No abstract available.
Genetic Therapy*

Intimal hyperplasia is a frequent cause of failure of vascular surgery and angioplasty including endarterectomy, bypass surgery, angioplasty and atherectomy. Some author reported 50% of late failure identified in 5000 arterial reconstructions, including both endarterectomy and bypass operations, were attributed to this hyperplastic intimal response. Clearly this response is a significant cause of morbidity in patients undergoing vascular procedures and investigations on methods to control this process are of great importance. The precise patholphysiologic pathways leading to the development of intimal hyperpllasia have not been characterized.The initial event is thought to be damage to the vascular endothelium. Intimal thickening is the characteristic fibromuscular cellular response of intimal injury and some author advanced the "response-to-injury" hypothesis of atherogenesis and intimal hyperplasia. The response of the medial smooth muscle cell (SMC) to vascular injury can be devided into four distinct stages: (1) an initial medial proliferative response, (2) migration from the media across the internal elastic lamina and into the intima, (3) subsequent proliferation within the neointima, and (4) synthesis and deposition of extra-cellular matrix. Ross and Gomset suggested that a high local concentration of growth factors, particularly platelet-derived growth factor (PDGF), releaed from degranulating platelets could stimulate SMC proliferation. But Clowes and Reidy concluded from their research result that platelet factors do not play a substantial role in the initial wave of proleferation after injury but do influence migration from the media to the intima. From the observation of response to the balloon injury of carotid artery, Lindner and Reidy concluded that damaged SMC might be releasing some kind of intracellular factor. A logical candidate is now basic fibroblast growth factor (bFGF) Currently the only available option for the treatment of intimal hyperplasia is mechanical intervention with revision or angioplasty of the affected vessel. The ability of several agents to suppress the development of intimal hyperplasia has been investigated and some drugs have been shown to be at least partially successful in this regard: antihypertensive drugs, antiplatelet agents, antiimflammatory agents, anticoagulants, antilipid agents, and other substances including angiopeptin, and porphyrin compounds. The variety of agents attests to the complexity of the pathways which responsible for the development of this lesion and suggests that no single agent will likely be entirely effective. Although the usefullness of pharmacologic therapy to prevent myointimal hyperplasia remains unclear, if effective pharmacologic therapy and thus prevent the assoiciated recurrent arterial stenosis, this would be major impact on the durability of vascular procedures and lower their associated morbidity, mortality and cost. Gene transfer methods are providing important information about the biology of vascular cells. The most gene transfer techniques involves the introduction of new genetic information into the genome of specific vascular cells. These genetically altered cells subsequently express individual proteins or traits for which they have been engineered. Most investigators have considered endothelial cells the ideal recipient for human gene therapy. Ths is because their location makes them easily accessible to recombinant vectors and allows for any produced products to be secreted directly into the bloodstream. In vitro experiments have already been performed that have documented the ability to transfer specific genes into cultured endothelial cells. Genes coding for neomycin resistance, b-galactosidase, growth hormone, prostacyclin, and tPA, have all been successfully transferred. More recently, expression of recombinant gene products, by transduced endothelial cells, has also been achieved in vivo. The potential of genetically engineered vascular cells to modify the vessel wall and interfere with the development of intimal hyperplasia is obvious and research into this possibility is developing rapidly. Intimal hyperplasia will continue to be a major cause of vein graft and native artery with resultant loss of life and limb. To prevent the problem successfully further understanding of the mechanism of intimal hyperplasia will be required so that treatment can be tailored to the key steps in the pathologic process. As we enter the 21st century, gene transfer, somatostatin, photodynamic theapy and brachytherapy, intravascular irradiation following angioplasty and stent insertion will be the importanat focus for research on intimal hyperplasia.
Angioplasty ; Anticoagulants ; Antihypertensive Agents ; Arteries ; Atherectomy ; Atherosclerosis ; Biology ; Blood Platelets ; Brachytherapy ; Carotid Arteries ; Clinical Coding ; Constriction, Pathologic ; Endarterectomy ; Endothelial Cells ; Endothelium, Vascular ; Epoprostenol ; Extremities ; Fibroblast Growth Factor 2 ; Gene Transfer Techniques ; Genetic Therapy ; Genome ; Growth Hormone ; Humans ; Hyperplasia* ; Intercellular Signaling Peptides and Proteins ; Logic ; Mortality ; Myocytes, Smooth Muscle ; Neointima ; Neomycin ; Platelet Aggregation Inhibitors ; Platelet-Derived Growth Factor ; Research Personnel ; Somatostatin ; Stents ; Transplants ; Vascular System Injuries ; Veins

