Abstract: Aortic aneurysm has been reported to be the dominant cause of primary iliac-enteric fistula (IEF) in >70% of cases [1]; other less common causes of primary IEF include peptic ulcer, primary aortitis, pancreatic pseudocyst, or neoplastic erosion into an adjacent artery [2, 3]. We describe an unusual case of IEF managed with a staged approach using an endovascular stent-graft as a "bridge" in the emergency setting to optimize the next elective definitive excision of the lesion.
Abstract: The aim of the present study was to identify the predictive factors associated with the development of postoperative complications in patients treated with surgical repair of iatrogenic femoral pseudoaneurysm.
Abstract: Tuberculosis (TB) is a serious infection in immunocompromised patients, such as solid organ transplant recipients and HIV-infected patients. The diagnosis and treatment in this population present several challenges because of the aspecific clinical manifestations, the difficulty in diagnosis, and the choice of the most appropriate therapeutic regimen. Therapeutic challenges arise from drug-related toxicities, interactions between immunosuppressive, antiretroviral, and antituberculous drugs. We present a case of primary TB infection that occurred 3 years after transplantation in a HIV-and hepatitis C virus-coinfected kidney-pancreas recipient. The infection was successfully treated with no hepatotoxicity or rejection with a non-rifampin-containing regimen.
Abstract: INTRODUCTION:: Nonalcoholic fatty liver disease (NAFLD) is associated with both dyslipidemia and increased risk for cardiovascular disease. Despite the indication to treat in patients affected by both dyslipidemia and NAFLD, an undertreatment in statin therapy due to the potential liver damage is frequently observed. We sought to evaluate retrospectively the impact of statin on the lipid profile and on the achievement of low-density lipoprotein (LDL) cholesterol targets in relation to the National Cholesterol Education Program-Adult Treatment Panel III-cardiovascular risk in dyslipidemic patients presenting with a clinical-diagnosis of NAFLD and elevated liver enzymes before statin prescription. As a secondary endpoint, the authors investigated whether statin could be associated with changes of liver enzymes. METHODS:: Forty-three patients with dyslipidemic NAFLD presenting with increased values of aspartate aminotransferase and/or alanine aminotransferase and/or γ-glutamyl-transferase at baseline were analyzed retrospectively as regard the lipid profile and liver enzymes (values reported before statin and during statin therapy). RESULTS:: Total cholesterol, LDL and triglycerides were significantly reduced at follow-up (5.4 ± 5.4 months). The LDL target was achieved at the second visit in 30 patients (69.8%).The number of patients achieving the LDL target was significantly higher in low-risk group compared with moderate- and high-risk subjects. Liver enzyme levels showed no significant changes between baseline and follow-up. CONCLUSIONS:: Statin treatment was effective (without changes in liver enzymes) in patients with dyslipidemia and NAFLD and therefore, affected by a profound alteration in lipoprotein metabolism. The number of patients achieving LDL target was related to the Adult Treatment Panel III risk classification, being higher in patients with lower risk.
Abstract: The purpose of this study was to review our personal experience with patients who underwent elective endovascular repair of abdominal aortic aneurysms so as to detect the predictors of early and late mortality.
Abstract: The purpose of this study was to review the outcomes of endovascular treatment and open repair of visceral artery aneurysms, and to compare their results.
Abstract: The purpose of this experience was to define patient characteristics, aneurysm anatomy and presentation, types of utilized repair options, and temporal changes over 2 decades in the management of femoral artery aneurysms (FAAs).
Abstract: Preoperative anemia creates a challenge for surgical treatment and patient outcomes after major surgery. Prior to a surgical intervention, it is optimal to increase erythropoiesis to improve oxygen transport through the bloodstream for patients at high risk of anemia and to avoid the complications of allogeneic blood transfusion. In this way, patients could receive predeposited autologous blood or, during the surgical procedures, undergo acute normovolemic hemodilution. This approach is allowed by the use of recombinant human erythropoietin in association with erythropoiesis-inducing factors such as iron and folic acid. In this article, we discuss the recent clinical evidences.
Abstract: We present the case of a late superficial femoral artery stent disconnection causing an asymptomatic pseudoaneurysm successfully treated with a stent-graft. A 67-year-old female was referred to our department for evaluation of claudication of the left lower limb and was diagnosed to have a total occlusion of the superficial femoral artery. Three nitinol stents were used to revascularize this artery. At 48 months, duplex-ultrasonography control revealed the presence of a 45-mm saccular femoral dilatation; X-rays and CT angiography showed fractures of the proximal stents and the presence of a pseudoaneurysm at the site of the distal stents disconnection. The pseudoaneurysm was excluded using two stent-grafts. We conclude that patients and surgeons should be aware of structural complications with all stents. Rigorous follow-up controls should be mandatory. Endovascular repair proved to be feasible and durable to manage a previous endovascular procedure.
Abstract: Endograft infection has received less attention than other complication, so that little is known about the general features, risk factors, and treatment. The purpose of this short series is to examine our experience of infective complications after EVAR.
Abstract: In recent years, experimental and clinical evidence has been provided regarding endothelial dysfunction and its contribution to the inflammatory process leading to atherosclerotic plaque formation. All the techniques employed direct to the study of endothelial dysfunction, however usually require isolation of endothelial cells and therefore tissue manipulation and destruction, with subsequent loss of information regarding morphology and topographical distribution of the lesions. By means of scanning electron microscopy (SEM), we have investigated the characteristics of the endothelial layer in carotid specimens obtained from subjects undergoing carotid endarterectomy. Carotid specimens obtained from 6 patients undergoing carotid endarterectomy for stenosis> or =70% were fixed, prepared and examined by use of SEM in a direct mode. All the plaque specimens showed increased thickness of subendothelial connective tissue with respect to post-mortem tissue obtained from an healthy subject. Endothelial layers were typically detached from the basal lamina surface and infiltrating cells (mainly erythrocytes and, possibly, monocytes) could be identified. Endothelial cells in proximity of the plaques had irregular shape, with prominent nuclei. In several areas, the endothelial layer was completely absent and basal lamina completely uncovered. In the present study, by using SEM analysis, the morphological features of dysfunctional endothelium in human carotid plaques were extensively documented at the ultrastructural level. SEM is a powerful investigational technique which allows tridimensional examination of specimens without disruption of the originary morphology.
