Hemodynamic changes in Chevalier eversion versus conventional carotid endarterectomy.

OBJECTIVES: The eversion carotid endartectomy (E-CEA), mainly performed by means of Vanmaele technique, has been associated with loss of the baroreceptor reflex and postoperative hypertension. The purpose of this paper is to determine whether the eversion endarterectomy performed by means of Chevalier technique (C-CEA) modifies the function and the efficiency of baroreceptors, leading to lower postoperative hemodynamic change. METHODS: A retrospective review of 380 patients who underwent carotid endarterectomy (120 Chevalier-CEA; 260 Standard-CEA) from December 2002 to November 2012 has been performed. The changes of blood pressure baseline during the postoperative course in C-CEA and S-CEA group were analysed and compared. Postoperative hypertension was defined as an elevation of systolic pressure >180 mm Hg or >40% rise above baseline. RESULTS: The patients with Chevalier eversion technique did not develop a significantly higher blood pressure in the postoperative course compared to those operated with the standard technique. In the recovery room, the mean systolic blood pressure was 134 ± 21.9 mm Hg in C-CEA group versus 132 ± 24.6 mm Hg in S-CEA group. In the first postoperative day it was 132 ± 17.2 mm Hg in C-CEA versus 133 ± 17.4 mm Hg in S-CEA group. During the first six hours in the recovery room, the need for intravenous antihypertensive drugs was similar in the two groups. Fourteen patients in C-CEA group (11%) and thirty patients (11.5%) in the S-CEA group required vasodilators, without any significant difference (p = 1). The dosage of current preoperative antihypertensive therapy was increased in six patients (4.9%) of C-CEA group and in twelve patients (4.9%) of S-CEA group, without significant difference (p = 1). CONCLUSIONS: C-CEA has the same rate of postoperative hypertension of standard-CEA, which is probably related to the sparing of baroreceptor apparatus, compared to standard E-CEA. The Chevalier procedure could represent an E-CEA technique with its inherent advantages, without penalties related to postoperative hypertension, commonly observed after E-CEA.

The Fluid-Dynamics of Endo Vascular Aneurysm Sealing (EVAS) System failure.

PURPOSE: The main objective of this work is to investigate hemodynamics phenomena occurring in EVAS (Endo Vascular Aneurysm Sealing), to understand if and how they could lead to type 1a endoleaks and following re-intervention. To this aim, methods based on computational fluid mechanics are implemented as a tool for checking the behavior of a specific EVAS configuration, starting from the post-operative conditions. Pressure and velocity fields are detailed and compared, for two configurations of the Nellix, one as attained after correct implantation and the other in pathological conditions, as a consequence of migration or dislocation of endobags. METHODS: The computational fluid dynamics (CFD) approach is used to simulate the behavior of blood within a segment of the aorta, before and after the abdominal bifurcation. The adopted procedure allows reconstructing the detailed vascular geometry from high-resolution computerized tomography (CT scan) and generating the mesh on which the equations of fluid mechanics are discretized and solved, in order to derive pressure and velocity field during heartbeats. RESULTS: The main results are obtained in terms of local velocity fields and wall pressures. Within the endobags, velocities are usually quite regular during the whole cardiac cycle for the post-implanted condition, whereas they are more irregular for the migrated case. The largest differences among the two cases are observed in the shape and location of the recirculation region in the rear part of the aorta and the region between the endobags, with the formation of a gap due to the migration of one or both of the two. In this gap, the pressure fields are highly different among the two conditions, showing pressure peaks and pressure gradients at least four times larger for the migrated case in comparison to the post-implanted condition. CONCLUSIONS: In this paper, the migration of one or both endobags is supposed to be related to the existing differential pressures acting in the gap formed between the two, which could go on pushing the two branches one away from the other, thus causing aneurysm re-activation and endoleaks. Regions of flow recirculation and low-pressure drops are revealed only in case of endobag migration and in presence of an aneurysm. These regions are supposed to lead to possible plaque formation and atherosclerosis.

Cervical access for filter-protected carotid artery stenting: a useful tool to reduce cerebral embolisation.

