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Regarding “Morphologic findings and management strategy of spontaneous isolated dissection of the celiac artery”
Journal of Vascular Surgery
Letters to the Editor
1549
Volume 64, Number 5 3.
Morsy AH, Kulbaski M, Chen C, Isiklar H, Lumsden AB. Incidence and characteristics of patients with hand ischemia after a hemodialysis access procedure. J Surg Res 1998;74:8-10. 4. Lazarides MK, Staramos DN, Panagopoulos GN, et al. Indications for surgical treatment of angioaccess-induced arterial “steal”. J Am Coll Surg 1998;187:422-6. 5. Scher LA. Ischemic monomelic neuropathy. J Hand Surg 2009;35:842-3. http://dx.doi.org/10.1016/j.jvs.2016.06.122
symptomatology and objective physiological evidence (digital or wrist pressures) of severe distal ischemia. The decision to perform revision using distal inflow (RUDI) or distal-revascularization-interval ligation (DRIL) at both centers is based on a combination of patient symptomatology consistent with steal syndrome, corroborating physiological tests, exclusion of a culprit inflow lesion, and the patient’s previous hemoaccess history and access requirements.
Reply
Jonathan Misskey, MD
First and foremost, thank you for your insightful comments, questions, and thoughtful consideration of our study. To address your questions in turn, the manner of presentation was dependent on the severity and timing of the onset of steal symptoms. Approximately 34% (14/41 patients) were identified and treated in the perioperative period or during initial clinical follow-up within 6 weeks, with the majority presenting to the emergency room, the dialysis access clinic, or in the immediate postoperative period with pain and motor/sensory neurologic dysfunction. Most of the remaining patients with delayed presentations and treated at >6 weeks from the time of their initial procedure were identified and re-referred during routine fistula monitoring/screening by a trained dialysis access nurse (18/41, 44%). The remaining patients (9/41, 22%) self-presented with symptoms, and the majority of these (7/9) dialyzed at centers apart from either center where the access was created. The relatively late nature between fistula creation and revision procedure for steal likely reflects an inherent selection bias, as only those with severe ischemia (Society for Vascular Surgery [SVS] grade 3) were included for analysis. Although the prospective dataset we used did not include data for the new onset of mild or moderate neurologic symptoms, anecdotally these symptoms occur frequently. Most of these patients are treated conservatively, as are all of those presenting with SVS grade 1 and most of those with SVS grade 2 steal. However, although suspected ischemic monomelic neuropathy necessitating ligation occurred in five patients in our series (0.2%), we certainly agree that this condition likely exists on a spectrum of severity and that the majority present with lesser degrees of neurologic dysfunction are underdiagnosed. To clarify, preoperative imaging is routinely performed on all cases of suspected ischemic steal syndrome at both institutions; however, this imaging is performed primarily to identify an arterial inflow lesion, with the majority of suspected steal patients investigated with computed tomography angiography. Because catheterbased angiography can demonstrate flow reversal in as many as 73% of proximal angioaccess creations (many of whom do not develop clinical steal syndrome),1 imaging demonstration of flow reversal is not considered mandatory at either institution when there is typical
Division of Vascular Surgery University of British Columbia British Columbia, Canada
Cathevine Yang, BSc Faculty of Medicine University of British Columbia British Columbia, Canada
Shaun MacDonald, MD, FRCSC Division of Vascular Surgery University of British Columbia British Columbia, Canada Division of Vascular Surgery Saint Paul’s Hospital Vancouver, British Columbia, Canada
Keith Baxter, MD, MSc, FRCS(C) York Hsiang, MB ChB, MHSc, FRCS(C) Division of Vascular Surgery University of British Columbia British Columbia, Canada Division of Vascular Surgery Vancouver General Hospital Vancouver, British Columbia, Canada
REFERENCE 1.
Kwun K, Schanzer H, Finkler N, Haimov M, Burrows L. Hemodynamic evaluation of angioaccess procedures for hemodialysis. Vasc Surg 1979;13:170-7.