Abstract: Endovascular intervention has emerged as a less traumatic alternative treatment for several diseases of the thoracic aorta.(1,2) However, depending on the different aortic pathologies, procedure related complications have become increasingly evident: severe complications include type I endoleaks, migration, and endograft (EG) collapse, as well as those observed during conventional surgery (eg, stroke and paraplegia).(3,4) One of the emerging and most alarming complication of thoracic endografting is iatrogenic retrograde type A acute dissection (RTAAD).(5) Retrograde type A acute dissection is defined as acute aortic dissection that originates distally to the ascending aorta with a retrograde flap progression into the ascending aorta.(6) This complication has been previously described during conventional cardiac surgery with high mortality rate; previous case reports suggested that the fragility of the aortic wall and Marfan disease were predisposing factors to such a life-threatening complication.(7-9) This report presents a case of iatrogenic RTAAD after EG repair of a descending thoracic penetrating aortic ulcer, requiring emergent surgical replacement of the ascending aorta and the aortic arch. The available English literature on RTAAD was also reviewed, in order to recognize potential predisposing factors and specific strategies to prevent it.
Abstract: Pyoderma gangrenosum is an uncommon, idiopathic, chronic ulcerative inflammatory skin disease characterized by a rapidly progressive necrosis of the wound edges, and mimics a postoperative infection. Few cases have been reported after cardiothoracic surgery. We present a case of a pyoderma gangrenosum occurring after coronary artery bypass graft.
Abstract: We investigated angiotensin type 1 receptor (AT1R) expression and interleukin-8 (IL-8) productions in polymorphonuclear leukocytes obtained from patients with peripheral arterial disease (PAD) undergoing femoral endarterectomy. Subjects at high cardiovascular risk (high-risk subjects, HRS) and healthy controls (HC) were also enrolled. To this end, patients with PAD were studied 1 month before surgery, at the time of surgery, and 3 and 6 months after surgery. Polymorphonuclear leukocytes were obtained from venous blood and evaluated for AT1R expression at messenger RNA (mRNA) and protein level and IL-8 production (by means of enzyme-linked immunosorbent assay). At baseline, AT1R membrane expression was similar in cells from patients with PAD, HRS, and HC, whereas AT1R mRNA was similar in patients with PAD and HC and higher in HRS. During the follow-up period, AT1R expression progressively decreased both on the cell membrane and at the mRNA level. Both resting and stimulated production of IL-8 was lower in patients with PAD in comparison to HC and HRS and did not change during the follow up period. In PAD patients, femoral endarterectomy is associated with reduction of AT1R expression however with no apparent effect on IL-8 production. The relevance of such effects for cardiovascular protection deserves consideration.
Abstract: Critical limb ischemia is a chronic pathologic condition defined by the lack of blood flow in peripheral circulation. Microdialysis is a well-known and sensitive method for the early detection of tissue ischemia. The aim of the present study was to use microdialysis in order to analyse cellular metabolism changes after peripheral endovascular revascularization.
Abstract: Cerebrovascular accidents are devastating and worrisome complications after thoracic endovascular aortic repair. The aim of this study was to determine cerebrovascular accident predictors after thoracic endovascular aortic repair.
Abstract: First described in 1989, HIV-related aneurysms have been rarely reported. Considered atypical if compared to classic atherosclerotic diseases, they show no preferred location and frequently involve young patients with no other risk factors for atherosclerosis but with an impaired immune system. They are probably related to an auto-immune damage inside the aortic wall associated with a necrotizing perivasculitis. Visceral artery aneurysms are rare and life-threatening diseases; the superior mesenteric and gastro-duodenal and pancreatic vessels are rarely involved. The advantages related to the endovascular approach to these aneurysms seems to be even more effective in immuno-impaired patients (i.e. HIV+). We report a case of a young patient affected by a HIV-related gastroduodenal artery aneurysm which was treated with a combined percutaneous and endovascular approach.
Abstract: Acute renal artery occlusion is a rare but threatening problem; optimal therapeutic treatment remains a challenge, and ultimate outcomes are still to be defined. In the last decades, several reports or short-case experiences have been reported describing the use of selective infusion of lytic agents into renal artery to treat acute occlusion. We report 4 cases of acute renal artery occlusion treated by catheter-directed intraarterial thrombolysis.
Abstract: Detection of mobile thrombus of the thoracic aorta has become increasingly higher after any embolic event. Although the indication for treatment remains controversial, there is a growing interest about the ethiopathogenesis of this rare entity, and to define proper diagnostic and therapeutic approaches. The purpose of this article was to review the current management strategies and follow-up results of this rare pathology.
Abstract: Diabetic foot is complex and difficult to treat. More aggressive treatment using peripheral distal by-pass frequently combined to minor amputations has greatly improved limb salvage in most patients. However, diabetes-related amputations are at high risk of non-healing or superinfection, thus requiring a second-step surgical revision treatment more frequently than in non-diabetic patients. Several advanced technologies have been developed to improve the treatment of diabetic foot wounds including Vacuum Assisted Therapy: we present 3 cases of diabetic patients treated with preliminary surgical peripheral revascularization, subsequent minor amputation in combination with Vacuum Assisted Therapy performed in a day-surgery regime.
Abstract: OBJECTIVES: The continued advances in imaging and stent/stent-graft technology have considerably expanded the indications for endovascular approach also in vascular trauma. We report our institutional experience with endovascular treatment of peripheral arterial injuries after blunt trauma. METHODS: Between January 2000 and June 2006 out of a series of 81 patients, 10 male patients (mean age of 50+/-14 years) with peripheral arterial injuries were managed endovascularly. At admission, haemorrhagic shock was present in three patients. Artery location involved common femoral (n=2), subclavian (n=2), axillary (n=2), external iliac (n=2), superficial femoral (n=1), and popliteal (n=1). Type of lesion was as follows: pseudoaneurysm (n=4), dissection (n=4), expanding haematoma (n=1), and arterio-venous fistula (n=1). Follow-up program included visit and duplex-ultrasonography, X-rays and/or spiral-computed tomography at 6-month interval during the first year, and yearly thereafter. RESULTS: The lesion was excluded in all cases. All patients survived. Major complications did not occur. Mean hospitalisation was 13 days. Limb-salvage was 100%. Follow-up ranged from 3 to 60 months (mean 16); a late occlusion of a popliteal stent-graft was managed with another endovascular procedure. CONCLUSION: In our experience, endovascular treatment of vascular injuries after blunt trauma was feasible and effective.
