A Greek Multicentre Study Assessing the Outcome of Late Rupture After Endovascular Abdominal Aortic Aneurysm Repair.

OBJECTIVE: Late rupture after endovascular aortic aneurysm repair (EVAR) for an abdominal aortic aneurysm (AAA) is an increasing complication associated with a high mortality rate. This study aimed to analyse the causes and outcomes in patients with AAA rupture after EVAR. METHODS: A multi-institutional Greek study of late ruptures after EVAR between 2008 - 2022 was performed. Primary outcomes were intra-operative and in hospital death. RESULTS: A total of 70 patients presented with late rupture after EVAR (proportion of ruptured EVARs among all EVARs, 0.6%; 69 males; mean age 77.2 ± 6.7 years). The mean time interval between EVAR and late rupture was 72.3 months (range 6 - 180 months). In all cases the cause of rupture was the presence of an endoleak (type I, 73%) with sac enlargement. Moreover, 34% of subjects with rupture after EVAR had been lost to follow up and 32% underwent a secondary intervention. Additionally, 57 patients (81%) were treated by conversion to open surgical repair (COSR) and the remainder by endovascular correction of endoleak (ECE). Eleven intra-operative deaths (16%) were recorded. The overall in hospital mortality rate was 41% (23% ECE vs. 46% COSR; p = .21). Of the patients who presented as initially haemodynamically stable, 23% died during hospitalisation, while the respective mortality rate for patients who presented as unstable was 78% (odds ratio [OR] 11.8, 95% confidence interval [CI] 3.6 - 39.1; p < .001). Multivariable logistic regression analysis revealed that severity of haemodynamic shock was the most significant risk factor for intra-operative (OR 7.15, 95% CI 1.58 - 32.40; p = .010) and in hospital death (OR 9.53, 95% CI 2.79 - 32.58; p < .001). CONCLUSION: These data underline the devastating prognosis of late rupture after EVAR. Haemodynamic status at presentation was an important predictive factor for death both in the ECE and COSR groups. Rigorous follow up and prompt evaluation of an unstable patient in case of rupture after EVAR is recommended.

A systematic review of therapies for aortobronchial fistulae.

OBJECTIVE: The aim of the study was to summarize epidemiologic data about aortobronchial fistulae and compare outcomes (mortality, recurrence, reoperation) of open, staged, and endovascular repair of aortobronchial fistula. METHODS: A systematic literature review was conducted to identify eligible studies published between January 1999 and December 2019. The Cochrane Library, PubMed, and Scopus databases were used as search engines. Eligible studies included articles reporting postoperative outcomes (death/follow-up). Literature review revealed only case reports and small case series, and thus, only descriptive data with data heterogeneity were available. The corresponding authors were contacted to provide additional information or outcome updates (recurrence/reoperation/death). RESULTS: Overall, 214 patients (90 studies) underwent 271 procedures (including redo procedures and staged procedures). Most of the patients were treated by endovascular means (72.42%). Open surgical repair was performed in 21.96% and staged procedures in 5.6%. Aortobronchial fistulae were located most often in the descending thoracic aorta (zone 3 or 4) (64.6%) and in zone 2 (23.8%). Fourteen percent of aortobronchial fistulae developed after thoracic endovascular aneurysm repair. Recurrence or infection occurred in 20% (43) patients. Recurrences were, to some extent, associated with the presence of endoleak. Long-term antibiotic administration (>1 month) was instituted in 63 patients (29.4%), whereas 90 patients (42%) did not receive antibiotics beyond hospitalization. From the remaining 61 patients, 3 received lifelong antibiotics and for 58 patients data were not available. Considering outcomes, the mean follow-up was 25.1 months (0-188 months) and not significantly different among treatments. LIMITATIONS: Literature review has revealed only case reports and small case series, and thus, only descriptive data were available. Randomized controlled trials are not available due to the rarity of the disease, which significantly decreases the power of the present study. Also, this study reflects significant data heterogeneity due to the nature of the analyzed manuscripts and would benefit from large patient cohort studies that have not been conducted till today. CONCLUSIONS: Aortobronchial fistula is a complex disease. Endoleaks may be involved in the development and the recurrence process, and they should not be disregarded. Considering major outcomes (length of follow-up), the available treating strategies are equal, and thus, surgeons should feel confident to apply the treatment of their choice, keeping in mind their experience, patient's age, and clinical condition.

