Carotid Plaque Composition Assessed by CT Predicts Subsequent Cardiovascular Events among Subjects with Carotid Stenosis.

BACKGROUND AND PURPOSE: Currently, the characteristics of carotid plaques are considered important factors for identifying subjects at high risk of stroke. This study aimed to test the hypothesis that carotid plaque composition assessed by CTA is associated with an increased risk of future major adverse cardiovascular events among asymptomatic subjects with moderate-to-severe carotid artery stenosis. MATERIALS AND METHODS: This single-center, retrospective cohort study included 194 carotid plaques from 176 asymptomatic subjects with moderate-to-severe carotid artery stenosis. The association of CTA-determined plaque composition with the risk of subsequent adverse cardiovascular events was analyzed. RESULTS: During a median follow-up of 41 months, the adverse cardiovascular event incidence among 194 carotid plaques was 19.6%. There were significant differences in plaque Hounsfield units (P < .001) and spotty calcium presence (P < .001) between carotid plaques from subjects with and without subsequent adverse cardiovascular events. Multivariable analysis revealed carotid plaque Hounsfield unit density (P < .001) and spotty calcium (P < .001) as independent predictors of subsequent adverse cardiovascular events. In association with moderate carotid artery stenosis, the plaque Hounsfield unit values were significantly lower among carotid plaques from subjects who experienced subsequent adverse cardiovascular events (P = .002), strokes (P = .01), and cardiovascular deaths (P = .04); the presence of spotty calcium was significantly associated with the occurrence of adverse cardiovascular events (P = .001), acute coronary syndrome (P = .01), and cardiovascular death (P = .04). CONCLUSIONS: Carotid plaque Hounsfield unit density and spotty calcium were independent predictors of a greater risk of adverse cardiovascular event occurrence.

Impact of Shaggy Aorta in Patients with Abdominal Aortic Aneurysm Following Open or Endovascular Aneurysm Repair.

OBJECTIVE: To analyze the impact of the presence of shaggy aorta on 30 day morbidity and mortality and long-term survival in patients undergoing abdominal aortic aneurysm (AAA) repair. METHODS: This retrospective observational study included 447 consecutive patients who underwent AAA repair between January 2009 and December 2012. The study included 209 patients (47%) having open surgical repair (OSR) and 238 patients (53%) having endovascular aneurysm repair (EVAR). RESULTS: Of the 447 patients having elective AAA repair, 48 patients (11%) had shaggy aorta. Both the OSR (p = .005) and EVAR group (p = .007) demonstrated a higher 30 day morbidity and mortality in patients with shaggy aorta. On multivariate regression analysis, patients with shaggy aorta had 4.1 fold (95% CI = 1.7-9.7; p = .002) increase in 30 day morbidity and mortality. According to the Kaplan-Meier analysis, patients with shaggy aorta had significantly decreased long-term overall survival in comparison with the non-shaggy group (log-rank test; p = .005), and this resulted from comorbidities. CONCLUSIONS: Shaggy aorta is a prominent risk factor associated with 30 day morbidity and mortality. Poor long-term survival was expected in patients with shaggy aorta.

Surgical treatment of central venous catheter related septic deep venous thrombosis.

OBJECTIVE/BACKGROUND: The aim of this study was to evaluate the clinical features and outcomes of catheter related central venous thrombosis and whether a surgical approach can be an effective treatment modality in selected cases that are refractory to conservative management. METHODS: This was a retrospective review of the 46 consecutive patients who were suspected of having central venous catheter related infected deep venous thrombosis and who met the eligibility criteria. RESULTS: Conservative management achieved clinical improvement in 26 (56.5%) patients and failed in 20 (43.5%), of whom surgical thrombectomy was performed in 13. The remaining seven patients died before surgery could be performed or their clinical condition was too poor. Apart from one case of wound hematoma (7.7%), post-operative complications that related to the surgical procedure were not observed. Patency of the involved vein was re-established in 12 of the 13 (92.3%) surgically treated patients, and clinical improvement was achieved in 11 (84.6%). In particular, the five patients whose blood cultures revealed Candida species exhibited prompt defervescence after surgical thrombectomy. CONCLUSION: Although conservative management is the first therapy of choice in patients with central venous catheter related infected thrombosis, surgical treatment that removes the septic material can be regarded as a last resort in critically ill patients with septic thrombophlebitis that is refractory to conservative management.

