Science topic

Vascular Surgery - Science topic

Vascular surgery is a specialty of surgery in which diseases of the vascular system, or arteries and veins, are managed by medical therapy, minimally-invasive catheter procedures, and surgical reconstruction. The specialty evolved from general and cardiac surgery as well as minimally invasive techniques pioneered by interventional radiology.
Questions related to Vascular Surgery
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Dear all,
Kindly provide your valuable comments based on your experience with surgical loupes
- Magnification (2.5 x to 5x)
- Working distance
- field of vision
- Galilean (sph/cyl) vs Kepler (prism)
- TTL vs non TTL/flip
- Illumination
- Post use issues (eye strain/ headache/ neck strain etc)
- Recommended brand
- Post sales services
Thank you
#Surgery #Loupes # HeadandNeck #Surgicaloncology #Otolaryngology
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According to Dawson and colleagues (2007), some surgical faculty identified some shortcoming of knowledge and skills. Example of these include the choice of catheter, balloon , and stent size. Adequate placing of the sheath was also identified as an issue in training residents.
What do vascular surgical residents struggle most with in their surgical education and training? Do vascular surgical residents and attendings believe that their medical education should be changed from the current standards?
Dawson and colleagues (2007)
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My lab is recruiting qualified individuals in the area of thrombosis/platelet biology signaling. No prior experience working with platelets is needed as full training and mentorship will be given. Strong skills in biochemistry, molecular biology, and/or animal models of vascular surgery would be advantageous. The surrounding basic research environment is exceedingly rich with 40 investigators publishing highly impactful studies, and my work at the Cleveland Clinic gives us access to patient data and specimens through institutionally-approved protocols. Our department was ranked #1 for the last 25 years in cardiovascular medicine. Please send me a message if interested.
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I have made considerable studies on neonatal thrombocytopenia in Nigeria and will gladly join your team to investigate more on newborn platelets. My PhD thesis was on aetiology and pattern of neonatal thrombocytopenia at birth in Delta State, Nigeria. Other similar publications include
1. prevalence of thrombocytopenia at birth among apparently healthy newborns in Delta State, Nigeria
2. Alterations in platelet-to-Lymphocyte ratio and some white blood cell indices in neonatal thrombocytopenia
3. Submitted for publication: Some maternal and neonatal risk factors associated with early on-set neonatal thrombocytopenia in Delta State, Nigeria
4. Submitted for review: Variation in some haematological parameters in the newborn at different locations in Delta State, Nigeria
I have over 12 other publications in reputation journals.
My research experience with add value to your Lab
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With development of new grafts many surgeons prefer to do the proximal femoral-to-popliteal bypass with synthetic prosthesis even if saphenous vein is avaliable. I'm looking for evidence-based bibliographic references that can state against this approach.
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Dear Dumitri,
I have two RCTs from two friends and compatriots of mine (Pieter Klinkert and Fob van Det) whose publications I have uploaded and one excellent review for which I attached the link.
Vascular surgeons that prefer prothetic grafts over autologous vein grafts in infrainguinal bypass surgery are, in my opinion, lazy and ignorant of overwhelming evidence condemning that practice and should be sued by their patients who run a real risk for losing their leg(s)!
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De Bakey and Cooley did the first successful operation for a visceral artery aneurysm (VAA) in 1953. They are relatively rare and the risk of rupture is associated with high mortality .The majority of patients are asymptomatic prior to rupture and the main indication of elective treatment is size, VAA larger than 2 cm and aneurysms in women of childbearing age is recommended. The goal of treatment is to prevent aneurysm expansion by excluding it from the arterial circulation saving branchs patency and freedom from rupture or reperfusion. Surgery has been considered the treatment of VAA for several decades, but now a days endovascular procedures as embolization or covered stents have increased the treatment options available to comorbid patients not suitable for open repair.
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Amplatzer is an excellent option in case of rupture due to rapid solution, when possible,.
I believe that  speaking  about the best  endovascular technique in the treatment of visceral aneurysms(VA) the  answer is: It depends.
The pre operative planning in the cases of not ruptured VA and studing and choosing the best technique for each case individually!
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After this operative procedure is performed how come the 'new' arterial surface doesn't form thrombi (or does it)? Shouldn't the exposed non-endothelial surface be highly thromogenic?