BACKGROUND: Filter-protected transcervical carotid artery stenting (CAS) has been suggested to reduce the intraoperative cerebral embolisation observed during transfemoral CAS. We therefore evaluated clinical outcome and incidence of ischaemic lesions at diffusion-weighted magnetic resonance imaging (DW-MRI) after transcervical and transfemoral CAS. METHODS: From March 2007 to May 2009, we performed filter-protected CAS in 135 patients with symptomatic (30%) or asymptomatic (70%) carotid stenosis above 70% and below 95%. In 44 patients with risky femoral access or unfavourable aortic arch anatomy, access to common carotid artery was achieved by a small cervical incision. In another 91 procedures we used a classic percutaneous femoral access. Preoperative and postoperative DW-MRI scans were obtained after 111 procedures (82%) - 35 transcervical and 76 transfemoral. RESULTS: The incidence of clinical events (transient ischaemic attack (TIA) and stroke) was 2.3% after transcervical CAS and 19.8% after transfemoral CAS (P<0.01), without any deaths. DW-MRI disclosed new ischaemic lesions in five patients (5/35, 14.3%) after transcervical CAS and in 28 patients (28/76, 36.8%) after transfemoral CAS (P=0.015). All ischaemic lesions depicted after transcervical procedures were ipsilateral to the treated artery. CONCLUSIONS: Transcervical filter-protected CAS, compared with classic percutaneous procedures, seems to reduce clinical events and DW-MRI ischaemic damage and may be useful in selected patients.

Aortic arch catheterization during transfemoral carotid artery stenting: an underestimated source of cerebral emboli.

Cerebral embolization is still a major concern in patients undergoing transfemoral carotid artery stenting. Intraoperative transcranial Doppler (TCD) monitoring and diffusion-weighted magnetic resonance imaging (DW-MRI), two techniques currently used to study this phenomenon, have provided data suggesting the importance of aortic arch catheterization in determining the overall embolic load observed during this procedure. In order to reduce this cerebral embolization, some Authors have proposed the performance of carotid artery stenting through a cervical access, either surgical or percutaneous. We review in this article the available TCD and DW-MRI data supporting transcervical CAS, along with its clinical results.

The Influence of Diabetes Mellitus on the Outcome of Superficial Femoral Artery Recanalization is Debatable.

Notwithstanding technological improvements in endovascular devices treatment of steno-obstructive lesions of the superficial femoral artery (SFA) remains a challenge for today's vascular surgeon. Current opinion dictates that the diabetic population may have worse outcome after revascularization of the lower extremities. Herein we examine the effects of endovascular treatment on steno-obstructive lesions of the SFA in diabetic and non-diabetic patients. METHODS: A retrospective analysis was carried out on 110 patients who had undergone endovascular treatment of the SFA from 2010 to 2017 comparing outcomes in diabetic (DM) vs non-diabetic patients (nDM). RESULTS: 56 (50.9%) of the patients were diabetic and 54 were non-diabetic (49.1%). 52.7% (62.7% DM vs 35.2% nDM, p = 0.0003) were patients with critical limb ischemia. SFA occlusion was present in 65.5% (60.7% DM vs 70.4% nDM, p = 0.29) of all patients. All had undergone PTA of the SFA and 40.9% had received adjunctive stenting (44.6% DM vs 37.0% nDM, p = 0.41). A multilevel treatment was executed in 39.1% (51.8% DM vs 25.9% nDM) of the cases whereas an infra-popliteal procedure was associated in 27.3% (37.5% DM vs 16.7% nDM). In both groups the presence of diabetes was significantly associated (p = 0.005 e p = 0.014, respectively). Reintervention rate was 22.7%; 13 in the diabetic group (23.2%) and 12 in the non-diabetic group (22.2%). Of those who had had reintervention (p = 0.77); 9 patients (8.2%) had undergone an open surgical operation, 6 of whom had diabetes (p = 0.32). 5 patients (4.5%) had had major amputation, 4 of whom were diabetic (p = 0.20). Curves assessing freedom from target lesion restenosis were substantially overlapping between the two groups. CONCLUSION: No statistical associations between diabetes and reintervention or amputation rates were found. Indication to treat the SFA were not influenced by the presence of diabetes but further investigation is required to verify our hypothesis.