http://dx.doi.org/10.1016/j.jvs.2016.08.001
Regarding “Morphologic findings and management strategy of spontaneous isolated dissection of the celiac artery” We read with great interest the recent article by Sun et al.1 The authors concluded that medical treatment can be used in stable patients (type I, IIa, IIIa, IVa); that endovascular therapy can be used in patients with recurrent symptoms, visceral malperfusion (type IIb, IIIb, IVb), or aneurysms (type V); and that open surgery should be considered if endovascular repair is not suitable or has failed. However, the authors did not exactly define the term stable, specifically whether they are referring to
1550
Journal of Vascular Surgery
Letters to the Editor
November 2016
stable symptoms or a stable dissection. Also, the authors did not define the exact criterion to define “visceral malperfusion,” nor did they define the characteristic diameter of the aneurysm that would mandate intervention. We fear that their recommendations might lead to the abuse of stent placement if every patient with visceral malperfusion or an aneurysm received endovascular therapy because initial conservative treatment is adequate for 79% of cases of spontaneous isolated dissection of the celiac artery according to a recent systematic literature review.2 In addition, it was not clear what the authors meant by failure of endovascular repair, whether this referred to clinical failure or technical failure. Finally, it might be more appropriately stated that open surgery should be considered for patients with persistence or recurrence of symptoms after endovascular treatments as well as for patients with arterial rupture or organ necrosis.
Shaoqin Li, MD Zhongzhi Jia, MD Guomin Jiang, MD Department of Interventional Radiography The Second Hospital of Changzhou Affiliated to Nanjing Medical University Changzhou, China
REFERENCES 1.
Sun J, Li DL, Wu ZH, He YY, Zhu QQ, Zhang HK. Morphologic findings and management strategy of spontaneous isolated dissection of the celiac artery. J Vasc Surg 2016;64: 389-94. 2. Cavalcante RN, Motta-Leal-Filho JM, De Fina B, Galastri FL, Affonso BB, de Amorim JE, et al. Systematic literature review on evaluation and management of isolated spontaneous celiac trunk dissection. Ann Vasc Surg 2016;34:274-9.
http://dx.doi.org/10.1016/j.jvs.2016.05.097
Regarding “Autonomic outcome is better after endarterectomy than after stenting in patients with asymptomatic carotid stenosis” I read with interest the article by Rupprecht et al1 and agree with the authors regarding the importance of autonomic function as a primary outcome measure after carotid endarterectomy (CEA) and carotid stenting (CAS). However, a clear distinction must be made between perioperative and long-term effects of carotid revascularization techniques on autonomic modulation. Perioperative hemodynamic derangements after CEA and CAS are associated with increased morbidity and morbidity, and have been frequently addressed in the literature. However, controversial results have been reported, including by definition those from the authors that were collected 30 days after the intervention,
regarding perioperative autonomic dysfunction. Such discrepancies are related to the different and inconstant effects of surgical trauma and endovascular stimulation, and the variable compensatory ability of the contralateral carotid baroreceptors and chemoreceptors.2 As a result, perioperative autonomic dysfunction is temporary2 and virtually unpredictable. Regarding long-term results, despite the relevance of autonomic function as prognostic indicator,3 thus, far comparative studies have failed to address the issue of the long-term implications of the choice of the carotid revascularization technique, and this appears particularly relevant in asymptomatic patients, in whom indication to treatment implies a long life expectancy. Previous studies evaluating long-term effects of CEA on postintervention autonomic function were published, and notably in the Journal of Vascular Surgery.2 CEA, regardless of the surgical technique used and even when performed on both sides, preserves baroreflexes and chemoreflexes and, therefore, does not confer permanent carotid sinus denervation.2 Long-term effects of CAS on autonomic function remain to be addressed, and represent a critical issue that may raise a word of caution regarding indication for patients with CAS and ischemic heart disease.3
Massimiliano M. Marrocco-Trischitta, MD, PhD Division of Vascular Surgery II IRCCS Policlinico San Donato San Donato Milanese, Italy
REFERENCES 1.
Rupprecht S, Finn S, Ehrhardt J, Hoyer D, Mayer T, Zanow J, et al. Autonomic outcome is better after endarterectomy than after stenting in patients with asymptomatic carotid stenosis. J Vasc Surg 2016;64:975-84. 2. Marrocco-Trischitta MM, Cremona G, Lucini D, NataliSora MG, Cursi M, Cianflone D, et al. Peripheral baroreflex and chemoreflex function after eversion carotid endarterectomy. J Vasc Surg 2013;58:136-44. 3. La Rovere MT, Bigger JT Jr, Marcus FI, Mortara A, Schwartz PJ. Baroreflex sensitivity and heart-rate variability in prediction of total cardiac mortality after myocardial infarction. ATRAMI (Autonomic Tone and Reflexes After Myocardial Infarction) Investigators. Lancet 1998;351:478-84. http://dx.doi.org/10.1016/j.jvs.2016.07.112
Reply We agree with Dr Marrocco-Trischitta that a clear differentiation needs to be made between short- and longterm effects on autonomic function after carotid revascularization. The majority of the studies published in the past focused either on short-term effects of endarterectomy and stenting on autonomic function1-4 or
Letters to the Editor
1549
Volume 64, Number 5 3.
