament (MAL), being a fibrous structure of the diaphragm, compresses the celiac trunk, causing a stenosis and the characteristic “hook-shape” found on imaging. Whether symptoms originate from malperfusion of the gastrointestinal organs or are caused by compression of sympathetic fibers is not fully elucidated. The syndrome is characterized by chronic abdominal pain, postprandiale pain and weight loss. Moreover, worsening of abdominal pain associated with physical activity and when lying supine is commonly described. Most centers are reluctant to perform percutaneous transluminal angioplasty (PTA), because of the significant risk of stent-fracture and failure, as well as open ligament release and revascularization due to the extensive nature of such a procedure. Within the last decade, laparoscopic approaches with release of the median arcuate ligament have shown promising results and few peri- and postoperative complications. In some cases with insufficient symptom relief after ligament relief, a postoperative PTA can be performed adjunctively without the risk of stent-fracture. Median arcuate ligament syndrome is a rare disease, and should be a diagnosis of exclusion. Correct patient selection is both crucial and challenging, and the best diagnostic strategy is still debatable. Ultrasound (US) is a good and non-invasive method for visualization of mesenteric vessels. In contrast to computer tomographic angiography (CTA), US provides real-time imaging and hereby the possibility to demonstrate respiratory synchronous velocity changes in the trunk, considered to be diagnostic for the disease with a high positive predictive value. In comparison to CTA and angiography, which supply better anatomical details, US is noninvasive and does not require contrast, but does rely on experienced sonographers. A CTA-verified “hook shape” of the coeliac trunk, together with relevant symptoms, should lead to referral to a vascular centre with interest and experience in this rare but probably underdiagnosed condition. A MALS-team consisting of specialists in gastroenterological laparoscopy, endovascular interventionists, clinical physiologists and vascular surgeons has been established at Rigshospitalet and Hvidovre Hospital in order to optimise the management of MALS.

Purpose: To compare the risk of gluteal claudication after endovascular aneurysm repair (EVAR) of aortoiliac aneurysms by interventional-exclusion of the internal iliac artery (HA) with plugs or coils versus a branch iliac device to maintain pelvic blood supply and to identify risk factors for postoperative gluteal claudication.Materials and Methods: A retrospective analysis of a prospectively collected data set included patients with aortoiliac aneurysms treated with EVAR from January 2007 to December 2013 at a tertiary referral vascular unit. Descriptive and procedural data were obtained from a database of prospectively enrolled patients. Medical records of 112 consecutive patients treated with EVAR were scrutinized for graft-related adverse events and pelvic ischemia. The occurrence of gluteal claudication was determined from medical records.Results: Iliac occlusion was performed in 115 limbs, and a branch iliac device was placed in 25 limbs. Gluteal claudication developed in 38% of limbs treated with HA exclusion but in none of the limbs treated with branch iliac devices.(P < .001). Procedure time, fluoroscopy time, and use of iodine contrast material did not differ between the two groups. The incidence of gluteal claudication was higher when coils rather than plugs were used for embolization of the IIA before EVAR (P = .002).Conclusions: The findings suggest that the use of a branch iliac device significantly reduces the risk of gluteal claudication after EVAR of aortoiliac aneurysm.

Vascular access and closure remain a challenge in transcatheter aortic valve replacement (TAVR). This single-center study aimed to report the incidence, predictive factors, and clinical outcomes of access-related vascular injury and subsequent vascular intervention. During a 30-month period, 365 patients underwent TAVR and 333 patients (94%) were treated by true percutaneous transfemoral approach. Of this latter group, 83 patients (25%) had an access-related vascular injury that was managed by the use of a covered self-expanding stent (n = 49), balloon angioplasty (n = 33), or by surgical intervention (n = 1). In 16 patients (5%), the vascular injury was classified as a major vascular complication. Absence of a preprocedural computed tomography angiography (CTA) of the iliofemoral arteries (OR 2.04, p = 0.007) and female gender (OR 2.18, p = 0.004) were independent predictors of the need for access-related vascular intervention. In addition, a high sheath/common femoral artery ratio as measured on preoperative CTA was associated with a higher rate of post-TAVR vascular intervention. The radiation dose, iodine contrast volume, transfusion need, length of hospitalization, and 30-day mortality were not significantly different between patients with versus without access-related vascular intervention. In conclusion, access-related vascular intervention in patients who underwent transfemoral-TAVR is not uncommon. Female gender and a high sheath/common femoral artery ratio are risk factors for access-related vascular injury, whereas preprocedural planning with CTA of the access vessels may reduce the risk of vascular injury. Importantly, most access-related vascular injuries may be treated by percutaneous techniques with similar clinical outcomes to patients without vascular injuries.

