Intermuscular implantation technique for subcutaneous cardioverter-defibrillators.

BACKGROUND: The conventional technique for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation has been associated with pocket complications. The aim of this study was to evaluate the efficacy and safety of an alternative intermuscular technique for S­ICD implantation. METHODS: S-ICDs were implanted in ten consecutive patients (ten males, mean age: 46.8 ± 14.7 years). The pocket for the pulse generator was made above the serratus anterior muscular fascia and beneath the latissimus dorsi muscle by detaching the fibrous tissue between the muscles. Electrode implantation was performed using the three- (n = 4) or the two-incision technique (n = 6). RESULTS: All S­ICDs were successfully implanted in the absence of any procedure-related complications with a successful 65-J standard polarity defibrillation threshold testing, apart from one patient with Brugada syndrome who needed device repositioning more dorsally. During a mean follow-up of 16.5 ± 7.3 months, no major complications requiring surgical repair were encountered, while patients demonstrated high levels of comfort and satisfaction with the cosmetic result. One patient experienced an inappropriate shock due to noise detection, which was resolved after reprogramming to a different sensing vector. CONCLUSION: The intermuscular technique is a safe and efficacious approach for S­ICD implantation. This technique could lead to fewer pocket-related complications and better cosmetic results.

Impact of baseline renal function on all-cause mortality in patients who underwent cardiac resynchronization therapy: A systematic review and meta-analysis.

BACKGROUND: Cardiac resynchronization therapy (CRT) improves both morbidity and mortality in selected patients with heart failure and increased QRS duration. However, chronic kidney disease (CKD) may have an adverse effect on patient outcome. The aim of this systematic review was to analyze the existing data regarding the impact of baseline renal function on all-cause mortality in patients who underwent CRT. METHODS: Medline database was searched systematically, and studies evaluating the effect of baseline renal function on all-cause mortality in patients who underwent CRT were retrieved. We performed three separate analyses according to the comparison groups included in each study. Data were analyzed using Review Manager software (RevMan version 5.3; Oxford, UK). RESULTS: We included 16 relevant studies in our analysis. Specifically, 13 studies showed a statistically significant higher risk of all-cause mortality in patients with impaired baseline renal function who underwent CRT. The remaining three studies did not show a statistically significant result. The quantitative synthesis of five studies showed a 19% decrease in all-cause mortality per 10-unit increment in estimated glomerular filtration rate (eGFR) [HR: 0.81, 95% CI (0.73-0.90), p<0.01, 86% I2]. Additionally, we demonstrated that patients with an eGFR<60 mL/min/1.73 m2 had an all-cause mortality rate of 66% [HR: 1.66, 95% CI (1.37-2.02), p<0.01, 0% I2], which was higher than in those with an eGFR≥60 mL/min/1.73 m2. CONCLUSION: Baseline renal dysfunction has an adverse effect on-all cause mortality in patients who underwent CRT.

Animal models in the research of abdominal aortic aneurysms development.

Abdominal aortic aneurysm (AAA) is a prevalent and potentially life threatening disease. Many animal models have been developed to simulate the natural history of the disease or test preclinical endovascular devices and surgical procedures. The aim of this review is to describe different methods of AAA induction in animal models and report on the effectiveness of the methods described in inducing an analogue of a human AAA. The PubMed database was searched for publications with titles containing the following terms "animal" or "animal model(s)" and keywords "research", "aneurysm(s)", "aorta", "pancreatic elastase", "Angiotensin", "AngII" "calcium chloride" or "CaCl(2)". Starting date for this search was set to 2004, since previously bibliography was already covered by the review of Daugherty and Cassis (2004). We focused on animal studies that reported a model of aneurysm development and progression. A number of different approaches of AAA induction in animal models has been developed, used and combined since the first report in the 1960's. Although specific methods are successful in AAA induction in animal models, it is necessary that these methods and their respective results are in line with the pathophysiology and the mechanisms involved in human AAA development. A researcher should know the advantages/disadvantages of each animal model and choose the appropriate model.

