A Review of Open and Endovascular Treatment of Superior Vena Cava Syndrome of Benign Aetiology.

BACKGROUND: The widespread use of central venous catheters, ports, pacemakers, and defibrillators has increased the incidence of benign superior vena cava syndrome (SVCS). This study aimed at reviewing the results of open and endovascular treatment of SVCS. METHOD: Medical literature databases were searched for relevant studies. Studies with more than five adult patients, reporting separate results for the SVC were included. Nine studies reported the results of endovascular treatment of SVCS including 136 patients followed up for a mean of 11-48 months. Causes of SVCS were central venous catheters and pacemakers (80.6%), mediastinal fibrosis (13.7%), and other (5.6%). Percutaneous transluminal angioplasty (PTA) and stenting was performed in 73.6%, PTA only in 17.3%, and thrombolysis, PTA, and stenting in 9%. Four studies reported the results of open repair of SVCS including 87 patients followed up between 30 months and 10.9 years. The causes were mediastinal fibrosis (58.4%), catheters and pacemakers (28.5%), and other (13%). Operations performed included a spiral saphenous interposition graft, other vein graft, PTFE graft, and human allograft. Thirteen patients required re-operations (15%) before discharge mainly for graft thrombosis. RESULTS: In the endovascular group technical success was 95.6%. Thirty day mortality was 0%. Regression of symptoms was reported in 97.3%. Thirty-two patients (26.9%) underwent 58 secondary procedures. In the open group the 30 day mortality was 0%. Symptom regression was reported in 93.5%. Twenty-four patients (28.4%) underwent a total of 33 secondary procedures. CONCLUSIONS: Endovascular is the first line treatment for SVCS caused by intravenous devices, whereas surgery is most often performed for mediastinal fibrosis. Both treatments show good results regarding regression of the symptoms and mid-term primary patency, with a significant incidence of secondary interventions.

Galectin-3, Carotid Plaque Vulnerability, and Potential Effects of Statin Therapy.

OBJECTIVES: Galectin-3, a member of galectines, a family of b-galactoside-specific lectins, has been reported to propagate vascular inflammation. The role of galectin-3 in carotid atherosclerosis is controversial. The aim of this study was to investigate the relationship of galectin-3 with plaque vulnerability in patients with high grade carotid stenosis. METHODS: This was a cross sectional study of patients undergoing carotid endarterectomy (CEA). Carotid plaques obtained from 78 consecutive patients (40 symptomatic [SG], 38 asymptomatic [AG]) undergoing CEA were histologically analyzed for galectin-3, macrophages (CD68) and laminin. Pre-operatively the biochemical profile and plaque echogenicity (gray-scale median, GSM) score were determined. RESULTS: There were no significant differences in clinical and demographic parameters between SG and AG(p > .05). The SG had a lower GSM score (44.21 ± 18.24 vs. 68.79 ± 28.79, p < .001) and a smaller positive stained area for galectin-3 (4.89 ± 1.60% vs. 12.01 ± 5.91%, p < .001) and laminin (0.88 ± 0.71% vs. 3.46 ± 2.12%, p < .001) than the AG. On the other hand, intra-plaque macrophage content was increased in SG (p < .001). For the whole cohort, symptomatic status was independently associated with intra-plaque contents of both galectin-3 (OR=0.634, p < .001), and GSM score (OR=0.750, p < .001). Notably, patients on long term statin treatment had elevated galectin-3 and lowered macrophage intra-plaque concentrations compared with those on short term treatment (p < .05). CONCLUSIONS: A low galectin-3 intra-plaque concentration seems to correlate with clinically and ultrasonically defined unstable human carotid plaques. Long term statin treatment may induce increase of intra-plaque galectin-3 concentration mediating plaque stabilization.

Factors Predisposing to Endograft Limb Occlusion after Endovascular Aortic Repair.

