text:
Maybelline Volum' Express The Mega Plush
641 reviews
53% would repurchase
Package Quality: 3.7
Price: $$
Package Quality: 3.7
Price: $$
on 6/17/2014 12:20:00 AM
Age: 18 & Under
Skin: Combination, Fair, Cool
Hair: Brunette, Wavy, Medium
Eyes: Green
When this mascara came out, I was super excited to get my hands on a tube as I really don't like the feel of stiff lashes. It did the job! My first tube, which is really cute by the way, worked wonderfully. Long, separated, volumized lashed without the stiffness. They were actually flexible when I touched them. No flakiness either. It worked great until it dried up after a couple of months. I just bought another tube last week and it hasn't let me down either.
on 6/16/2014 1:49:00 PM
Age: 25-29
Skin: Normal, Tan, Not Sure
Hair: Brunette, Other, Other
Eyes: Green
I love this mascara. Gives me well coated lashes with no flake. You only need 1-2 coats to get the job done. Makes lashes look nice without being too over the top
on 6/14/2014 11:44:00 AM
Age: 44-55
Skin: Very Dry, Fair, Not Sure
Hair: Red, Other, Other
Eyes: Blue
This mascara was a total waste of money. The brush was impossible to use because of that bend in the middle- it just pushed my lashes away, didn't coat them at all. Didn't someone test this product before they put it on the market? What were they thinking?! Cute packaging but that doesn't really matter if the product is terrible!
on 6/13/2014 8:40:00 PM
Age: 19-24
Skin: Dry, Fair, Cool
Hair: Brunette, Straight, Medium
Eyes: Blue
Oh Maybelline! Yet another under preformering, overhyped mascara.
Unlike certain other maybelline mascaras, the formula wasn't really the problem here (don't get me wrong, it's nothing to write home about).. it was the damn brush! I felt like I was using a cotton bud/qtip to apply mascara. The bristles of the brush all stuck together and just transferred blobs of the product directly onto my lashes.
Even after a few coats of this stuff, I saw no volume as promised. Some days, it would give a rather mediocre result.. and on bad days, it would just be clump mania.
Even though it is good value (I paid about �10 I think), it is not worth the money at all and I would not repurchase this.
on 6/12/2014 6:56:00 PM
Age: 44-55
Skin: Sensitive, Fair, Cool
Hair: Other, Straight, Fine
Eyes: Grey
I was excited when this mascara was introduced because I really like lightweight, natural looking mascaras, and the trend lately is just the opposite. But this mascara was really disappointing. I think the formula is okay, if a little sticky, but it's hard to tell because I can't get a good application with that awful wand. The brush has sparse, spindly bristles that are spaced too far apart, and it made my lashes look, well, sparse, spindly and spaced too far apart. I have made several attempts at this, and have been disappointed every time. I will not buy it again. I'm not even going to use up the tube I have.
on 6/10/2014 1:17:00 AM
Age: 25-29
Skin: Combination, Fair, Cool
Hair: Red, Wavy, Fine
Eyes: Brown
I have this in blackest black and it absolutely lifts and extends my eyelashes. Besides the lashes near the tearduct and outer end it is able to reach all across my lashline.
The brush wiggles a little because there is a cut toward the end section. I guess ' Maybelline' thought this would give consumers more control and it can but only if you have a steady hand. This has a wet feeling that takes a minute to dry so be careful not to blink or have something on hand to catch flecks.
This mascara comes in four shades.
on 6/9/2014 8:33:00 PM
Age: 36-43
Skin: Combination, Fair-Medium, Neutral
Hair: Brunette, Wavy, Medium
Eyes: Brown
Just like so many other mascaras, I bought this on a whim. I've had really good luck in the past, but this was disappointing. The name of this, to me, is deceptive. "Volume", "Mega", "Plush"...all words that sucked me in. I was really hoping it would deliver all those things.
This mascara is just okay. The formula is on the wet side, and I needed to apply 3 coats to get anything decent from it. I didn't find it to be volumizing or plush in any way. In fact, I think it's more lengthening than anything. It's nice and black, but the formula is thin. I also didn't much like the bendy wand. It made application a little bit messy. I guess this would be a good one if you're looking to just darken your lashes a bit for a very natural look, but if you're looking for mega plush volume...take a pass.
ETA: I just wanted to add that I thought this mascara was surprisingly difficult to wash off. It claims to be able to come off with just soap and water, but I did not find this to be true. I usually wash my makeup off with Purity by Philosophy, and it even gets water resistant formulas off with ease. But, I looked like a raccoon and had to reach for the cold cream to scrub it off.
on 6/9/2014 5:35:00 PM
Age: 36-43
Skin: Dry, Fair, Not Sure
Hair: Brunette, Wavy, Fine
Eyes: Blue
there is nothing volume or plush about it. I actually got it because I wanted volume and this is also one of the few brands that has navy mascara so that was one of the reasons why I got it.
However, it was the most average mascara-there was nothing special about it. I do have fairly dark lashes so navy color didn't show, it just looked black. And while my lashes are fairly long, they need volume. didn't happen with this one. I wouldn't repurchase
on 6/4/2014 12:05:00 PM
Age: 30-35
Skin: Normal, Fair, Cool
Hair: Brunette, Straight, Fine
Eyes: Brown
I purchased this mascara on a whim. The packaging was pretty and teal and I thought the mascara would be ok. I was so wrong. It's clumpy and the brush is super clumsy. Good luck trying to get any product on your lashes without also getting it ALL OVER your skin. Maybe a better brush would make this mascara tolerable, but even the formula is sub-par.
on 5/26/2014 8:51:00 PM
Age: 30-35
Skin: Combination, Fair, Neutral
Hair: Brunette, Curly, Medium
Eyes: Brown
This stuff is amazeballs. I love the formula - no irritation or smudging whatsoever. It was even a rather sweaty day and it didn't budge. Very volumizing and lengthening. Nice separated lashes. The wand feels a little weird because it's bendy, but it works fine.
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Marlo Suit Pant in New Tailor
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Wellar HC Suit Jacket in New Tailor
The Modern Jean
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Dover Spread Dress Shirt in Kenai
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The Classic Fit
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Bradley Pant in Brasted
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Sten S Short in Entick
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Wellar Jacket in Blenheim
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The Guide Tennie is the most popular approach shoe in the world, and the perfect choice for terrain that blends walking and climbing. The shoeââ¬â¢s internal rocker promotes a healthier stride, while a specially designed midsole and outsole help regulate flexibility and increase stability.
*Free Ground shipping applies to physical street addresses in the Continental USA. PO Box shipments are sent via USPS Priority Mail.


text:
DL1961 Jeans
Ashley Greene in DL1961 Amanda Skinny Jeans in Seville
Ashley Greene and her boyfriend, Paul Khoury, were seen hand-in-hand after grabbing lunch at Romancing the Bean in Los Angeles, California a couple of days ago.
Ashley wore a pair of DL1961 Amanda skinny jeans in Seville with a black and white striped tee, a black blazer and black boots. It's quite nice seeing more classic blue jeans out on the celebs lately. I do enjoy the bright colours, prints and leathers, but it's definitely a refreshing change seeing lots of classics! I think the distressing on this pair is good! Buy these jeans online at Shopbop for $178. I also styled the Amanda in 3 different washes, 3 different ways (including this Seville wash). If you want to check that out, click here.
Images courtesy of Pacificcoastnews.com.
Olivia Wilde in DL1961 Skinny Jeans and a Current/Elliott Jacket
Olivia Wilde and a friend were snapped while grabbing lunch at a cafe in Los Angles. She wore a pair of DL1961 Skinny jeans and a Current/Elliott army jacket over a striped shirt with black booties. This is one of the first times we've seen Olivia out in DL1961 and I think she looks amazing. She has definitely been glowing since she announced her pregnancy!
Since Olivia's style always has a bit of edge, I'd love to see her try out a pair of moto-jeans, like the Hazel jeans in Ducati. I think she'd look great in them and they would suit her style really well. You can buy DL1961 online from DL1961.com.
Styling DL1961's Amanda Jeans – 3 Different Ways
The Amanda jean from DL1961 is such a versatile cut, it can be worn with pretty much anything. DL1961 asked me to style 3 different washes in the Amanda in 3 very different ways, to prove how easy they are to wear. The Amanda is a great skinny jean, it has a 31″ inseam, a 8.25″ rise, a leg opening of 11″ and is one of the brands best sellers! It's similar to the Emma in fit, but it's skinnier and has a longer inseam. Now onto the styling!
Victoria Justice in DL1961 Amanda Skinny Jeans in Rapture
Actress Victoria Justice was all smiles as she waved to the cameras while she was on the set of the new TV show 'Eye Candy' in New York City.
Victoria wore a pair of DL1961 Amanda Skinny Jeans in Rapture with studded biker boots, a dark green leather jacket and a tee. I really like this outfit on her actually, it's casual and comfortable and perfect for Autumn! Buy DL1961 online at Shopbop.com.
Images courtesy of Zelig Shaul/ACE/INFdaily.com.


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World Vision Presents 'Beautiful Offerings Tour'
by TMC Staff
Truett-McConnell College will host The Beautiful Offerings Tour featuring Big Daddy Weave, Group 1 Crew, Chris August and Dara Maclean on Saturday, October 25, 2014 at 7:00 pm in the TMC Gymnasium.
Doors will open at 6:00 pm. You can purchase tickets by clicking on the following link:
For more information about the concert, please contact Truett-McConnell College at 706-865-2134.
