Vascular

Objectives: P-selectin inhibition has been found to limit venous thrombosis. We hypothesize that elevated levels of P-selectin will amplify thrombosis, mediated by procoagulant microparticles (MPs). Methods: Male mice (Mus musculus, n659), 20 to 25 grams, underwent IVC ligation to induce thrombosis. Groups consisted of wild type (WT) C57BL/6 controls, mice with high circulating levels of soluble P-selectin (^CT), P-selectin gene-interrupted knockout mice (PKO), and E-and P-selectin gene-interrupted mice (EPKO). Additional groups were used to evaluate the ability of a P-sel antagonist (rPSGL-Ig) and an antibody directed against PSGL-1 to downregulate the effects of P-sel in^CT mice and WT mice administered soluble P-sel at time of thrombosis. Animals were sacrificed on days 2 and 6 after IVC ligation. Thrombus mass (TM), vein wall morphometrics, and serum leukocyte/platelet microparticles (MPs) were evaluated by means of double-stained fluorescence-activated cell scanning analysis, and soluble P-and E-sel protein determination by ELISA. Results: At days 2 and 6 in phase I of the experiment, significant differences (P < .01) in TM were noted between groups, with^CT animals having the largest thrombi (50% and 57% increase in TM compared to WT at days 2 and 6) while EPKO mice had the smallest thrombi. Statistically, greater levels of neutrophils and total inflammatory cells were noted in the vein walls of^CT animals at day 2 compared with WT and PKO animals. A significant difference was noted between^CT and EPKO for neutrophils, monocytes, and total inflammatory cells, also at day 2. At day 6, the only statistically significant difference was found for monocytes, with a higher number in the^CT animals than in WT animals. The evaluation of MPs revealed that the^CT mice had a mixed leukocyte (MAC-1) and platelet (CD41) MP population that was also present in WT and PKO mice on day 2 and day 6. EPKO mice revealed a primarily platelet-derived MP population. Of interest, the^CT mice with the highest TM showed a high amount of mean channel fluorescence for MAC-1 (phycoerythrin) antibody, indicative of leukocyte MPs.^CT mice revealed statistically higher levels of soluble P-selectin at days 2 and 6. In phase 2, an antibody directed against PSGL-1 was more effective than rPSGL-Ig in decreasing TM and limiting leukocyte-derived MP fluorescence. Conclusions: This study demonstrates that high circulating levels of P-selectin are associated with increased thrombosis, whereas a lack of P-selectin and E-selectin is associated with a lessening of thrombosis. Additionally, leukocyte MPs are associated with venous thrombus formation. These data suggest the importance of selectins to venous thrombogenesis and show that P-selectin and leukocyte-derived MPs should be good targets to limit venous thrombus formation. (J Vasc Surg 2003;38:1075-89.)

A phylogeny based on nrITS1 and trnL-F sequences resolves the Lejeunea tumida species group polyphyletic with individuals belonging in two clades either side of the basal-most node within Lejeunea. It is impossible for the Lejeunea tumida species group to be more polyphyletic and still be attributed to the same genus under the existing generic classification. A simulation-based approach to testing the null hypothesis of group monophyly rejects this at the P < 0.01 level of significance. Bayesian tests find very strong support for polyphyly, given the data. The monophyly of L. tumida s.s. + L. colensoana is fully supported; however, although Lejeunea tumida s.s. is nested within L. colensoana, this position is not supported. Both L. oracola and L. rhigophila are resolved as monophyletic. Whereas there is moderate support for the monophyly of L. rhigophila, there is no support for the monophyly of L. oracola. Neither is the monophyly of L. oracola + L. rhigophila supported in Bayesian or parsimony analysis.

Percutaneous vertebroplasty and sacroplasty are becoming common modalities of treatment for vertebral body compression fractures and sacral insufficiency fractures, respectively. The present report describes a case of a coccygeal fracture treated with injection of polymethylmethacrylate cement, which resulted in immediate relief of symptoms. It is suggested that this procedure be called coccygeoplasty. J Vasc Interv Radiol 2006; 17:909 -912

Therapy with bisphosphonates, including alendronate (ALN), is considered a safe and effective treatment for osteoporosis. However, recent studies have reported an unexpected increase in serious atrial fibrillation (AF) in patients treated with bisphosphonates. The mechanism that explains this side effect remains unknown. Since AF is associated with an altered sarcoendoplasmic reticulum calcium load, we studied how ALN affects cardiomyocyte calcium homeostasis and protein isoprenylation in vitro. Acute and long-term (48 h) treatment of atrial and ventricular cardiomyocytes with ALN (10 − 8 -10 − 6 M) was performed. Changes in calcium dynamics were determined by both fluorescence measurement of cytosolic free Ca 2+ concentration and western blot analysis of calcium-regulating proteins. Finally, effect of ALN on protein farnesylation was also identified. In both atrial and ventricular cardiomyocytes, ALN treatment delayed and diminished calcium responses to caffeine. Only in atrial cells, long-term exposure to ALN-induced transitory calcium oscillations and led to the development of oscillatory component in calcium responses to caffeine. Changes in calcium dynamics were accompanied by changes in expression of proteins controlling sarcoendoplasmic reticulum calcium. In contrast, ALN minimally affected protein isoprenylation in these cells. In summary, treatment of atrial cardiomyocytes with ALN-induced abnormalities in calcium dynamics consistent with induction of a self-stimulatory, pacemaker-like behavior, which may contribute to the development of cardiac side effects associated with these drugs.