Safety and effectiveness of combining carotid artery stenting with cardiac surgery: preliminary results of a single-center experience.

AIM: Optimal strategy (staged or combined) for the treatment of patients with concurrent severe carotid and cardiac disease is still controversial. Moreover, carotid artery stenting (CAS), has become a valid alternative to carotid endarterectomy (CEA) and has been proposed for the treatment of cardiac patients. The authors report the preliminary results of a new therapeutic strategy consisting in combined CAS and cardiac surgery. METHODS: An initial series of 22 patients underwent combined CAS and cardiac surgery in the same operating room and under general anesthesia. All filter-protected CAS procedures were performed under only heparin and aspirin. A cervical approach (3-cm cervicotomy) was used in patients with documented vessel tortuosity or severe aorto-iliac occlusive arteriopathy. In all the other cases a femoral access was used. A double antiplatelet regimen was initiated in the early postoperative period, once major bleedings were excluded. RESULTS: Among the 22 patients who underwent this combined procedure, no deaths, no myocardial infarctions and one controlateral stroke (overall complication rate: 4.5%) were observed. This stroke was observed after transcervical CAS, coronary artery bypass and mitral valve replacement. No major postoperative bleedings nor stent thrombosis were observed. CONCLUSIONS: Combined carotid stenting and cardiac surgery, performed in the same operating room under only heparin and aspirin, seems a safe and effective strategy for the treatment of patients with concomitant carotid and cardiac disease.

Lag3+ regulatory T lymphocytes in critical carotid artery stenosis.

The aim of this study was to evaluate CD25+ and Lag3+ T regulatory subpopulations in patients with critical carotid artery stenosis (CAS) and Stanford-A acute aortic dissection (AAD). CD25+ and Lag3+ were measured in 36 patients affected by CAS and 24 patients with Stanford type A AAD. Based on neurological symptoms, patients affected by CAS were further divided in 25 asymptomatic (CAS-A) and 11 symptomatic (CAS-S) subjects. Twenty-five patients with traditional cardiovascular risk factors (RF), matched for age and sex, were used as control group. Interleukin (IL)-10, IL-6 and transforming growth factor-ß-levels were also measured. CD25+ T cells were significantly increased in CAS-S versus CAS-A (p > 0.05), AAD (p > 0.05) and RF (p > 0.05). Moreover, a significant increase in Lag3+ Tregs was observed in CAS e CAS-S versus AAD (p < 0.05) and RF (p < 0.05), whereas no significant difference was observed between CAS-S and CAS-A. IL-6 was higher in AAD compared to the other groups. Patients with neurological symptoms display a peculiar expansion of CD25+ T cells, strongly confirming a relationship between ischemic brain damage and this regulatory subpopulation, whereas Lag3+ Tregs early distinguish CAS from AAD and probably exert protective actions against aortic wall rupture throughout their anti-inflammatory functions.

Cerebral embolization in patients undergoing protected carotid-artery stenting and carotid surgery.

AIM: Intraoperative cerebral embolization is a greater concern in patients undergoing carotid-artery stenting (CAS) than in those undergoing the reference standard treatment carotid endarterectomy (CEA). We evaluated cerebral embolism with diffusion-weighted magnetic resonance imaging (DW-MRI) and transcranial Doppler monitoring during CAS and CEA. METHODS: A series of 75 patients with carotid stenosis, 40 undergoing CEA and 35 transfemoral protected CAS, underwent preoperative and postoperative cerebral DW-MRI. Of the 75 patients, 64 (85%) underwent intraoperative transcranial Doppler monitoring to evaluate the mean number of microembolic signals (MES) recorded in each procedure. RESULTS: None of the patients died. No patient in the CEA but two in the CAS group had strokes (5.7%, P=NS). The mean MES count on transcranial Doppler monitoring was higher in the CAS than in the CEA group (330.0 MES, range 2754 vs 13.2, range 0-49 MES; P<0.01). DW-MRI disclosed a significantly larger number of new ischemic lesions in the CAS than in the CEA group (40 lesions in 12/35 patients, 34.3% vs 4 lesions in 3/40 patients, 7.5%; P<0.01). In the CEA group, all patients with ischemic lesions were asymptomatic whereas in the CAS group 5 were symptomatic (14.3%) and 7 asymptomatic (20%). The cerebral distribution also differed in the two groups: no CEA but 20% of CAS lesions were contralateral. CONCLUSION: CAS is associated with a significantly higher rate of cerebral embolization than CEA. Even though the clinical meaning of new postoperative ischemic lesions remains debatable, it seems prudent to reduce the embolic load by improving procedural techniques and cerebral protection devices.