We are Truett-McConnell: Matt Gregory
By Jenny Gregory
CLEVELAND, Ga (TMNews) – Matt Gregory, a… Read More
A Journey to Peace: the Heatherlys' Story
by Emily Raley
Benjamin Heatherly was born… Read More
We are Truett-McConnell: Kasie Beris
By Jordan West
CLEVELAND, Ga (TMNews) – Kasie Beris has… Read More
We Are Truett-McConnell: LiPing Dykeman
by Bailey Jarnagin
CLEVELAND, Ga (TMNews) – Born in… Read More
We are Truett-McConnell: Fletcher Humphrey
By Bailey Jarnagin
CLEVELAND, Ga (TMNews) – After realizing he… Read More


text:
Neoseeker : Games : iPhone : Rhythm & Music : DJ Nights: Julie Thompson Ed.
BackgroundJulie Thompson has performed with Tiësto in his Elements Of Life world tour for hundreds of thousands of trance, house and techno fans. Her songs have featured in several mixes by renowned DJs like Deep Dish, Paul van Dyk and Ferry Corsten.
Julie is an amazing singer who writes and sings atmospheric lyrics and warm vocals - the perfect solution for days where you want to have fun and enjoy energetic, atmospheric electronic music.
DJ Nights: Julie Thompson Edition features ever song from Julie's last album, "Feeling for Corners" - we think you'll love it!
Game Play
Hardware Info
- Genre: Rhythm & Music (iPhone)
- Developer: Clickgamer Technologies Ltd
- Publisher: Clickgamer Technologies Ltd
Released North America Dec 5, 2009


text:
Wrangler Chocolate suede leather chelsea boots
Item No.0840101901
Item No.0840101901
70% Off - Save a total of £52.50
These chelsea boots from Wrangler come in a chocolate suede leather with stitch detail and a pull tab to the ankle. They have a soft blue lining and a durable rubber sole.
UK Home Delivery Free (UK orders over £30) or £3.49
Delivered within 5 working days
Next or Named Day Delivery
7 days a week between 8am - 6pm
Sunday to Friday - order by 9pm - £3.99
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7 days a week between 6pm - 10pm
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Collect from store the next day - FREE
Order before 9pm for next day collection after 12pm midday
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Subject to exceptions, Debenhams is happy to exchange or refund your purchase within 28 days of delivery. Please check here for more details on our returns policy and exceptions.


text:
Agnes B. Liquid Eyeliner
39 reviews
79% would repurchase
Package Quality: 4.1
Price: $$
Package Quality: 4.1
Price: $$
on 11/15/2003 10:48:00 PM
Age: 25-29
Skin: Acne-prone, Olive, Not Sure
Hair: Black, Other, Other
Eyes: Black
This is the only liquid liner I will use. I have three tubes and absolutely love them. I know when I put this on at 6am that it will still look great at 6pm. Once these go on they don't budge! I've fallen asleep with the liner still on and woke up with it still in place. The applicator is great and allow you to apply a line as thin or thick as you want. I just wish these weren't only available via mail order!
on 8/30/2003 8:15:00 AM
Age: 36-43
Skin: Acne-prone, Other, Not Sure
Hair: Red, Other, Other
Eyes: Hazel
I am eye liner challanged, but this product is fool proof. I have the black, coffee bean and a couple of other colours, and I love them. The felt applicator is easier for me to use than a brush. I will buy this again.
on 7/9/2003 12:26:00 AM
Age: 19-24
Skin: Combination, Other, Not Sure
Hair: Brown, Other, Other
Eyes: Blue
I have this product in the black/grey shade and it offsets my blue eyes nicely. The applicator is surprisingly easy to manuever. Liner goes on as thick or thin as desired. A very nice liquid formula.
on 5/30/2003 3:57:00 AM
Age: 19-24
Skin: Dry, Other, Not Sure
Hair: Black, Other, Other
Eyes: Black
This is an awesome product! I use eyeliners every day and this is my HG eyeliner. It is easy to apply, nice color and consistency. Most importantly, doesn't smudge or fade. I work very long hours and this is important to me. I am already on my 3rd one and is ready to purchase again!
on 3/30/2003 12:31:00 PM
Age: 19-24
Skin: Acne-prone, Other, Not Sure
Hair: Blond, Other, Other
Eyes: Green
this is the best liquid liner i've used thus far. it goes on very easily, very smoothly. i've used some liquid liners that were a pain to get on, but this is practically fool-proof. i use it in coffee bean, and it lasts all day, without any kind of smudging or flaking. the only way i've noticed it flake is if i get my face all wet and rub my eyes. but really, when's that going to happen, besides when you wash your face?..i have oily skin and i wear contacts, and it works great for me. price-wise, it's a lil on the expensive side. (for my cheap art-student tastes) but ccb-paris has it on sale for half-off sometimes, so i buy it then. it really is a great product, and the -only- liquid liner i will use ever again.
on 2/17/2003 1:53:00 PM
Age: 18 & Under
Skin: Combination, Other, Not Sure
Hair: Red, Other, Other
Eyes: Brown
I have three of these so far, they are a bit expensive but well worth it (12.00 or so). They come in a sleek silver pen. This is the best liquid eyeliner i've ever tried. It lasts all day and comes off easy with water or makeup remover, looks great, comes in a good variety of colours. I have tried Gold Sparkling Black which is just black with a gold shimmer, Bronze which is simply that and Ash Praline which is a light beigey colour.
I am extremely impressed by this eyeliner. I have a habit of drawing on myself (normally with pens...) and I happed to doodle with one of these eyeliners on my lower leg. That was early afternoon- the next morning it with still there, not smudged, flaked or faded at all. Its amazing- Nothing- not even sharpie marker- works that well.
on 1/23/2003 8:49:00 AM
Age: Unknown
Skin: Dry, Other, Not Sure
Hair: Brunette, Other, Other
Eyes: Brown
I love these eyeliners, I have every color (I like black gold and black silver best of all). Application is quite easy with the felt tip, if I want an even finer line, I use my own eyeliner brush (I apply the brush on the felt tip, I don't dip it in the container). It stays on great, doesnt flake or irritate my eyes (I wear contact lenses, so it's really important to me). I love the slight shimmer it has, it doesn't look dull like some other eyeliners. My favorite Agnes B. product.
on 7/18/2002 2:19:00 PM
Age: 19-24
Skin: Combination, Other, Not Sure
Hair: Black, Other, Other
Eyes: Brown
I have Agnes B. liquid eyeliner in Coffee Bean (a deep brown). I love the flexible felt tip applicator which makes it super easy to apply. It also lasts all day. At $12.50, it's a bit expensive but there are usually online deals so that you can get it for cheaper. I've bought this product a couple of times and have always been happy with it.
on 4/7/2002 10:39:00 PM
Age: 19-24
Skin: Other, Other, Not Sure
Hair: Brunette, Other, Other
Eyes: Brown
This is a fabulous liquid eyeliner. The staying power is crazy!! It has a skinny, felt tip pen that draws a very precise line. The color choices are quite creative (powder blue?!)but I'll stick to black. Fabulous for only about $10.
on 3/31/2002 8:20:00 AM
Age: 19-24
Skin: Combination, Other, Not Sure
Hair: Brown, Other, Other
Eyes: Brown
I really really love these liners! They come in a sleek silver tube, with a felt-tip brush for easy application. It's really easy to just 'draw' a line near my lashes, and this honestly lasts the entire day on me - no smudging, smearing, disappearing. Love it!
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614 Reviews
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text: We stayed at the Park Hotel because last year some friends stay at this hotel and enjoyed it. We usually stay at a hotel a few blocks away from the Park Hotel. So, we know the area well and we enjoy being near the museums, shopping, restaurants, flower market, Vondel Park. It is wonderful location. The room we had was small, but very clean and modern. The bed gave us a comfortable night sleep. If you use the internet in the room, there is a fee. If you use the internet in the lobby, it is free. There are couches, tables, chairs in the lobby for your comfort to use the internet. There is staff asking you if you would like a drink or snack while sitting in the lobby. Very helpful and friendly staff. We enjoyed our stay at the Park Hotel. It looks like we found a new hotel to stay in when we visit Amsterdam.


text:
BackgroundBallblazer Champions is like a futuristic soccer game but with only one person per team. Each person is armed has a hovercraft. Some players are more offensively oriented, some will take defensive weaponry, and some will opt for fast ships that can shoot the ball far. The arenas contain power-ups, weapons, and ramps.
Official URLOfficial Site
Recent threads
- Best game ever? Jan 18
- is it worth it Dec 8
Eggbart owns BallBlazer Champions
Poached_Eggadded 2 cheats
Mar 05, 04 9:06am
choochoomanadded a cheat
Jul 15, 03 7:24am
Jul 02, 02 2:16pm
A long awaited remake?
A long awaited remake? Yes. Worth it? Well I was a little disappointed.
This is a...
Guestadded 8 new screenshots
Jan 13, 01 2:54am
- Genre: Soccer (PSX)
- Developer: LucasArts
- Publisher: LucasArts
Released North America Nov 17, 1997


text:
Kelly Osbourne Puts Pet Pomeranian to Sleep
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- Prev
Kelly Osbourne is mourning the loss of her pet Pomeranian, Noodles.
"My poor baby girl Noodles is sick," the "Dancing With the Stars" alum tweeted Tuesday. "She had a seizure and they don't know why. I'm taking her to see a specialist two hours away for a brain scan."
