Initial experience with the inspire MD C-Guard stent in the treatment of carotid artery disease.

OBJECTIVE: One of the main issue concerning the treatment of carotid artery stenosis is about the use of stents which could offer the best navigability through the lesion and the smallest "maximum unprotected circular area", ensuring the lower risk of neurological complication both intraprocedurally and in the long term. Recently, the Inspire MD technology (Tel Aviv, Israel) presented the new stent Inspire MD C-Guard, a bare-metal stent covered by a micron level mesh (MicroNet).We report our experience about the use of this novel stent in the endovascular treatment of carotid artery stenosis, with some technical considerations. METHODS: Data about patients in whom the Inspire MD C-Guard was used for the treatment of carotid artery diseases were retrospectively collected and analyzed. RESULTS: The procedure was completed in all patients without any intraoperative complications. Postoperative course was uneventful in all cases and no complications have been recorded till now. CONCLUSIONS: In our limited experience, the Inspire MD C-Guard has proven to be a safe stent for the treatment of carotid artery diseases. However large studies are needed to better explain strengths and weaknesses of this device.

Analysis of Il-10 gene sequence in patients with sinonasal polyposis.

Sinonasal polyposis (SNP) is a chronic inflammatory disease of nasal and paranasal cavities. Human leukocyte antigen-G molecules (HLA-G) are non-classic HLA-I molecules with anti-inflammatory and tolerogenic properties. HLA-G production is mainly induced by interleukin (IL)-10. IL-10 is an anti-inflammatory cytokine that inhibits the production of proinflammatory cytokines and induces HLA-class II down-modulation. Recent studies suggest that HLA-G could play a role in SNP pathogenesis; in SNP patients physiological levels of IL-10 (produced by activated peripheral blood CD14+ monocytes) are not able to induce production of HLA-G. Different mechanisms could justify these findings: genomic or amino-acidic sequence alterations in IL-10 lower IL-10 receptor expression, lower IL-10 receptor affinity, or alterations of the intracellular signal transmission. This study analyzes nucleotidic sequence of IL-10 gene in SNP patients. Sequencing of IL-10 gene shows that the lack of HLA-G production by peripheral blood CD14+ monocytes is not related to alterations in IL-10 gene nucleotidic sequence.

Variability of Origin of Splanchnic and Renal Vessels From the Thoracoabdominal Aorta.

OBJECTIVE: To analyze the variability of origin of the celiac trunk (CT), the superior mesenteric artery (SMA), the right renal artery (RRA), and the left renal artery (LRA) in terms of mutual distances, angle from the sagittal aortic axis (clock position), and ostial diameters on computed tomography angiographies (CTAs) in three groups of patients. METHODS: One hundred and fifty CTAs of 50 patients with a non-dilated thoracoabdominal aorta (group A), 50 with thoracoabdominal aneurysm (B), and 50 with infrarenal aneurysm (C) were reviewed. The measurements performed on CTAs, as well as the patients' age, sex, and body surface area, were analyzed. p values <.05 were considered statistically significant. RESULTS: The clock position of the CT and the SMA, the diameters of all vessels, and the distance of the CTeSMA followed a Gaussian distribution. In contrast, the clock position of the renal vessels did not follow a normal distribution, and nor did the distances of the SMA-RRA, SMA-LRA, RRA-LRA or the distances between the renal arteries and the aortic bifurcation. The same values did not differ significantly among the three groups, with the exception of the distances between the renal arteries and the aortic bifurcation, significantly greater in group C. The clock position of the LRA and the distances of the SMA-LRA, SMA-RRA, RRA-LRA and between both renal arteries and the aortic bifurcation showed a significant correlation with the increase of aortic diameter. CONCLUSION: The anatomic variability of the origin of both the CT and the SMA in terms of clock position and mutual distances followed a Gaussian distribution, regardless of group. The same applies to the ostial diameters of renal and visceral vessels. In contrast, the origin of the renal vessels had a statistically significant heterogeneity that seemed to be correlated with the increase of aortic diameter in the mesenteric and renal aortic region.

Treatment options for visceral artery aneurysms: ten year experience.

AIM: Open surgical repair (OSR) and endovascular techniques (ET) are both described in the literature for treating visceral artery aneurysms (VAAs). Aim of this study is to report a two-center experience of patients treated for a VAA using either OSR or ET, analyzing perioperative outcomes. METHODS: Clinical data of 32 VAAs in 32 patients treated between January 2001 and May 2011 were retrospectively reviewed and outcomes analyzed. RESULTS: Eighteen patients were men (56.3%). Median age was 64 years (range 26-79). Sixteen aneurysms were symptomatic: half of them were ruptured causing hemoperitoneum or gastrointestinal bleeding. ET were employed in 19 cases (59%) using covered stents (7 patients), coil embolization (5), plug placement (1), thrombin injection (2) and multiple associated techniques (4). OSR consisted in aneurysmectomy with end to end anastomoses (5 patients) or interposition graft (1), aneurysm ligation (4), splenectomy (2). One patient died during open surgery for hemoperitoneum due to VAA rupture (3%). OSR and ET had similar perioperative complication rates (5.2% vs. 15.3%, P=0.76). OSR had a longer in-hospital stay than ET (8 vs. 4 days, P=0.04). The presence of pancreatitis and alcohol abuse were more frequent in patients who presented with VAAs rupture. Clinical presentation with hemoperitoneum or aneurysm rupture were associated with higher mortality, regardless of the type of treatment. CONCLUSION: Both OSR and ET offered a safe way to treat VAAs in our experience.