Carotid Stent Restenosis and Thrombosis in Rabbits: The Effect of Antiplatelet Agents.

BACKGROUND: The purpose of the study was the comparative assessment of ticagrelor and clopidogrel effects on carotid post-balloon injury (PBI) and on post carotid artery stenting (CAS) rate of in-stent restenosis (ISR) and in-stent thrombosis in atherosclerotic rabbits. METHODS: Forty-eight New Zealand white rabbits on high-fat diet were randomized into 4 groups: A1: PBI and clopidogrel (30 mg/kg/d), A2: PBI and ticagrelor (21 mg/kg twice daily), B1: PBI, CAS, and clopidogrel (30 mg/kg/d), B2: PBI, CAS, and ticagrelor (21 mg/kg twice daily). All rabbits received orally aspirin (10 mg/kg/d) and interventions were performed in their right carotid arteries (RCAs). Optical coherence tomography (OCT) and carotid angiography were performed at end point, while platelet aggregation and lipid profile were measured. After euthanasia both carotids were obtained for histological examination. RESULTS: In B1 group, 3 rabbits presented thrombotic total occlusion of the stents, while none such episode was observed in B2 group. The neointimal areas in RCAs, calculated by OCT, did not differ between A1 and A2 groups, and between B1 and B2 groups (P > .05). From the histological findings, the intima/(media + intima) percentage (%) in RCAs of balloon-injured rabbits did not present any difference between groups (P = .812). Similarly, the immunohistochemically determined accumulation of endothelial cells and macrophages on vascular walls was equivalent between groups (P > .05). CONCLUSION: Following carotid balloon injury and stenting, clopidogrel and ticagrelor did not show any differential effects on the extent of neointimal formation and ISR in atherosclerotic rabbits receiving aspirin. Three thrombotic stent occlusions were noted in the clopidogrel treatment group, but this finding was not statistically significant.

Early Post-EVAR Rupture in a Patient with Early Type II Endoleak: A Borderline Treatment.

PURPOSE: The detection of type II endoleak one month after endovascular aneurysm repair (EVAR) is usually neglected or considered benign. Aim of this report is to present a case of post-EVAR rupture, due to type II endoleak, and discuss on pathophysiology and differential diagnosis. CASE REPORT: We present a case of a 67-year-old male who was treated with EVAR for an asymptomatic abdominal aortic aneurysm and four months later, he presented with a contained rupture due to a type II endoleak. The patient was treated conservatively without any intervention with satisfying result. CONCLUSIONS: We are demonstrating conservative management as a valid therapeutic option for patients presenting with a contained post-EVAR rupture.

Fenestrated Endovascular Repair for Pararenal or Juxtarenal Abdominal Aortic Aneurysms: a Systematic Review.

BACKGROUND: This review aims to collect all available data on early and late outcomes in patients undergoing fenestrated endovascular aortic aneurysm repair (F-EVAR) for pararenal or juxtarenal abdominal aortic aneurysms (AAAs). METHODS: The Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Studies reporting at least early mortality after F-EVAR in patients with pararenal or juxtarenal AAA were included. Thirty-day outcomes were defined as early, and outcomes reported after 30 days postoperatively were defined as late. Basic characteristics of all studies and demographics of patients were reported. RESULTS: Overall, 30 studies (17 retrospective and 13 prospective) including 23,385 patients in total were included. Out of 23,385 patients, a total of 2,271 patients were treated with F-EVAR for pararenal/juxtarenal AAA. Overall, 4,216 target vessels were to be treated (data from 24 studies). Pooled early mortality reached 2.55% (ranging from 0% to 6.74%), with a pooled technical success of 96.8% (ranging from 82.8% to 100%). Regarding late outcomes, pooled all-cause mortality reached 17% (ranging from 0% to 50%), 1-year primary patency was 94.6% (ranging from 91.8% to 97.1%) and reintervention rate was 10.4% (ranging from 0% to 57.4%). Mean/median follow-up ranged from 3 to 60 months. CONCLUSIONS: Early outcomes indicate that F-EVAR is a safe and efficient treatment for patients with pararenal/juxtarenal AAAs. Although long-term outcomes are acceptable, late-intervention rate remains high.

Giant Dorsalis Pedis Pseudoaneurysm Following Cannulation for Arterial Line in a Patient with Systemic Lupus Erythematosus.

