Carotid endarterectomy with saphenous vein patch angioplasty: a single-center experience.

BACKGROUND: When performing a conventional CEA it is recommended the use of patch angioplasty (PA), since previous meta-analyses have shown PA to be superior to primary closure (PRC) in terms of stroke and restenosis rates. Different materials patches can be employed although none of them has been proved to be superior. Although autologous veins are potentially more resistant to immediate thrombosis as well as infection, cons may be represented by patch rupture and late dilatation. Aim of this study is to evaluate immediate and long-term results of CEA with saphenous vein patch angioplasty (SVPA) in a single-center experience. METHODS: A retrospective study was performed analyzing all patients undergoing CEA with SVPA at our institution from January 2012 to March 2020. CEA was performed in symptomatic patients with 50-99% carotid stenosis degree or asymptomatic patients with 70-99% stenosis degree. Exclusion criteria were critical limb ischemia, varicose disease, unavailability of saphenous veins, vein diameter <3.5 mm. All CEAs were performed under general anesthesia with routine shunting. Primary endpoints were perioperative stroke, death, carotid thrombosis and hematoma requiring surgery rates. Secondary endpoints included the rate of recurrent stenosis >70%, patch aneurysm/rupture/infection at follow-up. RESULTS: Overall, 488 interventions were performed on 461 patients. Most patients were male (77.8%) with a mean age of 71.2±8.3 years. Thirty-day mortality and stroke rates were 0.4% and 1.2% respectively. Carotid thrombosis occurred in five patients (1%). Five patients (1%) developed a surgical site hematoma requiring surgical drainage. At a mean follow-up of 34.4±25.8 months 12 restenoses (2.5%) were detected. Five-year freedom from restenosis rate was 96.7%. Restenosis at follow-up was more frequent in patients who had contralateral carotid stenosis (P=0.019). Two patients (0.4%) developed carotid patch aneurysmal degeneration at a mean follow-up of 78.7 months. No infection nor patch disruption were detected. CONCLUSIONS: CEA with SVPA resulted safe and effective in terms of early and late results. The perioperative complications rates we recorded were quite similar to those reported by other larger reviews and meta-analyses.

Long term efficacy and safety of rivaroxaban plus cilostazol in the treatment of critical ischemia of the lower limbs in a frail, elderly patient with non valvular atrial fibrillation.

BACKGROUND: Many patients with critical lower limb ischemia are not eligible for revascularization procedures. Still, given the emerging role of both platelet and coagulation activation in the formation of arterial thrombi, they may benefit from the novel anticoagulant and antiplatelet drugs. CASE PRESENTATION: We describe the case of a male with critical lower limb ischemia complicated by older age, frailty, polymorbidity and non valvular atrial fibrillation, who was deemed as non eligible for surgery. The patient was successfully treated with the combination of rivaroxaban and cilostazol, and the clinical benefit was maintained throughout 32 months, with no occurrence of major or minor hemorrhagic or thrombotic events. CONCLUSIONS: To our knowledge, this is the first report on the efficacy and safety of such a combination therapy in critical lower limb ischemia. In a clinical setting in which alternative pharmacological approaches are urgently needed, the association of rivaroxaban and cilostazol warrants further investigations.

Eversion Endarterectomy of the Femoral Bifurcation: Technique, Results and Potential Advantages.

BACKGROUND: Despite recent advances in endovascular techniques, surgical endarterectomy remains the "gold standard" for treatment of atherosclerotic lesions of the femoral bifurcation. Eversion endarterectomy (EE) of the femoral bifurcation is a well-known technique that ensures an extensive plaque removal; furthermore, EE can be performed to avoid the use of prosthetic material. The aim of this study is to evaluate the efficacy and safety of the EE of the femoral bifurcation in a contemporary prospective series from a single-center experience. MATERIALS AND METHODS: All patients undergoing EE at our institution between January 2014 and December 2016 were retrospectively reviewed. EE was performed as an isolated procedure or in a hybrid fashion. Clinical presentation was defined according to Rutherford's classification. End points included major complications and patency rates. RESULTS: Thirty-three EEs were performed on 31 patients during the study period. Thirteen procedures (39%) were performed in a hybrid fashion with concurrent endovascular interventions. Technical success was achieved in 100%. Thirty-day mortality was null, whereas 5 overall complications (15%) were recorded; among those, 2 (6%) were major. In both cases, an early thrombosis of the femoral bifurcation occurred, successfully treated by a short Dacron replacement of the common femoral artery. During follow-up, no femoral pseudoaneurysm or groin infections were observed. Two restenosis occurred at 7 and 10 months after EE, respectively. Two-year primary patency and assisted primary patency rates were 87% and 100%, respectively. During follow-up, two patients underwent percutaneous revascularization of the contralateral femoropopliteal axis at 5 and 8 months after EE, respectively. In both of them, the procedure was successfully performed through direct puncture of the endoarterectomized common femoral artery, without any access-site complications. CONCLUSIONS: Endarterectomy remains the gold standard in the treatment of atherosclerotic lesions of the femoral bifurcation with excellent long-term patency rates. Furthermore, EE adds the advantages of avoiding the use of prosthetic materials in the groin and the possibility to use the treated vessels as access for further percutaneous procedures.