Treatment of significant carotid artery stenosis in 1824 patients.

AIM: We report our experience of thirteen years of treatment of significant carotid artery stenosis. METHODS: Data of all consecutive patients who came to our Division for a significant carotid artery stenosis from January 1999 to January 2012 were collected about patients' demographic, cardiovascular risk factors, neurological symptoms and treatment (carotid endarterectomy, carotid artery stenting or best medical therapy). Retrospective review was performed and the occurrence of death, major cerebrovascular events (major stroke, minor stroke) and myocardial infarction (MI) were recorded both at 30-day and at long-term. Analysis was performed among groups by means of JMP 5.1(®). RESULTS: Of 1824 patients who were admitted to our Department for a significant carotid stenosis, 582 were unsuitable for surgery and underwent carotid artery stenting (CAS, Group A). Three hundred and seventy-three of them were symptomatic (64.1%). Carotid endarterectomy (CEA) was performed in 1030 patients (Group B), 741 (71.9%) of them were symptomatic. The remaining patients (Group C) were treated using best medical therapy (BMT). At 30-day CEA compared to CAS and BMT was associated with higher risk of MI (2.1% vs. 0.2%, and 0.4% respectively, P<0.05), most of all in asymptomatic patients. CEA had a higher risk of cranial nerve injuries than CAS (3.3% vs. 0%, P<0.001). Both risk of death and major neurological complications were similar among the three groups in both symptomatic and asymptomatic patients. At long-term, risk of stroke after CEA was similar to that after CAS, both for symptomatic and asymptomatic patients, while risk of 1-year stroke in Group C was higher than in Group A (P<0.001) and in Group B (P<0.001), for both symptomatic and asymptomatic patients. Risk of long-term MI was similar among the three groups. Mortality at long term in symptomatic patients was higher after CAS than after CEA (P=0.001). Also long-term mortality in Group C was higher than in Group A and B (both P<0.001) but only for asymptomatic patients. A procedure that lasted for more than 60 minutes, patients who had no prior Magnetic Resonance Angiography (MRA) or Computed Tomographic Angiography (CTA) study of the aortic arch were independent risk factors for major neurological complications after CAS. Symptomatic patients were likely to have more major neurological complications in the long term if they were treated with BMT only. CONCLUSION: In our experience, CAS offered a valid alternative for both symptomatic and asymptomatic patients who were poor candidates for CEA, with results that compared favourably to those of CEA both at 30-day and at long-term. Patients who couldn't be operated on neither with CAS nor with CEA had a lower risk of MI at 30-day but a higher risk of stroke during the first year, especially if they had previously experienced neurological symptoms.

Ulnar artery aneurysm: case report and review of the literature.

AIM: We report a case of ulnar and palmar arch artery aneurysm in a 77 years old man without history of any occupational or recreational trauma, vasculitis, infections or congenital anatomic abnormalities. We also performed a computed search of literature in PUBMED using the keywords "ulnar artery aneurysm" and "palmar arch aneurysm". CASE REPORT: A 77 years old male patient was admitted to hospital with a pulsing mass at distal right ulnar artery and deep palmar arch; at ultrasound and CT examination a saccular aneurysm of 35 millimeters at right ulnar artery and a 15 millimeters dilatation at deep palmar arch were detected. He was asymptomatic for distal embolization and pain. In local anesthesia ulnar artery and deep palmar arch dilatations were resected. Reconstruction of vessels was performed through an end-to-end microvascular repair. Histological examination confirmed the absence of vasculitis and collagenopaties. In postoperative period there were no clinical signs of peripheral ischemia, Allen's test and ultrasound examination were normal. At follow-up of six months, the patient was still asymptomatic with a normal Allen test, no signs of distal digital ischemia and patency of treated vessel with normal flow at duplex ultrasound. CONCLUSION: True spontaneous aneurysms of ulnar artery and palmar arch are rare and can be successfully treated with resection and microvascular reconstruction.

Inflammatory abdominal aortic aneurysms. A 20-year experience.

AIM: The aim of the study was to report a 20-year single Institution experience, with the early and late outcomes of surgical treatment of inflammatory abdominal aortic aneurysms. METHODS: In a 20-year period, 2 275 consecutive patients underwent elective surgical repair for non-rupture abdominal aortic aneurysm. Fifty-two patients (2.3%) were classified as inflammatory abdominal aortic aneurysms. Early and late outcomes were analyzed. RESULTS: One patient died in the perioperative period, giving a mortality rate of 1.92%. One patient died from a pseudoaneurysm rupture 7 months after operation. Three patients developed an aortic pseudoaneurysm in the follow-up period (mean 12.1 years, range 1-20 years) and underwent a redo operation. CONCLUSION: Overall surgical outcome of these patients, in terms of short-term and long-term is good. A high rate of pseudoaneurysm formation was observed.