PURPOSE: Transilluminated powered phlebectomy (TIPP) offers a minimally invasive operation alternative to stab avulsion for varicose veins. The purpose of this study is to compare the safety and efficacy of TIPP with conventional phlebectomy (CP) for removal of varicose veins. METHOD: A retrospective review was performed on the clinical records from March 2001 to March 2002. We divided the patients into 2 groups. The first group consisted of 87 patients (107 limbs) who had undergone TIPP. The second group of 27 patients (29 limbs) had undergone CP by the stab avulsion. We compared operation time, number of skin incisions, duration of hospital stay, patient's satisfaction scores, and complications. RESULT: Mean operation time was significantly shorter in the TIPP group than in the CP group (47.3 min vs. 64.0 min). The number of skin incision was also significantly less in the TIPP group (3.4 vs. 4.9). Length of hospital stay was significantly shorter in the TIPP group (2.5 days vs. 4.0 days). However, postoperative patient's satisfaction score was similar in both groups. 81 patients (93%) in the TIPP group developed ecchymosis postoperatively, resolved spontaneously within approximately 8 weeks. CONCLUSION: TIPP can make the better cosmetic result, shorter duration of hospitalization and operation time. These results suggest that TIPP is a feasible surgical treatment modality for varicose veins of the lower extremity. However, we should minimize postoperative ecchymosis and improve the surgical technique.
Ecchymosis ; Hospitalization ; Humans ; Length of Stay ; Lower Extremity* ; Retrospective Studies ; Skin ; Varicose Veins*

PURPOSE: The risk factors and clinical characteristics in young patients with deep venous thrombosis (DVT) were analyzed. METHOD: The clinical characteristics of the 118 patients registered at our DVT clinic, from September 2000 to August 2002, were retrospectively reviewed. Information reviewed included sex ratio, site and extent of DVT, frequency of pulmonary embolism (PE), recurrence rate, and thrombophilic states. The patients were dichotomized into two groups according to their age, less than 40 years vs. older than 40 years. Their risk factors were also analyzed according to "Reporting Standards in Venous Disease". RESULT: Among 118 patients, 48 (40.7%) were younger than 40 years. Right leg DVT was more common (37.5% vs. 18.2%) in the younger group although the more common site for DVT was in the left leg. Also, PE (14.6% vs. 10.0%) and mesenteric venous thrombosis (14.6% vs. 4.3%) were more common, with higher recurrence rates (35.4% vs. 21.4%), in the younger group. However, there was no significant difference. Except for age or pregnancy and postpartum state, mean total scores of risk factors were higher in the older group (1.06 vs. 1.77). On the contrary, positive family history of DVT (10.4%) was found only in the younger group. Thrombophilic states, including antithrombin III, protein C, and protein S deficiencies, and Behcet's disease were more prevalent in the younger group whereas activated protein C resistance was found more often in the older group. In patients who had thrombophilic states, recurrence rate of DVT was much higher. CONCLUSION: For proper diagnosis and management of young DVT patients, especially to prevent a disastrous PE and recurrence, we must make efforts to identify risk factors including thrombophilic states.
Activated Protein C Resistance ; Antithrombin III ; Diagnosis ; Humans ; Leg ; Postpartum Period ; Pregnancy ; Protein C ; Protein S Deficiency ; Pulmonary Embolism ; Recurrence ; Retrospective Studies ; Risk Factors ; Sex Ratio ; Thrombophilia ; Venous Thrombosis*