Salmonella reinfection manifesting as a fistula between the duodenum and an aortic stump pseudoaneurysm.

Despite the worldwide increase in Salmonella infections, a Salmonella infection of an aortic graft is an exceptional event. A Salmonella reinfection manifesting as a fistula between the duodenum and an aortic stump pseudoaneurysm 30 months after prosthetic excision, aortic ligature and extra-anatomic bypass for a Salmonella graft infection is a unique event. This unusual late complication described in this case report developed in 1 of the 5 patients whose Salmonella aortic graft infections have been previously reported. The reinfection causing septic aortitis responded to conventional surgery.

Relationships between risk factors and morphological patterns of human carotid atherosclerotic plaques. A multivariate discriminant analysis.

The histological characterization of the fibroatheromatous plaques and their histogenesis are still to be defined. Factors responsible for the evolution of intimal components and the mechanisms and stages of fibroatheromatous plaque formation are still largely obscure. Focusing on symptomatic plaques, the aim of this study is to determine whether plaque heterogeneity is the result of a haphazard clustering of various components or an organized pattern in response to risk factors. To this end, 180 carotid plaques from patients affected by transient ischemic attacks (TIA) or by stroke, with angiographic stenosis greater than 50%, were studied after endoarterectomy. Clinical and morphological data were collected by means of a pre-defined protocol, quantified and correlated, by using the discriminant analysis, with age, sex, hypertension, diabetes, hypercholesterolemia and smoking habit. Our results show that the relationships between plaque components are non-random and consistent with the knowledge derived from studies on human and experimental plaques. Moreover, some plaque patterns can be significantly correlated with single risk factors. The fibrous plaque was correlated with aging and diabetes; the granulomatous plaque, rich in giant cells, with the female sex and hypertension; the xanthomatous plaque, rich in foam cells and with extensive alcianophilia, with hypercholesterolemia. In the smokers, finally, the plaques were frequently complicated by mural thrombosis.

Immunodetection of human atherosclerotic plaque with 125I-labeled monoclonal antifibrin antibodies.

To test the affinity of a new F(ab')2 monoclonal antibody (TRF1) against human fragment D dimer of cross-linked fibrin for atherosclerotic plaques free of detectable thrombi, 6 atherosclerotic segments of carotid and femoral artery, and as a control 5 segments of atherosclerosis-free internal mammary artery, were drawn from 11 male patients undergoing bypass surgery. All segments were carefully washed in order to remove possible endoluminal thrombi, and cut to obtain pairs of intimal fragments of similar weight, containing either plaques (n = 16), or fatty streaks (n = 12), or normal endothelium (n = 20). Each fragment underwent a direct binding test to TRF1, or to a non-specific antibody, both labeled with 125I. The activity in each fragment was measured after 3 h of incubation at 37 degrees C, and after washing the fragments every hour for 3 h. TRF1 binding (as percentage of initial activity) was significantly higher (P < 0.001) in atherosclerotic than in normal fragments (26% +/- 11.5%, vs. 9.2% +/- 3.9% in fatty streaks, and 1.9% +/- 0.6% in normal endothelium), and indirect immunofluorescence confirmed TRF1 uptake within the plaque wall. By contrast, the non-specific antibody did not show any significant binding. These preliminary results demonstrate the high specific affinity of TRF1 for atherosclerotic plaques, probably due to the hemorheologic phenomena that activate platelets and provoke the formation of fragment D dimers of cross-linked fibrin on the plaque surface.

Immunoscintigraphy of atherosclerotic uncomplicated lesions in vivo with a monoclonal antibody against D-dimers of insoluble fibrin.

