Kidney injury secondary to endovascular treatment of renal artery stenosis. / Povrezhdenie pochki posle éndovaskuliarnogo vmeshatel'stva pri stenoze pochechnoi arterii.

In this paper, we present a case of kidney injury as a complication of renal artery angioplasty in a 54-year-old female patient that suffered from resistant renovascular hypertension. This case emphasises the unpredictable nature of endovascular procedures, the need for careful post-procedure evaluation and the role of 'old fashioned' surgical techniques in resolving complications of endovascular procedures.

Morphological Differences in the Aorto-iliac Segment in AAA Patients of Caucasian and Asian Origin.

OBJECTIVE: The objective was to quantify aorto-iliac morphology differences between AAA patients of Caucasian and Asian origin. Additionally, the impact of patient demographic characteristics was assessed, which could influence the morphological differences. METHODS: This international multicentre study included two tertiary referral institutions from Europe and one from China. CT scans with 3D reconstruction of 296 patients with infrarenal AAA >5 cm were analysed. Eighteen measurements were recorded from each CT scan and compared between Caucasian and Asian patients. RESULTS: Caucasian patients had longer common iliac arteries (right: 65.0 vs. 33.1 mm, p < .001 left: 65.0 vs. 35.2 mm, p < .001), longer aneurysm neck (33.0 vs. 28.4 mm, p < .001), greater aneurysm to aortic axis angle (153.0° vs. 142.2°, p < .001), and longer combined aorto-iliac length (195.7 vs. 189.2 mm, p < .001). However, Asian patients had a longer infrarenal abdominal aorta (152.0 vs. 130.0 mm, p < .001), longer AAA (126.2 vs. 93.0 mm), and greater linear distance from renal artery to aorto-iliac bifurcation (143.6 vs. 116.0 mm, p < .001). Caucasian patients had a larger inner common iliac artery diameter (right: 16.0 vs. 14.9 mm, p < .001, left: 16.0 vs. 15.2 mm, p < .001), larger inner exernal iliac artery diameter (right: 9.0 vs. 7.5 mm, p < .001 left: 9.0 vs. 7.7 mm, p < .001), and larger inner common femoral artery diameter (right: 10.0 vs. 5.9 mm, p < .001 left: 10.0 vs. 6.1 mm, p < .001). No difference was observed in AAA transverse diameter (62.0 vs. 63.1 mm, p = .492). CONCLUSION: The results showed that aorto-iliac anatomy in Caucasians differs significantly from Asians, particularly in the length of the common iliac arteries and infrarenal abdominal aorta, and in the transverse diameter of the common, external iliac, and common femoral arteries. Therefore, the exact criteria for stent graft design are dependent on the racial origin of the patient.

Posterior approach for sciatic aneurysm repair - technical note.

Aneurysm of the persistent sciatic artery is a rare cause of limb ischemia, which is a challenge for both diagnosis and treatment. After successful diagnosis adequate treatment may require skills in open and endovascular surgery. We present a patient with the aneurysm of the persistent sciatic artery treated by bypass procedure with PTFE graft using posterior approach. We named this procedure "dorsal bypass". Detailed explanation of clinical presentation, diagnosis and the surgical procedure is given in this paper.

Treatment strategy for ruptured abdominal aortic aneurysms.

Rupture is the most serious and lethal complication of the abdominal aortic aneurysm. Despite all improvements during the past 50 years, ruptured abdominal aortic aneurysms are still associated with very high mortality. Namely, including patients who die before reaching the hospital, the mortality rate due to abdominal aortic aneurysm rupture is 90%. On the other hand, during the last twenty years, the number of abdominal aortic aneurysms significantly increased. One of the reasons is the fact that in majority of countries the general population is older nowadays. Due to this, the number of degenerative AAA is increasing. This is also the case for patients with abdominal aortic aneurysm rupture. Age must not be the reason of a treatment refusal. Optimal therapeutic option ought to be found. The following article is based on literature analysis including current guidelines but also on my Clinics significant experience. Furthermore, this article show cases options for vascular medicine in undeveloped countries that can not apply endovascular procedures at a sufficient level and to a sufficient extent. At this moment the following is evident. Thirty-day-mortality after repair of ruptured abdominal aortic aneurysms is significantly lower in high-volume hospitals. Due to different reasons all ruptured abdominal aortic aneurysms are not suitable for EVAR. Open repair of ruptured abdominal aortic aneurysm should be performed by experienced open vascular surgeons. This could also be said for the treatment of endovascular complications that require open surgical conversion. There is no ideal procedure for the treatment of AAA. Each has its own advantages and disadvantages, its own limits and complications, as well as indications and contraindications. Future reductions in mortality of ruptured abdominal aortic aneurysms will depend on implementation of population-based screening; on strategies to prevent postoperative organ injury and also on new medical technology improvements. Taking this into consideration, education of young vascular surgeons in endovascular but also in open aortic surgery, is of vast importance.