Background: Complications after open vascular surgery are a major health challenge for the healthcare system and the patients. Infrainguinal vascular surgery is often perceived as less risky than aortic surgery and the aim of this study was to identify which risk factors correlated with postoperative complications after open vascular surgery for infrainguinal occlusive disease in an 8-year cohort using the Danish National Vascular Registry (Karbase), which gathers information on all vascular procedures in Denmark.Methods: This study is a retrospective cohort study. The Karbase was searched for the predefined procedures from January 1, 2005 through December 31, 2012 at our 2 vascular departments. Both elective and urgent surgeries were included. Complications were defined as wound, surgical, or general complication according to Karbase.Results: Three thousand two hundred two procedures were identified. Median age was 70 years and 21% were octogenarians. Sixty percent were male. There was an overall complication rate of 30%, with 19% being wound complications, 6% surgical, and 10% general complications. The greatest risk factors for developing a complication were high age, cardiac and renal disease, high American Society of Anesthesiologists score, and general anesthetics. The 30-day mortality was 5% (1% for claudicants and 8% for acute ischemia) and the 30-day amputation rate was 7% (0.5% for claudicants and 21% for gangrene).Conclusions: There is a high risk of complication in peripheral vascular surgery. Risk factors are modifiable or nonmodifiable. It is important to identify the risk factors and treat and optimize the patient cardiac and renal status before surgery if time allows, and also to perform surgery in local or regional anesthesia whenever possible, to reduce the risk of postoperative complications.

Background and Aim: To evaluate the amputation-free survival after below the knee percutaneous transluminal angioplasty in a consecutive group of patients with critical ischemia of the lower extremity.Materials and Methods: A total of 70 consecutive patients with critical ischemia were treated with below the knee percutaneous transluminal angioplasty at the vascular center at Rigshospitalet with the purpose of limb salvage. All patients were deemed unfit for major surgery due to anatomical limitations or severe co-morbidity, and no prior attempts of revascularization were performed. Follow-up clinical examinations were performed within 6weeks and after 1year. All medical records were crosschecked with the national vascular registry ensuring a valid 1-year status in 97% of the patients.Results: A total of 15 major amputations were performed during follow-up, with 11 amputations performed within the first year. Complications after percutaneous transluminal angioplasty were rare. Cumulative mortality after 1 and 2years was 22% and 34%, respectively. Amputation-free survival at 1 and 2years of follow-up was 68% and 58%, respectively. There were no association between known risk factors such as diabetes, ischemic ulcers, cardiac disease, history of smoking, major amputation, or overall amputation.Conclusion: Below the knee percutaneous transluminal angioplasty in patients with end-stage peripheral arterial disease and critical limb ischemia is a safe procedure in relieving critical ischemia, reducing the short-term rate of a major amputation as opposed to best medical treatment alone.

BACKGROUND:The effect of intensive smoking cessation programs on postoperative complications has never before been assessed in soft tissue surgery when smoking cessation is initiated on the day of surgery.METHODS:A single-blinded randomized clinical trial conducted at two vascular surgery departments in Denmark. The intervention group was offered the Gold Standard Program (GSP) for smoking cessation intervention. The control group was offered the departments' standard care. Inclusion criteria were patients with planned open peripheral vascular surgery and who were daily smokers. According to the power calculation a total of 144 patients were needed in the trial.RESULTS:Due to slow patient inclusion, the trial was terminated prior to fulfilling the power calculation. Thirty-two patients were included in the trial from March 2011 to September 2012. Of these, 11 were randomized to the GSP intervention and 21 as controls. There was no difference in 30-day complication rates or 6-week abstinence rates between the two groups.CONCLUSIONS:A trial assessing the effect of smoking cessation on postoperative complications on the day of soft tissue surgery is still needed. If another trial is to be planned it must be more pragmatic with less extended inclusion criteria and conducted nationally or internationally to ensure enough patients for the trial.TRIAL REGISTRATION:ClinicalTrials.gov ( NCT01469091 ). Registration date: 27 October 2011.