Evaluation of cerebrovascular reserve capacity in symptomatic and asymptomatic internal carotid stenosis with transcranial Doppler.

Cerebrovascular reserve capacity (CVRC) is a hemodynamic parameter indicating the brain's capacity to overcome ischemia. Transcranial Doppler (TCD) is a useful device to measure CVRC, with high availability and low cost. The aim of the study is to investigate asymptomatic patients with affected CVRC, who could benefit from CEA. One hundred and forty five consecutive patients (60 symptomatic and 65 asymptomatic), with internal carotid artery (ICA) stenosis >70 % and 20 healthy individuals without internal carotid stenosis underwent TCD-inhalation CO(2) tests in order to measure the CVRC in both hemispheres of each patient. CVRC between asymptomatic and symptomatic patients were significantly different in the 95 % confidence interval (CI) as well as the mean CVRC value in contralateral carotid artery. The correlation between CVRC in the carotid artery with stenosis and the existence of symptoms is significant at the 0.01 level. Additionally, symptoms and CVRC of the contralateral carotid artery are also significant at the 0.05 level and CVRC values in asymptomatic patients and the control group at the 0.01 level. None of the covariant factors, except the age, are significantly correlated with CRVC. CVRC could be an early mark-index to evaluate the risk of stroke in this group of patients and to design their therapeutic approach.

Homocysteine as a risk factor of restenosis after carotid endarterectomy.

AIM: Homocysteine (Hcy) has been identified as a potential risk factor for vascular disease. This study investigates the role of serum Hcy as clinical risk factor for restenosis after carotid endarterectomy (CEA). METHODS: In a prospective design, we studied patients who underwent carotid endarterectomy with venous patch closure technique with respect to alterations of Hcy levels pre and postoperatively. The patients studied were subjected to reevaluation for possible restenosis at time-points 3, 6, 9, 12, 18 and 24 months postoperatively. RESULTS: Fifty-three symptomatic and 37 asymptomatic patients with stenosis of internal carotid artery >70% were studied. Restenosis appeared in 7.25% of the patients within 24 months postoperatively. Hcy was the only parameter that correlated significantly with the presence of restenosis (P=0.010) and the presence of type VI (complicated) atheromatous plaque (P=0.005) within 24 months postoperatively. CONCLUSION: Hcy levels were found to be statistically significantly correlated with both the presence of complicated atheromatous plaque and the degree of internal carotid artery restenosis after CEA.

The effect of revascularization procedures on healing of mixed arterial and venous leg ulcers.

AIM: The optimal management of venous leg ulcers in patients with concomitant peripheral artery disease (PAD) remains unclear. The aim of the present study was to evaluate the effectiveness of revascularization procedures in healing of the ulcers of mixed etiology. METHODS: During a 6-year period a total of 20 patients with evidence of chronic venous insufficiency, impaired arterial perfusion (ABI<0.75) and active leg ulcer were treated. Patients with moderate PAD (0.5

Circulating biomarkers for abdominal aortic aneurysm: what did we learn in the last decade?

AIM: Abdominal aorta aneurysm (AAA) is a serious threat for human life, especially in such cases when it is asymptomatic until aneurysm rupture, which is a general cause of death in AAA subjects. We aim to give a conceptual description of the potential biomarkers that can correlate and predict the natural history of an AAA. METHODS: The MEDLINE/PubMed database was searched for publications with the medical subject heading "abdominal aortic aneurysms (AAA)" and the keyword "biomarkers". We restricted our search to English till January 2012. We focused on human studies that reported aneurysm size, expansion rates and/or rupture and the studied biomarkers. RESULTS: In this review we included 94 articles (4 reviews) that were accessible and available in English. We excluded articles referred exclusively to thoracic aneurysms and cardiac studies. CONCLUSION: There are no specific laboratory markers that would allow one to distinguish in a simple way between aneurysm bearers and the healthy population. Serum elastase peptides seem still to be sufficient biomarkers to predict expansion and rupture, but advanced techniques (ELISA) and larger studies are needed to establish its exact role. Plasmin-antiplasmin complexes (PAP) may also have clinical potential. Newer biomarkers may also have a role, not well established yet. Beyond that, there are many limitations related to the fact that many biomarkers related with AAA outcome are not disease specific, due to their established correlation with atherosclerosis. Future research is required to establish the underlying relations between these biomarkers and their role in AAA pathophysiology.