Abdominal aortic aneurysm volume and relative intraluminal thrombus volume might be auxiliary predictors of rupture-an observational cross-sectional study.

Objectives: The study aimed to identify differences and compare anatomical and biomechanical features between elective and ruptured abdominal aortic aneurysms (AAAs). Methods: Data (clinical, anatomical, and biomechanical) of 98 patients with AAA, 75 (76.53%) asymptomatic (Group aAAA) and 23 (23.46%) ruptured AAA (Group rAAA), were prospectively collected and analyzed. Anatomical, morphological, and biomechanical imaging markers like peak wall stress (PWS) and rupture risk equivalent diameter (RRED), comorbid conditions, and demographics were compared between the groups. Biomechanical features were assessed by analysis of Digital Imaging and Communication in Medicine images by A4clinics (Vascops), and anatomical features were assessed by 3Surgery (Trimensio). Binary and multiple logistic regression analysis were used and adjusted for confounders. Accuracy was assessed using receiving operative characteristic (ROC) curve analysis. Results: In a multivariable model, including gender and age as confounder variables, maximal aneurysm diameter [MAD, odds ratio (OR) = 1.063], relative intraluminal thrombus (rILT, OR = 1.039), and total aneurysm volume (TAV, OR = 1.006) continued to be significant predictors of AAA rupture with PWS (OR = 1.010) and RRED (OR = 1.031). Area under the ROC curve values and correct classification (cc) for the same parameters and the model that combines MAD, TAV, and rILT were measured: MAD (0.790, cc = 75%), PWS (0.713, cc = 73%), RRED (0.717, cc = 55%), TAV (0.756, cc = 79%), rILT (0.656, cc = 60%), and MAD + TAV + rILT (0.797, cc = 82%). Conclusion: Based on our results, in addition to MAD, other important predictors of rupture that might be used during aneurysm surveillance are TAV and rILT. Biomechanical parameters (PWS, RRED) as valuable predictors should be assessed in prospective clinical trials. Similar studies on AAA smaller than 55 mm in diameter, even difficult to organize, would be of even greater clinical value.

Dacron or ePTFE graft for above-knee femoropopliteal bypass reconstruction. A bi-centre randomised study.

BACKGROUND: The objective of this study was to compare polyester (Dacron) and expanded polytetrafluorethilene (ePTFE) grafts for above-knee femoropopliteal bypass. PATIENTS AND METHODS: Eighty five patients with disabling claudications or limb threatening ischemia suitable for above-knee femoropopliteal reconstruction were randomized into two groups. In the first group the surgery was performed using 8 mm Dacron graft, whereas the patients in the second group were operated using ePTFE grafts. RESULTS: The primary patency rates for Dacron and ePTFE were 100 %, and 88.37 % (p < 0.05), while secondary patency rates were 83.3 % and 75 % (p > 0.05) respectively. The early limb salvage rates for Dacron and ePTFE were 100 % and 97.7 % (p > 0.05). Early (30-day) complications (bleeding 2.38 % and 2.32 %; wound infection 11.9 % and 11.63 %) occurred in both groups with similar frequency (p > 0.05). The patients were followed up over a period of 6 to 12 months (mean 8.3 +/- 3.6 months). The overall mortality rate in the follow-up period was 2.38 % (one patient) for Dacron and 6.98 % (three patients) for ePTFE group (p > 0.05). Late graft infection was noted in three patients (7.1 %) in Dacron, and two patients (4.65 %) in ePTFE group (p > 0.05). Primary patency rates were not significantly influenced by obesity, diabetes, hypertension, hyperlipidemia, cigarette smoking, (p > 0.05). However, poor run-off (only one crural artery patent on preoperative angiography) significantly decreased patency of both grafts and favored the use of ePTFE graft (p < 0.05). CONCLUSIONS: This study confirms that both materials are suitable for above-knee femoropopliteal reconstructions. Above-knee femoropopliteal bypass does not have a good long-term prognosis in the presence of poor run-off.