Objective: The aim of this review was to identify clinical and/or imaging parameters that are associated with an increased (decreased) risk of early/late stroke in patients with symptomatic carotid disease.In the first 14 days: Natural history studies suggest that 8-15% of patients with 50-99% stenoses will suffer,a stroke within 72 hours of their index symptom. Currently, there are insufficient validated data to identify highest-risk patients for emergency carotid endarterectomy (CEA), but an increased risk of stroke appears to be predicted by (i) an ABCD(2) score of 4-7; (ii) the presence of acute cerebral injury on CT/MRI; (iii) Gray Scale Median (GSM) <15, (iv) spontaneous embolisation on Transcranial. Doppler (TCD); and (v) increased fluorodeoxyglucose (FDG) uptake in the carotid plaque on positron emission tomography (PET). A future goal must be to develop predictive algorithms (based on accessible imaging strategies) for identifying acutely symptomatic patients with highly unstable plaques for emergency CEA.Medium to long term: In the randomised trials, about 70% of patients with symptomatic 70-99% stenoses were stroke-free on "best medical therapy" at 5 years. Clinical predictors of increased stroke risk include (i) male gender; (ii) age >75; (iii) hemispheric symptoms; and (iv) increasing comorbidity.. Imaging features associated with increased stroke risk include (i) irregular stenoses; (ii) contralateral occlusion; (iii) increasing stenosis severity, but not subocclusion; (iv) tandem intracranial disease; (v) a failure to recruit intracranial collaterals; (vi) low GSM; (vii) MR diagnosis of intra-plaque haemorrhage; (vii) spontaneous embolisation on TCD; and (viii) increased FDG uptake in the carotid plaque on PET. Clinical/imaging parameters associated with a lower risk of stroke include (i) female gender, especially those with 50-99% stenoses; (ii) ocular symptoms/lacunar stroke; (iii) smooth stenoses; and (iv) chronic subocclusion. (C) 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Open repair of abdominal aortic aneurysm (AAA) is a well-established durable treatment. However, there is a continuing trend toward less invasive techniques via small incisions (mini laparotomy), retroperitoneal access, or laparoscopic repair [1–4] and by optimization of perioperative care [5,6]. Endovascular aneurysm repair, first introduced about 30 years ago [7,8], has contributed substantially to making aneurysm repair minimally invasive. Endovascular aortic repair (EVAR) consists of endoluminal deployment of a stent graft (a metal mesh lined by a synthetic graft) in the aorta by access via the femoral arteries (Fig. 1).

OBJECTIVE:Open surgery has given way to endovascular grafting in patients with aortoiliac occlusive disease. The growing use of endovascular grafts means that fewer patients with aortoiliac occlusive disease have open surgery. The declining open surgery caseload challenges the surgeon's operative skills, particularly because open surgery is increasingly used in those patients who are unsuitable for endovascular repair and hence technically more demanding. We assessed the early outcome after aortic bifurcated bypass procedures during two decades of growing endovascular activity and identified preoperative risk factors.METHODS:Data on patients with chronic limb ischemia were prospectively collected during a 20-year period (1993 to 2012). The data were obtained from the Danish Vascular Registry, assessed, and merged with data from The Danish Civil Registration System.RESULTS:We identified 3623 aortobifemoral and 144 aortobiiliac bypass procedures. The annual caseload fell from 323 to 106 during the study period, but the 30-day mortality at 3.6% (95% confidence interval [CI], 3.0-4.1) and the 30-day major complication rate remained constant at 20% (95% CI, 18-21). Gangrene (odds ratio [OR], 3.3; 95% CI, 1.7-6.5; P = .005) was the most significant risk factor for 30-day mortality, followed by renal insufficiency (OR, 2.5; 95% CI, 1.1-5.8; P = .035) and cardiac disease (OR, 2.1; 95% CI, 1.4-3.1; P < .001). Multiorgan failure, mesenteric ischemia, need for dialysis, and cardiac complications were the most lethal complications, with mortality rates of 94%, 44%, 38%, and 34%, respectively.CONCLUSIONS:Aortic bifurcated bypass is a high-risk procedure. Although open surgery has increasingly given way to endovascular repair, 30-day outcomes have remained stable during the past decade. Thus, it is still acceptable to consider an aortic bifurcated bypass whenever endovascular management is not feasible.