Abstract: BACKGROUND: This study assessed the endovascular embolization of splenic artery aneurysms and false aneurysms with special consideration given to postoperative complications. METHODS: Fifteen patients (11 women; mean age, 56 y; range, 39-80 y) with splenic artery aneurysm (n = 13) or false aneurysm (n = 2) were treated with coil embolization. The lesion was asymptomatic in 9 patients, symptomatic in 5 patients, and ruptured in 1 patient. The mean aneurysm diameter was 33 +/- 23 mm (range, 15-80 mm). Postoperative follow-up evaluation included a clinical visit and spiral computed tomography at 1, 4, and 12 months, and yearly thereafter. RESULTS: Endovascular treatment was possible in 14 patients (93%) (1 failure: neck cannulation). Perioperative mortality was not observed. Morbidity included postembolization syndrome in 5 patients (30%). Neither pancreatitis nor spleen abscess occurred. The mean follow-up period was 36 months (range, 3-60 mo). During follow-up evaluation we detected 1 sac reperfusion that was sealed successfully with additional coils. Surgical conversion or open repair were never required. CONCLUSIONS: At our institute, endovascular treatment represents the first-line treatment for splenic artery aneurysms. Postembolization syndrome and infarcts are common events but generally resolve without sequelae.
Abstract: AIM: Aorto-iliac obstructive disease has been traditionally treated with endarterectomy and/or a surgical bypass graft. Kissing-stents technique has been proposed to reconstruct the aorto-iliac bifurcation for complex aorto-iliac lesions. METHODS: We report 43 patients with complex aorto-iliac occlusions managed with endovascular repair. Between March 1999 and October 2005, a total of 43 patients with a mean age of 66+/-10 years underwent endovascular treatment for aorto-iliac obstructive disease. Lesions were classified C (n=34) and D (n=9), accordingly to the Trans-Atlantic Inter-Society Consensus (TASC) classification. All endovascular interventions were performed in the theatre under regional anesthesia. Predilation with kissing-balloons angioplasty was usually performed; the bifurcation was then eventually reconstructed using bilateral stents placed with the kissing technique. Clinical examination and duplex scans or computed tomography-angiography (CT-A) were performed at discharge and 1, 6, and 12 months after the procedure, with yearly studies thereafter. RESULTS: Kissing-stents technique was selectively used in 30 cases (69.7%); the remainder cases were treated with kissing-balloons. Major complications occurred in 2 patients (4.6%). Overall, mean hospitalization was 4.1+/-2.8 days (median 3 days). Mean follow-up was 32.4 months (range 1-84 months; median 36 months). During the follow-up, 2 patients (4.6%) died. Duplex and/or CT-A examination detected 4 re-occlusions. Primary patency rates at 12, 24, and 60 months were 92%, 85.7%, and 80.7%, respectively; overall secondary patency rate was 40/43 patients. CONCLUSIONS: We consider this approach most appropriate for patients deemed at high operative risk for conventional repair or for those who refuse surgery.
Abstract: Vascular injuries with acute arterial haemorrhage are rare but the infrequency of these complications may make their diagnosis and treatment challenging for surgeons unfamiliar with their management. In the past, surgery or coil embolisation has been used to treat these lesions; we describe the case of a pseudo-aneurysm of the common femoral artery developed during a total hip arthroplasty, promptly managed with an endovascular stent graft.
Abstract: OBJECTIVES: To report our mid-term results of stent-graft (SG) placement for the treatment of penetrating thoracic aortic ulcers. METHODS: In the last 30 months, 11 patients (9 men; mean age 73 years; range 55 to 81) were treated for 12 penetrating thoracic aortic ulcers using SGs. Five patients were symptomatic: 2 had ruptured ulcers and 2 cases were complicated with dissection. Mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 10. Three patients had concomitant endovascular repair for an infrarenal abdominal aortic aneurysm (AAA). Follow-up included periodic computed tomography angiography (CT-A) scans at 1, 4, and 12 months after the intervention, and yearly thereafter. RESULTS: Primary technical success was achieved in 100% of patients; no conversion was required. In-hospital mortality did not occur. Paraplegia was not observed. Mean follow-up was 15 months (range 2 to 36). One patient died of respiratory failure 2 months after the intervention. Radiologic follow-up did not detect endoleaks. Survival was 90% at 1 and 3 years. CONCLUSIONS: Our experience confirms the feasibility of SG treatment for elective and urgent repair of penetrating aortic ulcers. Our current attitude is to treat all the ulcers of the descending aorta using an endovascular technique, since SG treatment represents a good treatment option, as the morbidity and mortality are low.
Abstract: Arteriovenous fistulas (AVFs) are infrequently seen in the civilian health-care system; traditionally, these lesions have been treated with ligation, or direct surgical repair with concomitant revascularization. We describe a rare case of a peroneal AVF treated with a stent-graft.
Abstract: Detection levels of mobile thrombus of the thoracic aorta have greatly increased after any embolic event. Although the indication for treatment remains controversial, there is a growing interest about the etiopathogenesis of this rare entity and to define proper diagnostic and therapeutic approaches. We present a case of mobile thrombus of the thoracic aorta causing recurrent peripheral emboli managed with endovascular stent graft.
Abstract: OBJECTIVE: Penetrating atherosclerotic ulcer generally occurs in elderly patients with systemic atherosclerosis, predominantly in the descending thoracic aorta, and it is uncommon in the infrarenal aorta. We reviewed our experience of endovascular treatment of penetrating aortic ulcer in the infrarenal aorta. METHODS: In the last 4 years, out of 348 patients who underwent abdominal aortic procedures, a total of 13 patients (12 men and 1 woman) were found to have an abdominal penetrating aortic ulcer, corresponding to an incidence of 3.7%. Mean age was 73+/-7 years. All patients had hypertension. Three lesions were discovered incidentally and 10 were symptomatic. All patients underwent endovascular treatment in the operating room. Follow-up included CT-A control at 1, 4 and 12 months after the intervention, and yearly thereafter. RESULTS: Primary technical success was 100%. No postoperative death was observed. Mean operative time was 100+/-29 min. Mean blood loss was 168+/-133 ml. No patient required intensive care unit stay. We observed one major complication (transient ischemic attack). Mean hospital stay was 4+/-1 days. During a mean follow-up period of 26 months no endoleak, aneurysm evolution or stent graft failure was recognized in any patient. One patient died 24 months after the intervention after a stroke. CONCLUSIONS: In our experience, endovascular or repair of infrarenal aortic ulcer appears feasible, and midterm results satisfactory.