Alteration of expression of muscle specific isoforms of the fragile X related protein 1 (FXR1P) in facioscapulohumeral muscular dystrophy patients.

BACKGROUND: The Fragile X Mental retardation-Related 1 (FXR1) gene belongs to the fragile X related family, that also includes the Fragile X Mental Retardation (FMR1) gene involved in fragile X syndrome, the most common form of inherited mental retardation. While the absence of FMRP impairs cognitive functions, inactivation of FXR1 has been reported to have drastic effects in mouse and xenopus myogenesis. Seven alternatively spliced FXR1 mRNA variants have been identified, three of them being muscle specific. Interestingly, they encode FXR1P isoforms displaying selective RNA binding properties. METHODS AND RESULTS: Since facioscapulohumeral muscular dystrophy (FSHD) is an inherited myopathy characterised by altered splicing of mRNAs encoding muscle specific proteins, we have studied the splicing pattern of FXR1 mRNA in myoblasts and myotubes of FSHD patients. We show here that FSHD myoblasts display an abnormal pattern of expression of FXR1P isoforms. Moreover, we provide evidence that this altered pattern of expression is due to a specific reduced stability of muscle specific FXR1 mRNA variants, leading to a reduced expression of FXR1P muscle specific isoforms. CONCLUSION: Our data suggest that the molecular basis of FSHD not only involves splicing alterations, as previously proposed, but may also involve a deregulation of mRNA stability. In addition, since FXR1P is an RNA binding protein likely to regulate the metabolism of muscle specific mRNAs during myogenesis, its altered expression in FSHD myoblasts may contribute to the physiopathology of this disease.

Single-center prospective, randomized analysis of conventional and eversion carotid endarterectomy.

AIM: Several studies, comparing early and long-term results of the conventional carotid endarterectomy (CEA) and eversion carotid endarterectomy (EEA), were conducted for past 10 years. Nevertheless, it still remaining difficult to choose optimal endarterectomy technique. Choice yet mainly depends of experience of attending surgeon. The aim of this study was the comparison early and long-term results of the EEA and CEA. METHODS: Randomly, 103 patients were operated on in the eversion, and 98 patients in the conventional technique; 97 (48.3%) patients were asymptomatic and 104 (51.7%) had symptomatic lesions. All patients underwent preoperative cervical duplex scanning and neurological examination. The surgical procedure was carried out under general anesthesia. In cases with retrograde blood pressure less than 20 mmHg shunt was used; 78.6% of all CEA were finished up with ''patch'' angioplasty and 21.4% by primary suture. The primary outcomes were perioperative and late mortality, perioperative and late central neurological complications, a long-term survival rate and late restenosis incidence. RESULTS: The mean follow-up was 38 months. Mortality and long-term survival rate were similar in compared groups. The perioperative central neurological complications incidence were comparable in study groups (3.9% vs 12.1% , odds ratio 3.45, 95% confidence interval 1.1-11.1; P=0.029). The late restenosis incidence was significantly lower in eversion group (0.0% vs 6.1%). CONCLUSION: EEA has an advantage over the conventional procedure. The authors recommend CEA in cases when retrograde pressure indicated the use of the intraluminal shunting.

Heart and renal failure in renovascular hypertension caused by giant cell arteritis--case report.

We report a case of a male teenager with severe heart and acute renal failure as the dominant clinical manifestations of renovascular hypertension (RVH) caused by atypical giant cell arteritis (GCA). Unrecognized RVH and treatment of the consequent heart failure by angiotensin-converting enzyme inhibitors (ACEI) probably contributed to progression of renovascular disease to bilateral renal artery occlusion. Recurrent "flash" pulmonary edemas could not be prevented until surgical revascularization of the only functioning right kidney was achieved by an aortorenal bypass. Prompt post-operative normalization of heart function and arterial hypertension occurred despite the histopathological finding of the resected renal artery compatible with GCA and 4-year duration of significant renovascular disease. At the last check-up, the patient was asymptomatic, with normal arterial pressure on the prescribed treatment: carvedilol, hydrochlorothiazide, prednisolone 20 mg daily and aspirin. Subsequent follow-up is necessary to observe the evolution of GCA as an exceptionally rare cause of RVH.