Objective: Although infection following carotid endarterectomy is rare, consequences of this seldom seen complication can be devastating. Polyester, polytetrafluoroethylene (PTFE), and vein patches have all been used by many institutions for patch angioplasty, each with reported cases of infection following surgery. Our institution has preferentially used PTFE for the majority of cases, and here, we report our experience with postoperative infection following endarterectomy over the last decade. Methods: From January 2000 through July 2009, we treated infections following carotid endarterectomy in 25 patients. Results: Of the 25 patients undergoing treatment for postoperative infection, 21 had PTFE patches placed during the initial surgery. The remaining four consisted of two polyester patches and two bovine pericardial patches. Twenty-three of the 25 initial endarterectomies were performed at our institution, and the other two were referrals. The majority of cases (56%) were due to gram-positive organisms, with only two cases being polymicrobial. The interval from the original surgery to clinical presentation ranged from 7 days to 85 months, with 20 patients (80%) presenting within 60 days of the first operation. Thirteen patients underwent incision and drainage with antibiotics, and 12 patients underwent definitive surgical treatment. Four received patch excision with vein patch angioplasty, four received patch excision with vein interposition, and four received sternocleidomastoid flaps. The 30-day stroke rate was 8%, and the freedom from recurrent infection was 100% at a mean follow-up of 32 months. Conclusion: Infection following carotid endarterectomy occurs <1% of the time; however, the potential for morbidity is significant. Our results show that most infections following PTFE patch angioplasty occur in the early postoperative period (<60 days) and that simple drainage with antibiotics may be an adequate form of treatment in select cases. ( J Vasc Surg 2011;53:1473-7.)

Purpose: The purposes of this study were to evaluate the long-term results of different autogenous conduits used for infrainguinal bypass when ipsilateral greater saphenous vein (IGSV) is absent or inadequate and to determine the impact on the contralateral lower extremity. Methods: The study was performed as a retrospective evaluation of a prospective vascular registry together with review of patient records and telephone follow-up. Results: From January 1990 to June 2000, 226 autogenous infrainguinal reconstructions were performed in 203 patients without adequate IGSV. The patients consisted of 128 men and 98 women, with a mean age of 69 years. Prevalent risk factors included diabetes (51%) and prior coronary bypass (46%). Limb salvage was the predominant indication (93%), and 59% of the procedures were secondary reconstructions. All bypasses were completed with autogenous vein, which included contralateral greater saphenous vein (CGSV; 31%), single-segment lesser saphenous vein (5%), single-segment arm vein (19%), and autogenous composite vein (45%). Bypasses were performed to the tibial and pedal arteries in 84% of the cases. The 30-day mortality and graft occlusion rates were 1% and 9%, respectively. The overall postoperative morbidity rate was 24%, with a 7% rate of major complications. Follow-up was complete in 95% of patients over a mean period of 24 months (range, 0.1 to 106 months). The 5-year primary patency rates were significantly better for CGSV compared with autogenous composite vein grafts (61% ؎ 7% versus 39% ؎ 6%; P < .009). The 5-year secondary patency (60% to 73%) and limb salvage (78% to 81%) rates did not differ significantly between the three groups. Follow-up of the contralateral lower limb revealed that nine of 226 limbs (4%) were amputated at a mean of 36 months after the ipsilateral bypass. The overall 5-year contralateral limb preservation rate was 90% ؎ 3%. Contralateral vein harvest and the presence of diabetes did not affect the need for bypass or amputation of the contralateral limb. Conclusion: For most patients with inadequate IGSV, the CGSV is the alternative conduit of choice because of its length, superior performance, ease of harvest, and minimal risk to the donor limb. (J Vasc Surg 2002;35:1085-92.) From the Division of Vascular Surgery, Brigham and Women's Hospital, Harvard Medical School. Competition of interest: nil.