Morsy AH, Kulbaski M, Chen C, Isiklar H, Lumsden AB. Incidence and characteristics of patients with hand ischemia after a hemodialysis access procedure. J Surg Res 1998;74:8-10. 4. Lazarides MK, Staramos DN, Panagopoulos GN, et al. Indications for surgical treatment of angioaccess-induced arterial “steal”. J Am Coll Surg 1998;187:422-6. 5. Scher LA. Ischemic monomelic neuropathy. J Hand Surg 2009;35:842-3. http://dx.doi.org/10.1016/j.jvs.2016.06.122
symptomatology and objective physiological evidence (digital or wrist pressures) of severe distal ischemia. The decision to perform revision using distal inflow (RUDI) or distal-revascularization-interval ligation (DRIL) at both centers is based on a combination of patient symptomatology consistent with steal syndrome, corroborating physiological tests, exclusion of a culprit inflow lesion, and the patient’s previous hemoaccess history and access requirements.
Reply
Jonathan Misskey, MD
First and foremost, thank you for your insightful comments, questions, and thoughtful consideration of our study. To address your questions in turn, the manner of presentation was dependent on the severity and timing of the onset of steal symptoms. Approximately 34% (14/41 patients) were identified and treated in the perioperative period or during initial clinical follow-up within 6 weeks, with the majority presenting to the emergency room, the dialysis access clinic, or in the immediate postoperative period with pain and motor/sensory neurologic dysfunction. Most of the remaining patients with delayed presentations and treated at >6 weeks from the time of their initial procedure were identified and re-referred during routine fistula monitoring/screening by a trained dialysis access nurse (18/41, 44%). The remaining patients (9/41, 22%) self-presented with symptoms, and the majority of these (7/9) dialyzed at centers apart from either center where the access was created. The relatively late nature between fistula creation and revision procedure for steal likely reflects an inherent selection bias, as only those with severe ischemia (Society for Vascular Surgery [SVS] grade 3) were included for analysis. Although the prospective dataset we used did not include data for the new onset of mild or moderate neurologic symptoms, anecdotally these symptoms occur frequently. Most of these patients are treated conservatively, as are all of those presenting with SVS grade 1 and most of those with SVS grade 2 steal. However, although suspected ischemic monomelic neuropathy necessitating ligation occurred in five patients in our series (0.2%), we certainly agree that this condition likely exists on a spectrum of severity and that the majority present with lesser degrees of neurologic dysfunction are underdiagnosed. To clarify, preoperative imaging is routinely performed on all cases of suspected ischemic steal syndrome at both institutions; however, this imaging is performed primarily to identify an arterial inflow lesion, with the majority of suspected steal patients investigated with computed tomography angiography. Because catheterbased angiography can demonstrate flow reversal in as many as 73% of proximal angioaccess creations (many of whom do not develop clinical steal syndrome),1 imaging demonstration of flow reversal is not considered mandatory at either institution when there is typical
Division of Vascular Surgery University of British Columbia British Columbia, Canada
Cathevine Yang, BSc Faculty of Medicine University of British Columbia British Columbia, Canada
Shaun MacDonald, MD, FRCSC Division of Vascular Surgery University of British Columbia British Columbia, Canada Division of Vascular Surgery Saint Paul’s Hospital Vancouver, British Columbia, Canada
Keith Baxter, MD, MSc, FRCS(C) York Hsiang, MB ChB, MHSc, FRCS(C) Division of Vascular Surgery University of British Columbia British Columbia, Canada Division of Vascular Surgery Vancouver General Hospital Vancouver, British Columbia, Canada
REFERENCE 1.
Kwun K, Schanzer H, Finkler N, Haimov M, Burrows L. Hemodynamic evaluation of angioaccess procedures for hemodialysis. Vasc Surg 1979;13:170-7.