I link some studies concerning survival and long term outcomes which clearly prove the benefits od intervention and prove that thrombi formation isn't a rule, but which is in disagreement with the standard thaught mechanism of vascular thrombi formation (exposed subendothelium being highly thrombogenic).
Looking forward to hear some answers, thoughts and ideas from experienced people.
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You remove the media level together with the atherosclerotic plaque. After a good, clear, non-atheromatous thromboendarterectomy, the surface is devoid of plaques and quite clean. Also, during and after the procedure heparin is administered. 
I always close the arteriotomy with  a patch. If your hypothesis would be true, then everybody should also concern about thrombosis at the patch side.
Just perform an uneventful operation, leave a clean surface, close with a patch, give heparin after the procedure for 24-48 hours and continue with aspirin and clopidogrel, give statins; and don't worry about thrombus formation or re-stenosis.  
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Some time in case of extensive PAD and critical ischemia we need to perform the simultaneous reconstruction of aorto-iliac and femoral-popliteal segment. What is your opinion about the optimal site of proximal anastomosis for femoral-poplieal bypass with reversed saphenous vein? Should vein takes-off from the synthetic graft or from the common femoral (femoral) artery? Some surgeons claimed against the anastomosis between synthetic material and vein.
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I favored to anastomose the aorto-femoral graft limb end-to-side to the common femoral artery with a tongue extending for about 1-2 cm in the profunda femoris artery, and the venous bypass (preferentially over non-autologous graft) end-to-side implanted in the graft limb. I used to implant a venous patch in the graft limb for anastomosis with the vein graft in case the vein graft appeared rather small (< 4 mm in diameter). In skinny patients and patients in whom skin healing might be jeopardized (for instance a redo) I would cover the graft and its anastomic area with a sartorial muscle flap over which the skin is closed with an continuous intracutaneous absorbable suture.
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Data seems to have tremendous variability depending on the source. Vascular Access can be broken down into 3 distinct sub-groups, CVCs, PICC lines and ports (port-a-caths). I am trying to come up with annual procedures for each in the US and ROW.
Thank you
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According to the Joint Commission, about 3 million PICC lines are placed annually in this country, 70% by nurses. The reference is in a paper available on my site: femoral cannulation...in the press in Wounds.
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variation in branching of internal iliac artery radiological OR cadaveric?
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Perhaps This?
Indian Journal of Surgery
December 2015, Volume 77, Supplement 2, pp 248-252
Anatomical Study on the Variations in the Branching Pattern of Internal Iliac Artery
Or Perhaps this one
Anatomy Research International
Volume 2014 (2014), Article ID 597103, 6 pages
Variability in the Branching Pattern of the Internal Iliac Artery in Indian Population and Its Clinical Importance
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General surgeon should begin the reconstruction of the excised portal vein during laparoscopic cholecystectomy or send him to a reference center ?
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If the bleeding is already controlled, and there is no availability for a surgeon with experience in HBP or cardiovascular surgery I think is better to reffer. 
On the other hand I think that you should prevent this. If the anatomy is not clear you should convert to laparotomy. In this scenario, if the hepatoduodenal ligament is severly  inflamed, especially in a chronic fashion, I think is safer an incomplete cholecistectomy, abandoning the gallbladder infundibulum. 
If you have a portal vein injury, more frequent are right branch injuries. In this case the referral is better.
In case of complete transection early repair is necessary. I am very curios about other answers. 
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This 18 year old girl was detected to have Takayasu arteritis with hypertension during evaluation for polyarthralgias. MR angiography revealed her to have severe renal artery stenosis left and left subclavian artery stenosis. Recent literature seems to suggest a higher failure rate and restenosis with stenting rather than with plain angioplasty. This goes contrary to what we see in atherosclerotic coronary artery disease stents have a higher success rates. 
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I suggest angioplasty followed by drug coated balloon therapy.  I recently treated a young patient with a variant of pseudoxanthma elastica who developed sma stenosis and  mesenteric ischemia .  Plain balloon therapy lasted 6 months with recurrence.  I initially approached the patient as if it were fibromuscular dysplasia.  But the patient recurred and I did cutting balloon therapy followed by DCB.  She is now nearly 1 year out without recurrence.
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The choice of the more appropriate method of SFA recanalizazion represents a very interesting and actual topic. This is particularly relevant in claudicant patients. It is reasonable the use  in these cases of a covered Stent  ?
