Stent-Graft Relining in a Patient with Acute Aortic Aneurysm and a Completely Migrated Endograft.

Stent-graft migration and type I endoleaks are associated with a higher rate of reintervention and increased mortality and morbidity. This article describes a patient presented with an infrarenal aortic stent-graft which had migrated into the aortic sac with loss of all aortic neck attachment. The acutely expanding abdominal aortic aneurysm was treated by placing a second modular endograft within and above the migrated stentgraft. The patient returned 36 months later, with features of an acute myocardial infarction, severe bilateral lower limb ischemia, and renal failure. He was too ill for intervention and demised within 48 hours.

Stent-graft relining in a patient with acute aortic aneurysm and a completely migrated endograft

Abstract Stent-graft migration and type I endoleaks are associated with a higher rate of reintervention and increased mortality and morbidity. This article describes a patient presented with an infrarenal aortic stent-graft which had migrated into the aortic sac with loss of all aortic neck attachment. The acutely expanding abdominal aortic aneurysm was treated by placing a second modular endograft within and above the migrated stentgraft. The patient returned 36 months later, with features of an acute myocardial infarction, severe bilateral lower limb ischemia, and renal failure. He was too ill for intervention and demised within 48 hours.

Aorto-internal iliac artery endovascular reconstruction for critical limb ischaemia: a case report.

The internal iliac artery and cruciate anastomosis are important collateral vessels in severe aortoiliac occlusive disease. This report describes a patient with left leg rest pain due to occlusion of the left common and external iliac arteries. In addition, there was a high-grade stenosis of the right common iliac artery. Direct catheter canulation of the left internal iliac artery revealed that it was patent. Endovascular stent placement was successful in re-establishing blood flow into the left internal iliac artery. Ischaemic rest pain was relieved and the ankle brachial index was maintained at 0.85 at 6 months follow-up.

A case of Endovascular Treatment of Blunt Aortic Bifurcation Transection using peripheral stentgraft.

We present a case of endovascular management of aortic transection at the aortic bifurcation in a polytrauma patient.

Endovascular Treatment of an Acutely Thrombosed Abdominal Aortic Aneurysm.

BACKGROUND: Acute thrombosis of an infrarenal abdominal aortic aneurysm may be a life-threatening condition. REPORT: We describe a case of acute thrombosis of a 3.5-cm abdominal aortic aneurysm resulting in threatened lower limbs, in a high-risk surgical patient. Emergency stent-graft placement was undertaken using Fluency endoprostheses. The patient remains well at 1-year follow-up. CONCLUSION: High-risk surgical patients with acutely thrombosed abdominal aortic aneurysms may not be candidates for open surgery. Use of peripheral stent grafts in emergency situation has not been reported in such patients.

Large vessel adventitial vasculitis characterizes patients with critical lower limb ischemia with as compared to without human immunodeficiency virus infection.

OBJECTIVES: Whether a human immunodeficiency virus (HIV)-associated vasculitis in-part accounts for occlusive large artery disease remains uncertain. We aimed to identify the histopathological features that characterize large vessel changes in HIV sero-positive as compared to sero-negative patients with critical lower limb ischemia (CLI). MATERIALS AND METHODS: Femoral arteries obtained from 10 HIV positive and 10 HIV negative black African male patients admitted to a single vascular unit with CLI requiring above knee amputation were subjected to histopathological assessment. None of the HIV positive patients were receiving antiretroviral therapy. RESULTS: As compared to HIV negative patients with CLI, HIV positive patients were younger (p<0.01) and had a lower prevalence of hypertension (10 vs 90%, p<0.005) and diabetes mellitus (0 vs 50%, p<0.05), but a similar proportion of patients previously or currently smoked (80 vs 60%). 90% of HIV positive patients, but no HIV negative patient had evidence of adventitial leukocytoclastic vasculitis of the vasa vasorum (p<0.0001). In addition, 70% of HIV positive, but no HIV negative patient had evidence of adventitial slit-like vessels. Whilst T-lymphocytes were noted in the adventitia in 80% of HIV positive patients, T-lymphocytes were noted only in the intima in HIV negative patients. The presence of femoral artery calcified multilayered fibro-atheroma was noted in 40% of HIV positive and 90% of HIV negative patients with CLI. CONCLUSIONS: An adventitial vasculitis which characterizes large artery changes in CLI in HIV-infected as compared to non-infected patients, may contribute toward HIV-associated occlusive large artery disease.