The study was conducted to demonstrate improved survival (30-day mortality) after the introduction of an emergency endovascular therapy protocol for ruptured abdominal aortic aneurysms (rAAA). Numerous authors have successfully demonstrated reduced mortality in patients with rAAA using endovascular techniques. Comparison of endovascular aneurysm repair (EVAR) with open repair for rAAA may be misleading, however, because EVAR cannot be performed on all patients, and selection bias may explain the superior performance of any given surgical or endovascular strategy. We developed a model to predict mortality in patients before the introduction of EVAR (preprotocol population), applied this model to predict 30-day mortality among prospective patients (postprotocol population), and compared observed vs expected results. Methods: We assessed 126 patients with rAAA. Primary outcome was 30-day mortality. Potential confounding variables were age, sex, presurgical lowest recorded systolic blood pressure (SBP), and glomerular filtration rate (GFR). A logistic regression model incorporating significant confounders was used to evaluate changes in 30-day mortality for all patients with rAAA after introduction of the EVAR protocol. Separate logistic regressions were done to compare 30-day mortality for preprotocol vs patients receiving EVAR and preprotocol vs patients receiving postprotocol open repair. Cumulative sum (CUSUM) analysis was used to assess shifts in the performance of the rAAA program over time.

Morphometric data have long suggested the existence of three species of Sicyos in Australia and New Zealand. Molecular data now corroborate this and place the three species in the context of the remaining 72 species of Sicyos, most of them in the New World. We here describe and illustrate Sicyos undara I.Telford & P.Sebastian from northern Queensland and S. mawhai I.Telford & P.Sebastian from New Zealand, and emend the circumscription of S. australis to account for the removal of these two extraneous elements. We also provide a key to the three species, map their ranges, and note their habitat and conservation status.

PURPOSE: A multiple-electrode radiofrequency (RF) system was developed based on switching between electrodes that allows for the simultaneous use of as many as three electrically independent electrodes. The purpose of this study was to determine if each multiple-electrode ablation zone is identical to an ablation zone created with conventional single-electrode mode. MATERIALS AND METHODS: Nine female domestic pigs (mean weight, 90 kg) were used for this study. A prototype monopolar multiple-electrode RF ablation system was created with use of an RF generator and an electronic switching algorithm. A maximum of three electrodes can be used simultaneously by switching between electrodes at each impedance spike (30 ⍀ greater than baseline levels). A total of 39 zones of ablation were created at open laparotomy in pig livers with use of a conventional single electrode (n ‫؍‬ 9), two single electrodes simultaneously (n ‫؍‬ 6 ablations; 12 ablation zones), or three single electrodes simultaneously (n ‫؍‬ 6 ablations; 18 ablation zones). RF electrodes were spaced in separate lobes of the liver when multiple zones of coagulation were created simultaneously. Animals were euthanized after RF ablation, livers were removed, and ablation zones were sectioned and measured. RESULTS: Zones of coagulation created simultaneously with two or three electrodes were equivalent to ablation zones created with use of conventional single-electrode ablation. No significant differences were observed among control animals treated with a single electrode, those with two separate zones of ablation created simultaneously, and those with three simultaneously created ablation zones in terms of mean (؎SD) minimum diameter (1.6 cm ؎ 0.6, 1.6 cm ؎ 0.5, and 1.7 cm ؎ 0.4, respectively), maximum diameter (2.0 cm ؎ 0.5, 2.3 cm ؎ 0.5, 2.2 cm ؎ 0.5, respectively), and volume (6.7 cm 3 ؎ 3.7, 7.4 cm 3 ؎ 3.8, and 7.8 cm 3 ؎ 3.9; P > .30, analysis of variance, pairwise t-test comparisons). CONCLUSIONS: A rapid-switching multiple-electrode RF system was able to simultaneously create as many as three separate ablation zones of equivalent size compared with single-electrode controls. This system would allow physicians to simultaneously treat multiple tumors, substantially reducing procedure time and anesthesia risk.

Balloon-occluded retrograde transvenous obliteration (BRTO) of bleeding gastric varices (GV) is well described in the literature. Using Ethanolamine oleate as the sclerosing agent in BRTO, but it is not readily available in the United States in the desired concentrations. The authors' aim is to describe their initial experience with BRTO using sodium tetradecyl sulfate (STS) foam as an alternative sclerosing agent. Materials and Methods: The authors performed a retrospective review of their initial series in which STS foam was used to treat bleeding GV using BRTO. All study subjects had endoscopic evidence of gastric variceal bleeding. STS foam was made using a combination of agents with a 3:2:1 ratio of gas: 3% STS: Lipiodol (Ethiodol; Savage Laboratories, Melville, New York). Mean values and ranges were calculated for each variable, and clinical and imaging outcomes were assessed. Results: The authors performed BRTO in 22 cirrhotic patients (11 men and 11 women) with a mean age of 52 years (range, 23-83 years). Technical success was achieved in 20 of 22 (91%) patients. Complications occurred in three of 22 (14%) patients. The overall mean dose of STS used was 300 mg (range, 30-600 mg) with mean total volume of sclerosant mixture of 34.1 mL (range, 10-65 mL). Follow-up imaging was available for 18 of 20 (90%) technically successful procedures with a mean period of 89 days (range, 1-359 days). Complete obliteration of GV was achieved in 16 of 18 (89%) patients. There were no cases of recurrent variceal bleeding with a mean clinical follow-up period of 130 days (range, 1-510). Conclusions: BRTO utilizing STS foam appears effective in obliterating bleeding GVs with good short-term outcomes. ABBREVIATIONS BRTO ϭ balloon-occluded retrograde transvenous obliteration, EBC ϭ endoscopic N-butyl-2-cyanoacrylate, EO ϭ ethanolamine oleate, EUS ϭ endoscopic ultrasound, GRS ϭ gastrorenal shunt, GV ϭ gastric varices, STS ϭ sodium tetradecyl sulfate, TIPS ϭ transjugular intrahepatic portosystemic shunts