OBJECTIVES: The aim of this study was to investigate risk factors for endograft limb occlusion after endovascular abdominal aneurysm repair (EVAR), using a case control design. METHODS: All patients presenting with endograft limb occlusion after elective EVAR between January 2010 and June 2013, along with age, sex, and type of endograft matched controls were included in the study. The impact of atherosclerotic risk factors, anatomic characteristics of the aneurysm, procedural details, and antiplatelet therapy was investigated. Multivariate logistic regression analysis and conditional logistic regression analysis for 1:3 matched pairs deriving adjusted odds ratios (ORs) with 95% confidence intervals (CIs) in order to detect significant risk factors for endograft limb occlusion among cases and controls were modeled. RESULTS: Of the 439 patients treated by EVAR, 18 patients (4.1%) presented with endograft limb occlusion. These patients were compared to 54 matched controls. Limb occlusion was associated with iliac artery angulation ≥ 60° (OR = 5.76, 95% CI =1.24-26.74; p = .03) or perimeter calcification ≥ 50% (OR =5.87, 95% CI = 1.10-31.32; p = .04). Limb occlusion was also associated with ≥ 15% endograft oversizing in the common iliac artery (OR = 5.54, 95% CI = 1.11-27.60; p = .04). No other risk factors for limb occlusion were recognized. CONCLUSIONS: The presence of significant angulation and calcification of the iliac arteries as well as excessive limb oversizing appear to be independent predictors of endograft limb occlusion after EVAR.

New possibility of AAA treatment with E-vita abdominal device.

The most dramatic shift in the management of abdominal aortic aneurysms (AAAs) occurred in 1991, when the first endovascular AAA repair was reported. Endovascular aneurysm repair has revolutionized the treatment of infrarenal AAAs. In the last few years, the companies have developed renewed models of grafts and have modified delivery systems tending to make them more atraumatic and flexible in order to deal with difficult anatomies and severely atheromatous and tortuous vessels. The aim of the present paper was to analyze the technical characteristics and properties of the new stent-graft system E-vita abdominal XT and to review the current literature. The E-vita abdominal XT stent-graft seems to be safe and reliable; however, long-term results are needed.

Association between plaque echogenicity and embolic material captured in filter during protected carotid angioplasty and stenting.

OBJECTIVES/DESIGN: The aim of the study was to investigate debris captured in filter embolic protection devices (EPDs) during carotid artery stenting (CAS) and its possible correlation with plaque echogenicity and other risk factors. MATERIALS/METHODS: Between June 2010 and March 2011, 51 consecutive CAS patients (11 females, mean age 71.2 ± 7, 10 symptomatic) who underwent 53 procedures were included in this prospective study. Ultrasonographic Gray-Weale plaque type (I-V, echolucent to echogenic) characterisation was obtained in all cases. The same type of stent and filter EPD was used. Filters were collected and, after macroscopic evaluation, they were examined using the Thin-Prep(®) liquid-based cytology (LBC) technique. RESULTS: Technical success was 100%. Thirty-day stroke and death rates were 1.8% (1/53) and 0%, respectively. Visible debris was detected in eight (15%) filters, whereas LBC revealed the presence of embolic material particles in 30 filters (56.6%). The presence of embolic material into the filter EPD was 2.38-fold increased for every category change from type IV to type I carotid plaques (OR = 2.38, 95%CI = 1.15-4.93). This association remained robust even after adjustment for age, gender and known atherosclerotic disease risk factors (OR = 2.26, 95%CI = 1.02-5.02). In multivariate analysis for risk factors, hypertension was associated with increased presence of embolic material detection in filter EPD (OR = 20.4, 95%CI = 1.28-326.1). The time distance from symptom to CAS was inversely correlated with debris quantity in EPD (Spearman rho -0.716; p = 0.02). CONCLUSIONS: Echolucent plaques, smaller time frame from last symptom and hypertension were associated with increased presence of embolic material.