Abstract: The concomitant occurrence of abdominal aortic aneurysm and malignancy represents a therapeutic dilemma. Both lesions should be treated to achieve best life expectancy; the main controversy remains whether to treat them simultaneously or as staged procedures. Recently, endovascular repair has been suggested as a potential alternative to open standard intervention. We present a case of synchronous abdominal aortic aneurysm and colorectal cancer treated simultaneously by minimally invasive surgery.
Abstract: PURPOSE: The purpose of this article is to report on the effectiveness and durability of endovascular therapy for obstructive disease of the superior mesenteric artery and celiac trunk. PATIENTS AND METHODS: Our retrospective study population included nine patients (five women, four men; mean age 64 years, range 34-83 years) with 15 lesions. The indication for endovascular therapy was chronic mesenteric ischemia. The technical and clinical success rates and the incidence of complications were determined. Follow-up parameters included maintained patency and sustained clinical benefit. RESULTS: Ten vessels were treated. The primary technical and clinical success rates were both 100% with no perioperative mortality. Major complications occurred in two patients (pseudoaneurysms). During a mean follow-up of 31 +/- 18 months (range 3-60 months), thrombosis occurred in two patients at 1 and 3 months after the procedures, respectively. Thrombosis was successfully treated by catheter-directed intraarterial thrombolysis followed by percutaneous transluminal angioplasty (PTA) (n = 1) or stenting (n = 1). At 2 and 5 years, the primary patency rate was 78%, whereas survival was estimated to be 85% and 68% at 2 and 5 years, respectively. At this follow-up, all patients had obtained relief of symptoms. CONCLUSIONS: Our experience suggests that endovascular treatment for chronic mesenteric arterial obstructive disease is feasible, with a low incidence of complications and acceptable midterm results.
Abstract: AIM: The aim of this study was to report our experience with endovascular repair of anastomotic aneurysms occurring after graft replacement for abdominal aortic aneurysms or aorto-iliac obstructive disease. METHODS: Between January 2000 and April 2006, 19 consecutive male patients (median age 73 years) underwent endovascular repair for 22 anastomotic aneurysms [proximal aortic (n=15), iliac (n=4), concomitant aortic and iliac (n=3)], occurring 3 months to 18 years (mean 8.6 years) after open surgery. Three patients (15.7%) underwent emergency treatment for rupture. No patient had symptoms or positive blood tests for infection of the original graft. Twelve patients were treated with a bifurcated stent-graft, 4 patients with a proximal stent-graft cuff, 2 patients with a tube iliac stent-graft, and 1 patient with a mono-iliac stent-graft. RESULTS: Stent-grafts were successfully deployed in all patients. Procedure-related complications or death were not observed; open conversion was never required. Median hospitalisation was 9 days (range 3-45). During a median follow-up of 16 Euro-months (range, 2-44) all anastomotic aneurysms maintained excluded: 4 patients (21%) died. We observed 1 major complication (5.2%): an iliac branch occlusion occurred 1 month after the procedure, successfully treated with catheter-directed thrombolysis. Overall, survival rates at 6, 12, 18 and 36-months were 92.8%, 84.4%, 72.3%, and 57.8% respectively. CONCLUSION: Our experience confirms that endovascular stent-grafts can be used successfully to exclude anastomotic aortic aneurysms after open surgery. Endovascular repair seems to be effective at mid-term follow-up.
Abstract: BACKGROUND: Recent evidence supports the important role of inflammation in atrial fibrillation (AF) after coronary artery bypass grafting (CABG) and there is growing evidence that statin has cardiac antiarrhythmic effects. The aim of this study was to assess the efficacy of preoperative statins in preventing AF after CABG in a longitudinal observational study. METHODS: Over a two-year period, 405 consecutive patients underwent isolated CABG procedures. Univariate analysis was performed exploring the relationship regarding statin use and AF development. A propensity score for treatment with statins was obtained from core patient characteristics. The role of statin therapy on postoperative AF was assessed by means of a conditional logistic model, while stratifying on the quintiles of the propensity score. All analysis was performed retrospectively. RESULTS: Postoperative AF occurred in 29.5% of the patients with preoperative statin therapy compared with 40.9% of those patients without it (p = 0.021). No statistical differences among development of AF and type, dose, or duration of preoperative statin therapy were observed. Preoperative statins were associated with a 42% reduction in risk of AF development after CABG surgery (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37 to 0.91, p = 0.017, while stratifying on the propensity score). No different effect of statins on AF was observed with respect to age groups (< or = 70 and > 70 years) (interaction p = 0.711). CONCLUSIONS: Preoperative statins may reduce postoperative AF after CABG. Patients undergoing elective revascularization may benefit from a preventive statin approach.
Abstract: BACKGROUND: Surgical revascularization of the left subclavian artery (LSA) has been performed to warrant arm perfusion and to prevent paraplegia during thoracic stent graft (SG) procedures. We retrospectively investigated the outcome after intentional occlusion of the left subclavian artery during SG repair for thoracic aortic diseases. METHODS: From December 2000 to June 2005, 11 patients (mean age, 57 +/- 19 years) with a short (<1 cm) proximal aspect of a thoracic aortic lesion underwent intentional LSA coverage to expand the proximal landing zone for SG fixation. Three patients were treated in the emergency setting. We did not perform a prophylactic revascularization of the LSA prior to SG implantation. A preliminary balloon occlusion test of the LSA was not performed in this series. The SG was positioned so that its covering was immediately distal to the left common carotid artery. RESULTS: SG implantation was technically successful in all patients. Intraoperative mortality was not observed; no patient suffered any impairment of left carotid artery flow. Aortography after SG implantation showed no direct flow in the LSA and refilling of the LSA via the ipsilateral vertebral artery. After the intervention, mean systolic pressure in the left arm decreased by 38 +/- 17 mmHg. The stented length of the aorta was 171 +/- 73 (median, 150). During hospitalization, no patient showed any signs of left arm malperfusion. Paraplegia was not observed. One patient developed transient ischemic attack. During a mean follow-up of 19 +/- 8 months (range, 3-36), all patients were completely asymptomatic and had no functional deficit or temperature differential between arms. No leakage was detected. CONCLUSION: Intentional LSA occlusion seems to be well tolerated. Prophylactic surgical maneuvers may be relegated to an elective measure after an endovascular aortic intervention when intolerable signs or symptoms of ischemia occur.