"7, 10 and 14-days rabeprazole-based standard triple therapies for H. pylori eradication: are they still effective? A randomized trial".

BACKGROUND & STUDY AIMS: Increasing data suggests that the efficiency of standard triple therapies of 7-10-14 days duration has fallen below the threshold for acceptability (80% cure rates in intention to treat analysis). Use of rabeprazole, a PPI less influenced by CYP2C19 gene polymorphisms is reported to lead to improved eradication rates. This study aims to re-examine the effectiveness of 7-10-14 days triple therapies based on rabeprazole in Greek patients. PATIENTS AND METHODS: 307 patients, from 2 endoscopic centers in Greece, were randomized to receive Rabeprazole 20 mg bid, Clarithromycin 500 mg bid, and Amoxycillin 1gr bid for 7-days, for 10-days or for 14-days. Cure rates were assessed by CLO-test and histology. Clarithromycin sensitivity tests were carried out in the cultured pre-treatment H.pylori strains. The success rates were calculated by both intention-to-treat (ITT) and per protocol (PP) analyses. RESULTS: The eradication rates according to ITT analyses were 74.5% (95% CI: 66.5-82.9%) for 7-days, 80.6% (95% CI: 73.2-88.2%) for 10-days and 90.2% (95% CI: 84.5-95.9%) for 14-days treatment. PP cure rates were 76% (95% CI: 68.4-85.0%) for 7-days, 83% (95% CI: 76.6-91.0%) for 10-days and 93.9% (95% CI: 86.7-973%) for 14-days treatment. Side effects were generally minor and comparable in all treatment groups. CONCLUSIONS: Both 10- and 14-days rabeprazole-based triple regimens reached eradication rates above the threshold of 80% on an intention to treat basis. In our setting, the current regimen using rabeprazole, amoxicillin and clarithromycin was well tolerated, is still effective and should continue to be recommended as first-line therapy for H. pylori eradication.

Elective bypass surgery for chronic mesenteric ischemic disease: report of 3 cases and review of the literature.

Chronic mesenteric ischemic disease is an unusual cause of chronic abdominal pain. We present our experience from open surgical treatment of patients with this rare disease followed by a short review of the literature. During the period 2006-2008, three patients were referred to our department with clinical and radiological findings of chronic mesenteric ischemic disease. In all patients, at least 2 out of 3 splachnic vessels (celiac artery, superior and inferior mesenteric artery) were occluded, with severe stenosis of the third. Open surgical revasculation was performed in all patients, using autologous or synthetic (Dacron) bypass grafts. Graft patency was examined with triplex ultrasound studies at 3, 6 and 12 months postoperatively and/or follow up CT angiography. All patients had patent grafts during the follow up period and have regained their normal body weight. Immediate and late results, technical details and controversies in open surgical revasculation for chronic mesenteric ischemic disease are reviewed. In conclusion open surgical revasculation for chronic mesenteric ischemic disease is a technically challenging procedure with good results in patients younger than 70 years old , with long occlusions of the splachnic vessels and severe calcification of the vessel wall.

Oxidative stress during abdominal aortic aneurysm repair--biomarkers and antioxidant's protective effect: a review.