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I think that the risk is very small, and should not affect your decision to technically optimize your procedure.  However as I said in CLI pts with diffuse SFA disease and probably poor tibial runoff I would avoid implanting a covered stent.
 
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  • Utilizes algorithmic checklists to minimize data entry and validate data 
  • Web based, no installation or direct costs, just your feedback 
  • Procedural data only, outcomes need separate tracking
  • Faster than dictation, avoids abstraction, auto-coded
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Yes. It looks interesting and useful.
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Which force is needed to make an implant move/grow through soft tissue? There seems to be a threshold to be overcome by stents (or other implants) to make them grow through tissue. Too low means no growing through. Too high would create lesions. The only reported force I know is from bracelets on the teeth (nearly constant 1-2 N for extraction).
Is there anything known for soft tissue? Ideally for stents in atrial walls? Which biological processes enable this kind of "growing through"? How could i foster it?
I'd be thrilled to hear about your input!
Johannes
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Conventional arterial stents are designed not to grow into the intimal, medial or the adventitial layers. The stent is designed to distribute a uniform radial force sufficient to hold it in place reliably. Restenosis is and undesirable consequence that presents as a growth around the stent. If you want a stent to 'migrate' through the artery wall then it must be designed for that purpose. The form factor and profile for each strut should be reconsidered. Other considerations would be the edge effect of outward radial forces and perhaps other means of constricting the artery to provide a reactive force. These can be mechanically or pharmaceuticaly induced.
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A 15 Y/O girl with a localized non symptomatic hemangioma on the under surface of the tongue. What to do for? 
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you need to do MRA to be sure not AVM , and treatment early is better in her condition by local injection , if failed surgical option is the  2ed .
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And the energy needed using 980nm laser ?
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I must say here when I started this topic I was using a very low LEED because I did no intumescence at all. I had no problem or complication, but gradually I increased my LEED to 60-80 J/cm and the usage of intumescence.
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see above
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Sural nerve transplant is a hit and miss. 
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By surgery I mean, high ligation of tributaries along with surgical removal of the long saphenous vein, referred to as 'stripping'. The vein is accesses through the Sapheno-Femoral Junction through a lateral incision at the groin. Thermal ablation refers to the thermal destruction of the Long Saphenous Vein, 'in situ' by means of LASER or Radio Frequency heat induction.
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Obviously there is  a logical trend for quicker and last invasive techniques.To say that there is no room for stripping at now would also be nonsense as there are still wide and numerous insufficient superficial veins even more problematic if there are large perforators that needs surgery.
I grasp the opportunity of this discussion to remind that venous insufficiency is part of a larger problem which is " the venous illness" and as such there is no one definitive technique or status: to day sclerotherapy, maybee to morrow endovenous ttmnt or even surgery and back to sclerotherapy.
Our patients have there own lives !! they are pregnant,working,taking care of their families and home,standing and not for granting resting and even less using compression therapy/prevention. So ... no way that any procedure could be considered as definitive and comprehensive ( except for a rather low percentage of patients ).
This is kind of a life long follow up that is written in the time for the patient ,its family and... the venous specialist be it a surgeon or a medical phlebologist.
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I am working on a specific circular instrument for end to side vascular anastomoses and I am eager to know about other efforts made by my colleagues.
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Cardiac Sugeons worked with vein-to-coronary artery-anastomosis by magnet:
Arch Mal Coeur Vaiss. 2005 Apr;98(4):294-9.
[Preliminary clinical experience with the Ventrica automatic distal anastomosis system in coronary surgery].
[Article in French]
Klima U1, Farhat F, Beilner J, Maringka M, Bagaev E, Kirschner S, Haverich A.
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We had  reported  the case of a 57-year-old male patient with a history of acute amaurosis fugax. Carotid angiography was performed as blood pressure differed between his left and right arms and there was a pan-systolic murmur on the left common carotid artery. Total occlusion of the proximal right brachiocephalic artery and a thrombus occluding 90–99% of the left internal carotid artery were detected by carotid angiogram. We decided to place a graft-covered stent through the lesion first, and contain the plaque and thrombus between the stent and the lumen. Therefore, a graft covered stent (5×13, Direct) was implanted with 12 atm pressure. After removing the distal blockingbased protection system, we opened the selfexpanding stent (7×10×30, Cristallo) (figure 3) and dilated the stent using a post-dilatation balloon5×20, Tarcomgrande).