Abstract: The purpose of the study was to assess the effectiveness of contrast-enhanced ultrasonography (CEUS) in endoleak classification after endovascular treatment of an abdominal aortic aneurysm compared to computed tomography angiography (CTA). From May 2001 to April 2003, 10 patients with endoleaks already detected by CTA underwent CEUS with Sonovue to confirm the CTA classification or to reclassify the endoleak. In three conflicting cases, the patients were also studied with conventional angiography. CEUS confirmed the CTA classification in seven cases (type II endoleaks). Two CTA type III endoleaks were classified as type II using CEUS and one CTA type II endoleak was classified as type I by CEUS. Regarding the cases with discordant classification, conventional angiography confirmed the ultrasound classification. Additionally, CEUS documented the origin of type II endoleaks in all cases. After CEUS reclassification of endoleaks, a significant change in patient management occurred in three cases. CEUS allows a better attribution of the origin of the endoleak, as it shows the flow in real time. CEUS is more specific than CTA in endoleak classification and gives more accurate information in therapeutic planning.
Abstract: BACKGROUND: Adult cardiovascular surgery entails, in many cases, the use of some kind of prosthesis. Among the potential complications, prosthetic device infection is one of the most devastating in incidence, as well as in prognosis and damage to surrounding tissues. RESULTS: The most common bacterial agents in vascular and cardiac prosthetic device infections are Staphylococcus aureus and S. epidermidis among gram-positive bacteria and Escherichia coli, Proteus mirabilis, and Pseudomonas aeruginosa among gram-negative bacteria. CONCLUSION: The alternative modalities of treatment for prosthetic device infection encompass partial or total explantation of the prosthesis and its replacement with an infection-resistant graft (e.g., homologous tissue, autologous tissue, or synthetic prosthesis bonded with antibiotics).
Abstract: BACKGROUND: Resection and replacement of the inferior vena cava to remove malignant disease is a formidable procedure. The purpose of this review is to describe our experience with regard to patient selection, operative technique, and early and late outcome. METHODS: The authors retrospectively reviewed a 12-year series of 11 patients; there were 10 males, with a mean age 57 +/- 13 years (range 27-72) who underwent caval thrombectomy and/or resection for primary (n = 9) or recurrent (n = 2) vena cava tumours. Tumour location and type, clinical presentation, the segment of vena cava treated, graft patency, and tumour recurrence and survival data were collected. Late follow-up data were available for all patients. Graft patency was determined before hospital discharge and in follow-up by CT scan or ultrasonography. More than 80% of patients had symptoms from their caval involvement. The most common pathologic diagnosis was renal cell carcinoma (n = 6), and hepatocarcinoma (n = 2). In all but 2 patients, inferior vena cava surgical treatment was associated with multivisceral resection, including extended nephrectomy (n = 5), resection of neoplastic mass (n = 3), major hepatic resection (n = 2), and adrenal gland resection (n = 1). Prosthetic repair was performed in 5 patients (45%). RESULTS: There were no early deaths. Major complications occurred in 1 patient (9%). Mean length of stay was 16 days. Late graft thrombosis or infection did not occur. The mean follow-up was 22.7 months (range 6-60). There have been no other late graft-related complications. All late deaths were caused by the progression of malignant disease and the actuarial survival rate was 100% at 1 year. Mean survival was 31 months (median 15). CONCLUSION: Aggressive surgical management may offer the only chance for cure or palliation for patients with primary or secondary caval tumours. Our experience confirms that vena cava surgery for tumours may be performed safely with low graft-related morbidity and good patency in carefully selected patients.
Abstract: BACKGROUND: To update our experience with thoracic aortic stent-graft treatment over a 5-year period, with special consideration for the occurrence and management of complications. METHODS: From December 2000 to June 2006, 52 patients with thoracic aortic pathologies underwent endovascular repair; there were 43 males (83%) and 9 females, mean age 63 +/- 19 years (range 17-87). Fourteen patients (27%) were treated for degenerative thoracic aortic aneurysm, 12 patients (24%) for penetrating aortic ulcer, 8 patients (15%) for blunt traumatic injury, 7 patients (13%) for acute type B dissection, 6 patients (11%) for a type B dissecting aneurysm; 5 patients (10%) with thoraco-abdominal aortic aneurysms were excluded from the analyses. Fifteen patients (32%) underwent emergency treatment. Overall, mean EuroSCORE was 9 +/- 3 (median 15, range 3-19). All procedures were performed in the theatre under general anesthesia. All complications occurring during hospitalisation were recorded. Follow-up protocol featured CT-A, and chest X-rays 1, 4 and 12 months after intervention, and annually thereafter. RESULTS: Primary technical success was achieved in all patients; procedures never aborted because of access difficulty. Conversion to standard open repair was never required. Mean duration of the procedure was 119 +/- 75 minutes (median 90, range 45-285). Mean blood loss was 254 mL (range 50-1200 mL). The mean length of the aorta covered by the SGs was 192 +/- 21 mm (range 100-360). The LSA was over-stented in 17 cases (17/47, 36%). Overall 30-day operative mortality was 6.4% (3/47). Major complications included pneumonia (n = 9), cerebrovascular accidents (n = 4), arrhythmia (n = 4), acute renal failure (n = 3), and colic ischemia (n = 1). Overall, endoleak rate was 14%. CONCLUSION: Although this report is a retrospective and not comparative analysis of thoracic aortic repair, the combined minor and major morbidity rate was lower than previous reported to results of either electively and emergency performed conventional repair.
Abstract: Although major improvement has occurred to make elective repair of abdominal aortic aneurysms a safe procedure, the incidence of ruptured abdominal aortic aneurysms and mortality rates are still disappointing. Endovascular abdominal aortic aneurysm repair has produced quantum changes in aneurysm treatment. The successful application of the endovascular approach for the treatment of abdominal aortic aneurysms in the elective setting has prompted a strong interest regarding its possible use in dealing with the long-standing challenge of a ruptured abdominal aortic aneurysm. Since the first report, several centers have reported results and a wide spectrum of opinion regarding its application, with special consideration to logistical and practical barriers for appropriate utilization. The purpose of this article is to review all the available literature on the endovascular repair of ruptured abdominal aortic aneurysms and to analyze the most recent trends in their management, with special consideration given to comparing results of conventional and endovascular approaches.