East Orange and Newark, N.J. Purpose: Calf muscle pump dysfunction is a recognized factor in chronic venous insufficiency (CVI). We investigated the hypothesis that limbs with CVI have a reduced ankle range of motion (ROM) that may be responsible for the poor calf pump function associated with venous ulceration.

21 percutaneous cecostomy procedures were performed in 20 patients in whom classical therapeutic approaches for the management of fecal incontinence had failed. Eighteen patients had anorectal malformations, one had myelomeningocele, and one had chronic constipation. All procedures were performed under general anesthesia and fluoroscopic guidance. In all cases, an 8.5-F Dawson-Mueller catheter was placed in the cecum and exchanged after 45 days with a cecostomy button (ie, Trapdoor catheter). Data regarding complications, effectiveness of treatment, satisfaction, and quality of life were obtained by interviewing the patients' parents at follow-up consultation. RESULTS: Nineteen of 20 procedures were technically successful. There were no major complications. All patients' symptoms of incontinence improved. Ninety percent of patients in our series (n ‫؍‬ 18) reported satisfaction with the procedure, mainly related to their independence and quality of life. CONCLUSIONS: Percutaneous cecostomy is a safe and effective procedure for the management of pediatric patients with fecal incontinence. Percutaneous cecostomy allows antegrade and more physiologic colon irrigation, avoiding the need for multiple retrograde enemas, achieving more patient independence, and improving quality of life. J Vasc Interv Radiol 2007; 18:982-985 From the Departments of Interventional Radiology (S.S., J.L., H.Q.) and Surgery (M.B., J.S.), Hospital de

MATERIALS AND METHODS: This prospective study consisted of two consecutive investigations. In the first (n ‫؍‬ 30), only local anesthetic agent (prilocaine 2%) was injected into one arm, and local anesthetic agent plus 500 g nitroglycerin was injected into the other arm. Radial artery diameters before and after injections were measured by ultrasonography. In the second, 33 patients received local anesthetic agent (prilocaine 2%) plus 500 g nitroglycerin (group A) and 30 received only local anesthetic agent (group B) to determine whether the addition of nitroglycerin would improve radial artery access time, duration of angiography, perception of arterial pulse (ie, pulse score), number of punctures before successful cannulation, and complication rates. RESULTS: In the first investigation, radial artery diameter increased significantly in the nitroglycerin-treated arm (2.3 mm ؎ 0.4 vs 2.9 mm ؎ 0.5; P ‫؍‬ .05). In the second, there were no significant differences between groups with respect to age, sex, duration of angiography, and number of punctures before cannulation. However, the pulse score increased and radial artery access time improved significantly after addition of nitroglycerin (79% vs 10% [P < .001] and 75 sec ؎ 47 vs 132 sec ؎ 100 [P ‫؍‬ .005], respectively). Radial artery spasm and thrombosis were less frequently observed in group A, albeit to an insignificant extent (P ‫؍‬ .39 and P ‫؍‬ .49, respectively). CONCLUSIONS: Subcutaneous administration of nitroglycerin significantly increased radial artery diameter, which can lead to facilitation of catheterization of the radial artery for arteriography and interventions.

This study aimed to describe the practice patterns of primary healthcare practitioners who diagnose and manage venous disease to determine differences in clinical evaluation of disease, recognition of venous ulcers, and referral patterns. A survey was distributed at the August 2011 Primary Care Medical Conference (Pri-Med) in Baltimore, Maryland. Pri-med is a medical education company that caters to the continued professional development needs of a variety of physicians. A total of 305 surveys were completed. Of the respondents, 91% were physicians and 9% were advanced level practitioners. In all, 93% prescribed compression stockings as first-line treatment. Heterogeneous referral patterns were reported with 81% referring to vascular surgery, 25% to a vein clinic, 10% to interventional radiology, and 3% to interventional cardiology. Up to 35% responded that they met resistance (did not have their referral accepted) when attempting referral to a vascular surgery colleague. There was ...