PURPOSE: Despite the decrease in the number of lower limb amputation in ischemic limb patients as a result of advances in vascular reconstruction surgery, amputation still plays an important role in the management of end-stage peripheral vascular disease. Owing to the importance of the amputation level in postoperative rehabilitation and prevention of reamputation, there have been many reports defining theses level. Clinical characteristics were determined by retrospectively reviewing medical records of patients who underwent lower limb amputation for peripheral vascular disease. METHOD: Between June 1997 and September 2002, lower limb amputation was performed in 73 patients with peripheral vascular disease. RESULT: Mean follow-up period was 15 months; male to female ratio was 7.1 to 1; and mean age was 62.6 years. Associated diseases included DM (39 patients), hypertension (15 patients), ischemic heart disease (13 patients), and cerebrovascular disease (6 patients). Etiologies were atherosclerosis in 47.9%, Buerger's disease in 15.1%, DM foot in 13.7%, acute arterial embolization in 2.7%, ruptured abdominal aortic aneurysm in 1.4%, and combined atherosclerosis with DM foot in 19.2%. Bypass surgery was performed in 24 cases and only 4 cases underwent radiologic vascular intervention. The frequency of amputation was one surgery in 50 cases and more than two surgeries in 23 cases. Amputation level was digit amputation in 49 cases (67.1%), transmetatarsal in 10 cases (13.7%), below-knee in 11 cases (15.1%) and above-knee in 3 cases (4.1%). In 73 cases, reamputation was performed in 19 cases (26%) for poor stump wound healing. The cause of reamputation was atherosclerosis in 17.1%, Buerger's disease in 27.3%, DM foot in 60.0% and combined atherosclerosis with DM foot in 28.6%; the reamputation rate was the highest in DM foot patients. Bypass surgery for improved blood flow in the stump was performed in 24 cases, among these cases, reamputation was performed in 2 cases (8.3%). CONCLUSION: Amputation in ischemic limb patients was most commonly performed in artherosclerosis patients and the most common amputation level was digit. The reamputation rate was the highest in DM foot patients; a more careful selection of the amputation level in DM foot patients may be needed.
Amputation* ; Aortic Aneurysm, Abdominal ; Arteries ; Atherosclerosis ; Extremities ; Female ; Follow-Up Studies ; Foot ; Humans ; Hypertension ; Lower Extremity* ; Male ; Medical Records ; Myocardial Ischemia ; Peripheral Vascular Diseases ; Rehabilitation ; Retrospective Studies ; Thromboangiitis Obliterans ; Wound Healing

PURPOSE: Axillofemoral bypass for aortoiliac occlusive disease is a type of extra-anatomic bypass with varying reputations. This study was performed to observe early and late outcomes in patients underwent axillofemoral bypasses. METHOD: We retrospectively reviewed 25 patients who underwent 16 elective and 9 emergent axillofemoral bypasses. Mean age of patients was 72.5 years. Coexisting medical conditions included hypertension in 44%, ischemic heart disease in 28%, diabetes in 20%, chronic obstructive pulmonary disease in 20%, malignant tumor in 12% and cerebrovascular disease in 8%. All patients were presented with critical leg ischemia except for 2 with short-distance claudication. Axillofemoral bypass was performed under general anesthesia making configuration of inverted C shaped femoro-femoral bypass and redundant axillo-femoral limb using 8 mm ringed PTFE graft. RESULT: Two operative mortality occurred after emergent operations. Long-term folow-up results revealed 1 and 3 year primary graft patencies were 88% and 36% in the emergent operation group and 75% and 56% in the elective operation group. Limb salvage rates were 92% and 87% at 1 and 3 years respectively. Patient survival at 1 and 3 years after bypass operations were 78%, 22% in the emergent operation group and 86% and 54% in the elective operation group respectively. However, the differences between these 2 groups were not statistically significant. CONCLUSION: After performing 16 elective and 9 emergent axillofemoral bypasses for patients with higher surgical risk and poor distal runoff arteries, we experienced rather higher operative mortality, leg amputation rates and poor follow-up results. However, in the case of very high risk patients with no other treatment option, axillofemoral bypass can be, not only a limb saving, but a life saving procedure.
Amputation ; Anesthesia, General ; Arteries ; Extremities ; Follow-Up Studies* ; Humans ; Hypertension ; Ischemia ; Leg ; Limb Salvage ; Mortality ; Myocardial Ischemia ; Polytetrafluoroethylene ; Pulmonary Disease, Chronic Obstructive ; Retrospective Studies ; Transplants