Dorsalis pedis artery (DPA) aneurysms are very rare and fewer than 60 cases have been reported in the literature. Most affected patients present with false aneurysms after orthopedic surgery or trauma. Here we report an unusual case of a giant DPA pseudoaneurysm after cannulation for arterial line placement in a patient newly diagnosed with systemic lupus erythematosus (SLE). A diagnostic delay resulted in necrosis of the overlying skin. Excision of the pseudoaneurysm, ligation of the DPA, and debridement of the foot dorsum were performed, followed by a second flap coverage surgery. Although a DPA false aneurysm is rare after arterial line removal, it can cause the serious complications of skin necrosis, rupture and toe necrosis. Arterial puncture sites should be carefully monitored, especially in patients with SLE or other vasculitis.

Management and therapeutic options for abdominal aortic aneurysm coexistent with horseshoe kidney.

BACKGROUND: Horseshoe kidney (HSK), referring to the abnormal fusion of the lower renal poles, represents one of the most common renal anomalies. One of its most significant features is the anomalous vasculature, with a number of accessory renal arteries originating from the aorta, the mesenteric arteries, and even the iliac arteries supplying both the renal kidneys and the renal isthmus. METHODS: A literature review was performed to identify and to present the most recent data regarding classification and imaging evaluation of HSK concomitant with abdominal aortic aneurysm (AAA). Furthermore, an in-depth analysis of both open surgical and endovascular repair is made for management of this rare medical condition. RESULTS: The anomalous renal vasculature of HSK has led to the introduction of a number of classification systems, with Eisendrath's being currently the most commonly used. The concomitant presence of HSK in patients suffering from AAA plays a major role in preoperative planning, with a number of factors taken into consideration in deciding on either an open repair or an endovascular approach. Open repair requires careful decision-making between a transperitoneal and a left retroperitoneal approach to reach the aneurysm sac. In addition, technical points include the decision to divide the renal isthmus or not and the necessity of salvage or reimplantation of anomalous renal vessels. On the other hand, an endovascular approach requires careful preoperative imaging and evaluation of both the renal function and vasculature to decide on catheterization and salvage of accessory renal arteries or their exclusion. CONCLUSIONS: The concomitant presence of AAA and HSK poses a challenge for the modern vascular surgeon, who must possess all required technical skills-both endovascular and open repair-to deal accordingly with this rarely encountered medical condition. Preoperative determination of the perfusion pattern is necessary for the treatment strategy.

Carotid Endarterectomy versus Carotid Stenting or Best Medical Treatment in Asymptomatic Patients with Significant Carotid Stenosis: A meta-analysis.

BACKGROUND: This meta-analysis aimed to evaluate randomized trials (RTs) that compare outcomes among asymptomatic patients with significant carotid stenosis undergoing carotid endarterectomy (CEA) versus carotid stenting (CAS) or best medical treatment (BMT). MATERIAL AND METHODS: The Pubmed, Embase, Scopus and Cochrane Library databases were systematically searched to identify eligible studies. Data were analyzed by using the StatsDirect Statistical software (Version 2.8.0, StatsDirect Ltd). Odds ratios (OR) were used to determine effect size, along with 95% confidence interval (CI). PRISMA guidelines for conducting meta-analyses were utilized. RESULTS: Overall, 10 RTs including 8771 asymptomatic patients were evaluated. Compared to CAS, 30-day all stroke risk was found to be lower after CEA (pooled OR = 0.56; CI 95% [0.312-0.989]; P = 0.046). However, other early and late outcomes were not different between CEA and CAS. Furthermore, 30-day all stroke (pooled OR = 3.43; CI 95% [1.810-6.510]; P = 0.0002), death (pooled OR = 4.75; CI 95% [1.548-14.581]; P = 0.007) and myocardial infarction (MI) (pooled OR = 9.18; CI 95% [1.668-50.524]; P = 0.011) risks were higher after CEA compared to BMT, as expected. Additionally, 30-day all stroke/death and all stroke/death/MI risks were higher after CEA compared to BMT as well. Regarding long-term results, ipsilateral stroke risk was lower after CEA compared to BMT (pooled OR = 0.46; CI 95% [0.361-0.596]; P < 0.0001) although death due to stroke risk was not different (pooled OR = 0.57; CI 95% [0.223-1.457]; P = 0.240). Unfortunately, no study comparing CAS to BMT was found. CONCLUSIONS: CEA is associated with a lower early all stroke risk compared to CAS although other early or late outcomes did not show any difference between the two methods. Additionally, CEA seems to have a benefit over BMT against long-term ipsilateral stroke, although early outcomes are worse after CEA. No studies are available comparing CAS to BMT alone.