A self-expanding graft-covered stent was successfully implanted and there were no complications. This case  published in BMJ Case Journal “ Covered stents may provide extra protection during carotid artery stenting in high risk patients with an excessive thrombus burden”, Tatli E, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-010258.
 However , the patient presented transient  ischemic attacks after three years. DSA angiography show 99% instent restenosis in the  overleap segment of   the both stent.
What are your opinion with  this case ?
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Hi
if I well understand the restenosis was in the overlaping zone where there are two different materials in contact and a different radial force. It's very likely that these two factors have favored the neointimal iperplasia.
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Thoracic surgery.
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Yes. Seen a few patients. Usually need a combined surgical and adjuvant radiotherapy approach of treatment. 
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Can you recommend an intraoperative pressure monitoring technique, either external or intraluminal?
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You can connect you arterial pressure line on a small subcutaneous needle and after calibration you stuck the need in the venous graft (some surgeon use this needle for de-airing of venous bypass grafts) and you will get you pressure line on the scope. However it is probably not an option for arterial grafts.
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Surgical sites infections in vascular surgery are no less challenging or costly to treat compared with other SSIs. Taking the uniquity of vascular surgical interventions into considerations, are their any guidelines or clear bundles of care (BOC) concerning the prevention of wound infections? 
Anybody interested in establishing them?
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I work in preoperative medicine. We have all preop patients take a shower the night before surgery. 1 our afer their shower, we have them se 2% chlorhexidine gluconate cloth wipes, covering their whole body othr than their head, neck and genitilia, and let it dy. We have them sleep in clean bed clothes and on clean sheets, and then use the wipes aain. I can send you the patient instruction sheet if you are interested.
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purpura fulminans: a rare complication may be associated with DIC.
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Purpura fulminans (also known as "Purpura gangrenosa is an acute, often fatal, thrombotic disorder which manifests as blood spots, bruising and discolouration of the skin resulting from coagulation in small blood vessels within the skin and rapidly leads to skin necrosis and disseminated intravascular coagulation. Purpura fulminans lesions, once established, often progress within 24 to 48 hours to full-thickness skin necrosis or soft-tissue necrosis. Once purpura fulminans lesions progress to full-thickness skin necrosis, healing takes between 4-8 weeks and leaves large scars. Without treatment, necrotic soft tissue may become gangrenous, leading to loss of limbs.
The cardinal features of purpura investigations are the same as those of disseminated intravascular coagulation: prolonged plasma clotting times, thrombocytopenia, reduced plasma fibrinogen concentration, increased plasma fibrin-degradation products and occasionally microangiopathic haemolysis.
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There is very few data on how to manage these lesions, but the thromboembolic potential seems to be high, namely visceral and renal artery ischemia. Do you think we should preemptive treat these patients?
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I think the first option is aggressive anticoagulation if patient is asymptomatic with close monitoring with TEE. I' ve seen 2 patient treated in this way with good result. TEVAR shows a theoretical embolic potential larger than a conservative approach. Open surgery is only for peculiar cases of associated lesion. Of course we ' ve to consider a second stage of treatment if the thrombus is due to an atherosclerotic burden of the aorta rather then to a coagulation disorder.
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I'm a doctor in training and and I would like to explore this new type of stent understanding how it works in detail.
Thank you
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Hello. You should check this article.: Sfyroeras GS, Dalainas I, Giannakopoulos TG, Antonopoulos K, Kakisis JD, Liapis CD. Flow-diverting stents for the treatment of arterial aneurysms. J Vasc Surg. 2012 Sep;56(3):839–46.
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I'm developing a project and hope to locate outdated and/or open, unused filters. This is a proof-of concept which is on a tight budget.
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Best to contact the company making the filters and ask for outdated stock
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What is your approach to cellulitis and erythema  over arterial side of prosthetic AV graft for dialysis without purulent discharge after 2 weeks of surgery? Antibiotic or graft excision?
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Does the patient exhibit any other signs of infection? Also is there either an elevated white count, or CRP level?
Differentiating between an inflammatory reaction to the PTFE graft versus infection can be tricky. If all you have is erythema in the absence of any systemic markers then I suggest you give a week of antibiotics and continue to observe the situation.