http://dx.doi.org/10.1016/j.jvs.2016.08.001
Regarding “Morphologic findings and management strategy of spontaneous isolated dissection of the celiac artery” We read with great interest the recent article by Sun et al.1 The authors concluded that medical treatment can be used in stable patients (type I, IIa, IIIa, IVa); that endovascular therapy can be used in patients with recurrent symptoms, visceral malperfusion (type IIb, IIIb, IVb), or aneurysms (type V); and that open surgery should be considered if endovascular repair is not suitable or has failed. However, the authors did not exactly define the term stable, specifically whether they are referring to
1550
Journal of Vascular Surgery
Letters to the Editor
November 2016
stable symptoms or a stable dissection. Also, the authors did not define the exact criterion to define “visceral malperfusion,” nor did they define the characteristic diameter of the aneurysm that would mandate intervention. We fear that their recommendations might lead to the abuse of stent placement if every patient with visceral malperfusion or an aneurysm received endovascular therapy because initial conservative treatment is adequate for 79% of cases of spontaneous isolated dissection of the celiac artery according to a recent systematic literature review.2 In addition, it was not clear what the authors meant by failure of endovascular repair, whether this referred to clinical failure or technical failure. Finally, it might be more appropriately stated that open surgery should be considered for patients with persistence or recurrence of symptoms after endovascular treatments as well as for patients with arterial rupture or organ necrosis.
Shaoqin Li, MD Zhongzhi Jia, MD Guomin Jiang, MD Department of Interventional Radiography The Second Hospital of Changzhou Affiliated to Nanjing Medical University Changzhou, China
REFERENCES 1.
Sun J, Li DL, Wu ZH, He YY, Zhu QQ, Zhang HK. Morphologic findings and management strategy of spontaneous isolated dissection of the celiac artery. J Vasc Surg 2016;64: 389-94. 2. Cavalcante RN, Motta-Leal-Filho JM, De Fina B, Galastri FL, Affonso BB, de Amorim JE, et al. Systematic literature review on evaluation and management of isolated spontaneous celiac trunk dissection. Ann Vasc Surg 2016;34:274-9.
http://dx.doi.org/10.1016/j.jvs.2016.05.097
Regarding “Autonomic outcome is better after endarterectomy than after stenting in patients with asymptomatic carotid stenosis” I read with interest the article by Rupprecht et al1 and agree with the authors regarding the importance of autonomic function as a primary outcome measure after carotid endarterectomy (CEA) and carotid stenting (CAS). However, a clear distinction must be made between perioperative and long-term effects of carotid revascularization techniques on autonomic modulation. Perioperative hemodynamic derangements after CEA and CAS are associated with increased morbidity and morbidity, and have been frequently addressed in the literature. However, controversial results have been reported, including by definition those from the authors that were collected 30 days after the intervention,
regarding perioperative autonomic dysfunction. Such discrepancies are related to the different and inconstant effects of surgical trauma and endovascular stimulation, and the variable compensatory ability of the contralateral carotid baroreceptors and chemoreceptors.2 As a result, perioperative autonomic dysfunction is temporary2 and virtually unpredictable. Regarding long-term results, despite the relevance of autonomic function as prognostic indicator,3 thus, far comparative studies have failed to address the issue of the long-term implications of the choice of the carotid revascularization technique, and this appears particularly relevant in asymptomatic patients, in whom indication to treatment implies a long life expectancy. Previous studies evaluating long-term effects of CEA on postintervention autonomic function were published, and notably in the Journal of Vascular Surgery.2 CEA, regardless of the surgical technique used and even when performed on both sides, preserves baroreflexes and chemoreflexes and, therefore, does not confer permanent carotid sinus denervation.2 Long-term effects of CAS on autonomic function remain to be addressed, and represent a critical issue that may raise a word of caution regarding indication for patients with CAS and ischemic heart disease.3
Massimiliano M. Marrocco-Trischitta, MD, PhD Division of Vascular Surgery II IRCCS Policlinico San Donato San Donato Milanese, Italy
REFERENCES 1.
Rupprecht S, Finn S, Ehrhardt J, Hoyer D, Mayer T, Zanow J, et al. Autonomic outcome is better after endarterectomy than after stenting in patients with asymptomatic carotid stenosis. J Vasc Surg 2016;64:975-84. 2. Marrocco-Trischitta MM, Cremona G, Lucini D, NataliSora MG, Cursi M, Cianflone D, et al. Peripheral baroreflex and chemoreflex function after eversion carotid endarterectomy. J Vasc Surg 2013;58:136-44. 3. La Rovere MT, Bigger JT Jr, Marcus FI, Mortara A, Schwartz PJ. Baroreflex sensitivity and heart-rate variability in prediction of total cardiac mortality after myocardial infarction. ATRAMI (Autonomic Tone and Reflexes After Myocardial Infarction) Investigators. Lancet 1998;351:478-84. http://dx.doi.org/10.1016/j.jvs.2016.07.112
Reply We agree with Dr Marrocco-Trischitta that a clear differentiation needs to be made between short- and longterm effects on autonomic function after carotid revascularization. The majority of the studies published in the past focused either on short-term effects of endarterectomy and stenting on autonomic function1-4 or