BACKGROUND AND OBJECTIVES: Oxidative stress during abdominal aortic aneurysm (AAA) repair is likely to result as a response to an ischemia-reperfusion injury (IRI) to the lower limbs and gastrointestinal tract. This paper reviews the oxidative stress during AAA repair, with specific reference to biological markers and the potential antioxidant's protective effect. EVIDENCE AND INFORMATION SOURCES: The current literature (1966 to July 2010) was reviewed specifically for all articles describing human studies relevant with the particular subject: oxidative stress in patients with AAA repair. Key-words used as single or combined searches included "abdominal aortic aneurysm", "open repair", "EVAR", "oxidative stress", "oxidation" and "antioxidant". RESULTS: A total of 14 relevant human studies were identified. In the majority of studies all samples (blood samples or/and muscle biopsies) were obtained from the patients using regional sampling techniques before or after anaesthesia, during aortic clamping or balloon occlusion (ischemic time) and after aortic clamp removal (reperfusion time) in different time intervals up to 24 or 48 hours. The oxidative status during AAA repair operation was evaluated by measuring quantitative changes of different substances including mainly vascular endothelial adhesion molecules, lipid peroxidation by-products or reactive oxygen species (ROS) and their metabolites. Two studies compared two groups of patients with AAA treated either by open or endovascular repair (EVAR), while four studies used different types of antioxidant supplementation in order to correlate it with a reduction in oxidative stress and damage in the antioxidant group of patients. PERSPECTIVES AND CONCLUSIONS: Current evidence suggests that there is a high-grade oxidative stress during AAA repair operation. This was higher in cases of open repair beside EVAR and in cases with ruptured AAAs beside elective cases. The beneficial effect of an antioxidant supplementation in reducing the oxidative stress during AAA repair was also demonstrated. The use of a biological marker as a predictor of the development of systemic complications could also give a therapeutic advantage.

ICU transfer after elective abdominal aortic aneurysm repair can be succesfully reduced with a modified protocol. A fourteen year experience from a University Hospital.

AIM: To compare different selective criteria for Internal Care Unit (ICU) admission in two different timeframes, after abdominal aortic aneurysm (AAA) repair. A retrospective audit of acquired data was performed. METHODS: During a period of fourteen years (1994-2008), 1152 patients underwent an elective open operation for infrarenal abdominal aortic aneurysm, in our department. Six hundred and two patients (Group A) were treated in the period January 1994-January 2003, and 550 patients (Group B) between January 2003 and August 2008. Postoperatively, all patients were transferred to postanesthesia unit (PAU). After a 2 hours period of close observation, they were transferred either to the ICU or to the surgical ward, according to certain selective criteria (SC). In group A we used SC-A, for admission to an ICU, and in group B we used new, stricter, criteria (SC-B). Thirty-day mortality and morbidity, elective admissions to ICU, rate of subsequent ICU admission, from ward to ICU, and the mean hospital and ICU length of stay, were compared between the two groups. RESULTS: The use of SC-B resulted in a significant reduction of elective admissions to ICU (3.1% vs 8.5%, P<0.001). Nevertheless, the portion of patients, which were transferred with a severe postoperative complication from the ward to ICU, remained similar between the two groups (1.1% vs 0,9%, in group A and B, respectively). All other endpoints were similar in both groups. CONCLUSION: Modifying the protocol of ICU transfer, after elective abdominal aortic aneurysm repair, we can reduce the number of patients requiring ICU, without compromising patients' safety.

Carotid endarterectomy versus carotid angioplasty with or without stenting for treatment of carotid artery stenosis: an updated meta-analysis of randomized controlled trials.