PURPOSE: Behcet's disease is a systemic condition with multiple clinical manifestations, the basis of which is a vasculitis with unknown etiology. The most common cause of death in Behcet's disease is secondary to arterial complications. The pathogenesis of these arterial complications is related to the diseased arterial wall or vasa vasorum seen in the Behcet's disease process. Although vascular lesions are not listed among the criteria for diagnosis of Behcet's disease, up to 25~35% of patients develop vascular complications and probably even a greater proportion of patient may have small vessel vasculitis as the pathological basis for the systemic manifestation. Therefore, early diagnosis and aggressive management can result in the long-term salvaging of both limbs and may allow early intervention of arterial complications and prevent the usual fatal outcome. METHOD: We report 59 cases of Behcet's disease, involving the abdominal aorta and its main branches with variable operative procedure. The medical records of these 59 cases were retrospectively reviewed to examine the operation characteristics. RESULT: To manage recurrent aneurysms at previous anastomosis sites, we used PTFE (polytetrafluoroethylene), or autogenous vein and artery (internal iliac artery) as bypass or patch material. The results of the autogenous vessel grafts for arterial reconstructions in Behcet's vasculitis were superior to those of artificial grafts. CONCLUSION: In one case of multiple recurrent anastomotic aneurysm, we attempted aortic blood flow diversion after closure of the false anastomotic aneurysm. This aortic blood flow diversion should be considered as an adopted surgical treatment of recurrent false AAA in Behcet's vasculitis.
Aneurysm ; Aneurysm, False* ; Aorta, Abdominal ; Arteries ; Cause of Death ; Diagnosis ; Early Diagnosis ; Early Intervention (Education) ; Extremities ; Fatal Outcome ; Humans ; Medical Records ; Polytetrafluoroethylene ; Retrospective Studies ; Surgical Procedures, Operative ; Transplants ; Vasa Vasorum ; Vasculitis* ; Veins

For below-knee leg arterial bypass, autogenous saphenous vein graft is a well- known bypass conduit of choice. With increasing cardiovascular bypass procedures, autogenous vein graft is not always available for leg artery bypass secondary to various causes. To improve prosthetic graft patency, distal anastomotic vein cuff or patch can be performed as adjunctive procedure for leg artery bypass. PURPOSE: We attempted to determine the effects of distal anastomotic autogenous vein cuff or patch on prosthetic bypass graft patency. METHOD: Among the patients with below-knee prosthetic bypass, 22 bypasses with distal anastomotic vein cuff or patch (Group I) and 10 bypasses without vein cuff or patch (Group II) were compared retrospectively. All grafts material were 7 mm externally supported ringed PTFE graft. Clinical features and bypass procedures, frequencies of concomitant inflow procedure, emergent operation, thrombus removal from native artery and redo bypass were compared between 2 groups with similar results seen. However, the levels of distal anastomosis were tibioperoneal in 77.3% and below-knee popliteal artery in 22.7% in group I while it was all below-knee popliteal artery in group II. RESULT: In group I, primary (secondary) patency rates at 12 months and 36 months were 45.8% (60.5%) and 32.1% (40.9%), respectively, by Kaplan Meier method. These rates were 23.3% (45.7%) and 23.3% (34.3%), respectively, in group II. But these differences in patency rates did not meet statistical significance. CONCLUSION: Despite considering the weak power or our retrospective study, we would like to conclude that vein cuff or patch at distal anastomosis of prosthetic graft can improve graft patency, though not meeting statistical significance. This adjunctive procedure makes prosthetic grafting feasible even in the very small crural arteries.
Arteries ; Humans ; Leg* ; Polytetrafluoroethylene* ; Popliteal Artery ; Retrospective Studies ; Saphenous Vein ; Thrombosis ; Transplants* ; Veins*