Arteriovenous access creation defers chronic hemodialysis initiation.

AIMS: This study evaluated whether arteriovenous access (AVA) creation before hemodialysis might affect the rate of decline of renal function. METHODS: This was a retrospective, case-control study comparing two groups of 80 patients each. The AVA group underwent AVA creation more than 2 months before initiation of chronic hemodialysis (CHD). The catheter group (i.e., the control group) commenced CHD through a temporary catheter. The catheter group patients were matched with AVA group patients in terms of age, gender, nature of underlying disease, and rate of decline in estimated glomerular filtration rate (eGFR) before AVA creation. The zero point (Z-point) was defined as the date of AVA creation for AVA patients, or the date on which the same eGFR was attained by each catheter group patient compared with a matched AVA patient. Time-to-dialysis was defined as the interval from the Z-point to the date of initiation of dialysis. The rates of change in eGFR before and after the Z-point were also measured. RESULTS: The AVA and catheter groups were similar in terms of baseline characteristics. The Z-point eGFR (ml/min/1.73 m2) was 11.4±3.1 in the AVA group and 11.3±3.2 in the catheter group. The eGFR at the time of dialysis was 6.4±2.0 in the AVA group and 6.1±1.9 in the catheter group. The mean and median dialysis-free time was longer in the AVA than in the catheter group (14.2±9.4 vs. 5.9±4.1 months, 13.1 (3-41) vs. 5.0 (2-17) months, p<0.001). Multivariate proportional Cox's hazard modeling showed that the AVA group and the Z-point eGFR were each independent predictors of the time to initiation of CHD. The mean changes in eGFR per month (delta eGFR) before the Z-point were similar for the two groups. For the AVA group, the mean delta eGFR was lower after the Z-point compared to before (-0.63 vs. -0.21 ml/min/1.73 m2, p=0.002). For the catheter group, the mean delta eGFR was similar before and after the Z-point (-0.63 vs. -0.67 ml/min/1.73 m2). The mean delta eGFR after the Z-point was less in the AVA group compared to the catheter group (-0.67 vs. -0.21 ml/min/1.73 m2, p=0.002). CONCLUSION: In this retrospective observational study, AVA creation appears to retard the rate of decline in eGFR and to defer CHD initiation.

Conservative management of symptomatic spontaneous isolated dissection of the superior mesenteric artery.

BACKGROUND: Spontaneous isolated dissection of the superior mesenteric artery (SMA) is uncommon. Because of its rarity, the risk factors, aetiology and natural history are unclear, and there is no consensus on the optimal treatment strategy. METHODS: Seven consecutive patients with symptomatic spontaneous isolated SMA dissection who received conservative treatment between March 2003 and February 2008 were included in this study. Their clinical characteristics, treatment methods and outcomes were analysed retrospectively. RESULTS: Acute abdominal pain was the most common clinical manifestation. Initial contrast-enhanced dynamic computed tomography (CT) showed isolated SMA dissection with partial thrombosis in all seven patients. Full anticoagulation was carried out immediately after the diagnosis. Clinical symptoms disappeared within 14 days and follow-up CT showed complete resolution of the dissection in four patients. After a mean follow-up of 23 months, there was no mortality or morbidity related to the dissection. CONCLUSION: In patients with symptomatic spontaneous isolated dissection of the SMA, conservative management is feasible if there is no evidence of bowel infarction or bleeding.

Protein C and/or S deficiency presenting as peripheral arterial insufficiency.