Abstract: AIM: The aim of this study was to report our experience with total and subtotal endovascular stent-grafting combined with aortic arch branch surgical revascularization for thoracic aortic arch aneurysms in high-risk patients. METHODS: From December 2000 to June 2005, among 38 patients treated with thoracic stent-grafts in our department, 10 patients (9 men; mean age 71+/-6 years) at high risk for open repair were candidates for endovascular repair and/or aortic arch branch extra-anatomical reconstruction due to inadequate proximal landing zones. The left subclavian artery was over-stented 6 cases for zone 2 aneurysms, and partial or total arch stent-grafting with simultaneous revascularization of the arch branches was performed in 4 cases for zones 0-1 aneurysms. RESULTS: Primary technical success rate was 100%. In-hospital mortality rate was 10%. Neither paraplegia, nor acute renal failure were recorded. Immediate or late surgical conversion was never required. One type 1b was successfully treated with additional stent-graft and 2 type-2 endoleaks were sealed by coil embolization. Mean follow-up was 21-months (range 3-48 months); overall, survival rate at 12, 26, and 36 months was 90%, 60%, and 30%, respectively. CONCLUSIONS: Endovascular repair for thoracic aortic arch aneurysms is feasible. However, our experience suggests stent-grafting is not free of risk, and long-term and larger follow-up is required.
Abstract: OBJECTIVE: We report the results of our ongoing experience of urgent and emergency stent-graft implantation in acute thoracic aortic syndromes. METHODS AND RESULTS: In the last 5-years, 19 patients were treated for acute thoracic aortic syndromes. Traumatic rupture was diagnosed in 7 patients, complicated acute type B dissection was present in 5 patients, penetrating ulcer in 4, and symptomatic thoracic aortic aneurysm in 3 patients. There were 17 male patients with a mean age of 54 +/-26 years (range 18-87 ; median 63). Patients were treated in the theatre suite under general anesthesia. Stent-graft placement was technically successful in all patients. The early postoperative mortality was 10.5 %. Neurological events or upper arm ischemia due to overstenting of the left subclavian artery were not observed. Average intensive care unit and hospital stay were 18 and 21 days, respectively. Major complications occurred in 6 patients. Follow-up ranged between 3 and 60 months (mean 25) and included clinical examinations and serial CT-angiography at 1, 4 and 12 months, and every year thereafter. Only one type II endoleak was detected and treated by coil embolization of the left subclavian artery. CONCLUSIONS: Our experience suggests emergency stent-graft repair in patients with acute thoracic aortic syndromes is a less-invasive attractive alternative, showing encouraging early and mid-term results.
Abstract: Intravenous leiomyomatosis is an uncommon nonmalignant tumor which originates from the smooth muscle cells and is usually confined to the pelvic venous system. Rarely, intracaval and intracardiac extension has been described: the literature includes only 100 cases with cardiac involvement. We report a case of a young woman with intravenous leiomyomatosis originating from the uterus and extending into the right atrium, successfully treated through a two-stage surgical approach.
Abstract: OBJECTIVES: We report three cases of isolated infrarenal aortic dissecting aneurysms managed with stent-graft. MATERIALS AND METHODS: Three patients, two men and one woman, with a mean age at diagnosis of 69 years were identified. In all cases, chest CT-A did not reveal evidence of thoracic aortic dissection. The mean maximal aneurysm diameter was 6.7+/-1.5 cm (range: 5.5-8 cm). All patients underwent stent-graft repair. Follow-up computed tomographic (CT)-angiography examinations were scheduled 1, 4, and 12 months after the procedure. RESULTS: Stent-graft deployment was technically successful in all cases. Intraoperative mortality was not observed. All patients were adequately treated with a bifurcated device. Intensive care unit (ICU) stay was never required. Mean hospitalization was 4.6 days (range: 4-6 days). Mean follow-up was 18 months. No stent-graft-related complications were observed. CONCLUSIONS: Endovascular repair for isolated infrarenal abdominal aortic dissecting aneurysms is feasible and effective.
Abstract: We report our experience of endovascular repair of isolated iliac artery aneurysms using commercially available stent grafts (SGs). Twenty-five patients (mean age 71 +/- 7 years) presented with 33 isolated iliac artery aneurysms (common iliac artery n = 29, external iliac artery n = 4). Five patients were symptomatic. Depending on the proximal iliac neck and the presence of unilateral or bilateral iliac artery aneurysms, the patient was treated by tube or bifurcated SG that was delivered percutaneously (n = 14) or through surgical exposure of one femoral artery (n = 12). In our follow-up control protocol, the patients are routinely scheduled after 1, 4, and 12 months and then annually after the intervention. Primary technical success with an instant exclusion of the aneurysm was achieved in all patients. The perioperative (<30 days) mortality rate was 0. Major complications did not occur. Mean hospitalization was 6 +/- 6 days (range 2-28, median 4). Four patients (16%) died during follow-up. At a mean follow-up of 32 months (range 3-72, median 36), we detected three type 1 endoleaks (14.3%) that were managed with additional SG; two stenoses at the distal extremity of the SGs, treated with mechanical thrombectomy; and additional stent. In the remaining patients (n = 17), computed tomography angiography confirmed the patency of the SG and the absence of device complication (e.g., endoleak, migration, breakage); shrinkage of the aneurysm was observed in 11 cases (52.4%). Overall, survival rates at 1, 4, and 5 years were 91.6%, 73.3%, and 58.6%, respectively; event-free rates at 1 and 3 years were 79.4% and 67.4%, respectively. In our experience, SG treatment for isolated iliac artery aneurysm proved to be a feasible and low-risk procedure with acceptable mid-term results. At our institute, it is the primary alternative to conventional surgical repair and is offered as first-line treatment.