Osbourne, who adopted Noodles in March, nicknamed the pooch "Noody Bear." Three months later, the puppy's health took a turn for the worse. "I can't even look at my baby girl without crying," Osbourne tweeted. "She just looks so sick and helpless."
A veterinarian performed a brain scan and delivered some bad news: Noodles was suffering from brain swelling.
"Noodles is not going to make it," Osbourne, 26, wrote. "She was born with a brain defect and I have to put her to sleep today. I'm devastated. I just can't believe it."
When one of Osbourne's followers criticized her for putting down her puppy, she defended her decision by saying: "She was not in peace. Her brain was swelling in her head. I don't play God! It was unfortunately necessary!"
Reese and her donkeys; plus more celebs with their pets
Kelly and more of Hollywood's hottest single ladies
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text:
Commenting on the announcement, Vaden Landers, chairman and managing partner of Singular Payments said, "This new partnership further demonstrates our commitment to the medical professional vertical." He added, "It is our mission to partner with forward thinking practice management software providers such as Beaver Creek who see value in providing technology that will allow their clients to reduce costs, improve cash flows, eliminate paper invoices, shorten billing cycles and enhance collections."
For more information, please contact Vaden Landers at Singular Payments at 877-829-2170, x. 7008, via email vlanders(at)singularpayments(dot)com, or visit the Singular Payments website at http://www.SingularPayments.com
About Singular Payments
Singular Payments is a leading provider of electronic payment solutions within the Dental, Veterinary, Optometry, Medical, Specialty Retail, Utility & other Electronic Bill Pay verticals. Singular Payments currently processes nearly $1 billion in annual sales for businesses owners all across the country. The company prides itself on being one of the most highly recommended and endorsed merchant services providers in the industry today.
About Beaver Creek Software
Beaver Creek Software was founded in Corvallis, Oregon in June of 1988 by Peter Gysegem, now president and CEO of the company. Originally named Yarrow Data Systems, the company formed a partnership with Northwest Training Programs to sell The THERAPIST from their Monmouth, Oregon location. The name Beaver Creek Software was adopted by th
|Source: PRWeb
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All rights reserved


text:
Museum of Fine Arts, Houston - Brown Auditorium Theater
Houston, TX 77005
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text:
Caol Ila
Caol Ila 18 year old 43%
A very leafy opening – bog myrtle and mint followed by briny peat. Quite phenolic but just delicately peated with a serious weight of rich, oily, rubbery fruit along with a brief, stinky, manure note. A touch of citrus just about balances the oiliness.
On the palate it is full and weighty. Very oily and herbal. It's a veritable sweet mouthful of butch, malty almost savoury fruit. Some gentle sooty peat wafts in on the middle and tries it's best to force away through the oils, but that oily, rubbery character hangs on in there! Just like the nose a vein of briny citrus accented by shellfish notes runs through it and balances it – just! Good length with a long, sooty finish.
Age : 16-18 yrs
Bottle size : 70
Primary Cask : American oak
Floral : Moderate
Fruity : Moderate
Sulphury : Light
You can see the delivery cost and change the delivery country in the basket page and checkout.
Whisky & spirits are sent using Parcelforce's 48 hour service.
Your order can also be delivered to an alternative address such as a work address, just give us separate delivery and billing addresses at the checkout.
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Don't worry if you need to return something, we will happily accept any returns within 30 days.
We are very friendly and at the end of a telephone so if you do need to return anything please just call us on 0115 911 0555 to arrange.


text:
Most Cited Journal of Vascular Surgery Articles
The most cited articles published since 2010, extracted from Scopus.
The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum
Volume 53, Issue 5 SUPPL., May 2011, Pages 2S-48S
Peter Gloviczki | Anthony J. Comerota | Michael C. Dalsing | Bo G. Eklof | David L. Gillespie | Monika L. Gloviczki | Joann M. Lohr | Robert B. McLafferty | Mark H. Meissner | M. Hassan Murad | Frank T. Padberg | Peter J. Pappas | Marc A. Passman | Joseph D. Raffetto | Michael A. Vasquez | Thomas W. Wakefield
The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines for the care of patients with varicose veins of the lower limbs and pelvis. The document also includes recommendations on the management of superficial and perforating vein incompetence in patients with associated, more advanced chronic venous diseases (CVDs), including edema, skin changes, or venous ulcers. Recommendations of the Venous Guideline Committee are based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system as strong (GRADE 1) if the benefits clearly outweigh the risks, burden, and costs. The suggestions are weak (GRADE 2) if the benefits are closely balanced with risks and burden. The level of available evidence to support the evaluation or treatment can be of high (A), medium (B), or low or very low (C) quality. The key recommendations of these guidelines are: We recommend that in patients with varicose veins or more severe CVD, a complete history and detailed physical examination are complemented by duplex ultrasound scanning of the deep and superficial veins (GRADE 1A). We recommend that the CEAP classification is used for patients with CVD (GRADE 1A) and that the revised Venous Clinical Severity Score is used to assess treatment outcome (GRADE 1B). We suggest compression therapy for patients with symptomatic varicose veins (GRADE 2C) but recommend against compression therapy as the primary treatment if the patient is a candidate for saphenous vein ablation (GRADE 1B). We recommend compression therapy as the primary treatment to aid healing of venous ulceration (GRADE 1B). To decrease the recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy (GRADE 1A). For treatment of the incompetent great saphenous vein (GSV), we recommend endovenous thermal ablation (radiofrequency or laser) rather than high ligation and inversion stripping of the saphenous vein to the level of the knee (GRADE 1B). We recommend phlebectomy or sclerotherapy to treat varicose tributaries (GRADE 1B) and suggest foam sclerotherapy as an option for the treatment of the incompetent saphenous vein (GRADE 2C). We recommend against selective treatment of perforating vein incompetence in patients with simple varicose veins (CEAP class C2; GRADE 1B), but we suggest treatment of pathologic perforating veins (outward flow duration <500 ms, vein diameter <3.5 mm) located underneath healed or active ulcers (CEAP class C5-C6; GRADE 2B). We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together (GRADE 2B). © 2011 Society for Vascular Surgery.
Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: An intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy
Volume 51, Issue 5 SUPPL., May 2010, Pages 5S-17S
Andrew W. Bradbury | Donald J. Adam | Jocelyn Bell | John F. Forbes | F. Gerry R Fowkes | Ian Gillespie | Charles Vaughan Ruckley | Gillian M. Raab
Background: A 2005 interim analysis of the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed that in patients with severe lower limb ischemia (SLI; rest pain, ulceration, gangrene) due to infrainguinal disease, bypass surgery (BSX)-first and balloon angioplasty (BAP)-first revascularization strategies led to similar short-term clinical outcomes, although BSX was about one-third more expensive and morbidity was higher. We have monitored patients for a further 2.5 years and now report a final intention-to-treat (ITT) analysis of amputation-free survival (AFS) and overall survival (OS). Methods: Of 452 enrolled patients in 27 United Kingdom hospitals, 228 were randomized to a BSX-first and 224 to a BAP-first revascularization strategy. All patients were monitored for 3 years and more than half for >5 years. Results: At the end of follow-up, 250 patients were dead (56%), 168 (38%) were alive without amputation, and 30 (7%) were alive with amputation. Four were lost to follow-up. AFS and OS did not differ between randomized treatments during the follow-up. For those patients surviving 2 years from randomization, however, BSX-first revascularization was associated with a reduced hazard ratio (HR) for subsequent AFS of 0.85 (95% confidence interval [CI], 0.5-1.07; P = .108) and for subsequent OS of 0.61 (95% CI, 0.50-0.75; P = .009) in an adjusted, time-dependent Cox proportional hazards model. For those patients who survived for 2 years after randomization, initial randomization to a BSX-first revascularization strategy was associated with an increase in subsequent restricted mean overall survival of 7.3 months (95% CI, 1.2-13.4 months, P = .02) and an increase in restricted mean AFS of 5.9 months (95% CI, 0.2-12.0 months, P = .06) during the subsequent mean follow-up of 3.1 years (range, 1-5.7 years). Conclusions: Overall, there was no significant difference in AFS or OS between the two strategies. However, for those patients who survived for at least 2 years after randomization, a BSX-first revascularization strategy was associated with a significant increase in subsequent OS and a trend towards improved AFS. Crown Copyright © 2010.
Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease
Volume 54, Issue 3, September 2011, Pages e1-e31
John J. Ricotta | Ali Aburahma | Enrico Ascher | Mark Eskandari | Peter Faries | Brajesh K. Lal
Management of carotid bifurcation stenosis is a cornerstone of stroke prevention and has been the subject of extensive clinical investigation, including multiple controlled randomized trials. The appropriate treatment of patients with carotid bifurcation disease is of major interest to the community of vascular surgeons. In 2008, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, only one randomized trial, comparing carotid endarterectomy (CEA) and carotid stenting (CAS), had been published. Since that publication, four major randomized trials comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2008 guidelines with specific emphasis on six areas: imaging in identification and characterization of carotid stenosis, medical therapy (as stand-alone management and also in conjunction with intervention in patients with carotid bifurcation stenosis), risk stratification to select patients for appropriate interventional management (CEA or CAS), technical standards for performing CEA and CAS, the relative roles of CEA and CAS, and management of unusual conditions associated with extracranial carotid pathology. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system, as has been done with other Society for Vascular Surgery guideline documents. In contrast to the multispecialty guidelines recently published, the committee recommends CEA as the first-line treatment for most symptomatic patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 60% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. CAS should be reserved for symptomatic patients with stenosis of 50% to 99% at high risk for CEA for anatomic or medical reasons. CAS is not recommended for asymptomatic patients at this time. Asymptomatic patients at high risk for intervention or with <3 years life expectancy should be considered for medical management as the first-line therapy. © 2011 Society for Vascular Surgery.
Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals
Volume 52, Issue 3, September 2010, Pages 539-548
K. Craig Kent | Robert M. Zwolak | Natalia N. Egorova | Thomas S. Riles | Andrew Manganaro | Alan J. Moskowitz | Annetine C. Gelijns | Giampaolo Greco
Background: Abdominal aortic aneurysm (AAA) disease is an insidious condition with an 85% chance of death after rupture. Ultrasound screening can reduce mortality, but its use is advocated only for a limited subset of the population at risk. Methods: We used data from a retrospective cohort of 3.1 million patients who completed a medical and lifestyle questionnaire and were evaluated by ultrasound imaging for the presence of AAA by Life Line Screening in 2003 to 2008. Risk factors associated with AAA were identified using multivariable logistic regression analysis. Results: We observed a positive association with increasing years of smoking and cigarettes smoked and a negative association with smoking cessation. Excess weight was associated with increased risk, whereas exercise and consumption of nuts, vegetables, and fruits were associated with reduced risk. Blacks, Hispanics, and Asians had lower risk of AAA than whites and Native Americans. Well-known risk factors were reaffirmed, including male gender, age, family history, and cardiovascular disease. A predictive scoring system was created that identifies aneurysms more efficiently than current criteria and includes women, nonsmokers, and individuals aged <65 years. Using this model on national statistics of risk factors prevalence, we estimated 1.1 million AAAs in the United States, of which 569,000 are among women, nonsmokers, and individuals aged <65 years. Conclusions: Smoking cessation and a healthy lifestyle are associated with lower risk of AAA. We estimated that about half of the patients with AAA disease are not eligible for screening under current guidelines. We have created a high-yield screening algorithm that expands the target population for screening by including at-risk individuals not identified with existing screening criteria. Copyright © 2010 Society for Vascular Surgery.
A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients
Volume 53, Issue 5, May 2011, Pages 1167-1173.e1
Jean Pierre Becquemin | Jean Chistophe Pillet | Franois Lescalie | Marc Sapoval | Yann Goueffic | Patrick Lermusiaux | Eric Steinmetz | Jean Marzelle
Background: Several studies, including three randomized controlled trials (RCTs), have shown that endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) offered better early results than open surgical repair (OSR) but a similar medium-term to long-term mortality and a higher incidence of reinterventions. Thus, the role of EVAR, most notably in low-risk patients, remains debated. Methods: The ACE (Anevrysme de l'aorte abdominale: Chirurgie versus Endoprothese) trial compared mortality and major adverse events after EVAR and OSR in patients with AAA anatomically suitable for EVAR and at low-risk or intermediate-risk for open surgery. A total of 316 patients with >5 cm aneurysms were randomized in institutions with proven expertise for both treatments: 299 patients were available for analysis, and 149 were assigned to OSR and 150 to EVAR. Patients were monitored for 5 years after treatment. Statistical analysis was by intention to treat. Results: With a median follow-up of 3 years (range, 0-4.8 years), there was no difference in the cumulative survival free of death or major events rates between OSR and EVAR: 95.9% ± 1.6% vs 93.2% ± 2.1% at 1 year and 85.1% ± 4.5% vs 82.4% ± 3.7% at 3 years, respectively (P = .09). In-hospital mortality (0.6% vs 1.3%; P = 1.0), survival, and the percentage of minor complications were not statistically different. In the EVAR group, however, the crude percentage of reintervention was higher (2.4% vs 16%, P < .0001), with a trend toward a higher aneurysm-related mortality (0.7% vs 4%; P = .12). Conclusions: In patients with low to intermediate risk factors, open repair of AAA is as safe as EVAR and remains a more durable option. © 2011 Society for Vascular Surgery.
Endovascular repair of traumatic thoracic aortic injury: Clinical practice guidelines of the Society for Vascular Surgery
Volume 53, Issue 1, January 2011, Pages 187-192
W. Anthony Lee | Jon S. Matsumura | R. Scott Mitchell | Mark A. Farber | Roy K. Greenberg | Ali Azizzadeh | Mohammad Hassan Murad | Ronald M. Fairman
The Society for Vascular Surgery® pursued development of clinical practice guidelines for the management of traumatic thoracic aortic injuries with thoracic endovascular aortic repair. In formulating clinical practice guidelines, the Society selected a panel of experts and conducted a systematic review and meta-analysis of the literature. They used the Grading of Recommendations Assessment, Development and Evaluation methods (GRADE) to develop and present their recommendations. The systematic review included 7768 patients from 139 studies. The mortality rate was significantly lower in patients who underwent endovascular repair, followed by open repair, and nonoperative management (9%, 19%, and 46%, respectively, P < .01). Based on the overall very low quality of evidence, the committee suggests that endovascular repair of thoracic aortic transection is associated with better survival and decreased risk of spinal cord ischemia, renal injury, graft, and systemic infections compared with open repair or nonoperative management (Grade 2, Level C). The committee was also surveyed on a variety of issues that were not specifically addressed by the meta-analysis. On these select matters, the majority opinions of the committee suggest urgent repair following stabilization of other injuries, observation of minimal aortic defects, selective (vs routine) revascularization in cases of left subclavian artery coverage, and that spinal drainage is not routinely required in these cases. © 2011 Society for Vascular Surgery.
Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: Analysis of amputation free and overall survival by treatment received
Volume 51, Issue 5 SUPPL., May 2010, Pages 18S-31S
Andrew W. Bradbury | Donald J. Adam | Jocelyn Bell | John F. Forbes | F. Gerry R Fowkes | Ian Gillespie | Charles Vaughan Ruckley | Gillian M. Raab
Background: An intention-to-treat analysis of randomized Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial data showed that initial randomization to a bypass surgery (BSX)-first strategy was associated with improvements in subsequent overall survival (OS) and amputation-free survival (AFS) of about 7 and 6 months, respectively. We describe the nature and timing of first, crossover, and reinterventions and examine AFS and OS by first treatment received. We also compare vein with prosthetic BSX and transluminal with subintimal balloon angioplasty (BAP) and examine outcomes from BSX after failed BAP. Methods: We randomly assigned 452 patients with SLI due to infrainguinal disease in 27 United Kingdom hospitals to a BSX first (n = 228) or a BAP first (n = 224) revascularization strategy. All patients have been monitored for 3 years and more than half for >5 years. We prospectively collected data on every procedure, major amputation, and death. Results: Patients randomized to BAP were more likely to have their assigned treatment first (94% vs 85%, P = .01, χ2test). BAP had a higher immediate technical failure rate of 20% vs 2.6% (P = .01, χ2test). By 12 weeks after randomization 9 BAP (4%) vs 23 BSX (10%) patients had not undergone revascularization; 3 BAP (1.3%) vs 13 BSX (5.8%) had undergone the opposite treatment first; and 35 BAP (15.6%) and 2 (0.9%) BSX had received the assigned treatment and then undergone the opposite treatment. BSX distal anastomoses were divided approximately equally between the above and below knee popliteal and crural arteries; most originated from the common femoral artery. About 25% of the grafts were prosthetic and >90% of vein BSX used ipsilateral great saphenous vein. Most (80%) BAP patients underwent treatment of the SFA alone (38%) or combined with the popliteal artery (42%) and crural arteries (20%). Outcome of vein BSX was better for AFS (P = 0.003) but not OS (P = 0.38, log-rank tests) than prosthetic BSX. There were no differences in outcome between approximately equal numbers of transluminal and subintimal BAP. AFS (P = 0.006) but not OS (P = 0.06, log rank test) survival was significantly worse after BSX after failed BAP than after BSX as a first revascularization attempt. Conclusions: BAP was associated with a significantly higher early failure rate than BSX. Most BAP patients ultimately required surgery. BSX outcomes after failed BAP are significantly worse than for BSX performed as a first revascularization attempt. BSX with vein offers the best long term AFS and OS and, overall, BAP appears superior to prosthetic BSX. Crown Copyright © 2010.
Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratification
Volume 52, Issue 6, December 2010, Pages 1486-1496.E5
Andrew N. Nicolaides | Stavros K. Kakkos | Efthyvoulos Kyriacou | Maura Griffin | Michael Sabetai | Dafydd J. Thomas | Thomas Tegos | George Geroulakos | Nicos Labropoulos | Caroline J. Dor | Tim P. Morris | Ross Naylor | Anne L. Abbott | R. Adovasio | B. Ziani | F. P. Alò | C. G. Cicilioni | G. Ambrosio | A. Andreev | G. M. Andreozzi | F. Verlato | G. Camporese | E. Arosio | E. Barkauskas | A. A B Barros D'Sa | P. Brannigan | V. Batchvarova | A. Dramov | P. Belardi | GP Novelli | G. Simoni | P. Bell | G. M. Biasi | P. Mingazzini | N. M. Bornstein | D. Bouchier-Hayes | P. Fitzgerald | M. A. Cairols | P. G. Cao | P. DeRango | G. P. Carboni | C. Geoffredo | M. Catalano | B. Chambers | M. Goetzmann | A. Dickinson | D. Clement | M. Bobelyn | S. Coccheri | E. Conti | E. Diamantopoulos | E. A. Andreadis | P. B. Dimakakos | T. Kotsis | B. Eikelboom | L. Entz | Ferrari-Bardile | T. Aloi | M. Salerno | J. Fernandes e Fernandes | L. Pedro | D. E. Fitzgerald | Anne O'Shaunnersy | J. Fletcher | S. Forconi | R. Cappeli | M. Bicchi | S. Arrigucci | V. Gallai | G. Cardaiolli | G. Geroulakos | S. Kakkos | L. F. Gomez-Isaza | G. Gorgoyannis | N. Liasis | M. Graf | P. Guarini | S. Hardy | P. Harris | S. Aston | G. Iosa | A. Katsamouris | A. Giannoukas | M. Krzanowski | G. Ladurner | J. Leal-Monedero | B. B. Lee | C. Liapis | P. Galanis | W. Liboni | E. Pavanelli | E. Mannarino | G. Vaudo | P. McCollum | R. Levison | G. Micieli | D. Bosone | L. Middleton
Background The purpose of this study was to determine the cerebrovascular risk stratification potential of baseline degree of stenosis, clinical features, and ultrasonic plaque characteristics in patients with asymptomatic internal carotid artery (ICA) stenosis. Methods This was a prospective, multicenter, cohort study of patients undergoing medical intervention for vascular disease. Hazard ratios for ICA stenosis, clinical features, and plaque texture features associated with ipsilateral cerebrovascular or retinal ischemic (CORI) events were calculated using proportional hazards models. Results A total of 1121 patients with 50% to 99% asymptomatic ICA stenosis in relation to the bulb (European Carotid Surgery Trial [ECST] method) were followed-up for 6 to 96 months (mean, 48). A total of 130 ipsilateral CORI events occurred. Severity of stenosis, age, systolic blood pressure, increased serum creatinine, smoking history of more than 10 pack-years, history of contralateral transient ischemic attacks (TIAs) or stroke, low grayscale median (GSM), increased plaque area, plaque types 1, 2, and 3, and the presence of discrete white areas (DWAs) without acoustic shadowing were associated with increased risk. Receiver operating characteristic (ROC) curves were constructed for predicted risk versus observed CORI events as a measure of model validity. The areas under the ROC curves for a model of stenosis alone, a model of stenosis combined with clinical features and a model of stenosis combined with clinical, and plaque features were 0.59 (95% confidence interval [CI] 0.54-0.64), 0.66 (0.62-0.72), and 0.82 (0.78-0.86), respectively. In the last model, stenosis, history of contralateral TIAs or stroke, GSM, plaque area, and DWAs were independent predictors of ipsilateral CORI events. Combinations of these could stratify patients into different levels of risk for ipsilateral CORI and stroke, with predicted risk close to observed risk. Of the 923 patients with <70% stenosis, the predicted cumulative 5-year stroke rate was <5% in 495, 5% to 9.9% in 202, 10% to 19.9% in 142, and <20% in 84 patients. Conclusion Cerebrovascular risk stratification is possible using a combination of clinical and ultrasonic plaque features. These findings need to be validated in additional prospective studies of patients receiving optimal medical intervention alone. Copyright © 2010 by the Society for Vascular Surgery.
Revision of the venous clinical severity score: Venous outcomes consensus statement: Special communication of the American Venous Forum Ad Hoc Outcomes Working Group
Volume 52, Issue 5, November 2010, Pages 1387-1396
Michael A. Vasquez | Eberhard Rabe | Robert B. McLafferty | Cynthia K. Shortell | William A. Marston | David Gillespie | Mark H. Meissner | Robert B. Rutherford
In response to the need for a disease severity measurement, the American Venous Forum committee on outcomes assessment developed the Venous Severity Scoring system in 2000. There are three components of this scoring system, the Venous Disability Score, the Venous Segmental Disease Score, and the Venous Clinical Severity Score (VCSS). The VCSS was developed from elements of the CEAP classification (clinical grade, etiology, anatomy, pathophysiology), which is the worldwide standard for describing the clinical features of chronic venous disease. However, as a descriptive instrument, the CEAP classification responds poorly to change. The VCSS was subsequently developed as an evaluative instrument that would be responsive to changes in disease severity over time and in response to treatment. Based on initial experiences with the VCSS, an international ad hoc working group of the American Venous Forum was charged with updating the instrument. This revision of the VCSS is focused on clarifying ambiguities, updating terminology, and simplifying application. The specific language of proven quality-of-life instruments was used to better address the issues of patients at the lower end of the venous disease spectrum. Periodic review and revision are necessary for generating more universal applicability and for comparing treatment outcomes in a meaningful way. Copyright © 2010 by the Society for Vascular Surgery.
Reporting standards for thoracic endovascular aortic repair (TEVAR)
Volume 52, Issue 4, October 2010, Pages 1022-1033.e5
Mark F. Fillinger | Roy K. Greenberg | James F. McKinsey | Elliot L. Chaikof
Randomized comparison of everolimus-eluting versus bare-metal stents in patients with critical limb ischemia and infrapopliteal arterial occlusive disease
Volume 55, Issue 2, February 2012, Pages 390-398
Marc Bosiers | Dierk Scheinert | Patrick Peeters | Giovanni Torsello | Thomas Zeller | Koen Deloose | Andrej Schmidt | Jrg Tessarek | Erwin Vinck | Lewis B. Schwartz
Objective: Critical limb ischemia, the most severe form of peripheral arterial disease, results in extremity amputation if left untreated. Endovascular recanalization of stenotic or occluded infrapopliteal arteries has recently emerged as an effective form of therapy, although the duration of patency is typically limited by restenosis. Recently, it has been suggested that drug-eluting stents originally developed for the coronary arteries might also be effective in preventing restenosis in the infrapopliteal arteries. This prospective, randomized, controlled clinical trial tested the hypothesis that treatment of infrapopliteal arterial occlusive lesions with an everolimus-eluting stent (Xience V) would provide superior patency to treatment with a bare-metal stent (Multi-Link Vision). Methods: A sample size of 140 patients was planned to be enrolled at five European investigative sites. The primary end point was arterial patency at 12 months, defined as the absence of <50% restenosis based on quantitative analysis of contrast angiography. Results: Between March of 2008 and September of 2009, 74 patients were treated with Xience V and 66 patients were treated with Vision. After 12 months, the primary patency rate after treatment with Xience V was 85% compared with 54% after treatment with Vision (P =.0001). Treatment with Xience V significantly reduced mean in-stent diameter stenosis (21% ± 21% vs 47% ± 27%; P <.0001) and mean in-stent late lumen loss (0.78 ± 0.63 vs 1.41 ± 0.89 mm; P =.001). There were no differences in the percentage of patients receiving a designation of Rutherford class 0 or 1 at the 12-month follow-up visit (56% for Vision, vs 60% for Xience V; P =.68). Major extremity amputations were rare in both groups (two for Vision and one for Xience V). The use of the Xience V stent significantly reduced the need for repeat intervention: freedom from target lesion revascularization was 91% for Xience V vs 66% for Vision (P =.001). Conclusions: Treatment of the infrapopliteal occlusive lesions of critical limb ischemia with everolimus-eluting stents reduces restenosis and the need for reintervention compared with bare metal stents. © 2012 Society for Vascular Surgery.
Endovascular chimney technique versus open repair of juxtarenal and suprarenal aneurysms
Volume 53, Issue 4, April 2011, Pages 895-905
Kevin J. Bruen | Robert J. Feezor | Michael J. Daniels | Adam W. Beck | W. Anthony Lee
Objective To compare early outcomes of endovascular repair of juxtarenal and suprarenal aneurysms using the chimney technique with open repair in anatomically-matched patients. Methods Between January 2008 and December 2009, 21 patients underwent endovascular repair of juxtarenal and suprarenal aortic aneurysms with chimney stenting (Ch-EVAR) of 1 or 2 renal and/or superior mesenteric artery (SMA) vessels. These were compared with 21 anatomically-matched patients that underwent open repair (OR) during the same time period. Primary end points were 30-day mortality, chimney stent patency, and type Ia endoleak. Secondary end points included early complications, renal function, blood loss, and length of stay (LOS). Results Despite a higher proportion of women, oxygen-dependent pulmonary disease and lower baseline renal function, 30-day mortality was identical with one death (4.8%) in each group. Blood loss and total LOS were significantly less for Ch-EVAR. Six patients (29%) in the chimney group had acute kidney injury (AKI) compared with the open group, in which there were one (4.8%) AKI and four (19%) acute renal failures, of which two (9.5%) required chronic hemodialysis. Renal function at 12 months demonstrated similar declines in the overall estimated glomerular filtration rate (eGFR) in the Ch-EVAR and OR groups (11.1 ± 19.6 vs 10.4 ± 25.2, P = NS, respectively). There was one asymptomatic SMA stent occlusion at 6 months and partial compression of a second SMA stent which underwent repeat balloon angioplasty. Primary patency at 6 and 12 months was 94% and 84%, respectively. There was one type Ia endoleak noted at 30 days which resolved by 6 months. Conclusions Ch-EVAR may extend the anatomical eligibility of endovascular aneurysm repair using conventional devices. It appears to have similar mortality to open repair with less morbidity. Long-term durability and stent patency remain to be determined. © 2011 Society for Vascular Surgery.