Although protein C and/or S deficiency has frequently been associated with venous thromboembolic events, instances of arterial thromboses have been reported. However, the exact incidence of protein C and/or S deficiency in patients with peripheral arterial insufficiency has not been established. Furthermore, given the lack of adequate studies to define the natural history and angiographic findings of these patients, the treatment has not been well delineated. Therefore, we conducted a prospective study to investigate the prevalence, characteristic angiographic findings and optimal treatments in patients with peripheral arterial insufficiency associated with protein C and/or S deficiency. Between September 2000 and August 2004, 133 patients who presented with peripheral arterial insufficiency underwent hypercoagulability tests before the initiation of any treatments. Of these, 11 patients (8.3%) with protein C and/or S deficiency were included in this study. There were nine males and two females. The ages ranged from 38 years to 72 years (mean 57 years). All patients showed characteristic angiographic findings: long segment thrombotic occlusion of a main peripheral artery without evidence of atherosclerosis or with mild atherosclerotic changes in the aorta and other major arterial trees. Surgical or endovascular procedures were performed in nine patients: bypass graft in four, thrombectomy in four and catheter-directed thrombolysis in one. Conservative treatment with full anticoagulation was performed in two patients. All patients received pre- and post-operative anticoagulation. Except for one amputated case, clinical and vascular laboratory improvements were achieved in 10 patients. Mean follow-up period was 21 months (range 4-45 months). However, one patient, in whom re-vascularization surgery was performed successfully, discontinued warfarin therapy himself at 10 months after surgery, graft occlusion and limb loss occurred at 30 months after surgery. This initial experience suggests that protein C and/or S deficiency may be an independent risk factor for peripheral arterial insufficiency. Patients who present with peripheral arterial insufficiency and protein C and/or S deficiency demonstrate characteristic angiographic findings. Once the diagnosis of protein C and/or S deficiency is made, patients should be treated with life-long anticoagulation.

Cytomegalovirus infection of the graft duodenum and urinary bladder after simultaneous pancreas-kidney transplantation.

Cytomegalovirus (CMV) is an important cause of morbidity after solid organ transplantation. We report a case of CMV infection involving the transplanted duodenum that developed after simultaneous pancreas-kidney transplantation. The patient, a 30-year-old woman with insulin-dependent diabetes undergoing hemodialysis due to chronic renal failure, received a simultaneous cadaveric pancreas-kidney transplantation. The exocrine secretion was diverted using bladder drainage. Immunosuppression was maintained by a combination of tacrolimus, mycophenolate mofetil, and steroids together with OKT3 induction. Both the donor and the recipient were serologically positive for CMV IgG CMV prophylaxis consisted of a short course of parenteral gancyclovir. The patient was discharged on postoperative day 39 with normal pancreas and kidney function. She presented 2 months after transplantation with hematuria. Cystoscopic pancreas allograft biopsy specimens showed evidence of tissue invasive CMV infection in the graft duodenum and bladder. The CMV antigenemia test was positive. At 4 months after transplantation, the patient underwent surgery with the diagnosis of acute abdomen. The surgical findings consisted of a diffuse acute purulent peritonitis due to perforation of the duodenal graft. We sutured the perforation with nonreabsorbable material. The CMV antigenemia test was negative. Eight days later, the patient developed massive hematuria. At surgery, the graft was removed. The patient was discharged from the hospital with normal renal function. Pathological study of the removed graft showed the duodenal segment to have multiple wide ulcers with CMV inclusions in epithelial cells.

Deep venous thrombosis associated with protein C and/or S deficiency: management with catheter-directed thrombolysis.

We performed this study to evaluate the efficacy of catheter-directed thrombolysis with urokinase in treating acute symptomatic iliofemoral deep venous thrombosis associated with protein C and/or S deficiency. A total of 42 consecutive patients with deep venous thrombosis were seen between September 2000 and August 2002. Of these, catheter-directed thrombolysis via the popliteal vein was performed in 5 patients (11.9%) with acute iliofemoral deep venous thrombosis associated with protein C and/or S deficiency. Average duration of symptoms was 4.2 days (range, 1-7 days). The average urokinase dose was 2.7 million IU (range, 0.6 million to 7.0 million IU) infused over an average of 33.1 h (range, 16-67 h). Lysis was complete in all five treated cases. Two cases had underlying iliac venous stenoses (>50%) that were treated with angioplasty and stent placement. In one patient in whom recanalization of a right iliac vein occlusion was successful, thrombosis occurred in the treated vein within 3 weeks of intervention despite full anticoagulation therapy, and further intervention was required. There were no complications or clinically detectable pulmonary emboli. The technical and clinical success rates were 100%. This initial experience suggests that catheter-directed thrombolysis for treatment of acute symptomatic iliofemoral deep venous thrombosis associated with protein C and/or S deficiency is safe and effective.