Hybrid procedures for the treatment of multi-focal ipsilateral internal carotid and proximal common carotid or innominate artery lesions.

We report three cases with concomitant ipsilateral proximal common carotid and internal carotid artery stenosis treated in one stage with carotid endarterectomy and retrograde primary stenting of the common carotid artery. The internal carotid artery was clamped during stenting to avoid cerebral embolization. All procedures were successfully completed and all patients remain asymptomatic at 18 months follow up. The one-stage hybrid approach appears to be a safe and effective procedure for the treatment of ipsilateral multifocal significant lesions.

Association of plaque echostructure and cardiovascular risk factors with symptomatic carotid artery disease.

AIM: Severity of stenosis remains the main factor for assessing risk of stroke in patients with internal carotid artery (ICA) disease. This study was conducted to investigate the association of plaque echostructure and other established and emerging cardiovascular risk factors with symptomatic ICA disease. METHODS: Cross-sectional study of consecutive patients with significant (>50%) ICA stenosis. Carotid plaque echostructure, smoking, hypertension, diabetes mellitus, serum lipoprotein (a), homocysteine, vitamin B12, folate, cholesterol to high-density lipoprotein ratio, triglycerides, C-reactive protein, and the Framingham risk score were assessed in 124 consecutive patients (70 asymptomatic; 54 symptomatic) with significant (>50%) ICA stenosis. RESULTS: The asymptomatic and symptomatic groups did not differ in terms of gender distribution (P=0.76) and severity of stenosis (P=0.62). Echolucent plaques (type 1 and 2) were more predominant in patients with symptomatic disease (P=0.004, OR=2.13, 95% CI=1.26-3.6). Patients with plaques type 1 were relatively younger than those with type 4 (P=0.02). None of the other factors assessed had any significant association with symptomatic disease and any type of carotid plaque. CONCLUSION: Besides the severity of carotid stenosis, the presence of an echolucent plaque appears as an important factor associated with symptomatic ICA disease. Also young patients are more likely to have an echolucent plaque suggesting an age-related association with plaque maturation.

Periodontitis and carotid atheroma: is there a causal relationship?

Periodontal diseases are highly prevalent in the population. Several studies implicated that chronic periodontitis may affect the arterial wall inducing subclinical atherosclerosis by triggering a systemic inflammatory response. Three theories have been put forward to explain potential mechanisms involved: the theory of bacterial invasion, the cytokine theory and the autoimmunization theory. Periodontal inflammation could have a role in the initiation and progression of arterial diseases such as coronary artery disease and carotid atherosclerosis. Further clinical studies are required to investigate if there is a causal relationship of chronic periodontitis with echolucent unstable carotid plaques.

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

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

Endovascular treatment of symptomatic and ruptured abdominal aortic aneurysms.

AIM: To report our early experience with endovascular treatment of symptomatic and ruptured abdominal aortic aneurysms (AAA) using the Talent bifurcated stent graft. PATIENTS-METHODS: From August 2003 to May 2007 nine patients with symptomatic AAA (sAAA) (two after previous endovascular repair and endoleak), and eleven patients with ruptured AAA (rAAA) (one with ruptured iliac aneurysm and one with spontaneous aortic rupture) were treated endovascularly. Seven bifurcated stent grafts, (six Talent), and two iliac extensions were implanted into the patients with sAAA, and nine bifurcated stent grafts (eight Talent) and two aorto-uniliacs were implanted into the patients with rAAA. RESULTS: The deployment of the endovascular device in the intended location was successful in all patients. There was no conversion to open surgery. One patient with sAAA died after stroke and sepsis resulting in 11.1% 30-day mortality in this group. One required re-intervention for a type I endoleak before his discharge. Eight patients were discharged and during a follow-up period of 4-42 months (median 18 months) they have remained well. Two patients with rAAA died in the 30-day postoperative period. Thirty-day mortality was 18.1%. An unintended occlusion of one renal artery was performed. There were 9 survivors. During a follow-up period of 17-45 months (median 26 months) one more died of myocardial infarction. CONCLUSION: Initial experience with endovascular treatment of patients with symptomatic or ruptured AAA, using the Talent bifurcated stent graft is promising. Bifurcated endografts can be implanted into patients with rAAA. A larger number of patients and longer follow-up is necessary to arrive at more reliable conclusions.