Diagnosis, management, and future developments of fibromuscular dysplasia
Volume 53, Issue 3, March 2011, Pages 826-836.e1
Jeffrey W. Olin | Brett A. Sealove
Fibromuscular dysplasia (FMD) is a nonatherosclerotic noninflammatory vascular disease that primarily affects women from age 20 to 60, but may also occur in infants and children, men, and the elderly. It most commonly affects the renal and carotid arteries but has been observed in almost every artery in the body. FMD has been considered rare and thus is often underdiagnosed and poorly understood by many health care providers. There are, however, data to suggest that FMD is much more common than previously thought, perhaps affecting as many as 4% of adult women. When it affects the renal arteries, the most common presentation is hypertension. When it affects the carotid or vertebral arteries, the patient may present with transient ischemic attack or stroke, or dissection. An increasing number of patients are asymptomatic and are only discovered incidentally when imaging is performed for some other reason or by the detection of an asymptomatic bruit. FMD should be considered in the differential diagnosis of a young person with a cervical bruit; a "swishing" sound in the ear(s); transient ischemic attack, stroke, or dissection of an artery; or in individuals aged ≤35 years with onset hypertension. Treatment consists of antiplatelet therapy for asymptomatic individuals and percutaneous balloon angioplasty for patients with indications for intervention. Patients with aneurysms should be treated with a covered stent or open surgical repair. Little new information has been published about FMD in the last 40 years. The recently instituted International Registry for Fibromuscular Dysplasia will remedy that situation and provide observational data on a large numbers of patients with FMD. © 2011 Society for Vascular Surgery.
First clinical trial of nitinol self-expanding everolimus-eluting stent implantation for peripheral arterial occlusive disease
Volume 54, Issue 2, August 2011, Pages 394-401
Johannes Lammer | Marc Bosiers | Thomas Zeller | Martin Schillinger | Els Boone | Margo J. Zaugg | Patrick Verta | Lei Peng | Xingyu Gao | Lewis B. Schwartz
Background: A novel self-expanding drug-eluting stent was designed to slowly release everolimus to prevent restenosis following peripheral arterial intervention. The purpose of the first-in-human Superficial Femoral Artery Treatment with Drug-Eluting Stents (STRIDES) trial was to evaluate the safety and efficacy of this device for the treatment of symptomatic superficial femoral and proximal popliteal arterial occlusive disease. Methods and Results: One hundred four patients were enrolled at 11 European investigative centers in a prospective, nonrandomized, single-arm trial. The patients had severe symptomatic vascular disease, including a significant proportion of patients with critical limb ischemia (17%), diabetes (39%), and single-vessel outflow (26%). The mean lesion length was 9.0 ± 4.3 cm. Ninety-nine percent of patients were available for 12-month follow-up, including duplex imaging in 90% and arteriography in 83%. Clinical improvement, defined as a sustained decrease in Rutherford-Becker clinical category, was achieved in 80% of patients. Primary patency (freedom from <50% in-stent restenosis) was 94 ± 2.3% and 68 ± 4.6% at 6 and 12 months, respectively. Plain radiographic examination of 122 implanted devices at 12 months revealed no evidence for stent fracture. Conclusions: The everolimus-eluting self-expanding nitinol stent can be successfully implanted in patients with severe peripheral arterial disease with favorable outcomes and clinical improvements observed in the majority of patients. © 2011 Society for Vascular Surgery.
Meta-analysis of open versus endovascular repair for ruptured descending thoracic aortic aneurysm
Volume 51, Issue 4, April 2010, Pages 1026-1032.e2
Frederik H W Jonker | Santi Trimarchi | Hence J M Verhagen | Frans L. Moll | Bauer E. Sumpio | Bart E. Muhs
Introduction: Ruptured descending thoracic aortic aneurysm (rDTAA) is associated with high mortality rates. Data supporting endovascular thoracic aortic aneurysm repair (TEVAR) to reduce mortality compared with open repair are limited to small series. We investigated published reports for contemporary outcomes of open and endovascular repair of rDTAA. Methods: We systematically reviewed all studies describing the outcomes of rDTAA treated with open repair or TEVAR since 1995 using MEDLINE, Cochrane Library CENTRAL, and Excerpta Medica Database (EMBASE) databases. Case reports or studies published before 1995 were excluded. All articles were critically appraised for relevance, validity, and availability of data regarding treatment outcomes. All data were systematically pooled, and meta-analyses were performed to investigate 30-day mortality, myocardial infarction, stroke, and paraplegia rates after both types of repair. Results: Original data of 224 patients (70% male) with rDTAA were identified: 143 (64%) were treated with TEVAR and 81 (36%) with open repair. Mean age was 70 ± 5.6 years. The 30-day mortality was 19% for patients treated with TEVAR for rDTAA compared 33% for patients treated with open repair, which was significant (odds ratio [OR], 2.15, P = .016). The 30-day occurrence rates of myocardial infarction (11.1% vs 3.5%; OR, 3.70, P < .05), stroke (10.2% vs 4.1%; OR, 2.67; P = .117), and paraplegia (5.5% vs 3.1%; OR, 1.83; P = .405) were increased after open repair vs TEVAR, but this failed to reach statistical significance for stroke and paraplegia. Five additional patients in the TEVAR group died of aneurysm-related causes after 30 days, during a median follow-up of 17 ± 10 months. Follow-up data after open repair were insufficient. The estimated aneurysm-related survival at 3 years after TEVAR was 70.6%. Conclusion: Endovascular repair of rDTAA is associated with a significantly lower 30-day mortality rate compared with open surgical repair. TEVAR was associated with a considerable number of aneurysm-related deaths during follow-up. © 2010 Society for Vascular Surgery.
A comprehensive review of Paget-Schroetter syndrome
Volume 51, Issue 6, June 2010, Pages 1538-1547
Karl A. Illig | Adam J. Doyle
Venous thoracic outlet syndrome progressing to the point of axilosubclavian vein thrombosis, variously referred to as Paget-Schroetter syndrome or effort thrombosis, is a classic example of an entity which if treated correctly has minimal long-term sequelae but if ignored is associated with significant long-term morbidity. The subclavian vein is highly vulnerable to injury as it passes by the junction of the first rib and clavicle in the anterior-most part of the thoracic outlet. In addition to extrinsic compression, repetitive forces in this area frequently lead to fixed intrinsic damage and extrinsic scar tissue formation. Once primary thrombosis is recognized, catheter-directed thrombolytic therapy is usually successful if initiated within ten to 14 days of clot formation, but often unmasks an underlying lesion. The vast majority of investigators believe that decompression of the venous thoracic outlet, usually by means of first rib excision, partial anterior scalenectomy, resection of the costoclavicular ligament, and thorough external venolysis, is necessary, although opinion is less uniform as to the need for and method of treatment of the venous lesion itself. Using this algorithm, long-term success rates of 95 to 100% have been reported by many investigators. This review, in addition to discussing the overall treatment algorithm in more detail, attempts to point out controversies that still exist and research directions, both clinical and basic, that need to be pursued. Prospective randomized trials addressing this entity are surprisingly lacking, and although there is consensus based on experience, it may be necessary to step back and rigorously explore several aspects of this entity. © 2010 Society for Vascular Surgery.
Use of angiotensin converting enzyme inhibitors is associated with increased growth rate of abdominal aortic aneurysms
Volume 52, Issue 1, July 2010, Pages 1-4
Michael J. Sweeting | Simon G. Thompson | Louise C. Brown | Roger M. Greenhalgh | Janet T. Powell
Objectives: To evaluate whether either angiotensin converting enzyme (ACE) inhibitors or other classes of antihypertensive drug attenuate or increase growth rates of small infrarenal abdominal aortic aneurysms. Methods: Prospective cohort study of 1701 patients enrolled in the UK Small Aneurysm Trial or associated study at 93 hospitals between 1991 and 1995 and who had at least two ultrasound measurements of aneurysm diameter and baseline drug prescription data recorded. Abdominal aortic aneurysm diameter was measured in the anterior-posterior plane using ultrasound. The mean growth rate was estimated through a mixed-effects linear growth model. Results: Mean aneurysm growth rate in 169 patients taking ACE inhibitors at baseline was 3.33 mm/y vs 2.77 mm/y in the remaining 1532 patients, P = .009. The significance of this finding did not alter after adjustment for known confounders. The prescription of any antihypertensive agent and other specific classes of antihypertensive drugs were not found to be associated with aneurysm growth rate. Conclusion: These results show that patients taking ACE inhibitors have faster aneurysm growth and are in conflict with the observation from a large Canadian data-base that aneurysm patients taking ACE inhibitors are less likely to present with aneurysm rupture. There is an urgent need for a randomized trial to assess whether ACE inhibitors are beneficial or harmful to patients with aneurysms below the threshold size for surgical intervention. © 2010 Society for Vascular Surgery.