Carotid angioplasty with or without stent placement (CAS) has been proposed as an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis. We performed a systematic review and meta-analysis of randomized controlled trials to compare the safety and efficacy of endovascular techniques with surgery for carotid stenosis. We searched MEDLINE, PubMed and Cochrane databases to identify randomized controlled trials comparing CAS with CEA. Both random and fixed effects models were used to calculate the pooled odds ratios (OR) and their confidence intervals, with values lower than one indicating a benefit from the endovascular approach. Continuity correction was used for studies with zero events in one arm. We identified 11 trials randomizing a total of 3 258 patients; 1 623 to CEA and 1 635 to CAS. By random effects model, there was no significant difference between the treatments for any stroke (OR, 1.28; 95% CI, 0.82-2.02), or death or any stroke at 30-day (OR, 1.30; 95% CI, 0.92-1.84) and death or any stroke at 6 months (OR, 1.34; 95% CI, 0.86-2.09) or 1 year (OR, 1.41; 95% CI, 0.24-8.27). However there was a significantly higher risk of 30-day death or any stroke (OR, 1.33; 95% CI, 1.01-1.75) after CAS by fixed effects model. Endovascular treatment significantly reduced the risk of 30-day cranial nerve injury (OR, 0.13; 95% CI, 0.04-0.44). In conclusion treating carotid artery stenosis with CAS offers lower rates of cranial nerve injury compared with CEA. CAS could not be proved to be as safe as CEA in treating carotid artery stenosis. The results of ongoing randomized trials comparing CAS with CEA are easily awaited because they may provide sufficient evidence for a change in clinical practice.

Transradial access for carotid artery stenting: a single-center experience.

AIM: The aim of this study was to report our initial experience using the radial artery as access for carotid artery stenting (CAS) and review the existing literature. METHODS: From January to June 2008, nine high-risk consecutive patients were treated with carotid stents by using the radial artery as an access point. Major complications (perioperative myocardial infarction, stroke, transient ischemic attack [TIAs] and death) and minor complications (radial artery occlusion or hematomas) were evaluated during this procedure. RESULTS: Seven of these patients had a right (77.8%) and two had a left (22.2%) sided carotid artery stenosis. Patients were symptomatic (TIAs or strokes or both) and had a >60% stenosis of the internal carotid artery. The technical success rate was 100% and all patients mobilized two hours after the procedure and were discharged home on the first postoperative day. No major or minor complications were reported. CONCLUSION: Patients with vessel pathology or unfavorable anatomy in the iliofemoral arteries or/and the aorta, can be candidates for CAS through the radial artery. Refinement of the technique and improvement in endovascular devices may lead to the replacement of the conventional femoral access by the transradial route in the near future.

Long-term results of plastipore prostheses in reconstruction of the middle ear ossicular chain.

PURPOSE: To examine the acoustic results over a long period of time, in patients who underwent ossiculoplasty with Plastipore, and to report the percentage of prosthesis extrusion and factors related to the prognosis. PROCEDURES: Forty-two patients, who underwent ossiculoplasty with Plastipore, were studied. Patients were followed up for the next 14 years. The surgical procedures were classified as: tympanoplasty, tympanoplasty with mastoidectomy with canal wall up, and tympanoplasty with mastoidectomy with canal wall down. A successful hearing result was defined as a postoperative air-bone gap (ABG) of 20 dB or less. RESULTS: Successful results were seen in 65% of our patients, 68.8% with a partial ossicular replacement prosthesis (PORP) and a 62.5% success rate with a total ossicular replacement prosthesis (TORP). The mean value for ABG improvement was 25.5 dB. Prosthesis extrusion occurred in 4.7%. CONCLUSIONS: The ossiculoplasty-Plastipore technique leads to good hearing results and a low percentage of prosthesis extrusion in long-term follow-ups.

Guided remote endarterectomy for superficial femoral artery occlusions: a technical note.

The aim of this paper was to describe a new modification of the remote endarterectomy for the treatment of long superficial femoral artery (SFA) occlusions and to present our preliminary results. Through a subinguinal incision and arteriotomy over the SFA origin, a hydrophilic guidewire was introduced into the subintimal plane of the SFA and advanced distally until reentry into the distal patent popliteal artery. The hydrophilic guidewire is exchanged for an Ablatz wire to provide support for the advancement of the single endarterectomy ring. The MollRing Cutter was introduced in the SFA after the removal of the single endarterectomy ring and it was advanced until the re-entry point. The atherosclerotic core was removed and a nitinol self-expanding stent was placed at the peripheral end of the endarterectomy. Arteriotomy was closed with a patch. Guided subintimally-assisted remote endarterectomy seems to be a successful and safe modification of the traditional technique in the treatment of SFA occlusion, in patients with critical limb ischemia.