Chronic diseases are not being managed effectively in either high-risk or low-risk populations in South Africa.

BACKGROUND: Primary healthcare is the foundation of a country's healthcare system. Without an efficient and cost-effective programme, the level of healthcare offered across all levels of health management is adversely affected. OBJECTIVE: To analyse the effectiveness of the management of hypertension and diabetes mellitus (DM) among two distinct patient populations, one with significant cardiovascular risk factors and the other without. METHOD: We performed a case control study of a high-risk group of patients presenting with chronic critical limb ischaemia (CLI) to the Divisions of Vascular Surgery at Charlotte Maxeke Johannesburg Academic Hospital and Chris Hani Baragwanath Academic Hospital, and a randomly selected group of 'healthy' community participants from Johannesburg's South Western Townships (Soweto). RESULTS: We assessed 217 patients with CLI and 1 030 participants from the community. We assessed the number of patients who were not achieving their therapeuatic targets, among those known to be hypertensive (CLI: 44.7%; community: 59.9%) and diabetic (CLI: 83.5%; community: 66%). Undiagnosed diabetes affected 10.8% of patients with CLI and 11% of the community sample. CONCLUSION: Traditional vascular risk factors are managed poorly at both primary healthcare and at tertiary care levels. There is a need to identify factors that will address this issue.

Education in vascular surgery-critical issues: a Southern African perspective.

Southern Africa is made up of some of the poorest countries in the world. In addition, the common perception that the population of Southern Africa has a low incidence of vascular disease has resulted in vascular surgical training being a low priority. The assumption that in the future vascular disease in Southern Africa will remain uncommon is being challenged, and strategies to address the resultant shortage of vascular surgeons, both in the medium and long term, are suggested.

Assessment of the medial head of the gastrocnemius muscle in functional compression of the popliteal artery.

OBJECTIVE: Nonfunctional popliteal entrapment is due to embryologic maldevelopment within the popliteal fossa. Functional entrapment occurs in the apparent absence of an anatomic abnormality. Gastrocnemius hypertrophy has been associated with the latter. Both forms of entrapment may cause arterial injury and lower limb ischemia. This study assessed the attachment of the medial head of the gastrocnemius muscle in healthy occluders and healthy nonoccluders. METHODS: Provocative tests were used to identify 58 nonoccluders and 16 occluders. Ten subjects from each group underwent magnetic resonance imaging evaluation of the popliteal fossa. The medial head of the gastrocnemius muscle attachment was assessed in the supracondylar, pericondylar, and intercondylar areas. RESULTS: In the occluder group, significantly more muscle was attached towards the femoral midline (supracondylar), around the lateral border of the medial condyle (pericondylar), and within the intercondylar fossa. CONCLUSION: The more extensive midline position of the medial head of the gastrocnemius in occluders is likely to be a normal embryological variation. Forceful contraction results in compression and occlusion of the adjacent popliteal artery. The clinical significance of these anatomic variations remains unclear. However, these new observations may provide insight for future analysis of the causes and natural history of functional compression and the potential progression to clinical entrapment.

Metabolic syndrome and subclinical atherosclerosis in rheumatoid arthritis.

OBJECTIVE: We assessed whether features of metabolic syndrome (MetSyn) were risk factors for subclinical atherosclerosis independent of previously identified determinants of cardiovascular disease in 74 patients with rheumatoid arthritis (RA). We further evaluated the clinical utility of currently recommended MetSyn definitions in the identification of RA patients with subclinical atherosclerosis. METHODS: We investigated the associations of MetSyn features and MetSyn definitions with ultrasonographically determined common carotid artery intima-media thickness (CCA-IMT) and plaque, with adjustment for age, radiographic scores (cumulative inflammation), polymorphonuclear cell counts (current inflammation), or hypothyroidism. RESULTS: The Quantitative Insulin Sensitivity Check Index (QUICKI) (partial R = -0.24 to -0.26, p = 0.04 to 0.02), log triglycerides (partial R = 0.23 to 0.30, p = 0.05 to 0.01), and systolic blood pressure (partial R = 0.22 to 0.30, p = 0.06 to 0.002) were consistently associated with the log CCA-IMT. Log triglycerides (OR 1.04, 95% CI 1.01-1.08, p = 0.02) and the QUICKI (OR 0.22, 95% CI 0.05-0.91, p = 0.03) were associated with plaque after adjusting for cumulative inflammation. Hypertension (blood pressure > or = 130/85 mm Hg or drug treatment for hypertension) was consistently associated with CCA-IMT (p = 0.05 to 0.0003) and plaque (p = 0.03 to 0.006). The WHO-defined MetSyn was associated with CCA-IMT (p = 0.08 to 0.04) but not with plaque (p > or = 0.1). The National Cholesterol Education Program-defined MetSyn was not associated with CCA-IMT or plaque (p > or = 0.3). CONCLUSION: In this RA cohort, the MetSyn features of hypertension, insulin resistance, and triglycerides were risk factors for subclinical atherosclerosis, independent of previously identified determinants of cardiovascular disease. Individual MetSyn features were more strongly associated with subclinical atherosclerosis than were currently recommended MetSyn definitions.