Diabetes mellitus (DM) is a chronic metabolic disorder characterized by inappropriate hyperglycemia due to lack of or resistance to insulin. Patients with DM are frequently afflicted with ischemic vascular disease or wound healing defect. It is well known that type 2 DM causes amplification of the atherosclerotic process, endothelial cell dysfunction, glycosylation of extracellular matrix proteins, and vascular denervation. These complications ultimately lead to impairment of neovascularization and diabetic wound healing. Therapeutic angiogenesis remains an attractive treatment modality for chronic ischemic disorders including PAD and/or diabetic wound healing. Many experimental studies have identified better approaches for diabetic cardiovascular complications, however, successful clinical translation has been limited possibly due to the narrow therapeutic targets of these agents or the lack of rigorous evaluation of pathology and therapeutic mechanisms in experimental models of di...

Endovascular strategies for the treatment of critical infrageniculate peripheral arterial occlusive disease exist and are becoming the primary methodology for such lesions at many centers. Although technically feasible for experienced operators, the evidence to support this strategy for below the knee (BTK) interventions is still evolving. We studied the 6-month and 1-year outcomes of percutaneous transluminal angioplasty (PTA) alone, PTA with stenting, and excimer laser recanalization for BTK lesions in patients with critical limb ischemia.

treated with povidone-iodine percutaneous sclerotherapy. Percuta-Marco A. Amendola, MD neous catheters were placed by means of sonographic, computed Daniel Seckinger, MD tomographic, or combined fluoroscopic and sonographic guidance. Sclerotherapy was initiated while patients were in the hospital, and the patients then instilled povidone-iodine twice a day at Index terms: Kidney, transplantation, home. 81.455 Lymphatic system, intenentional procedure, 99.126 Lymphocele, RESULTS: One patient had an inadequate trial period of therapy 81.4556

To determine the effect of elastic compression stockings on deep venous hemodynamics we measured ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, amplitude of venous pressure excursion, and duplex-derived common femoral and popliteal vein diameter and peak flow velocities with and without stockings in 10 healthy subjects and 16 patients with chronic deep venous insufficiency. The effects of below-knee and above-knee 30 to 40 torr and 40 to 50 torr gradient stockings were studied. Despite documentation of substantial stocking compressive effects by skin pressure measurements, neither below-knee or above-knee elastic compression stockings significantly improved ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, or the amplitude of venous pressure excursion in healthy patients or in patients with deep venous insufficiency (p > 0.05).

Objective: To produce a comprehensive anatomical and hemodynamic ultrasound scan mapping of the whole limb in patients with primary varicose veins (VVs). Design: An analysis of venous duplex scans performed on patients referred for treatment of primary VVs. Methods: A total of 2036 limbs were evaluated, looking for the origin of VVs in the saphenous systems and in the perforating vein (PV) systems, as well as for the presence of non-saphenous reflux. Results: The sapheno-femoral junction (SFJ) of the great saphenous vein (GSV) was involved in 1330 limbs (65.3%). We have noted that finding reflux in the groin does not imply that it originates at that point necessarily, as reflux from the pelvis or abdominal wall can also cause primary VVs (SFJ reflux, 41.9% and competent SFJ with reflux from proximal veins, 35.4%). We also noted that analyzing only the presence of reflux in the SFJ of the GSV would miss 10.9% of limbs of reflux in the SFJ of the anterior accessory GSV. In 237 limbs (11.6%), reflux was observed in the popliteal fossa. In the PV system, we distinguished those PVs with retrograde flow that acted as an origin of the VVs, and other PVs that acted as re-entry points. Based on this difference, the location identified as the most frequent origin of VVs in the PV system was the thigh, specifically in the group of PVs of the medial thigh of the femoral canal, with 85 PVs with a total of 238 incompetent PVs identified. Pure non-saphenous reflux was observed in 162 limbs (8%).

Vascular injuries, although highly feared, can occur after total joint arthroplasty, often resulting in legal suits. This study evaluates the circumstances related to vascular injuries after joint arthroplasty. Using prospectively collected data on 13 517 patients undergoing total joint arthroplasty at our institution, 16 (0.1%) vascular injuries were identified. Eleven injuries occurred after total knee arthroplasty (TKA) and 5 after total hip arthroplasty (THA). Indirect injury was the most common mechanism in TKA. In contrast, direct injury was most prevalent in THA. One patient died of complications related to vascular injury. Of 16 patients, 8 (50%) had launched a legal suit against the operating surgeon. There appears to be no further specific measure that can be taken to absolutely avoid this complication. Patient awareness regarding this real problem may play a role in defraying the high likelihood of legal suits associated with this complication.