Association of plaque echostructure and cardiovascular risk factors with symptomatic carotid artery disease.

BACKGROUND: Severity of stenosis remains the main factor for assessing risk of stroke in patients with internal carotid artery (ICA) disease. This study was conducted to investigate the association of plaque echostructure and other established and emerging cardiovascular risk factors with symptomatic ICA disease. DESIGN: Cross-sectional study of consecutive patients with significant (> 50%) ICA stenosis. PATIENTS AND METHODS: Carotid plaque echostructure, smoking, hypertension, diabetes mellitus, serum lipoprotein (a), homocysteine, vitamin B12, folate, cholesterol to high-density lipoprotein ratio, triglycerides, C-reactive protein, and the Framingham risk score were assessed in 124 consecutive patients (70 asymptomatic; 54 symptomatic) with significant (> 50%) ICA stenosis. RESULTS: The asymptomatic and symptomatic groups did not differ in terms of gender distribution (p = 0.76) and severity of stenosis (p = 0.62). Echolucent plaques (type 1 and 2) were more predominant in patients with symptomatic disease (p = 0.004, OR = 2.13, 95% CI = 1.26-3.6). Patients with plaques type 1 were relatively younger than those with type 4 (p = 0.02). None of the other factors assessed had any significant association with symptomatic disease and any type of carotid plaque. CONCLUSIONS: Besides the severity of carotid stenosis, the presence of an echolucent plaque appears as an important factor associated with symptomatic ICA disease. Also, young patients are more likely to have an echolucent plaque suggesting an age-related association with plaque maturation.

Hybrid endovascular and open treatment of severe multilevel lower extremity arterial disease.

OBJECTIVE: To evaluate the feasibility and efficacy of simultaneous combined endovascular and open lower extremity arterial reconstruction. DESIGN: Case series study with retrospective analysis of prospectively collected non-randomised data. METHODS: Patients were divided into three groups: group 1 and group 2 included patients who underwent endovascular reconstruction proximal and distal to the site of open reconstruction, respectively, whereas group 3 included patients who underwent open surgery with both proximal and distal endoluminal procedures. Patency analyses were performed using Kaplan-Meier life tables. Univariate and multivariate analyses were used to assess the influence of various risk factors on primary patency. RESULTS: Complete data were obtained from 60 patients who underwent 61 single-step hybrid procedures. Technical and haemodynamic success rates were 100% and 95%, respectively. The perioperative mortality rate was 3%. The primary and assisted-primary patency rates at 12 months were 71% and 98%, respectively. Primary patency rates were lower in group 3 when compared with groups 1 and 2 (log-rank test, p=0.006). The presence of diabetes and dyslipidaemia were independent predictors of decreased primary patency (p=0.003 and p=0.014, respectively). CONCLUSIONS: Hybrid procedures provide an effective treatment management of selected patients with multilevel lower extremity arterial disease. The extent of the disease, diabetes and dyslipidaemia are associated with worse outcome.

Lower-extremity arteriovenous access for haemodialysis: a systematic review.