Abstract: OBJECTIVE: To report the mid-term results of 63 patients who received a new commercially-available retrievable vena cava filter, ALN. METHODS: Between January 2001 and October 2005, 63 patients (mean age 65 +/- 15 years) underwent placement of ALN filters. Filter removal was performed when anti-thrombotic prophylaxis was considered unnecessary or when the patient could safely resume full anticoagulant therapy. RESULTS: Thirty-five patients (55%) had ilio-femoral venous thrombosis and 28 patients (45%) had ilio-caval thrombosis. Overall, 49% had pulmonary embolism. Technical success for filter insertion was 100%, without any complications. None of the procedures aborted or was converted due to technical difficulties. After a median follow-up of 21-months (range 1-48, median 18), there were no cases of pulmonary embolism or vena cava thrombosis. Two patients died of a cause unrelated to deep venous thrombosis during the follow-up period, without clinical evidence of pulmonary embolism or filter-associated complications. No device migration was observed. There were 20 (31.7%) retrieval attempts: in 16 cases filters were retrieved successfully, but 4 cases were aborted. The mean implantation period of the retrieved filter was 179 days (range 53-370). CONCLUSION: Our results confirm the clinical efficacy of the ALN filter for preventing potentially fatal pulmonary embolism whilst implanted and in absence of post-insertion complications, even when left in place indefinitely.
Abstract: INTRODUCTION: Percutaneous closure devices have been used to obtain rapid hemostasis and early mobilization of the patient after arterial catheterization. However, we observed challenging problems with the sealing procedure that require further surgical intervention. The present report is a retrospective analysis of the patterns of injury and the final outcome of four cases of femoral artery injury following the use of Angio-Seal. METHODS: During the last 24 months, in a group of 175 patients (131 men, 44 women; median age 68.4 years, range 47-81 years) underwent percutaneous closure after diagnostic (n = 53) or therapeutic (n = 122) endovascular procedures. Among them we observed four patients (three men, one woman; median age 65.2 +/- 10.8 years, range 47-75 years) who developed severe limiting claudication and required vascular repair of an iatrogenic vascular injury following deployment of the Angio-Seal. They had a femoral thrombosis due to narrowing/severe intimal dissection. RESULTS: All patients required operative intervention with removal of the device. We performed femoropopliteal thrombectomy and common femoral endarterectomy with patch angioplasty (n = 2), resection of the femoral bifurcation and reimplantation of the deep femoral artery (n = 1), and femoral bifurcation endarterectomy with direct arterial suture (n = 1). The median hospital stay was 6.5 +/- 3.8 days (range 4-12 days). Limb salvage was achieved in all of the surviving patients at a mean follow-up of 7 months (range 1-12 months). CONCLUSIONS: Vascular injuries are uncommon after use of the hemostasis closure device. When they occur, however, they are likely to require challenging surgical correction.
Abstract: A 53-year-old man with a significant respiratory history waiting for lung transplantation presented with severe bilateral buttock and thigh claudication. Angiography revealed severe stenosis of the left renal artery and total occlusion of the infrarenal abdominal aorta and iliac vessels. Via a bilateral surgical femoral exposure, we performed semiclosed endarterectomy of the iliofemoral vessels and percutaneous transluminal angioplasty stenting of the infrarenal aorta with two Palmaz stents and percutaneous transluminal angioplasty "kissing stents" of the iliac arteries with three Luminexx stents bilaterally. Completion angiography showed successful complete recanalization of the aortoiliofemoral axis. Palpable distal pulses were restored. A combined surgical and endovascular approach should be considered a viable alternative to laparotomy in selected patients with total juxtarenal aortic occlusion.
Abstract: OBJECTIVE: Patients with multilevel aortic disease represent a small subgroup with the need for extensive surgical treatment at considerable risk. We present our experience of endovascular exclusion for simultaneous thoracic and abdominal aortic disease in four patients. METHODS: Between January 2002 and January 2005, four patients underwent endovascular repair for simultaneous thoracic and abdominal aortic disease. Mean age was 69+/-10 years (range, 60-81). Thoracic lesions included penetrating aortic ulcer (n=2, ruptured=1), atherosclerotic aneurysm (n=1), and chronic type B dissection (n=1). Abdominal aortic disease included atherosclerotic infrarenal (n=3) and juxtarenal (n=1) aortic aneurysms. Thoracic aortic stent-grafts had been the following: Excluder/TAG (n=3) or Talent (n=1) straight tube devices. Abdominal aortic stent-grafts used were as following: Excluder (n=3) or Zenith (n=1). All patients were followed-up with CT-angiography and chest X-rays 1, 4, 12 months after the procedure, and once per year thereafter. RESULTS: Stent-graft deployment was technically successful in all cases. Intraoperative mortality was not observed. Mean procedure time was 94+/-34 min (range, 70-145). Early postoperative complications occurred in one patient that developed acute renal failure but dialysis was not required. Mean hospitalisation was 8+/-5 days (range, 4-15). Late death occurred in one patient for an undetected ruptured thoracic type 1 endoleak. All three survivors are currently well 16.5 months (range, 3-36) after surgery. No neurological complications developed. CONCLUSION: Simultaneous abdominal and thoracic endovascular repair for multilevel aortic disease is feasible and could be a viable alternative in high-risk patients, who otherwise may not be suitable candidates for conventional repair.
Abstract: Conventional open repair of the traumatic injuries of the inferior vena cava still represents a surgical challenge, since it carries high morbidity and mortality rates close to 100% in emergency setting. Surgical techniques required the total mobilization of the liver in the former case and the anatomic exposure of the aorto-iliac bifurcation in the latter. We report a case of uncontrolled hemorrhage from the inferior vena cava, managed by endovascular technique. A 65-year-old woman underwent endovascular stent-grafting for traumatic injury of the inferior vena cava. We performed the endovascular approach as we similarly did for aortic repair using a simple groin access through the common femoral vein; no additional dissection of the inferior vena cava or adjacent structures was needed using endovascular approach, thus avoiding additional operative trauma, and time with the stent-graft procedure was 9 min. Inferior vena cava stent-grafting without laparotomy and retroperitoneal dissection is feasible and could be a very attractive alternative to open surgery for rupture of the vena cava.
Abstract: PURPOSE: To describe a technique combining endovascular and conventional surgery for the treatment of distal aortic arch and thoracoabdominal aortic aneurysms. MATERIAL AND METHODS: In the last two years, we used hybrid approach to treat six patients with distal aortic arch or thoracoabdominal aortic aneurysms unfit for open conventional repair owing poor cardio-respiratory function. RESULTS: The primary technical success rate was 100%. Intraoperative mortality rate was 0; conversion to open conventional repair was never required. Mean operation time and blood loss averaged 256 minutes and 1233 ml, respectively. Neurological complications were not observed. Overall, two patients died postoperatively. During a mean 17-month follow-up, two minor type II endoleak occurred and were successfully managed with coil embolization. All stent-grafts and conventional bypasses were patent, and no stent-graft-related complication was observed. CONCLUSION: Our initial experience attests the feasibility and potential attractive alternative of hybrid treatment for distal arch and thoracoabdominal aortic aneurysms.