Objective: Assessment of walking distance by treadmill testing is the most commonly used method to evaluate the effect of treatment in patients with peripheral arterial disease. However, treadmill testing is time consuming, relatively expensive, and does not adequately reflect real life functional ability. We hypothesized that the Walking Impairment Questionnaire (WIQ) could be an alternative tool to assess objective improvement in functional walking ability of patients with intermittent claudication. Methods: This was a validation study. It was conducted through the outpatient clinic for vascular surgery. Patients with intermittent claudication were referred for supervised exercise therapy. Treadmill testing (absolute claudication distance [ACD]), WIQ, and quality of life questionnaires (RAND-36 and EuroQol) were administered at study onset and after 3 months of supervised exercise therapy. Responsiveness was determined by mean changes in and correlation coefficients of WIQ, ACD, and quality of life questionnaires. Patients were categorized into quartiles based on the increase in ACD, which were subsequently related to change in WIQ and quality of life. Results: The mean pre-and post-treatment total WIQ scores of 91 patients were 0.45 (0.22) and 0.58 (0.22), respectively. The correlation coefficient between the change in total WIQ score and ACD was 0.331 (P ‫؍‬ .004). A 0.1 change in total WIQ score corresponded to a change of 345 meters in ACD. Analysis of the four quartiles compared to an increase in ACD showed that a greater increase in ACD corresponded with a greater increase in WIQ score, from 0.06 to 0.25 (P ‫؍‬ .011). Conclusion: These data indicate that the WIQ is a valid tool to detect improvement or deterioration in the daily walking ability of patients with intermittent claudication. Hence, the WIQ can be used as an alternative to treadmill testing for objective assessment of functional walking ability, both in daily practice and in clinical trials. ( J Vasc Surg 2009;50:89-94.)

Identification of Australian species of Nitella is problematic. Several species of monoecious Nitella have been described from south-eastern mainland Australia, but identification of these based on current treatments has been difficult. In response to the discovery of a new monoecious Nitella from the swamps of the Fleurieu Peninsula in South Australia, the monoecious species of Nitella from south-eastern mainland Australia were examined and compared. N. paludigena M.T.Casanova & K.G.Karol is distinguished from other monoecious species on the basis of its overall vegetative morphology and oospore morphology. N. paludigena is found in peaty tea-tree (Leptospermum sp) swamps on the Fleurieu Peninsula in South Australia, and in the south-west of Victoria. A description of the morphology and ecology of the five monoecious Nitella species from south-eastern mainland Australia is given, along with a key.

: As yet, there is no patient-assessed, condition-specific instrument for the assessment of health-related quality of life in intermittent claudication. We evaluated the intermittent claudication questionnaire (ICQ) for properties required of a measure of health outcome. Methods and results: Interviews with patients with intermittent claudication and vascular specialist opinion produced a pool of statements used to itemize a self-completed ICQ. This was piloted in 20 patients for practicality and then administered to 124 stable claudicants. Reliability was assessed through a retest in 63 (51%) patients at 14 days and analysis of Cronbach's ␣ for internal consistency. Spearman's correlation coefficient was used to assess construct validity in comparisons between the ICQ and ankle brachial pressure index, treadmill-walking distances, the walking impairment questionnaire, the EuroQol, and the Short Form-36. Responsiveness of the ICQ to changes in health was assessed in 60 patients treated conservatively and 40 patients undergoing angioplasty. The standardized response mean was used to identify the most responsive instrument in the study. A 16-item ICQ with a test-retest intraclass correlation of 0.95 and Cronbach's ␣ of .94 was produced. One hundred twenty-one (98%) patients completed the ICQ (mean time, 3.7 minutes). The ICQ correlated better with the EuroQol (r ‫؍‬ 0.58) and 7 out of 8 subscales of the Short Form-36 (r ‫؍‬ 0.33-0.68) compared with the walking impairment questionnaire. The ICQ demonstrated the largest standardized response mean in relation to health transition compared with the other instruments. Conclusions: The patient-assessed ICQ is a practical, reliable, valid, and responsive measure of patient health-related quality of life in intermittent claudication. (J Vasc Surg 2002;36:764-71.)

traction. Nifedipine significantly reduced Ca 2+ wave frequency and tonic contraction, while the nifedipine-insensitive component was abolished by SKF-96365. Ca 2+ waves and tonic contraction were abolished by 2-aminoethoxydiphenylborate, but were unaffected by ryanodine or tetracaine. Conclusion: Phenylephrine-induced Ca 2+ waves underlie tonic contraction in resistance-sized mesenteric arteries and appear to be produced by repetitive cycles of regenerative Ca 2+ release from the sarcoplasmic reticulum. Decreased frequency of Ca 2+ waves in Marfan syndrome appears to be responsible for reduced tonic contraction.

PURPOSE: Outpatient home infusion therapy is increasing; however, little data exist on the outcomes of patients receiving care. The purpose of this study was to document the natural history of central venous catheters (CVCs) used in home infusion care to determine the rate and type of catheter complications.