Traditional and nontraditional cardiovascular risk factors are associated with atherosclerosis in rheumatoid arthritis.

OBJECTIVE: To determine the association between cardiovascular (CV) risk factors and atherosclerosis in patients with rheumatoid arthritis (RA). METHODS: The common carotid artery intima-media thickness (IMT) and plaque were evaluated by high resolution B-mode ultrasound in 74 consecutive patients with RA. Patients with an IMT > or = 0.60 mm and plaque were considered to have atherosclerosis and advanced atherosclerosis, respectively. Traditional risk factors as well as an extensive range of other clinical and laboratory variables were recorded. Methods used to analyze the data included logistic regression, classification and regression tree (CART), and factor analyses. RESULTS: Fifty-three (72%) patients had atherosclerosis, 23 (31%) had plaque, and 21 (28%) were free of atherosclerosis. In multivariable analysis, age and hypertension were independently associated with atherosclerosis and plaque (p < or = 0.04). Radiographic scores and polymorphonuclear cell counts were also strongly associated with plaque (p < or = 0.008). Uric acid concentrations were associated with atherosclerosis, and hypothyroidism was associated with plaque, both with borderline significance (p = 0.078 and 0.052, respectively). In CART analysis, age, polymorphonuclear cell counts, and joint space narrowing in the hands were considered to be the most important determinants of plaque, and 62% of patients could be classified correctly after cross-validation. Factor analysis (varimax rotation) revealed that age and uric acid levels were related to low glomerular filtration rates, polymorphonuclear cell counts to disease activity, and radiographic scores to disease duration, and hypertension was associated with high cholesterol levels. The 10-year risk for a coronary event estimated using the Framingham risk equation (calculated from traditional risk factors) was only 7% in patients with plaque. CONCLUSION: Atherosclerosis in RA is associated with the traditional CV risk factors age and hypertension, as well as nontraditional risk factors comprising current inflammation as reflected by polymorphonuclear cell counts, cumulative inflammation as disclosed by radiographic scores, and, to a lesser extent, with uric acid levels and hypothyroidism. Multiple risk factor assessment equations that are based on traditional risk factors only are likely to be insufficient to capture CV risk extent in RA.

High-dose atorvastatin therapy is required for significant improvement of endothelial function in heterozygous familial hypercholesterolaemic patients.

This study evaluated endothelial dysfunction (ED) by measuring flow-mediated vasodilation (FMD) and for six months documented changes in ED, LDL-C levels and serum concentrations of inflammatory markers with high- and low-dose atorvastatin therapy. In 23 heterozygous familial hypercholesterolaemic (FH) patients, FMD, LDL-C and inflammatory markers (sVCAM-1, sICAM-1, E-selectin and highly sensitive C-reactive protein) were measured at baseline (untreated) and on atorvastatin 20 and 80 mg/day. In untreated patients, FMD was significantly reduced (mean +/- SD = 3.09 +/- 0.91%) compared with 10 normocholesterolaemic controls (8.71 +/- 2.41%; p < 0.01). FMD improved non-significantly with atorvastatin 20 mg/day (5.60 +/- 1.17%), but showed a significant improvement (8.54 +/- 1.11%; p < 0.01) with atorvastatin 80 mg/day. LDL-C decreased markedly (-42.4%; p < 0.0001) on 20 mg/day and decreased further (-48.6%; p < 0.05) on 80 mg/day. FMD improvement, however, did not correlate with LDL-C reduction. No significant changes occurred in any inflammatory markers. We concluded that ED was present in untreated FH patients and improved significantly on high-dose atorvastatin. There was no correlation between the changes in FMD and LDL-C, suggesting either a LDLC-independent effect on ED, or that a marked reduction in LDL-C is required to normalise ED in FH.