Abstract: INTRODUCTION: Injury to the subclavian and axillary arteries is uncommon. Standard surgical techniques require wide exposure and dissection in traumatised areas which is often challenging and associated with significant morbidity, and mortality ranges from 5 to 30%. We report our experience with the endovascular treatment of these injuries. METHODS: We retrospectively studied patients with blunt or penetrating (including iatrogenic) injuries to the subclavian or axillary artery between January 2000 and September 2004. Demographic data, mechanism of injury, concomitant injuries, angiographic findings, and treatment method and outcome were recorded. Nine patients with injury to the subclavian or axillary artery were seen at our institution during the study. Two patients underwent interventions, seven patients had lesions amenable to endovascular repair. RESULTS: Immediate success was obtained in all procedures (100%). All patients continue to have patent grafts with a follow-up ranging from 3 to 48 months (mean 22.6 months). The procedure-related complication was the need for a brachial artery pseudoaneurismectomy at the site of device insertion in one patient (14.7%). None of the patient developed a device fracture. CONCLUSION: Endovascular stent-grafts offer an effective, less invasive alternative to standard techniques in treating traumatic arterial lesions, resulting in shorter procedure time and less blood loss than previously reported.
Abstract: Behçet disease is a heterogeneous, multisystem inflammatory disorder; vascular involvement has been considered to result from systemic vasculitis, which most frequently affects veins and occurs in 5% to 10% of these patients. However, superior vena cava (SVC) involvement is rare; it accounts for only 6% of the cases. The aim of this article is to a report on a case of SVC recanalization through the use of fibrinolysis and self-expanding stents as treatment of life-threatening SVC syndrome in a young male patient with Behçet disease.
Abstract: Epithelioid hemangioendothelioma (EHE) is an extremely rare vascular tumor of intermediate malignancy. Generally it develops from the peripheral veins (usually the femoral vein). We report on a case of EHE of the radial artery, developed in a 26-year-old male patient, which presented as a solitary painless mass. He had a complete resection of the tumor and of the segment of radial artery involved. The histologic examination revealed an intravascular EHE, with low mitotic index and with insufficient histologic anormalities.
Abstract: BACKGROUND: This report describes our preliminary experience in endovascular management of 25 ruptured abdominal aortic aneurysms (rAAAs). METHODS: In the past 3 years we treated 46 patients who had rAAA, and 25 (54.3%) were treated with an endovascular approach. Patients' mean age was 76 +/- 9 years. The diagnosis was confirmed by computed tomographic angiography in 23 patients (92%). Mean aneurysm diameter was 73 +/- 17 mm. We used an infrarenal bifurcated device in 17 patients (68%), a suprarenal bifurcated in four patients (16%), and an aortomonoiliac graft in four patients (16%). Overall, nine patients (36%) required intensive care. Every patient underwent radiologic follow-up according to the Eurostar register, with concomitant evaluation of the D-dimer level (cut-off <200 microg/L) as a biological marker for endoleaks. RESULTS: The primary technical success rate was 100%. Overall in-hospital mortality rate was 20%. Mean hospitalization was 7 days (range, 3-30), and mean follow-up was 7 months. One occlusion (4%) of the iliac limb and two type II endoleaks (8%) occurred. The mean D-dimer level in type I endoleak was 1045 microg/L (range, 459-2021). CONCLUSIONS: In our experience, endovascular management of rAAA is feasible and safe and produces better results than conventional surgery, provided the morphology is suitable and the procedure is carried out by an experienced endovascular team.
Abstract: BACKGROUND: The aim of this study is to evaluate diagnostic methods, indications and surgical technique in SEPS procedure and to analyze short term results. METHODS: Eighteen patients affected by chronic venous insufficiency (CVI) have been analyzed. According to NAVS (North American Vascular Society) classification three patients were included in class 6 (C6), 3 (C5), 6 (C4), 2 (C3) and 4 (C2). From 2 to 5 selective subfascial endoscopic ligation of perforator veins, especially I and II Cockett perforator veins' were performed. In 7 cases, total stripping of the great (6) or less (1) saphenous vein was associated with SEPS procedure. After the operation, an elastic bandage of the lower limbs was performed and a medical treatment with LMVH was started. RESULTS: In 6 patients of the C2 and C3 groups, neither recurrence or pathological reflux were observed at clinical examination and at color duplex. In 12 patients of C4, C5 and C6 groups a reduction of the perimalleolar oedema was observed. In the last 3 patients, with leg ulceration, a resolution of the lesion in 2 cases, and a reduction in diameter in the last one, were observed. CONCLUSIONS: SEPS is particularly advised in those patients belonging to C5 and C6 groups, especially in presence of leg ulceration. This operations is suggested also in patients with CVI and incontinence of perforator veins detected by at color duplex. This diagnostic investigation seems to be adequate in the diagnosis of CVI and in the mapping of perforator veins of the leg.
Abstract: BACKGROUND: The aim of surgical therapy of varicose veins is the elimination of reflux from the deep to superficial system at the saphenous crosse and perforant vessel and conservation of the superficial venous system due to possible surgical procedures for arterial revascularization. This latter condition leads to an extension of indications for short stripping procedures, although the venous distal segment may undergo hypoplastic degeneration not compatible for revascularization purposes. Another important reason is the minor incidence of neurologic complication due to saphenous nerve lesion which may occur during long saphenous stripping. METHODS: From January 1994 to June 1999, we considered 233 patients (182 women, 51 men); 180 cases underwent long saphenous stripping procedures, whereas 53 a short stripping of GSV. The incidence of neurologic complications of the saphenous nerve were recorded in 11.6% of the patients treated with the standard procedure, whereas no such complication was observed in all cases treated with the short stripping procedure. RESULTS: ECD follow-up performed for a period of three months from the surgical procedure revealed the patency of the residual saphenous vein, with a minimum diameter of 3 mm, in 28 patients (56.6%). CONCLUSIONS: Our opinion is to extend the indication for short stripping of the saphenous vein to all cases where the distal saphenous trunk is not involved, when the ECD shows a pathological ostial reflux, a truncular reflux limited to the thigh, which may be associated with incontinence of the perforant vein of Dodd.