Small dense low-density lipoprotein in familial combined hyperlipidemia: Independent of metabolic syndrome and related to history of cardiovascular events.

INTRODUCTION: It is unclear whether small dense low-density lipoprotein (sdLDL) are associated with familial combined hyperlipidemia (FCHL), independently of the metabolic syndrome (MS). It is also unclear whether sdLDL are related to history of cardiovascular (CVD) events in FCHL patients, independently of MS. PATIENTS AND METHODS: Serum levels of sdLDL, expressed as percentage of total LDL cholesterol (LDL score), were determined in 137 probands with FCHL and in 133 normolipidemic, normotensive, normoglycemic healthy subjects. RESULTS: In binary logistic regression age- and gender-adjusted LDL score values above the 90th and 95th percentiles of the values in the control group (10.23 and 13.11%, respectively) were found to be significant predictors of FCHL status, independently of MS diagnosis (p=0.007 and p<0.0001, respectively). Values of the LDL score above the 90th and the 95th percentile of the control group resulted to be significantly related to FCHL status, even after adjustment for the components of MS (p=0.006 and p=0.001, respectively). Among FCHL patients, values of the LDL score above 95th percentile of the values in the control group were found to be significantly related to personal and/or family history of CVD events, independently of age, gender, total cholesterol, apolipoprotein (apo) B, and MS status (p=0.016). The same significant relationship was found adjusting for all components of MS (p=0.034). CONCLUSIONS: High concentrations of sdLDL are highly specific markers of FCHL, independently of concomitant MS. In FCHL patients high levels of sdLDL are related to history of CVD events, independently of MS, total cholesterol and apo B.

Tumor necrosis factor-alpha is a marker of familial combined hyperlipidemia, independently of metabolic syndrome.

It is unclear whether an association between familial combined hyperlipidemia (FCHL) and inflammatory markers exists, independently of age, sex, body weight, insulin resistance, and metabolic syndrome. Serum concentrations of soluble vascular cell adhesion molecule-1 (sVCAM-1), monocyte chemoattractant protein 1, interleukin 6, tumor necrosis factor-alpha (TNF-alpha), and high-sensitive C-reactive protein were determined in 135 probands with FCHL and in 146 normolipidemic, normotensive, normoglycemic healthy subjects. Insulin resistance was evaluated using homeostasis model assessment (HOMA). All inflammatory parameters, except interleukin 6, were significantly higher in FCHL according to medians or mean comparisons. After adjustment for age, sex, body mass index, and HOMA, only TNF-alpha remained an independent predictor of FCHL status by binary logistic regression (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.07-1.31; P = .001). In particular, elevated levels of TNF-alpha (above the 90th and 95th percentiles of the value observed in the control group, 9.6 and 9.8 pg/mL, respectively) were independent predictors of FCHL status: for TNF-alpha above the 90th percentile, OR was 7.91 (95% CI, 3.27-19.13; P < .001), and for TNF-alpha above 95th percentile, OR was 13.08 (95% CI, 4.60-37.15; P < .0001). The independent role of TNF-alpha as predictor of FCHL status was confirmed after adjustment for components of the metabolic syndrome (P = .007 and P = .003, for TNF-alpha values above 90th and 95th percentiles, respectively). In conclusion, among the inflammatory markers most commonly measured, only TNF-alpha was associated with FCHL independently of age, sex, body mass index, and HOMA. The association of TNF-alpha with FCHL was also independent of the metabolic syndrome.