To test the effectiveness of a new F(ab')2 monoclonal antibody against human fragment D-dimer of cross-linked fibrin in the detection of uncomplicated atherosclerotic lesions of the carotid vessel previously documented at echo-color-Doppler and selective arteriographic study, 8 patients underwent a scintigraphic study including dynamic and early and delayed (3 h later) static imaging of the neck after injection of a bolus of 99mTc-labeled monoclonal antibody, and were subsequently operated. Vessel specimens and blood samples were drawn at operation and counted. No adverse reaction occurred after administration of the monoclonal antibody. The atherosclerotic lesion appeared as a focal area of asymmetrical tracer uptake, already visible at early images in four patients, and at delayed images in five. The average tracer uptake ratio between pathological and normal vessels was 1.40+0.24 (P < 0.05) at time-activity curves derived from dynamic images, 2.17+/-0.97 (P < 0.05) at early static images and 2.05+/-0.98 (P < 0.05) at delayed static images, respectively. Mean vessel to blood uptake rate of specimens obtained at operation was 2.22+/-0.59 (P < 0.001). The study shows that the 99mTc-labeled antibody was found to be safe and capable of detecting atherosclerotic plaques in humans.

Criteria for prognostic evaluation of the results of lumbar sympathectomy: clinical, haemodynamic and angiographic findings.

Lumbar sympathectomy still has an important role in the surgical treatment of occlusive peripheral arterial diseases of the lower limbs located below the inguinal ligament, when the presence of peripheral lesions makes revascularization difficult. A consecutive series of 143 patients who underwent lumbar sympathectomy was considered, and the clinical, angiographic and haemodynamic findings evaluated. Haemodynamic studies on these patients showed a relation between the clinical improvement and the pressure index, measured at the ankle before lumbar sympathectomy. The patients with pressure index values above 0.5 had a symptomatic improvement whereas the patients with a pressure index below 0.3 gave less good results. It is therefore believed that lumbar sympathectomy showed not be considered a second operative choice but an elective operation, especially in patients affected by lesion of the superficial femoral artery, the popliteal artery and its branches, with pressure indices above 0.5 where revascularization is not possible.

Clinical and therapeutical evaluation of inflammatory aneurysms of the abdominal aorta.

Unexpected anatomical and clinical features of abdominal aortic aneurysm (AAA) may be encountered by the vascular surgeon creating technical problems that increase the normally low mortality rates of this affection. One such variant is the so called inflammatory aneurysm (IA) as a characteristic fibrosis involving the arterial wall and thus surrounding structure scan be observed. In our series of 525 patients affected by AAA the incidence of IA was about 4% (19 cases). Two groups of patients were considered: group A, including all the atherosclerotic patients, and group B 19 patients affected by IA. The latter group referred to a typical painful symptomatology in 84% of the cases: this element is of interest as only 20% of the cases of group A complained of pain. No other significant clinical or laboratory data were recorded which could allow the surgeon to perform a pre-operative differential diagnosis. In all 19 cases that underwent surgical treatment there was a 2-3 cm thick aneurysmal wall with a shiny white surface adhering to the IV portion of the duodenum, vena cava and iliac vessels and in some cases to the ureters. Histological examination of specimens of the aortic wall showed evident signs of atherosclerosis of the media and marked fibrotic thickening of the adventitia with the presence of lymphocyte aggregates: a sign of chronic inflammation. As what concerns indications and surgical treatment, there are no substantial differences. Pre-operative differential diagnosis can be made with CAT scan and ultrasound and the usual operative manoeuvres of aneurysmorrhaphy should be modified.

Outcome after early treatment of popliteal artery aneurysms.

BACKGROUND: Aneurysms of the popliteal artery are rare events with an estimated incidence of 0.1-2.8%. Their clinical importance depends on their propensity to cause thromboembolic complications or to rupture (18 to 31% of cases). This study was designed to assess the advantages of elective treatment of asymptomatic popliteal artery aneurysms so as to avoid the severe clinical manifestations that eventually arise if they remain untreated. METHODS: From 1980 to 1995, in our department we treated 28 popliteal aneurysms in 23 patients (19 elective operations and 6 emergencies). Three of the aneurysms proved amenable to fibrinolytic therapy alone. Follow-up lasted a mean 48 months (range 3 months to 15 years) in 20 patients (23 revascularizations). RESULTS: Global patency was 91.3%. Two thrombosed bypasses were treated by thrombolysis; in one case it did not resolve the ischaemia and the leg was amputated. In one case only, a graft became infected but this responded to conservative therapy with drainage and antibiotics. CONCLUSIONS: These findings suggest that popliteal aneurysms with good distal run-off should be repaired electively. Completely thrombosed aneurysms with coexistent limb-threatening ischaemia should be treated initially by thrombolysis. This will usually restore run-off and in some cases offers a valid alternative to emergency surgery for limb salvage.