Symptomatic Bilateral Carotid Artery Occlusion: An Uncommon Pattern of Carotid Pathology.

We report an unusual case of an 83-year-old man who was admitted with dizziness and repeated drop attacks. He was diagnosed with bilateral carotid artery occlusion and he underwent a left subclavian to left carotid bypass with ringed polytetrafluoroethylene graft. The patient's postoperative course was uneventful and no symptoms presented during a 6-month follow-up. Finally, we discuss on proper management of such patients.

A Rare Case of Axillary Artery Pseudoaneurysm Due to Shoulder Dislocation Treated With Percutaneous Thrombin Injection.

The incidence of combined neurovascular injuries among patients with high-energy shoulder trauma ranges from 27% to 44%. However, the presentation of an axillary artery pseudoaneurysm (PSA) due to shoulder dislocation without an associated osseous fracture is a very rare condition. Moreover, treatment of combined neurologic and vascular injuries of the shoulder remains controversial. Additionally, minimally invasive treatments such as thrombin injection have been mainly evaluated in patients with iatrogenic femoral artery PSAs. Therefore, we aim to report a rare case of axillary artery PSA associated with brachial plexus injury after shoulder dislocation treated with percutaneous thrombin injection.

Late Rupture of a Totally Thrombosed Abdominal Aortic Aneurysm: A Case Report and Literature Review.

Chronic totally thrombosed abdominal aortic aneurysms (AAAs) comprise a rare medical situation, with only a few cases reported in literature. Optimal management has been controversial, although an early risk for rupture is present. Therefore, we present a rare case of late rupture in a patient with a totally thrombosed AAA, and we discuss proper treatment.

Conservative treatment of patients with thromboangiitis obliterans or cannabis-associated arteritis presenting with critical lower limb ischaemia.

BACKGROUND: Proper management of patients with thromboangiitis obliterans (TAO) or cannabis-associated arteritis (CAA), presenting with critical lower limb ischaemia (CLI) remains controversial, and data are limited. PATIENTS AND METHODS: Patients with TAO or CAA presenting with CLI between 2011 and 2016 were retrospectively evaluated. Patients requiring primary intervention were excluded. Conservative treatment included: (a) weight-adjusted bemiparin plus six hours/day intravenous iloprost for 28 days, (b) aspirin (100 mg/day) plus cilostazol (100 mg twice/day) after discharge, and (c) strict recommendations/monitoring for smoking cessation. Main outcomes included symptom recession, ankle-brachial index (ABI) improvement, and healing of lesions at the time of discharge as well as amputation, revascularization, and abstinence rate during follow-up. RESULTS: Overall, 23 patients (TAO: 15; CAA: 8) were included within six years, none of the patients reported any other factor than smoking. All patients presented with rest pain and 12 patients with ulcer or necrotic lesions. Mean ABI measurement at presentation was 0.46 ± 0.2, after 28 days of treatment, all patients showed improvement regarding clinical picture and ABI measurement (0.54 ± 0.1; p < 0.05). During follow-up, only three patients underwent bypass surgery and two patients underwent major amputation, although the smoking abstinence rate was very low (13 %). CONCLUSIONS: Intravenous iloprost plus bemiparin for 28 days together with per os aspirin plus cilostazol seem to produce promising results in patients with TAO/CAA, treated for CLI, even with a low smoking abstinence rate. However, larger series are needed to further evaluate inter-group differences and potential prognostic factors.

New predictors of complications in carotid body tumor resection.

OBJECTIVE: This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury. METHODS: Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi-institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination. RESULTS: There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0-10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1-1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0-3500 mL). Twenty-four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables-Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)-was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1-cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25-2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19-1.92). CONCLUSIONS: This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1-cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.

Oxidative Stress and Total Antioxidant Status During Internal Carotid Artery Clamping with or without Shunting: An Experimental Pilot Study.

