"Silent" thrombosis of an abdominal aortic aneurysm not producing acute limb ischemia.

Thrombosis of an abdominal aortic aneurysm is a rare devastating complication with an estimated mortality rate of 50%. Simultaneous acute pain, pallor and coldness of the lower limbs, mottling from the level of iliac crests or umbilicus, paraplegia and absence of femoral pulses are all manifestations of a sudden and acute interruption of blood flow through the aneurysmatic aorta. We report a case of an occlusion of an abdominal aortic aneurysm during hospitalization which was not manifested with symptoms of limb ischemia. In this case we feature the rare and unusually "silent" presentation of the event.

Persistent endoleak after endovascular exclusion of an aortocaval fistula, producing renal insufficiency.

This report presents a case of type II endoleak after endovascular exclusion of a primary aortocaval fistula, producing renal vein hypertension and renal insufficiency. A 74-year-old patient presented with acute renal insufficiency, hematuria, lower limb edema, and weight gain. The abdominal CT scan revealed an abdominal aortic aneurysm and an aortocaval fistula. An endograft was deployed but type II endoleak was present and persisted after surgical ligation of the inferior mesenteric artery and subsequent unsuccessful attempt of coil-embolization. The patients renal function continued to be impaired. Surgical ligation of aortocaval communication with preservation of the endograft was performed, resulting in restored renal function.

Serum interleukin-6 is elevated in symptomatic carotid bifurcation disease.

INTRODUCTION: The levels of circulating proinflammatory cytokines may express the extent of the inflammatory response and their participation in plaque progression and rupture needs to be evaluated. We aimed to investigate differences in circulating levels of proinflammatory cytokines and in plaque infiltration by macrophages between patients undergoing carotid endarterectomy for symptomatic and asymptomatic carotid atherosclerotic disease. METHODS: One hundred nineteen patients (91 men and 28 women; mean age 66 +/- 8 years; range 42-83 years) who underwent carotid endarterectomy for significant (>70%) carotid bifurcation stenosis were enrolled in this study. Patients were characterized as symptomatic (n = 62) or asymptomatic (n = 57) after neurological examination. Serum levels of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), IL-1beta, serum amyloid A (SAA), and high-sensitivity C-reactive protein (hs-CRP) were evaluated. Macrophage infiltration of the plaque was assessed quantitatively from endarterectomy specimens using the monoclonal antibody CD68. RESULTS: Serum IL-6 levels were significantly higher in patients with symptomatic compared with those with asymptomatic carotid disease (3.3 [2.0-6.5] pg/ml vs 2.5 [1.9-4.1] pg/ml, P = 0.02). TNF-alpha, IL-1beta, SAA, and hs-CRP levels did not differ significantly between the two groups. Symptomatic patients had also more intense macrophage accumulation in the carotid plaque compared with asymptomatic patients (0.6 +/- 0.1% vs 0.4 +/- 0.1%, P < 0.001). Although there were correlations between the levels of the different inflammatory markers, there were no correlation between any of them and the extent of plaque macrophage infiltration. CONCLUSION: Patients with symptomatic carotid atherosclerotic disease have elevated serum IL-6 levels compared with asymptomatic patients. Symptomatic patients have also more intense macrophage infiltration of the atherosclerotic plaque suggesting that inflammatory process may contribute to the destabilization of the carotid plaque.

Giant abdominal aortic aneurysms: clinical and technical considerations.

The rupture risk of abdominal aortic aneurysms (AAA) depends primarily on their diameter and increases substantially in large aneurysms. Only a few cases of giant AAAs, with a maximum diameter > 13 cm have been reported in the English literature. This case series report describes 3 cases of giant AAAs presented with rupture. All cases were managed with open surgical repair, since anatomic factors prevented us from choosing an endovascular approach. The huge size of the aneurysm, the short length of the neck and the dislodgement of abdominal organs, that may be densely adhered to its surface with fistula formation, make surgery of this entity very challenging. Open repair of giant AAAs is often the only available treatment, though not always with good results.

Cardiac troponin I in patients with acute upper and lower limb ischemia.

BACKGROUND: The aim of this study was to investigate the presence, etiology and clinical significance of elevated troponin I in patients with acute upper or lower limb ischemia. The high sensitivity and specificity of cardiac troponin for the diagnosis of myocardial cell damage suggested a significant role for troponin in the patients investigated for this condition. The initial enthusiasm for the diagnostic potential of troponin was limited by the discovery that elevated cardiac troponin levels are also observed in conditions other than acute myocardial infarction, even conditions without obvious cardiac involvement. PATIENTS AND METHODS: 71 consecutive patients participated in this study. 31 (44%) of them were men and mean age was 75.4 +/- 10.3 years (range 44-92 years). 60 (85%) patients had acute lower limb ischemia and the remaining (11; 15%) had acute upper limb ischemia. Serial creatine kinase (CK), isoenzyme MB (CK-MB) and troponin I measurements were performed in all patients. RESULTS: 33 (46%) patients had elevated peak troponin I (> 0.2 ng/ml) levels, all from the lower limb ischemia group (33/60 vs. 0/11 from the acute upper limb ischemia group; p = 0.04). Patients with lower limb ischemia had higher peak troponin I values than patients with upper limb ischemia (0.97 +/- 2.3 [range 0.01-12.1] ng/ml vs. 0.04 +/- 0.04 [0.01-0.14] ng/ml respectively; p = 0.003), higher peak CK values (2504 +/- 7409 [range 42-45 940] U/ml vs. 340 +/- 775 [range 34-2403] U/ml, p = 0.002, respectively, in the two groups) and peak CK-MB values (59.4 +/- 84.5 [range 12-480] U/ml vs. 21.2 +/- 9.1 [range 12-39] U/ml, respectively, in the two groups; p = 0.04). Peak cardiac troponin I levels were correlated with peak CK and CK-MB values. CONCLUSIONS: Patients with lower limb ischemia often have elevated troponin I without a primary cardiac source; this was not observed in patients presenting with acute upper limb ischemia. It is very important for these critically ill patients to focus on the main problem of acute limb ischemia and to attempt to treat the patient rather than the troponin elevation per se. Cardiac troponin elevation should not prevent physicians from providing immediate treatment for limb ischaemia to these patients, espescially when signs, symptoms and electrocardiographic findings preclude acute cardiac involvement.