A lateral approach to the popliteal artery Is described. The anatomic limits of the exposure, appropriate technical maneuvers to maximize this exposure, and alternative procedures are discussed. Groin or thigh Infections In patients requiring urgent revascularlzatlon are the most common Indications. However, some traumatic Injuries and certain elective reconstructions are appropriately treated with this technique. The lateral exposure to the popliteal artery Is not technically demanding and offers a useful alternative for treatment of selected vascular problems.

An international journal devoted t o t h e t a x o n o my, b i o g e o g r a p hy and evolution of all plant groups a u s t r a l i a n s y s t e m a t i c b o t a n y Abstract. A taxonomic revision with full descriptions and key are presented for the 109 known species of Gastrolobium, including 29 new species described here for the first time. Brachysema, Jansonia and Nemcia are formally placed into Gastrolobium and new combinations have been made where necessary. Included in the revision are full taxonomic descriptions for all species, full synonymies, literature references for original publications, typification, including selection of lectotypes where necessary, distributions complete with maps, and taxonomic and nomenclatural notes.

Late Eocene prickly-leaved and scaly-fruited palm macrofossils are described from Pikopiko, Southland, New Zealand, and compared with extant Arecaceae: Calamoideae. Lamina prickles and scaly fruits support affinities to the subfamily and tribe Calameae and possible association with the extant genus Calamus. Because isolated calamoid leaf fragments and fruit are difficult to determine precisely, the fossils are placed into a new form genus (Calamoides) for the leaves and the existing form genus Lepidocaryopsis for the fruits. These represent the first calamoid-like palm macrofossils from New Zealand and suggest a subtropical to tropical palaeoclimate at far southern latitudes in the Late Eocene and an early, widespread vicariant Gondwanan distribution for the subfamily.

An international journal devoted to t h e t a xo n o my, b i o g e o g r a p hy and evolution of all plant groups a u s t r a l i a n s y s t e m a t i c b o t a n y Australian Systematic Botany 14, 689-869 Abstract A total of 222 taxa (excluding Cyanophyceae and non-geniculate corallinales) are reported from the Suva Lagoon and Reef (Fiji), consisting of 71 Chlorophyceae, 24 Phaeophyceae and 127 Rhodophyceae. Of these, five represent new or undescribed species. The Suva flora is comparatively impoverished with only 222 species, although the relative percentage of the three classes is comparable to the overall Fijian flora, in particular with respect to the Rhodophyceae. M a r i n e a l g a e f r o m S u v a A . D . R . N ' Y e u r t A n t o i n e De R a m o n N ' Y e u r t S B 0 0 0 1 5

BACKGROUND CONTEXT: Vascular etiologies are a significant source of radiculopathy. The entities that are reviewed here include epidural spinal hematoma, subdural spinal hematoma, spinal arteriovenous malformation, vertebral hemangioma, spinal epidural cavernous hemangioma, vertebral artery anomalies (both tortuosity and dissection), aortic aneurysm, hemorrhagic synovial cysts, ligamentum flavum hematoma, and venous varices. The incidence, pathophysiology, typical clinical presentation, appropriate diagnostic workup, and management are summarized. PURPOSE: To review and summarize various vascular causes of radiculopathy and how it impacts the management of patients with radicular spinal pain. STUDY DESIGN: Literature review. METHODS: An extensive literature review was done on each of the vascular entities and their presentation as radiculopathy. RESULTS: Vascular etiologies of radiculopathy may be underestimated in the literature. Imaging in addition to the history and physical examination is essential to identifying vascular sources of radiculopathy and establishing correct treatment. CONCLUSIONS: In examining patients with radicular pain, extraspinal causes of radiculopathy including vascular entities should be included in the differential. Knowledge of the incidence, pathophysiology, clinical presentation, and management of the possibly underreported various vascular causes of radiculopathy increase the ability of the physician to provide optimal care for the patient.

Objective: The purpose of this study was to examine the results of remote superficial femoral artery endarterectomy (RSFAE) in conjunction with distal aSpire stenting. Methods: RSFAE is a minimally invasive procedure performed through a limited groin incision. Forty patients were included in the study. The indications for the procedure were claudication in 36 patients and limb salvage in 4 patients. RSFAE was performed with the MollRing Cutter device through a femoral arteriotomy. The distal atheromatous plaque was "tacked" with the aSpire stent, which is an expandable polytetrafluoroethylene-covered nitinol stent with high radial strength, yet is flexible and able to withstand compressive forces proximal to the knee joint. Before stent deployment, if the stent position is not optimal it can be wrapped down, repositioned, and re-expanded. Therefore, not only is the plaque end point tacked, but the collateral vessels may be preserved. All patients underwent follow-up examination with serial color-flow ultrasound scanning. Results: The mean length of endarterectomized superficial femoral artery was 26.2 cm ؎ 6.2 cm (range, 13-41 cm). The primary cumulative patency rate by means of life table analysis was 68.6% ؎ 13.5% (SE) at 18 months (mean, 13.2 months; range, 1-31 months). During follow-up percutaneous transluminal balloon or stent angioplasty was necessary in 6 patients, for a primary assisted patency rate of 88.5% ؎ 8.5% at 18 months. The locations of recurrent stenoses after RSFAE were evenly distributed along the endarterectomized artery. There were no deaths and one wound complication, and mean hospital length of stay was only 2.1 ؎ 0.5 days. Conclusions: RSFAE with distal aSpire stenting is a safe and moderately durable procedure. If long-term patency rates are similar to those of above-knee femoropopliteal bypass graft, this procedure may prove to be a minimally invasive adjunct for the treatment of superficial femoral artery occlusive disease. (J Vasc Surg 2004;40:67-72.)