Late results of reconstructive surgery for renovascular hypertension.

In order to evaluate the late results of reconstructive surgery for renovascular hypertension, a review was made on a series of 120 consecutive patients who underwent operations over a 11 year period. There were 82 males (68.3%) and 38 females (31.7%) with a mean age of 48.4 years. Renal artery by-pass grafts were used in 90% (120/133), a thromboendarterectomy in 5.2% (7/133), and other surgical procedures were performed in 4.8% (6/133). Associated vascular procedures were performed in 38.3% (46/120) of patients. Operative mortality was 2.5% (3/120) overall; there was no mortality in the isolated renal artery reconstructions. There was a clinical success (after a mean follow-up of 48 months) in 80.4% of patients. The most important factors influencing clinical result after renal revascularization were: a generalized atherosclerosis (p less than 0.05), duration of hypertension (p less than 0.01) and the early post-operative response of the blood pressure (p less than 0.01). The overall five- and ten-year actuarial survival probabilities were 85 and 68%, respectively. The most common causes of death were myocardial infarction, stroke and cancer. Cox regression analysis for variables influencing survival indicated that persistence of severe hypertension was the major determinant of late survival (p less than 0.05). Hypertension in females is better tolerated, while younger patients appear to have better results and late survival after surgical treatment.

[Role of aortofemoral bypass in the management of unilateral iliac occlusive disease. A follow-up study of 95 patients over a 25-year period]. / Terapia endoscopica del sanguinamento non varicoso del tratto digestivo superiore.

BACKGROUND: To evaluate the results in a series of patients submitted to aortofemoral bypass due to an unilateral iliac occlusion. METHODS: Retrospective follow-up study. A total of 95 patients underwent, between 1975 and 2000, aortofemoral bypass because of unilateral iliac occlusion. Most of them (71 patients) were claudicants, Fontaine stage II b, while 12 complained rest pain and 12 suffered ischemic ulcers. Mean follow-up was 128 months (min 2.5 - max 292). RESULTS: Immediate success was obtained in 88 cases (92.6%), 7 patients were submitted to early redo with restored patency in 6 cases. One month global patency was gained in 98.9% (94 cases). The mean Ankle-brachial index (ABI) improvement was 0.35. At a mean follow-up of 128 months the cumulative patency was 90.8%. During the follow-up, 15 graft occlusions were observed, followed by 9 successful reoperations achieving a 5-year secondary patency of 92.1%. The contralateral iliac artery evolved toward an occlusion in 10 patients (10.5%) during a long time observation (104 months average). CONCLUSIONS: The unilateral aortofemoral bypass confirmed an excellent long term outcome regarding effectiveness and graft related complications. The low contralateral occlusion rate, in our series, does not justify a more aggressive approach as first surgical option.

[Clinical study of picotamide in patients with vascular diseases]. / Studio clinico sulla picotamide in pazienti vasculopatici.

The authors report on a group of 44 patients operated on for vascular disease, treated with antiplatelet therapy (picotamide). These patients were followed up for a period of 12 months with clinical and instrumental controls (Doppler ultrasound) in order to evaluate the evolution of atherosclerotic disease.

Pulmonary embolism due to popliteal vein aneurysm: approach and surgical treatment - a case report.

Pulmonary embolism is the first presentation in 70-80% in patients with aneurysm of popliteal vein. We present a case of young man admitted in our hospital with respiratory distress, tachycardia and D-dimer >3000 mg/dL. The observation of pulmonary embolism required the placement of a caval temporary filter before the surgical treatment. The use of temporary filter is recommended in symptomatic patients for thromboembolic phenomena, and when ultrasound detects the presence of floating thrombus.