Endovascular treatment of penetrating aortic ulcers: mid-term results.

OBJECTIVES: The aim of this study was to evaluate mid-term results of endovascular treatment of penetrating aortic ulcers. METHODS: Between February 2000 and November 2006, 18 consecutive patients underwent endovascular treatment of the descending thoracic aorta (N=16) and abdominal infrarenal aorta (N=2) for penetrating aortic ulcer, in a single University Hospital. Data were prospectively collected and retrospectively analyzed. Mean follow-up was 41 months (range 4 to 77 months). RESULTS: Technical success was achieved in all patients. No perioperative deaths occurred. No conversion to open repair or secondary procedures were required. Two patients died in the follow-up period for reasons not related to penetrating aortic ulcers. One type II endoleak was observed. It was still present, unchanged, twelve months after the procedure. CONCLUSION: Endovascular treatment of penetrating aortic ulcers of the descending thoracic and infrarenal aorta were safe and effective in the mid-term in this small series of patients.

Case report of adventitial cystic disease of the popliteal artery presented with the ''dog-leg'' sign.

Adventitial cystic disease of the popliteal artery constitutes an infrequent cause of claudication in non-atherosclerotic young or middle-aged population. Here, we report the case of a 43-year-old female with adventitial cystic disease of the popliteal artery causing left lower leg claudication, detected by duplex scanning. The angio-CT showed the "dog-leg" sign, typical of the aneurysm of the popliteal artery. Surgery was performed through the posterior approach. The cyst and the affected segment of the artery were successfully excised and replaced with an autogenous saphenous vein graft. In 1 year follow-up the graft is patent and the patient is completely asymptomatic.

Endovascular treatment of a renal artery branch aneurysm.

A 58-year-old woman was admitted to our institution because of a left renal artery branch saccular aneurysm with a 2 cm diameter. Due to a hostile abdomen and the infrarenal location, an endovascular approach was chosen. A Jostent Peripheral Stent-Graft was placed under angiographic control, excluding the aneurysm from the circulation. No peri- or postprocedural complications were observed. At 6 months follow-up, the endograft is patent, excluding the aneurysm. Endovascular treatment may represent an alternative to surgery, especially in the distal infraparenchymal location.

Duplex scanning on admission prevents unnecessary carotid endarterectomies.

AIM: This retrospective single Institution study, aims to evaluate the performance of duplex scanning on admission of patients with carotid artery disease to avoid unnecessary carotid endarterectomies. METHODS: From 1 January 1997 until 31 Decem-ber 2004, 1 504 patients were admitted to our Institution to undergo carotid endarterectomy. A duplex scan on admission was performed in all of them. RESULTS: A total of 1 369 from these patients (91%) underwent surgery, while 135 (9%) were dismissed because there was no indication for surgical treatment. They were put in conservative treatment and periodic duplex control appointments. CONCLUSIONS: In 9% of the patients, unnecessary carotid endarterectomy was avoided.

Retrograde aorto-mesenteric by-pass grafting as treatment option of recurrent chronic mesenteric ischemia after thrombosed superior mesenteric artery stenting. Report of a case.

We report a case of early stent failure in a patient with chronic mesenteric ischemia and its treatment with a retrograde aorto-mesenteric by-pass. The patient was initially treated with angioplasty and stenting. Seven months after the procedure complete thrombosis of the stent was achieved. A retrograde aorto-mesenteric by-pass was performed. After two years the patient remains asymptomatic and color Duplex scan confirm the patency of the graft.

Life at depth: Photobacterium profundum genome sequence and expression analysis.

Deep-sea life requires adaptation to high pressure, an extreme yet common condition given that oceans cover 70% of Earth's surface and have an average depth of 3800 meters. Survival at such depths requires specific adaptation but, compared with other extreme conditions, high pressure has received little attention. Recently, Photobacterium profundum strain SS9 has been adopted as a model for piezophily. Here we report its genome sequence (6.4 megabase pairs) and transcriptome analysis. The results provide a first glimpse into the molecular basis for life in the largest portion of the biosphere, revealing high metabolic versatility.

[Aneurysms of the abdominal aorta in elderly patients]. / Aneurismi dell'aorta addominale nei pazienti anziani.

Aneurysms of the abdominal aorta are often diagnosed in the over-75s. Although for many Authors the presence of risk factors such as cardiopathies, cerebrovascular problems, renal or respiratory insufficiency, which are clearly more frequent in elderly patients, represent a contraindication to the intervention of choice, personal experience has shown that surgery remains the best solution. In fact, in a group of patients operated on for aneurysm of the abdominal aorta in a heart, no significant differences in age-related mortality were observed. Surgery therefore remains the treatment of choice in the elderly too for it must also be remembered that the natural history of the disease has shown that, in a comparatively short time, the aneurysm ruptures and operating mortality is markedly higher.