Clinical predictors of major adverse cardiovascular events during long-term follow-up after carotid endarterectomy.

BACKGROUND: Those patients who undergo a carotid endarterectomy (CEA) will present a higher cardiovascular risk during follow-up than the general population. The objective of this study was to determine the prognostic factors and validate the accuracy of 3 cardiovascular risk scores as predictors of major adverse cardiovascular events (MACEs) during long-term follow-up after CEA. METHODS: Observational retrospective follow-up study with 416 CEAs conducted consecutively in 385 patients from 1994 to 2011. The primary end point was MACE, single event including myocardial infarction, stroke, and cardiovascular death. Preoperative risk factors and medical treatment at discharge were collected. A general cardiovascular risk score, the Revised Cardiac Risk Index (RCRI), was used, and 2 scores specific for CEA (Halm and Tu). Descriptive analysis and Cox regression were conducted. Informed consent from patients was obtained and approval by the ethics committee. RESULTS: The median follow-up was 4.94 years. MACEs appeared in 22.1% (95% confidence interval [CI], 18.0-26.2%) of the series during follow-up. The MACEs rate at 1 year, 3 years, and 5 years, was 3.1%, 9.3%, and 15.8%, respectively. In the Cox regression model, the MACE predictor variables were: the presence of peripheral artery disease (hazard ratio [HR], 1.69; 95% CI, 1.06-2.70) and RCRI (HR,1.61; 95% CI, 1.04-2.50). The RCRI area under the curve for predicting events, with a 2.5 cutoff point, was 0.59 with 85.9% sensitivity and a positive predictive value of 25.2%. CONCLUSIONS: Peripheral artery disease and high RCRI have an independent effect on predicting MACEs. The 3 different scores have a low ability for predicting MACEs during long-term follow-up.

Anatomopathological and immunohistochemical study of explanted cryopreserved arteries.

BACKGROUND: The aim of the study was to analyze the mechanism of deterioration of implanted arteries. METHODS: Eleven patients were included. Samples of vascular segments obtained from multiorgan donors and samples of the same vascular segments after explantation in the recipient were analyzed. Blood group, time of cold and warm ischemia, cause of death, time spent in the intensive care unit, time of storage of the cryopreserved grafts, and anatomopathological and immunohistochemical studies were analyzed using the preimplant samples obtained from the multiorgan donor. For samples obtained from the recipient, blood group, duration for which the tissue from the donor has been implanted, reason for graft explantation, and anatomopathological and immunohistochemical studies were analyzed. RESULTS: Histopathologically, the main finding has been the substitution of the muscular cap of the arterial wall by an intense fibrosis, in most of the cases, of a symmetrical nature. Besides this degeneration of myocytes, there is marked perivascular fibrosis and fibrointimal thickening also exists. The T lymphocytes suggest the importance of the immunological mechanism in the distortion of the architecture of the arteries. The atherosclerosis plays a less relevant role. CONCLUSIONS: Evidence of immune-mediated injury was found, and this mechanism seems to be responsible for the degenerative process in cryopreserved homografts.

Urgent endovascular treatment of a ruptured tibioperoneal pseudoaneurysm in Behçet's disease.

BACKGROUND: Behçet's disease is an autoimmune, systemic vasculitis disease that is characterized by oral aphthous and genital ulcerations and ocular lesions. Vascular manifestations in the form of aneurysms are the main predictors of mortality and morbidity in such cases. Normally, these aneurysms are located in the pulmonary arteries, the aorta, carotid, subclavia, and the femoropopliteal sector. Open surgery presents a maximum complication rate of 50%, principally in the form of anastomotic pseudoaneurysms. METHODS: We report the case of a 41-year-old man who was diagnosed with Behçet's disease 3 years before, and attended the emergency department after a 10-day history of pain and an infragenicular swelling edema in the right limb, without any previous record of trauma. RESULTS: An initial vascular exploration revealed a pusatile mass in the infrapopliteal region and absence of the posterior tibial pulse in the right limb. The rest of the exploration did not reveal any alterations. A Doppler ultrasound scan showed a ruptured infrapopliteal pseudoaneurysm. An emergency, selective arteriography of the popliteal artery was performed by using a contralateral femoral access approach, and a ruptured tibioperoneal pseudoaneurysm was embolized with three 5-mm metallic coils (Cook). The patient was discharged after 4 days and in the 2 years since then has remained asymptomatic. CONCLUSIONS: Aneurysms of the distal vessels in Behçet's disease are very infrequent and each case should be evaluated on an individual basis. Endovascular treatment is a good therapeutic alternative.