Treatment of visceral artery aneurysms: retrospective study of 35 cases.

BACKGROUND: Visceral artery aneurysms (VAA) represent a rare clinical entity with possible life-threatening complications. The presentation, diagnosis and management vary accordingly to the artery involved and the underlying pathology. PATIENTS AND METHODS: During a 25-year period (1980-2005), 35 patients (25 males + 10 females, age range 36-73 years-median 59.2 years) with VAA were treated at two tertiary vascular surgery centers in Belgrade. All data were retrospectively collected from the patient's records. RESULTS: On presentation, 19/35 patients were symptomatic, and 3/35 had ruptured VAA. Surgery was performed in 28 cases; most commonly involved arteries were splenic (11), hepatic (5), celiac trunk (5), superior mesenteric (3), inferior mesenteric (3) and gastroduodenal (1). Fatal rupture occurred in two patients. In 5 patients abdominal aortic aneurysm was associated with VAA, and in 4 patients multiple aneurysms of the involved artery were noted. Successful embolization was performed in 3 patients. Overall, four patients were treated medically. In the surgically treated patients, perioperative mortality and morbidity were 11% (3/28) and 40% (10/25) respectively. Of 25 patients included in the long-term follow up, six died. CONCLUSION: Since VAA have considerable tendency to rupture, an active approach is necessary. Based on our experience, surgical treatment could be recommended for any VAA patient with symptoms. In addition, we believe that the choice of the therapeutic procedure should be made on an individual basis.

Hip fracture risk in older white men is associated with change in body weight from age 50 years to old age.

BACKGROUND: Change in body weight is a potentially modifiable risk factor for hip fracture in older women but, to our knowledge, its relationship to risk in older men has not been reported previously. OBJECTIVE: To investigate the effects of weight loss and weight gain from age 50 years to old age on the risk of hip fracture among elderly men. METHODS: The association between weight change and risk of hip fracture was studied in a cohort of 2413 community-dwelling white men aged 67 years or older from 3 sites of the Established Populations for Epidemiologic Study of the Elderly. RESULTS: The older men in this study, observed for a total of 13620 person-years during the 8 years of follow-up, experienced 72 hip fractures, yielding an overall incidence rate of 5.3 per 1000 person-years. Extreme weight loss (> or =10%) beginning at age 50 years was associated in a proportional hazards model with increased risk of hip fracture (relative risk, 1.8; 95% confidence interval, 1.04-3.3). Weight loss of 10% or more was associated with several indicators of poor health, including physical disability, low mental status score, and low physical activity (P<.05). Weight gain of 10% or more beginning at age 50 years provided borderline protection against the risk of hip fracture (relative risk, 0.4; 95% confidence interval, 0.1-1.00). CONCLUSIONS: Despite differences between older men and women in the incidence of and risk factors for hip fracture, weight history is also an important determinant of the risk of hip fracture among older men. Weight loss of 10% or more beginning at age 50 years increases the risk of hip fracture in older white men; weight gain of 10% or more decreases the risk of hip fracture. The relationship between extreme weight loss and poor health suggests that weight loss is a marker of frailty that may increase the risk of hip fracture in older men. Physicians should include weight history in their assessment of the risk of hip fracture among older men.

Ex vivo repair of renal artery aneurysm associated with repairing of abdominal aortic aneurysm. Case report.

A case of right renal artery distal aneurysm associated with juxtarenal abdominal aortic aneurysm in a 75-year-old male, who presented with abdominal and back pain and chronic renal failure, is reported. The abdominal aortic aneurysm was repaired with a bifurcated Dacron graft. The right kidney was simultaneously explanted, ex vivo reconstruction of the renal artery with PTFE graft was performed, followed by autotransplantation of the kidney into the right iliac fossa. In the postoperative course the renal function returned to normal.