Most occluded venous segments recanalize over the first 6 to 12 months after an episode of acute DVT, leading to chronic luminal changes and a combination of partial obstruction and reflux. Such morphological changes produce venous hypertension with the highest levels of ambulatory venous pressure occurring in patients with combined outflow obstruction and distal reflux. The clinical manifestations of secondary CVD, including pain, venous claudication, edema, skin changes, and ulceration are commonly referred to as the post-thrombotic syndrome. Such sequelae are best avoided by early and aggressive treatment of proximal DVT.

At least seven foliar taxa of Proteaceae occur in Oligo-Miocene lignite from the Newvale site. These taxa include two new species of the fossil genus Euproteaciphyllum, and previously described species of tribe Persoonieae and Banksia. Other specimens from Newvale are not assigned to new species, but some conform to leaves of the New Caledonian genus Beauprea, which is also represented in the lignite by common pollen. Two other Euproteaciphyllum species are described from the early Miocene Foulden Maar diatomite site. One of these species may belong to Alloxylon (tribe Embothrieae) and the other to tribe Macadamieae, subtribe Gevuininae. Ecologically, the species from Newvale represented important components of wet, oligotrophic, open vegetation containing scleromorphic angiosperms and very diverse conifers. In contrast, Proteaceae were large-leaved and rare in Lauraceae-dominated rainforest at the volcanic Foulden Maar site. Overall, the Oligo-Miocene fossils confirm that Proteaceae was formerly much more diverse and dominant in the New Zealand vegetation, and provide fossil evidence for biome conservatism in both leaf traits and lineage representation.

Purpose: Some patients with aortic arch or descending thoracic aorta pathologies are not suited for open repair because of comorbidities that may increase their risk of procedural complications or death. Endovascular approaches may also be difficult when there are inadequate proximal landing zones in the aortic arch. We report our experience using rerouting techniques with bypass, stenting of the branches, or a combination of both to create a landing area in zones 0 and 1 of the aortic arch. Methods: Since November 2002, thoracic aortic endoluminal grafts were placed in 38 patients in whom the endograft was deployed in zone 0 (n ‫؍‬ 27) or zone 1 (n ‫؍‬ 11). A retrospective review is included. Results: There were 11 women and 27 men with a mean age of 65.4 years (range 38-88). Aortic pathology included 12 Stanford type A dissections, 10 aortic arch aneurysms, 8 Stanford type B dissections, 3 descending thoracic aortic aneurysms, 2 aortobronchial fistulas, 1 innominate artery aneurysm and 2 aortic arch pseudoaneurysms. In zone 0, 21 had thoracic debranching with an ascending bypass, three patients had a remote-inflow and three patients had a chimney-stent with carotid-carotid bypass. In zone 1, five patients had a carotid-carotid bypass, one patient had an aortic to left common carotid artery (LCCA) bypass and five patients had chimney-stent on the LCCA. Fifty-eight percent of the patients were symptomatic and 26% emergent. Three patients required hemodialysis postoperatively (7.9%), 18 patients (47.4%) required prolonged mechanical ventilation for respiratory insufficiency. Paraplegia occurred in one patient (2.7%), and five patients suffered a cerebrovascular accident (13.1%). There were four early type I and two type II endoleaks. Overall 30-day mortality was 23.7%. Conclusions: The hybrid approach for repair of the aortic arch pathologies is feasible in patients unfit for open repair. We present the results of performing different techniques to treat the aortic arch with hybrid repair with antegrade or retrograde inflow, stenting of the branches or a combination of both. Long-term results are unknown, and larger series results and comparative studies are needed to determine safety and efficacy. ( J Vasc Surg 2012;55:318-25.)

evaluate patients with peripheral arterial disease. It is therefore increasingly important for all vascular specialists to become familiar with the strengths and limitations of this new technique. The aims of this review are to explain the principles of scanning and injection technique for a wide range of CT scanners, to explain and illustrate the properties of current image postprocessing tools for effective visualization and treatment planning, and to provide an overview of current clinical applications of peripheral CT angiography. J Vasc Interv Radiol 2006; 17:3-26