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Renal artery aneurysms are considered the second most common visceral aneurysm (15-22 %), most common being splenic artery aneurysm (60%). It is more common in females. Most of the lesions are saccular and tend to occur at the bifurcation of main renal artery. Management depends on various factors like age, sex, severity of hypertension, any anticipated pregnancy and aneurysm morphology. Surgical treatment is recommended in aneurysms > 2 cm in size.
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Dear All,
I  agree with Mr. Alexander , Muradi and Tarhan, but at this moment i do  prefer endovascular coil embolization or covered stent instead of multilayer to treat renal artery aneurism. Some reports are ambiguous about multilayer results.
I would like to ask Ms. A. Lombardi to send her suggestion of paper ?
Giuliànotti PC et al.
J Vasc Surg. 2010 Apr;51(4):842-9.
My email address : vascular@pauloocke.com.br
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Surgical repair is usually durable, and can be performed with low risk. Some physicians have recommended stent grafts to repair popliteal aneurysms. What is your opinion?
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Endovascular Popliteal Aneurysms repair with covered stents is increasingly used. It is, however, unclear when an endovascular approach is preferred to traditional open repair with great saphenous vein bypass .
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In those patients with critical iliac aterosclerotic lesions, limiting claudication, pain at rest, limiting lifestyle and despite medical treatment shows no improvement .
Covered stents can afford a protective mechanism that shields stents from tissue in-growth and may reduce restenosis caused by intimal hyperplasia?
They may offer an improvement in performance in the treatment of more complex iliac disease?
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The Covered Versus Balloon Expandable Stent Trial (COBEST), a prospective, multicenter, randomized controlled trial, was performed involving 168 iliac arteries in 125 patients with severe aortoiliac occlusive disease who were randomly assigned to receive a covered balloon-expandable stent or bare-metal stent.
COBEST demonstrates covered and bare-metal stents produce similar and acceptable results for TASC B lesions. However, covered stents perform better for TASC C and D lesions than bare stents in longer-term patency and clinical outcome.
References
1BP Mwipatayi, S Thomas, J Wong, SE Temple, et al.: A comparison of covered vs bare expandable stents for the treatment of aortoiliac occlusive disease. J Vasc Surg. 54 (6):1561-1570 2011 21906903
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What is better, endo or open?
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I agree that endovascular procedure must be a recommendation but only after remission of inflamatory phase of disease .
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In carotid disease the most important consideration for decision-making regarding an invasive approach is the risk for complications associated with the respective approaches. CEA has been performed for more than 50 years with an established record in both prospective and community-wide trials. CAS is still an evolving procedure, and there are limited data with respect to results across the large numbers of practitioners who could potentially offer the procedure .We believe that CAS could be useful in the treatment of some patients with carotid disease. What is your opinion?
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I believe that ECST2 have conditions to answer this question!
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In recent years we`ve preferred the Endovascular Technique for almost all of our patients with clinical indication obviously associated with serious and advanced lesions TASC
C & D as a first Femoral Artery approach as disclosed in TASC II B. I wonder about the experience of our colleagues, vascular and endovascular surgeons.
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Dear Peter Fellmer and Fellows ,
Do you have experience with Heparin Bonded Viabahn Stent-Grafts in lower extremity?If the answer is yes, which are your technical considerations to improve results?
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Generally we do an elective repair of Abdominal Aneurysms when they are > 5,0cm, also as we know, small aneurism can rupture .How to predict AAA rupture Risk of aneurisms < 5,0 cm?
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I Agree but The UK Small aneurism Trial(Lancet 1998) showed that early elective surgery did not offer any all-cause survival advantage over regular ultrasound surveillance. The ADAM TRIAL (N Eng J Med 2002) published similar findings. The Eurostar(JVS 2004) registry indicate that even with the single outcome of freedom from aneurysm-related death following EVAR deployment,the rate of AAAs measuring between 4,0 and 5,4 cm is 3% within 5 years. Clearly ,there is very weak evidence to justify either open surgery or endovascular intervention in patients with aneurysms measuring less than 5,0 cm.
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Endovascular abdominal aortic aneurysm repair(EVAR) have many advantages but endoleaks, persistent flow outside the graft or endotension,elevated pressure within the aneurysm sac are the principal reasons for failure of the aneurysm endovascular treatment.
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Thus CEUS may be a breakthrough in fact, some authors have considered the endotension an undetected endoleak. So as Prof.Maria said "it`s minimally invasive , more accurate than conventional ultrasonography in the EVAR follow-up . It is imaging "in real-time"."