The chimney graft technique for preserving visceral vessels during endovascular treatment of aortic pathologies
Volume 55, Issue 5, May 2012, Pages 1497-1503
Konstantinos G. Moulakakis | Spyridon N. Mylonas | Efthimios Avgerinos | Anastasios Papapetrou | John D. Kakisis | Elias N. Brountzos | Christos D. Liapis
Objective: Patients with juxtarenal, pararenal, or thoracoabdominal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. The "chimney graft" or "snorkel" technique has evolved as a potential alternative to fenestrated and side-branched endografts. The purpose of this study is to review all published reports on chimney graft (CG) technique involving visceral vessels and investigate the safety and efficacy of the technique. Methods: Studies were included in the present review if visceral revascularization during endovascular treatment of aortic pathologies was achieved via a CG implantation. Reports on the chimney technique for aortic arch branches revascularization were excluded. A multiple electronic health database search was performed on all articles published until April 2011. Results: The electronic literature search yielded 15 reports that fulfilled the inclusion criteria. A total of 93 patients (81.3% male; mean age, 71.9 ± 0.9 years) were analyzed. In 77.4% of the patients, the CG procedure was applied for the treatment of abdominal aortic aneurysms. Out of the 93 patients, 24.7% were operated on in an urgent setting (symptomatic or ruptured aneurysm). A total of 134 CGs were implanted: 108 to the renal arteries, 20 to the superior mesenteric artery, five to the celiac trunk, and one to the inferior mesenteric artery. In 57 patients, a single CG was deployed; in 32 patients, two CGs; in three patients, three CGs; and in one patient, four CGs were deployed. Ninety-four percent of CGs were directed proximally, whereas 6.0% were directed caudally. Primary technical success was achieved in all patients. A total of 13 patients (14.0%) developed a type I endoleak. Three were detected and treated intraoperatively. Postoperatively, 10 type I endoleaks were revealed, four of which required secondary intervention. During a mean follow-up period of 9.0 ± 1.0 months, 131 of 134 (97.8%) CGs remained patent. Two CGs to the renal arteries and one to the superior mesenteric artery occluded. Postoperatively, 11.8% of patients suffered renal function impairment and 2.1% a myocardial infarction. Ischemic stroke presented in 3.2% of patients. The 30-day in-hospital mortality was 4.3%. Conclusions: The role of the chimney technique in the management of complex abdominal aortic aneurysms is still unclear. This technique has relatively good results, considering the anatomic limitations of the aortic neck. However, long-term endograft durability and proximal fixation remains a significant concern. Thus, there is a reasonable hesitation to embrace the method for widespread use in the absence of long-term data. © 2012 Society for Vascular Surgery.
Results of the randomized, placebo-controlled clopidogrel and acetylsalicylic acid in bypass surgery for peripheral arterial disease (CASPAR) trial
Volume 52, Issue 4, October 2010, Pages 825-833
Jill J F Belch | John Dormandy
Objective: Dual antiplatelet therapy with clopidogrel plus acetylsalicylic acid (ASA) is superior to ASA alone in patients with acute coronary syndromes and in those undergoing percutaneous coronary intervention. We sought to determine whether clopidogrel plus ASA conferred benefit on limb outcomes over ASA alone in patients undergoing below-knee bypass grafting. Methods: Patients undergoing unilateral, below-knee bypass graft for atherosclerotic peripheral arterial disease (PAD) were enrolled 2 to 4 days after surgery and were randomly assigned to clopidogrel 75 mg/day plus ASA 75 to 100 mg/day or placebo plus ASA 75 to 100 mg/day for 6 to 24 months. The primary efficacy endpoint was a composite of index-graft occlusion or revascularization, above-ankle amputation of the affected limb, or death. The primary safety endpoint was severe bleeding (Global Utilization of Streptokinase and Tissue plasminogen activator for Occluded coronary arteries [GUSTO] classification). Results: In the overall population, the primary endpoint occurred in 149 of 425 patients in the clopidogrel group vs 151 of 426 patients in the placebo (plus ASA) group (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.78-1.23). In a prespecified subgroup analysis, the primary endpoint was significantly reduced by clopidogrel in prosthetic graft patients (HR, 0.65; 95% CI, 0.45-0.95; P = .025) but not in venous graft patients (HR, 1.25; 95% CI, 0.94-1.67, not significant [NS]). A significant statistical interaction between treatment effect and graft type was observed (Pinteraction = .008). Although total bleeds were more frequent with clopidogrel, there was no significant difference between the rates of severe bleeding in the clopidogrel and placebo (plus ASA) groups (2.1% vs 1.2%). Conclusion: The combination of clopidogrel plus ASA did not improve limb or systemic outcomes in the overall population of PAD patients requiring below-knee bypass grafting. Subgroup analysis suggests that clopidogrel plus ASA confers benefit in patients receiving prosthetic grafts without significantly increasing major bleeding risk. © 2010 Society for Vascular Surgery.
Endovascular repair compared with surveillance for patients with small abdominal aortic aneurysms
Volume 51, Issue 5, May 2010, Pages 1081-1087
Kenneth Ouriel | Daniel G. Clair | K. Craig Kent | Christopher K. Zarins
Background: Although repair of large abdominal aortic aneurysms (AAAs) is well accepted, randomized clinical trials have failed to demonstrate benefit for early surgical repair of small aneurysms compared with surveillance. Endovascular repair has been shown to be safer than open surgical repair in patients with large aneurysms, prompting a randomized trial of early endovascular repair vs surveillance in patients with small aneurysms. Methods: We randomly assigned 728 patients (13.3% women; mean age, 71 ± 8 years) with 4 to 5 cm AAAs to early endovascular repair (366 patients) or ultrasound surveillance (362 patients). Rupture or aneurysm-related death and overall mortality in the two groups were compared during a mean follow-up of 20 ± 12 months. Results: Among patients randomized to treatment, 89% underwent aneurysm repair. Among patients randomized to surveillance, 31% underwent aneurysm repair during the course of the study. After a mean follow-up of 20 ± 12 months (range, 0-41 months), 15 deaths had occurred in each group (4.1%). The unadjusted hazard ratio (95% confidence interval) for mortality after early endovascular repair was 1.01 (0.49-2.07, P =.98). Aneurysm rupture or aneurysmrelated death occurred in two patients in each group (0.6%). The unadjusted hazard ratio was 0.99 (0.14-7.06, P =.99) for early endovascular repair. Conclusions: Early treatment with endovascular repair and rigorous surveillance with selective aneurysm treatment as indicated both appear to be safe alternatives for patients with small AAAs, protecting the patient from rupture or aneurysm-related death for at least 3 years. Copyright © 2010 by the Society for Vascular Surgery.
The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the Revised Cardiac Risk Index in vascular surgery patients
Volume 52, Issue 3, September 2010, Pages 674-683.e3
Daniel J. Bertges | Philip P. Goodney | Yuanyuan Zhao | Andres Schanzer | Brian W. Nolan | Donald S. Likosky | Jens Eldrup-Jorgensen | Jack L. Cronenwett
Objective: The Revised Cardiac Risk Index (RCRI) is a widely used model for predicting cardiac events after noncardiac surgery. We compared the accuracy of the RCRI with a new, vascular surgery-specific model developed from patients within the Vascular Study Group of New England (VSGNE). Methods: We studied 10,081 patients who underwent nonemergent carotid endarterectomy (CEA; n = 5293), lower extremity bypass (LEB; n = 2673), endovascular abdominal aortic aneurysm repair (EVAR; n = 1005), and open infrarenal abdominal aortic aneurysm repair (OAAA; n = 1,110) within the VSGNE from 2003 to 2008. First, we analyzed the ability of the RCRI to predict in-hospital major adverse cardiac events, including myocardial infarction (MI), arrhythmia, or congestive heart failure (CHF) in the VSGNE cohort. Second, we used a derivation cohort of 8208 to develop a new cardiac risk prediction model specifically for vascular surgery patients. Chi-square analysis identified univariate predictors, and multivariate logistic regression was used to develop an aggregate and four procedure-specific risk prediction models for cardiac complications. Calibration and model discrimination were assessed using Pearson correlation coefficient and receiver operating characteristic (ROC) curves. The ability of the model to predict cardiac complications was assessed within a validation cohort of 1873. Significant predictors were converted to an integer score to create a practical cardiac risk prediction formula. Results: The overall incidence of major cardiac events in the VSGNE cohort was 6.3% (2.5% MI, 3.9% arrhythmia, 1.8% CHF). The RCRI predicted risk after CEA reasonably well but substantially underestimated risk after LEB, EVAR, and OAAA for low- and higher-risk patients. Across all VSGNE patients, the RCRI underestimated cardiac complications by 1.7- to 7.4-fold based on actual event rates of 2.6%, 6.7%, 11.6%, and 18.4% for patients with 0, 1, 2, and <3 risk factors. In multivariate analysis of the VSGNE cohort, independent predictors of adverse cardiac events were (odds ratio [OR]) increasing age (1.7-2.8), smoking (1.3), insulin-dependent diabetes (1.4), coronary artery disease (1.4), CHF (1.9), abnormal cardiac stress test (1.2), long-term β-blocker therapy (1.4), chronic obstructive pulmonary disease (1.6), and creatinine <1.8 mg/dL (1.7). Prior cardiac revascularization was protective (OR, 0.8). Our aggregate model was well calibrated (r = 0.99, P < .001), demonstrating moderate discriminative ability (ROC curve = 0.71), which differed only slightly from the procedure-specific models (ROC curves: CEA, 0.74; LEB, 0.72; EVAR, 0.74; OAAA, 0.68). Rates of cardiac complications for patients with 0 to 3, 4, 5, and <6 VSG risk factors were 3.1%, 5.0%, 6.8%, and 11.6% in the derivation cohort and 3.8%, 5.2%, 8.1%, and 10.1% in the validation cohort. The VSGNE cardiac risk model more accurately predicted the actual risk of cardiac complications across the four procedures for low- and higher-risk patients than the RCRI. When the VSG Cardiac Risk Index (VSG-CRI) was used to score patients, six categories of risk ranging from 2.6% to 14.3% (score of 0-3 to 8) were discernible. Conclusions: The RCRI substantially underestimates in-hospital cardiac events in patients undergoing elective or urgent vascular surgery, especially after LEB, EVAR, and OAAA. The VSG-CRI more accurately predicts in-hospital cardiac events after vascular surgery and represents an important tool for clinical decision making. Copyright © 2010 Society for Vascular Surgery.