Peripheral arterial insufficiency associated with protein C deficiency.

Two patients with protein C deficiency who presented with peripheral arterial insufficiency were successfully managed. One patient was managed with bypass surgery for focal gangrene followed by full anticoagulation whilst the other patient was managed with full anticoagulation. Both patients showed characteristic arteriographic findings. Patients who present with peripheral arterial insufficiency demonstrating thrombotic occlusion of main peripheral artery without atherosclerosis and other risk factors should be evaluated for hypercoagulable states.

Carotid endarterectomy with bovine patch angioplasty: a preliminary report.

Carotid endarterectomy with patch angioplasty is a durable procedure for prevention of recurrent neurological symptoms and stroke. However, no definitive study has demonstrated a clear benefit of one class of the patch material over another. The aim of this study was to evaluate the clinical outcome of carotid endarterectomy with bovine pericardium patch in comparison with autologous vein patch. One hundred and twenty-two carotid endarterectomies were performed using patch closure of the arteriotomy with bovine pericardium (61 cases) and autologous vein (61 cases) between September 1995 and June 1999. Though this is not a double-blind type randomized comparative study, effort was made to achieve a 1:1 ratio in sequence with a few exceptions such as non-available veins at time of surgery or for future use. In bovine pericardium patch closure group, the mean total operating time was significantly shorter than autologous vein closure group (P<0.01), but the mean carotid clamping time was similar in both groups, regardless of the use of shunt. The incidence of postoperative local complications including groin wound was less in bovine pericardium patch closure group. The patients were followed with duplex scans in one month post-CEA and 6 months interval thereafter. During the follow-up period, three patients developed non-critical stenosis (two in bovine and one in vein patch), and one aneurysmal dilation occurred in vein patch group. The incidence of restenosis was similar in both groups. Although this is a preliminary report, it is concluded that the results of carotid angioplasty using bovine pericardium compare favorably with autologous vein.

Metabolic changes in the ischemic penumbra after carotid endarterectomy in stroke patients by localized in vivo proton magnetic resonance spectroscopy (1H-MRS).

Carotid endarterectomy (CEA) is known to be effective in reducing recurrent ischemic attacks, sometimes accompanied with the functional improvement, for patients with internal carotid artery (ICA) flow lesions by increase in perfusion and/or removal of embolic sources. However, the exact mechanism of how the CEA affects the cerebral metabolism in relations to the perfusion increase in noninfarcted hypoperfused peripheral areas to the center of the lesion (e.g., ischemic penumbra or border zone) is not yet clearly known. The existence of the ischemic penumbra and its long-term viability has also been argued. We designed a prospective study to investigate the metabolic changes in the ischemic penumbra for patients with ICA flow lesions and cerebral infarct (or ischemia) before and after CEA using localized in vivo proton magnetic resonance spectroscopy ((1)H-MRS). The results of (1)H-MRS showed significantly decreased choline (Cho)/creatine (Cr) and increased N-acetylaspartate (NAA)/Cho ratios in the periphery of the lesion for the patients after CEA as compared to those who underwent only medical treatments. The more significant changes in the cerebral metabolite levels were observed in the patients who showed the improved cerebral perfusion by single photon emission computed tomography after CEA than in those who did not. In conclusion, our data suggest the existence of the ischemic penumbra, which were viable for a longer period than previously thought; CEA seems to improve the cerebral metabolism that may result from the improved perfusion at the ischemic penumbra.

Acetazolamide stress brain-perfusion SPECT predicts the need for carotid shunting during carotid endarterectomy.