BACKGROUND The exact role of shunting during carotid endarterectomy remains controversial and unclear. The aim of this experimental study was to investigate to what degree carotid clamping may induce changes in the cerebral oxidative status and to focus on the relation of these changes with shunt insertion. MATERIAL AND METHODS Forty New-Zealand rabbits were randomized into 4 groups: group 1 classifying animals with carotid shunt and patent contralateral carotid artery; group 2 shunt and occlusion of the contralateral carotid artery; group 3 no-shunt and patent contralateral carotid artery; and group 4 no-shunt and occlusion of the contralateral carotid artery. Blood samples were collected from the ipsilateral internal jugular vein, immediately after carotid clamping (time 0), and then at 5, 10, 15, 30, and 60 minutes afterwards. Evaluation of oxidative stress was accomplished by measuring the lag-time, representing the initial phase of oxidation, rate of accumulation (RA), showing concentration of free oxygen radical and total antioxidant status (TAS) representing antioxidant composition of serum. RESULTS Lag-time was significantly different in time points 0, 30 and 60 minutes within each different group. TAS was significantly different in time points 0, 15 and 60 min and RA in time points 0, 5, 10 and 60 min within each different group. 60 minutes after carotid clamping, the rate of accumulation as well as lag-time and TAS were increased in all groups, independently of using or not shunting or the presence of contralateral occlusion. After comparing groups 1, 2 and 3 regarding lag-time, TAS and RA, we did not find statistical difference among the groups at any time point. On the contrary, groups 1, 2 and 3 did show significantly different values comparing to group 4 after 60 min of occlusion. CONCLUSIONS Our experimental work based on cerebral metabolism found a significantly higher oxidative stress in models with contralateral carotid occlusion. The use of shunt in all other models did not have any influence on oxidative response. Future human studies should focus on the relation of oxidative status and shunt insertion to determine the benefit of selective or routine shunting during CEA.

Inflammatory response and renal function following endovascular repair of the descending thoracic aorta.

PURPOSE: To evaluate inflammatory response and renal function after thoracic endovascular aortic repair (TEVAR) of lesions in the descending thoracic aorta. METHODS: Thirty-two consecutive patients treated with TEVAR from January 2010 to August 2013 were enrolled in this prospective study. Two were excluded owing to dissecting thoracic aortic aneurysm (TAA) extending into the renal arteries with renal failure in one and a saccular TAA in which a multilayer flow-modulating stent was implanted in the other. This left 30 patients (28 men; mean age 68.8±5.9 years) with 28 TAAs, an aortic dissection, and an aortic ulcer for the analysis. Temperature and serum levels of white blood cells (WBCs), C-reactive protein (CRP), interleukin-10 (IL-10), IL-6, IL-8, tumor necrosis factor-alpha (TNF-α), creatinine, urea, and cystatin C were measured preoperatively and at 24 and 48 hours postoperatively. RESULTS: Statistically significant increases in temperature and serum levels of WBCs, CRP, IL-10, and IL-6 were observed 24 and 48 hours postoperatively compared to baseline (all p<0.05). The number of endografts and the coverage of the celiac or subclavian artery did not affect the magnitude of the inflammatory response. No significant differences were observed concerning serum levels of IL-8, TNF-α, creatinine, or cystatin C from baseline to 24 or 48 hours postoperatively. CONCLUSION: Endograft implantation in the thoracic aorta may propagate an inflammatory response during the early postoperative period. No clinical adverse events related to the increased inflammatory response were observed. Renal function does not seem to be deteriorated after TEVAR in the descending thoracic aorta.

Diagnosis and surgical treatment of extrahepatic portal vein aneurysm: A case report.

Extrahepatic portal vein aneurysm is a relatively uncommon entity. We reported the case of a 51-year-old man, who was incidentally diagnosed with an asymptomatic 52 × 65 mm portal vein aneurysm, which was located at the main trunk of the portal vein, just before its bifurcation. The patient was treated with partial clamping of the portal vein aneurysm and aneurysmorrhaphy. Postoperative course was uneventful. Surgical intervention should be considered for patients with large, symptomatic or expanding portal vein aneurysms.

Outcome after preservation of infected abdominal aortic endografts.