Prospective randomized trial comparing endovenous laser ablation and surgery for treatment of primary great saphenous varicose veins with a 2-year follow-up
Volume 52, Issue 5, November 2010, Pages 1234-1241
Jan T. Christenson | Salah Gueddi | Gino Gemayel | Henri Bounameaux
Background: Endovenous laser therapy (EVLT) for ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity compared with high ligation and stripping (HL/S). Only a few randomized trials have reported early results. This prospective randomized trial compared EVLT (980 nm) and HL/S results at 1 and 2 years after the intervention. Method: Patients with symptomatic varicose veins due to GSV insufficiency were randomized to HL/S (100 limbs) or EVLT (104 limbs). Four EVLT procedures failed primarily and were excluded. Phlebectomy and ligature of incompetent perforators were performed whenever indicated in both groups. Patients were re-examined clinically and by duplex ultrasound imaging preoperatively and at 12 days and at 1 and 2 years after treatment. Closure rate, complication rate, time to return to normal activity, the Aberdeen Varicose Vein Symptom Severity Score (AVVSS), the Varicose Venous Clinical Severity Score (VVCSS), and the Medical Outcome Study Short Form-36 scores were also recorded. Results: There were no differences in patient demographics, CEAP class, Widmer class, or severity scores between the groups. Simultaneous interventions did not differ between the groups. Similar times for the return to normal activity and scores for postoperative pain were reported. No major complications after treatment were recorded. HL/S limbs had significantly more postoperative hematomas than EVLT limbs, and EVLT patients reported more bruising. Follow-up at 1 year was 100% for HL/S and 99% for EVLT. Two GSVs in the EVLT group reopened and three partially reopened. No open GSVs occurred in HL/S limbs. Ninety-eight percent of the limbs in both groups were free of symptoms. VCSS, AVVSS, and Short Form-36 scores did not reveal any group differences. At 2 years, no differences compared with 1-year results were observed, except that two more GSVs in the EVLT group were partially reopened. Conclusions: Abolition of GSV reflux and improvement in quality of life was similar after HL/S and EVLT. After EVLT, however, two GSVs were found completely reopened and five were partially reopened, which was significantly higher than after HL/S. A prolonged follow-up is ongoing. Copyright © 2010 by the Society for Vascular Surgery.
Technical aspects, current indications, and results of chimney grafts for juxtarenal aortic aneurysms
Volume 53, Issue 6, June 2011, Pages 1520-1527
Raphael Coscas | Hicham Kobeiter | Pascal Desgranges | Jean Pierre Becquemin
Introduction: Juxtarenal aortic aneurysms (JAA) can be successfully treated by fenestrated/branched endografts (FBE), but with significant cost and a long manufacturing process. "Chimney" grafts (CG) have been advocated as a cheaper and immediately available alternative. Because scant data are available, the aim of this study was to report our early experience with CG to treat JAA. Methods: From 2000 to 2010, data were prospectively collected for 975 consecutive endovascular aortic repairs (EVAR). Among them, 57 patients undergoing EVAR for JAA were retrospectively reviewed, and those undergoing planned CG were analyzed further. All CG patients were thought to be at high risk for open surgery and were usually unsuitable for FBE. Results: The series included 16 patients with CGs for JAA, and 14 (88%) were men. Median age was 73 years old (range, 22-91 years). Median aneurysm diameter was 62 mm (range, 30-100 mm). Indications for CG were an anatomic condition precluding FBE in four patients (including three with iliac occlusion), emergent repair of painful or ruptured aneurysm in four, a large-diameter aneurysm whose treatment could not wait for the manufacturing delay of an FBE in three, type Ia endoleak in three patients previously treated by infrarenal EVAR, and elective in two. Treatment involved 26 target vessels (6 superior mesenteric arteries, 20 renal arteries). Intraoperative technical success was 94% (1 type Ia endoleak). Postoperatively, one patient died of a retroperitoneal hemorrhage and one patient died of mesenteric ischemia after leaving the hospital against medical advice. One patient had a stroke, and four presented with local vascular complications (iliac dissection, hematoma). The postoperative computed tomography scan showed two patients (12.5%) had a type Ia endoleak. With a median follow-up of 10.5 months (range, 2-19 months), two more patients died (not aneurysm-related). No rupture occurred. All target vessels were patent (primary patency rate, 96%), and one type Ia endoleak persisted. Conclusion: CG is feasible and efficient to treat JAA in patients unsuitable for FBE. However, in this preliminary experience, complications of devices insertion and type I endoleaks were not rare. Until the anatomic applicability of FBE is extended and off-the-shelf FBE devices are available, CG remains a feasible endovascular option for high-risk JAA patients.
Unexpected major role for venous stenting in deep reflux disease
Volume 51, Issue 2, February 2010, Pages 401-408
Seshadri Raju | Rikki Darcey | Peter Neglén
Background: Treatment of chronic venous insufficiency (CVI) has largely focused on reflux. Minimally-invasive techniques to address superficial and perforator reflux have evolved, but correction of deep reflux continues to be challenging. The advent of intravascular ultrasound (IVUS) scan and minimally invasive venous stent technology have renewed interest in the obstructive component in CVI pathophysiology. The aim of this study is to assess stent-related and clinical outcomes following treatment by iliac venous stenting alone in limbs with a combination of iliac vein obstruction and deep venous reflux. Methods: A total of 528 limbs in 504 patients, ranging in age from 15 to 87, underwent IVUS-guided iliac vein stent placement to correct obstruction over an 11-year period. The etiology of obstruction was nonthrombotic in 196 (37%), post-thrombotic in 285 (54%) limbs, and combined in 47 (9%). Clinical severity class of CEAP was C3 in 44%, C4,5 in 27%, and C6 in 25% of stented limbs. Deep venous reflux was present in all limbs, associated with superficial and/or perforator reflux in 69%. Reflux was severe in 309/528 (59%) limbs (reflux multisegment score ≥3) and 224/528 (42%) limbs had axial reflux. Venography and other functional tests had poor diagnostic sensitivity to detect obstruction, which was ultimately diagnosed by IVUS. The IVUS-guided iliac vein stenting was the only procedure performed and the associated reflux was left uncorrected. Results: There was no mortality; morbidity was minor. Cumulative secondary stent patency was 88% at 5 years; no stent occlusions occurred in nonthrombotic limbs. Cumulative rates of limbs with healed active ulcers, freedom of ulcer recurrence in legs with healed ulcers (C5), and freedom from leg dermatitis at 5 years were 54%, 88%, and 81%, respectively. Cumulative rate of substantial improvement of pain and swelling at 5 years was 78% and 55%, respectively. Quality of life improved significantly. Reflux parameters did not deteriorate after stenting. Conclusion: Iliac venous stenting alone is sufficient to control symptoms in the majority of patients with combined outflow obstruction and deep reflux. Partial correction of the pathophysiology in limbs with multisystem or multilevel disease can provide substantial symptom relief. Percutaneous stent technology in concert with other minimally-invasive techniques to address superficial and/or perforator reflux offers such partial correction in limbs with advanced CVI and complex venous pathology. Open correction of obstruction or reflux is now required only infrequently as a "last resort". © 2010 Society for Vascular Surgery.
Long-term patency of small-diameter vascular graft made from fibroin, a silk-based biodegradable material
Volume 51, Issue 1, January 2010, Pages 155-164
Soichiro Enomoto | Makoto Sumi | Kan Kajimoto | Yasumoto Nakazawa | Rui Takahashi | Chiyuki Takabayashi | Tetsuo Asakura | Masataka Sata
Objective: There is an increasing need for vascular grafts in the field of surgical revascularization. However, smaller vascular grafts made from synthetic biomaterials, particularly those <5 mm in diameter, are associated with a high incidence of thrombosis. Fibroin is a biodegradable protein derived from silk. Silk fibroin from Bombyx mori provides an antithrombotic surface and serves as a scaffold for various cell types in tissue engineering. We evaluated the potential of fibroin to generate a vascular prosthesis for small arteries. Methods: A small vessel with three layers was woven from silk fibroin thread. These fibroin-based grafts (1.5 mm diameter, 10 mm length) were implanted into the abdominal aorta of 10- to 14-week-old male Sprague-Dawley rats by end-to-end anastomosis. Polytetrafluoroethylene (PTFE)-based grafts were used as the control. To investigate the origin of the cells in the neointima and media, bone marrow transplantation was performed from green fluorescent protein (GFP) rats to wild-type rats. Results: The patency of fibroin grafts at 1 year after implantation was significantly higher than that of PTFE grafts (85.1% vs 30%, P < .01). Endothelial cells and smooth muscle cells (SMCs) migrated into the fibroin graft early after implantation and became organized into endothelial and medial layers, as determined by anti-CD31 and anti-α-smooth muscle actin immunostaining. The total number of SMCs increased 1.6-fold from 1 month to 3 months. Vasa vasorum also formed in the adventitia. Sirius red staining of the fibroin grafts revealed that the content of collagen significantly increased at 1 year after implantation, with a decrease in fibroin content. GFP-positive cells contributed to organization of a smooth muscle layer. Conclusions: Small-diameter fibroin-based vascular grafts have excellent long-term patency. Bone marrow-derived cells contribute to vascular remodeling after graft implantation. Fibroin might be a promising material to engineer vascular prostheses for small arteries. © 2010 Society for Vascular Surgery.