BACKGROUND: The lower extremity is increasingly used as an access site in end-stage renal disease patients. However, reports present conflicting results, creating confusion regarding the feasibility and outcomes. Our objective is to review the available literature and analyse the patency rates and complications of various types of lower-extremity arteriovenous access. METHODS: An Internet-based literature search was performed using MEDLINE to identify all published reports on lower-extremity vascular access. The analysis involved studies comprising at least 10 arteriovenous accesses with both inflow and outflow vessels in the lower extremity, and reporting on patency rates and access-related complications. The weighted mean patency rates were calculated, and the chi-square (chi(2)) test was used to evaluate the differences in the complication rates in the subgroups of patients identified. RESULTS: Three main types of lower-extremity vascular access were identified: the upper thigh prosthetic, the mid-thigh prosthetic and the femoral vein transposition arteriovenous access. There are limited data on saphenous vein loop grafts, which report poor results. The weighted mean primary patency rates at 12 months were 48%, 43% and 83%, respectively. The weighted mean secondary patency rates at 12 months were 69%, 67% and 93%, respectively. Access loss as a result of infection was more common in upper thigh and mid-thigh grafts than femoral vein transposition arteriovenous access (18.40%, 18.33% vs. 1.61%; P<0.05). Ischaemic complications rates were higher in autologous than prosthetic arteriovenous access (20.97% vs. 7.18%, P<0.05). CONCLUSIONS: Lower-extremity vascular access has acceptable results in terms of patency, with femoral vein transposition having better patency rates than femoral grafts. Autologous access is associated with less infective complications, however, at the expense of increased ischaemic complications rates. Further research with randomised trials is required to assess the outcomes of lower-extremity vascular access.

Visceral venous aneurysms: clinical presentation, natural history and their management: a systematic review.

AIM: Aneurysms of the visceral veins are considered rare clinical entities. The aim is to assess their clinical presentation, natural history and management. METHODS: An electronic search of the pertinent English and French literature was undertaken. All studies reporting on aneurysms of visceral veins were considered. Cases describing patients with arterial-venous fistulae and extrahepatic or intra-hepatic portosystemic venous shunts were excluded. RESULTS: Ninety-three reports were identified, including 176 patients with 198 visceral venous aneurysms. Patients' age ranges from 0 to 87 years, and there is no apparent male/female preponderance. The commonest location of visceral venous aneurysms is the portal venous system (87 of 93 reports, 170 of 176 patients, 191 of 198 aneurysms). Aneurysms of the renal veins and inferior mesenteric vein are also described. Portal system venous aneurysms were present with abdominal pain in 44.7% of the patients, gastrointestinal bleeding in 7.3%, and are asymptomatic in 38.2%. Portal hypertension is reported in 30.8% and liver cirrhosis in 28.3%. Thrombosis occurred in 13.6% and rupture in 2.2% of the patients. Adjacent organ compression is reported in 2.2% (organs compressed: common bile duct, duodenum, inferior vena cava). The management ranged from watchful waiting to intervention. In 94% of the cases, aneurysm diameter remained stable and no complications occurred during follow-up. In most of the cases, indications for operation were symptoms and complications. Six cases of renal vein aneurysm are reported; three of them were asymptomatic. Three of these patients were treated surgically. CONCLUSION: The most frequent location of visceral venous aneurysms is the portal venous system. They are often associated with cirrhosis and portal hypertension. They may be asymptomatic or present with abdominal pain and other symptoms. Watchful waiting is an appropriate treatment, except when complications occur. Most common complications are aneurysm thrombosis and rupture. Other visceral venous aneurysms are extremely rare.

Cerebral perfusion patterns in patients with extracranial carotid atherosclerosis and the impact of carotid stenting. A review.

Patients with extracranial carotid atherosclerosis, either symptomatic or asymptomatic, demonstrate altered cerebral perfusion. Carotid revascularization procedures, such as carotid endarterectomy or stenting, aim mainly at stroke prevention from thromboembolic events, whereas their effects on cerebral perfusion, particularly those seen after carotid stenting, have not been extensively examined. Moreover, ischemia and reperfusion injury have been recognized as devastating complications of these procedures. The present work is a literature review of cerebral perfusion patterns in normal individuals and in patients with carotid artery stenosis prior to and after carotid stenting.