The relationship of endothelin-1 and inducible nitric oxide synthase at several stages of the anastomotic healing process.

AIM: The aim of this study was to investigate the interaction between the endothelin-1 (ET-1) and inducible NO synthase (iNOS) in anastomotic healing. METHODS: The expression of ET-1 and iNOS were investigated by immunohistochemistry in a rat end-to-end arterial anastomotic model. The aorta of 50 male Wistar rats was exposed, then transversely divided and re-anastomosed. The animals were sacrificed immediately after the operation (group A, control group), after 24 h (group B), on 7th postoperative day (group C), on 30th day (group D) and at 6 months (group E). Intima and media thickness and their ratio of the anastomotic segments in each group were calculated from computer digitized images of the individual sections. ET-1 and iNOS expression were measured on a semiquantitative scale ranging from 0 to 3. RESULTS: ET-1 was expressed from endothelial and smooth muscle cells (SMCs), while iNOs was expressed from SMCs and inflammatory cells. An intense expression of ET-1 was demonstrated mainly at 1 week and to a lesser degree at 1 month. Yet, at 6 months this expression was significantly weakened (P<0.001). In contrast, an intense iNOS expression was identified at 24 h, substantially regressing at statistical significant lower levels after 1 week (P<0.001). Bivariate correlation test showed a positive correlation between ET-1 and iNOS expression. CONCLUSION: ET-1 appears to play an important role in intimal thickening during anastomotic healing, especially in the late period of the process. Although there is a positive correlation between ET-1 and iNOS production, the activity of the latter is relatively limited after the first postanastomosis week.

Can the diameter of endoluminal shunt influence the risk of hyperperfusion syndrome after carotid endarterectomy?

AIM: The aim of this study was to evaluate if there is a possible relation between the size of endoluminal shunt, in carotid endarterectomy (CEA), and the risk of postoperative hyperperfusion syndrome. METHODS: We retrospectively studied prospectively collected data from 156 patients, who were subjected to CEA using shunting and vein patch angioplasty. One hundred and thirty-eight of the patients had bilateral, high grade (> or = 90%) internal carotid lesions and the remaining 18 had a high-grade stenosis (> or = 90%) and a contralateral internal carotid artery (ICA) occlusion. In 81 patients varying diameters of shunts were used (8-14 Fr) according to the diameter of ICA (group A) and in the other 75 patients (group B) only the smallest shunt was used (8 Fr). Development of hyperperfusion syndrome was evaluated both clinically and radiologically with magnetic resonance imaging. RESULTS: Fifteen patients developed hyperperfusion syndrome (9.6%), between 0 to 6 days postoperatively. Thirteen belonged to group A (86.6%), and 2 (13.3%) belonged to group B (P<0.05). One had an intracerebral hemorrhage (0.6% of the study group) the 3rd postsurgical day. CONCLUSIONS: During CEA in patients with high-grade bilateral lesions, we recommend the use of a shunt with small diameter: this aims at reducing the risk of hyperperfusion syndrome.

Lemierre's syndrome associated with consumption coagulopathy and acute renal failure: a case report.

BACKGROUND: Acute tonsillitis or pharyngitis may lead to suppurative thrombophlebitis of the internal jugular vein. This complication, also known as Lemierre's syndrome, remains, even nowadays, life threatening, due to dissemination of septic thromboemboli to various organs. Respiratory deficiency and renal impairment are often reported in patients suffering from Lemierre's syndrome. CASE REPORT: The unusual clinical manifestation of this case involves severe acute renal and respiratory deficiency in addition to microangiopathic consumption coagulopathy in a young patient treated with macrolides five days after the onset of acute tonsillitis. CONCLUSION: The usual causative pathogen, namely Fusobacterium necrophorum, shows a varying sensitivity to macrolides. As a result, the syndrome may present itself in a variety of clinical forms even in patients under treatment with macrolides. A high index of suspicion is therefore crucial for in time prevention of potentially life threatening complications.