Aorto-caval fistulas: a review of eighteen years experience.

The operative treatment of 26 aorto-caval fistulas during the last 18 years is reviewed (24 male and two female patients; average of 65.3 year). Out of 1698 cases presenting an abdominal aortic aneurysm, 406 presented with rupture, and 26 had aorto caval fistula. In 24 cases (92.3%) it concerned an atherosclerotic aneurysm. One aneurysm with aorto-caval fistula was secondary to abdominal blunt trauma (3.8%), and one due to iatrogenic injury (3.8%). The time interval between first clinical signs of aorto-caval fistula and diagnosis, ranged from 6 hours to 2 years (average 57,3 days). Clinical presentation included congestive heart failure infive patients (11.5%), extreme leg edema in 13 (50.0%), hematuria in 2 (7.0%), renal insufficiency 2 (7.0%), and scrotal edema in six patients. Diagnosis was made by means of color duplex scan in eight patients (30.7%), CT in seven patients (27%), NMR in three patients (11.5%), and angiography in seven patients (27%). Most reliable physical sign was an abdominal bruit,present in 20 patients (77%). In ten patients (38.4%) correct diagnosis was not made prior to surgery. The operative treatment consisted of transaortic suture of the vena cava (25 pts-96.0%), and aneurysm repair. Five operative deaths occurred (19,2%), and for all of them it concerned a misdiagnosis. Cause of death was myocardial infarction (one patient-3.8%), massive bleeding (one patient-3.8%), MOF (two patients-7, 0%), and colon gangrene (one patient-3.8%). Follow-up period varied from six months to 18 years (mean 4 years and two months). Long term results showed a 96% patency rate. No postoperative lower extremity venous insufficiency nor pelvic venous hypertension was observed post-operatively.

Differences between immediate and late onset of spinal cord ischemia after open and endovascular aortic interventions.

Spinal cord ischemia remains the most impressive and colliding complication following open surgical and endovascular aortic procedures. Paraparesis and paraplegia are devastating, having a major invalidating impact on the patient's life. Also for the surgeon and the entire team this dramatic adverse event causes a significant concussion. Surgeons faced this problem in practice in the 1950s when this surgery started being applied. Even A. Carrel in 1910 said, "The main danger of the aortic operation does not come from the heart or from the aorta itself, but from the central nervous system". As the number of these surgeries grew, some were followed by the spinal cord ischemia. Now, in 21st century, problem of spinal cord ischemia still exists. By understanding the reasons of its development we shall be able to find more useful methods for prevention as well as for the treatment. The aim of this article was to search what is behind this dreadful complication, explaining different mechanisms which take part in its development during endovascular and open surgical treatment.

Incidence of and indications for conversion of cervical plexus block to general anesthesia in patients undergoing carotid surgery: a single center experience.

AIM: He aim of this paper was to investigate the incidence of and the indications for conversion to general anesthesia (GA) in a large single-center series of patients undergoing carotid surgery under cervical plexus block (CPB). METHODS: With IRB approval we retrospectively analyzed the medical records of all patients who underwent carotid surgery under CPB from November 2007 to October 2010. Cervical plexus was blocked at both the superficial and deep levels. An intraluminal shunt was inserted in patients who demonstrated signs of inadequate cerebral perfusion upon carotid clamping (CC). Propofol was given to patients reporting pain or discomfort throughout the procedure. The primary outcomes were the number and percentage of conversions to GA as well as the indications for this intervention. The secondary outcome was the incidence of partial cervical block failure, defined as the need for supplemental propofol administration for pain relief during surgery. RESULTS: In total, 1464 carotid surgical procedures were performed under CPB in 1305 consecutive patients during the investigated period. Conversion to GA was required in 17 (1.2%) patients. The most common reason for conversion to GA was persisting neurological deterioration upon CC and intraluminal shunt insertion, which was recorded in 8/17 (47.1%) procedures. Other indications to convert were systemic toxicity of local anesthetics, pain, general discomfort and restlessness during surgery, and acute myocardial infarction. CONCLUSION: Cervical plexus block for carotid surgery is associated with a low rate of conversions to GA. Neurological deterioration upon carotid clamping and local anesthetic toxicity are identified as the most common indications for such intervention.