PURPOSE: To review the published outcomes of aortic endograft infection treated with preservation of the stent-graft. METHODS: An extensive electronic health database search was undertaken to identify all articles published up to May 2013 that reported endograft infection after endovascular aneurysm repair (EVAR) in which treatment included preservation of the stent-graft. The search found 17 articles with 29 patients (27 men; mean age 73.1±7.6 years) fulfilling the inclusion criteria. RESULTS: In 2 (7%) cases, the endograft infection was diagnosed within 30 days of the initial procedure; 4 (14%) were identified within 3 months and the remaining 23 (79%) within 12 months. Staphylococcus species, Streptococcus species, and Escherichia coli were the most common isolated microorganisms. Seven (24%) had a secondary aortoenteric fistula after EVAR. Twelve (41%) patients received only antibiotic therapy, while the remaining had an additional procedure (drainage, surgical debridement, sac irrigation, and/or omentoplasty). The in-hospital mortality was 21% (n=6). During a mean follow-up of 11.4±3.1 months, 7 more patients died (overall mortality 45%). None of the 7 patients with fistula survived. Half (50%) of the 12 patients who received only antibiotic therapy died, while 7 (41%) of the 17 patients who underwent an additional procedure died during follow-up. CONCLUSION: Among patients treated for endograft infection without explantation, those with aortoenteric fistula had the worst outcome. There is evidence for lower mortality in patients who underwent an additional procedure, such as drainage, surgical debridement, and sac irrigation. Larger studies are needed to examine the efficacy of this approach compared to surgical conversion with endograft excision and in situ reconstruction or extra-anatomical bypass.

Endograft infection and treatment with preservation of the endograft: early results in 3 cases.

We present 3 cases of stent graft infection in patients who were treated with preservation of the endograft. In the first patient, the contamination of the endograft was the consequence of a bleeding aortoenteric fistula, whereas in the second patient, the endograft was implanted into a ruptured contaminated aortic aneurysm because of the patient's hemodynamic instability. In the third patient, the presence of a consistent type Ia endoleak after a chimney graft procedure followed by secondary interventions led to an infection of the stent graft. In each case, a laparotomy was performed with debridement, followed by appropriate antibiotic therapy. The first patient suffered a fatal pulmonary embolism. The other 2 patients are alive 4 and 24 months after the diagnosis of endograft infection. In unstable patients or those with severe comorbidities who cannot tolerate endograft excision and aortic reconstruction, surgical debridement followed by appropriate antibiotic therapy can be a temporary or bridging solution.

Association between carotid artery occlusion and ultrasonographic plaque type.

BACKGROUND: Internal carotid artery (ICA) occlusion is associated with acute stroke and carries significant morbidity and mortality. The aim of this study was to examine whether ultrasonographic carotid plaque type may be associated with ICA occlusion. METHODS: Two hundred eleven patients (85% men, mean age 66.0±9.5 years, 28.9% asymptomatic) with ICA occlusion were included in this case-control study. Ultrasonographic Gray-Weale plaque type (I-IV, echolucent to echogenic) characterization was obtained in both the occluded and the contralateral ICA. Univariate and conditional logistic regression analyses with 1:1 pair matching per artery were undertaken. Each contralateral carotid artery with stenosis was treated as control to the ipsilateral-occluded ICA of the same patient. RESULTS: A total of 261 ICAs (61.9%) were recorded with type I-II plaque, of which 165 (63.2%) were among the occluded and 96 (36.8%) were among the contralateral ICAs with stenosis (P<0.001). Mean contralateral ICA stenosis was 58.2%±20.4%. Regression analysis showed that carotid plaque type I-II was significantly associated with carotid artery occlusion compared with plaque type III-IV (crude odds ratio [OR]=4.29, 95% confidence intervals [CI]=2.81-6.57%, P<0.001, adjusted OR=5.60, 95% CI=3.23-9.70, P<0.001). Previous neurological events did not seem to be significantly associated with plaque echolucency (OR=0.62, 95% CI=0.29-1.35, P=0.23). CONCLUSIONS: A significant association between echolucent plaque and ICA occlusion was observed. This observational hypothesis may prompt for further investigation of the causal mechanism between carotid plaque type and ICA occlusion by larger cohort studies.

Late renal artery occlusion following endovascular repair of abdominal aortic aneurysm: a possible complication of mural thrombus formation within aortic endografts.

Mural thrombus formation within aortic endoprostheses has been described to occur in up to one-third of aortic endografts depending on the device type. Data regarding the clinical significance of such a phenomenon are scarce, but in most cases it is considered to be clinically innocent. The authors describe a rare case of late renal artery occlusion due to intraprosthetic thrombus formation and extension into the right renal orifice 30 months after endovascular abdominal aortic aneurysm repair. Additionally, a brief literature review regarding the incidence and natural history of mural thrombotic deposits within aortic endografts is also conducted.