PURPOSE: Immediate revascularization is required for patients with critical lower extremity ischemia, but sometimes only nonoperative treatments are performed due to multilevel arterial occlusive lesions, poor outflow tracts, deteriorated general conditions, and severe associated diseases. We undertook this study to detrmine the long-term results of nonoperative treatments for patients with critical lower extremity ischemia. METHOD: From January 1992 to July 2002, among the patients with lower extremity arterial disease who visited the Department of Surgery at Kyung Hee Medical Center, 72 patients with critical lower extremity ischemia who had been treated with only conservative managements were chosen. Medical records were reviewed retrospectively and telephone interviews were performed. We assessed the functional outcome of the salvaged limb according to the recommended scale for gauging changes in clinical status, the 1997 revised version. RESULT: There were 63 men and 9 women (M : F=7 : 1), and mean age was 70.1 years. At median follow-up of 64.7 months, amputation rate was 27.8%, limb salvage rate was 71.9%, and the mortality rate was 20.8%. Cerebrovascular attacks (40%) and ischemic heart disease (27%) were the major causes of death. Underlying disease were diabetes (65.3%), hypertension (54.2%), ischemic heart disease (11.1%), and previous cerebrovascular attacks (13.9%). Clinical categories of involved patients were grade II (ischemic rest pain) in 80.5%, and grade III (tissue loss) in 19.5%. In survivors with limb salvage, functional outcomes were +3 in 12.5%, +2 in 26.8%, +1 in 35.7%, 0 in 23.2%, and -1 in 1.8%. CONCLUSION: The long-term results of this study suggest that nonoperative treatments for patients with critical lower extremity ischemia can achieve a higher limb salvage rate and significant improvements in the functional outcomes of salvaged limbs.
Amputation ; Cause of Death ; Extremities ; Female ; Follow-Up Studies* ; Humans ; Hypertension ; Interviews as Topic ; Ischemia* ; Limb Salvage ; Lower Extremity* ; Male ; Medical Records ; Mortality ; Myocardial Ischemia ; Retrospective Studies ; Survivors

PURPOSE: Treatment modalities of acute limb ischemia have evolved over the last decades, but the morbidity and mortality of the disease still remains high. We performed a retrospective study to analyze the demographics, risk factors, and prognosis of this disease. METHOD: Our subjects included a total of 49 patients (55 limbs) with acute peripheral arterial occlusion who underwent operative procedures between September 1996 and August 2001 at Gil Medical Center. Cases with graft occlusion or blue toe syndrome were excluded. The SVS/ISCVS reporting standards was used. RESULT: Mean age was 64.2 years (range: 25~85) and male-to-female ratio was 1.7 : 1. Clinical categories of ischemia were classified as the following: Viable (I) in 10 cases, Marginally threatened (IIa) in 14, Immediately threatened (IIb) in 17, and Irreversible (III) in 8. There were 40 lower extremity and 8 upper extremity arterial occlusions, and 1 aortic occlusion. The causes of occlusion were thrombosis in 14 and embolism in 35. Thromboembolectomy was performed in 42 cases, bypass graft in 9, primary amputation in 7, thrombolysis in 1, and stent insertion in 1. The 30-day mortality rate was 8%, mainly due to reperfusion injury and underlying cardiopathy. The 30-day major amputation rate was 23.8%. CONCLUSION: An aggressive, prompt operative management is important in saving patients with acute arterial occlusion. Higher amputation rates were related to more severe categories of ischemia at initial presentation. Patient education along with early referral and intervention will possibly reduce the amputation rate.
Amputation ; Blue Toe Syndrome ; Demography ; Embolism ; Extremities ; Humans ; Ischemia ; Lower Extremity ; Mortality ; Patient Education as Topic ; Prognosis ; Referral and Consultation ; Reperfusion Injury ; Retrospective Studies ; Risk Factors ; Stents ; Surgical Procedures, Operative ; Thrombosis ; Transplants ; Upper Extremity