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It is usual to encounter pseudoaneurysm of femoral artery of large size due to delayed diagnosis as whole attention in trauma goes initially to bony injury if there is fracture of bones. In this situation either vascular injury is missed or iatrogenic injury of artery may lead to pseudoaneurysm. So, what should be the best mode of intervention in femoral artery pseudoaneurysm.
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Vikas Goyal said some of the reasons Why to prefer open access.
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Aneurysm formation is a known issue with these grafts, but - according to literatur - in only up to 7%. We have observed a lot more at our institution.
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Dear Dr Fink,
we have quite a lot of experience in using omniflow as a regular graft in cases of prior graft infection. In this circumstances we did not see any aueurysmatic degegenartion, except one case with an anastomotic problem maybe due to not relay stich the mesh but anly the collagen. From my point of view it is very important to keep the mesh intact.Maybe when omniflow is used as an av access you destroy the mesh. Anyway we use in in a few replacement scenarios in case of infection as av access and had no problem. follow up might be 2 or 3 years.
Yours
P.Fellmer
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Stem cells viability assessment in the therapeutic angiogenesis for CLI.
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Dear Gopi,we are using flow cytometry only in humans.With cytometry we use also /for viability/trypane blue staining.Viability is 75 to 95 per cent (after 16 h)and our procedure is successful,for.ex.see: Therapeutic angiogenesis for the salvage od ischemic limb,CLAHT,September 1-3,2011,Montevideo,Uruguay
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Do You analyze concentration of CD 133+/34- endothelial progenitor cells
in the bone marrow and in stem cell products before administration in the critically ischemic limb of the patients with critical limb ischemia? Do you examine the viability of the stem cells before their administration to the ischemic limb?
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What is the stability and viability of 133+/34- cells? Is it
possible to analyze (with relevant results) even the next day after bone
marrow collection?
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I am actually a bit confused.
I want to find a relationship ( if there is one) between an independent continuous variable and a dependent categorical variable.
e.g. The effect of systolic BP reading ( continuous parametric variable ) on stroke dependent categorical i.e. no stroke event =0, stroke =1. I can't use correlation as both have to be continuous variables. Which test? I use SPSS.
Thanks
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Simple logistic regression
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Patient with symptomatic varicose veins, duplex reported: absence of incompetence of the femoral valve before the saphenous femoral union, terminal valve incompetence, preterminal valve incompetence, your plan to follow would be:
1.- surgery: ligation adyacent to saphenous femoral union to the femoral vein, ligation of colaterals then to first divison, close of the cribiform fascia (oval fosse), and stripping
2.- thermal ablation of the saphenous vein(laser or radiofrecuency)
3.- chemical ablation of the saphenous vein (Foam)
4. Ligation the saphenous femoral union and distal foam.
Seconds question: your academic level
Vascular surgeron with 6 years subespeciality training
Phebologist with 2 years od training
Other especiality ( wich.........)
General physician.
Thanks. ALEJANDRO LATORRE
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Alejandro Latorre • last week in Bucaramanga, Colombia, in the 6 Colombian Phebology Simposium. The expertes in the treatment of varicose viens in conferences, videos, expert metting, about the question, experts defined according to their experience the following therapeutic alternatives
Options
1.- Surgery, Alejandro Latorre, Colombia
2.- EVLA +phlebectomy, Dra Marianne de Maessener, Belgica
3.- FOAM, dr P. Coleredge Smith, England
4.- Crossectomy + distal FOAM, Valete Guerrero, Mexico
5.- Phlebectomy only, without saphenous and saphenous femoral union, dr. Paul Pittaluga and Sylvain Chastenet , France
6.- Scleroterapy (Foam only tributaries without saphenous and saphenous femoral union) Dr. Angelo Scuderi, Brasil
finding: all alternatives are in place, with medium-term recurrences very similar, where above all the experience of the surgeon prevails
Thanks for your concepts
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Is there surgical treatment?
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Surgery usually not indicated, I agree with Tristan. I suggest extensive evaluation of the patient and judicious follow-up. Atresia of the inferior vena cava may be associated with cardiac and visceral abnormalities, such as destrocardia, pulmonary stenosis, atrial defects, polisplenia, asplenia or situs inversus and complicated by deep vein thrombosis. DVT are usually bilateral and extensive, involving both iliac veins and an enlarged shadow of the azygos vein may appear on chest X-rays.