UNLABELLED: Although carotid shunting is occasionally necessary to prevent cerebral ischemia during carotid endarterectomy, there is no reliable indication for this procedure. The purpose of this study was to evaluate whether acetazolamide stress brain-perfusion SPECT can predict the need for carotid shunting during carotid endarterectomy. METHODS: Basal and acetazolamide stress brain-perfusion SPECT imaging was performed using a 1-d protocol and 99mTc-ethylcysteinate dimer (ECD) in 75 patients (12 women, 63 men; mean age, 64.8 y) before carotid endarterectomy. The need for carotid shunting during carotid endarterectomy was determined by the development of neurologic deterioration after carotid clamping under regional anesthesia. Regional cerebral blood flow, cerebrovascular reserve, the presence of contralateral carotid stenosis (> or =70%), and clinical risk factors, including age, sex, history of minor stroke or transient ischemic attack, diabetes mellitus, hypertension, and smoking, were assessed with regard to whether they could predict the need for shunting. RESULTS: Carotid endarterectomy was performed safely without carotid shunting in 61 of 75 patients (81.3%). Carotid shunting was required in 14 patients (18.7%). Seven of 21 patients with a contralateral carotid stenosis, 9 of 41 with a reduced regional cerebral blood flow, and 11 of 30 with a reduced regional cerebrovascular reserve underwent carotid shunting. Patients with a reduced cerebrovascular reserve had a significantly higher number of carotid shunts performed (P < 0.01) than did those with a normal reserve, whereas contralateral carotid stenosis (P = 0.054) showed borderline significance. Reduced cerebral blood flow and clinical risk factors did not predict the need for carotid shunting (P > 0.1). Multiple logistic regression analysis showed that reduced cerebrovascular reserve was the only reliable predictor of the need for carotid shunting (P < 0.01). When a severely reduced cerebrovascular reserve (8/8) or reduced cerebral blood flow and cerebrovascular reserve with contralateral carotid stenosis (6/7) were present, carotid shunting was necessary, with positive and negative predictive values of 91% (10/11) and 94% (60/64), respectively. CONCLUSION: A reduced cerebrovascular reserve can predict the development of cerebral ischemia during carotid clamping. Acetazolamide stress brain-perfusion SPECT may be useful as a complementary method in determining selective carotid shunting during carotid endarterectomy.

Inflammatory pseudotumor of carotid artery: a case report.

Inflammatory pseudotumor is an uncommon round and spindle cell proliferative lesion of unknown etiology that occurs most commonly in the lung. But it also occurs in diverse extrapulmonary locations such as the abdomen, retroperitoneum, pelvis, heart, head and neck, upper respiratory tract, trunk, bladder and extremities. The extrapulmonary inflammatory pseudotumor is often larger, less well circumscribed and multinodular. Proximity of the tumor to vital structures or involvement of vital organs compromises the opportunity for complete resection, thus higher recurrence rates are often reported even after surgical treatment. The authors report a case of inflammatory pseudotumor originating from the common carotid artery in a 42-year-old female patient with a rapidly growing neck mass, treated by en-bloc resection of inflammatory pseudotumor and a long segment of common carotid artery followed by PTFE graft interposition.

Gait improvement after carotid endarterectomy.

A prospective study was performed to investigate whether carotid endarterectomy was accompanied by changes in the cerebral circulation and gait of patients with gait disturbance caused by cerebral ischemia from an internal carotid artery flow lesion. Gait analysis was performed pre-and postoperatively in 16 patients who had a gait disturbance from April 1997 to May 1998. A correlation between change of volume flow measured by duplex sonography, a change in cerebral perfusion (CP) by single photon emission computed tomography (SPECT), the status of collateral circulation by cerebral angiogram or magnetic resonance angiogram, and improvement of gait disturbance was analyzed. Of 16 patients with gait disturbance, 14 (87.5%) showed improvement in various gait analysis parameters. Statistical significance was noted in cadence, speed, stride length, step time, and knee range of motion (P<05). Dramatic gait improvement was observed in 8 patients who had markedly increased Doppler volume flow after carotid endarterectomy. Among those 8 patients, 7 had a significant increase of CP as measured by SPECT and an incomplete circle of Willis. In conclusion, the most significant gait improvement was noted in patients who had severely decreased preoperative volume flow, an incomplete circle of Willis, and significantly increased postoperative CP as measured by SPECT.