Our experience with carotid endarterectomy without patch and shunt.

The purpose of the present study was to assess the efficacy of endarterectomy without patch and shunt using a homogeneous group of patients. From January 1987 through December 1994, ninety-eight patients (70 males and 28 females) with mean age 67 years and unilateral atherosclerotic carotid stenosis underwent endarterectomy without the use of a shunt, patch, EEG, stump pressure measurements or other methods. The patients were preoperatively classified into three groups according to clinical symptoms. The overall neurologic morbidity consisted of 2 (2%) permanent and 3 (4%) temporary deficits. Based on our results we concluded that endarterectomy without a shunt is a simple, safe method in cases with no hemodynamically concomitant significant lesions. The neurological complications are probably due to embolization rather than temporary ischemia during operation.

Vascular manifestations of Behcet's disease: report of a case and review of the literature.

Adamantiades-Behçet's disease (ABD) is a relapsing vasculitis of unknown aetiology and variable clinical manifestations. The syndrome can be presented in a myriad of ways and can involve nearly every organ. Although vascular involvement is not included among the ABD diagnostic criteria, it is a unique clinical manifestation in adults with a potentially devastating outcome. We report an ABD case, presenting with a thrombotic occlusion of the inferior vena cava. The authors review the recent literature, emphasizing the spectrum of vascular manifestations accompanying Behçet's disease.

Duration of aortic cross-clamping during elective open abdominal aortic aneurysm repair operations and postoperative cardiac/renal function.

AIM: To determine the effect of the duration of aortic cross-clamping during elective infrarenal abdominal aortic aneurysm (AAA) repair operations on postoperative cardiac and renal function. METHODS: Fifty patients scheduled for open infrarenal AAA repair underwent pre- and postoperative evaluation of serum creatinine and troponin levels. The patients were divided into 2 groups according to the duration of aortic cross-clamping (Group A: <50 min; Group B: >50 min). RESULTS: A prolonged (>50 min) duration of aortic cross-clamping was associated with an increase in post-operative serum troponin (P<0.001) and serum creatinine values (P<0.001). A prolonged duration of aortic cross-clamping was the only independent predictor of postoperative renal (r=0.534; P<0.001) and cardiac dysfunction (r=0.578; P<0.001). CONCLUSION: Elective open infrarenal AAA repair procedures may be associated with mild/moderate cardiac and/or renal dysfunction, especially when aortic cross-clamping time is prolonged. Measuring serum troponin and creatinine levels before and after such operations may reveal an often clinically-silent post-operative cardiac and/or renal dysfunction.

Anastomotic pseudoaneurysms: our experience with 49 cases.

We investigated the factors implicated in the pathogenesis of anastomotic aneurysm formation and the postoperative course of patients with such a complication. Forty-five patients with 49 anastomotic aneurysms were diagnosed and treated in two vascular surgery departments in Athens, Greece, during an 8-year period. Emergent complications occurred in 15 cases, rupture in 11, and thromboembolic episodes in another four. Preoperative diagnostic workup in the remaining elective cases (n = 34) included color duplex scan, computed tomographic scan, and angiography. All patients underwent operation, and cultures were obtained during the surgical procedures. Histological examination of the host artery wall adjacent to the aneurysm was also performed. Aortobifemoral bypass was the original operation performed in the majority of cases (71%), and the femoral anastomosis was the most frequent site involved (85.7%). Emergent procedures were associated with increased mortality (46.6%), whereas elective operation resulted in high patency rates and no mortality. In an attempt to isolate predisposing factors that contributed to aneurysm formation, we concluded that the etiology was multifactorial in approximately one-third of the cases and degenerative host artery disease was the main cause (40%). Arterial degeneration is the leading cause of anastomotic aneurysm formation, and emergency arterial reconstruction in cases of aneurysm complication is associated with a poor prognosis.

Arterial injuries associated with lower-extremity fractures.

The records of 110 patients with arterial injuries of the lower extremities associated with bone fractures, and managed in the authors' vascular surgery clinic, were reviewed. The majority (72%) were young men; 66 had blunt and 44 penetrating arterial injuries. A total of 92 patients were treated by saphenous vein interposition grafting, 12 with composite grafts and six with polytetrafluoroethylene grafts. The limb salvage rate was 93%. All eight amputations were in neglected cases with arterial injury at the popliteal or infrapopliteal level and associated with muscle loss.