Pancreatic injury during AAA repair: a comparison between EVAR and open repair.

OBJECTIVES: Enzymatic pancreatic injury (EPI) in abdominal aortic aneurysm (AAA) treatment has been scarcely studied in the literature. Aim of this work was to compare perioperative EPI in AAA patients treated by endovascular repair (EVAR) or open repair (OR). METHODS: Forty AAA patients consecutively treated with either EVAR (GI, 20 pts) or OR (GII, 20 pts) were prospectively evaluated in terms of epidemiology, comorbidities and technical details. Serum levels of amylase, lipase and pancreatic isoamylase were assessed before treatment (T0), before aortic clamping/endograft deployment (T1), 1, 2, and 6 hours after aortic declamping/endograft deployment (T2, T3, T4) and 24, 48, and 72 hours after the procedure (T5, T6, T7). GI and GII were compared by Mann Whitney test with significance set at p < 0.05. RESULTS: GI patients were significantly older and with higher frequency of preoperative renal insufficiency than GII ones (p = 0.001 and 0.047 respectively). Other characteristics were not significantly different. Pancreatic enzymes values at T0 were within normal parameters in all patients. Total serum amylase was significantly greater at T4 (p = 0.003), T5 (p = 0.010), T6 (p = 0.003), T7 (p = 0.011) and isoamylase at T3 (p = 0.052), T4 (p = 0.037), T5 (p = 0.016) and T6 (p = 0.014) in GII compared with GI. Amylase and isoamylase peak occurred 24 hours after the procedure. Lipase was significantly different in the two groups only in T4 (p = 0.028). No acute pancreatitis occurred in the whole study group. CONCLUSIONS: EVAR significantly reduces EPI compared with OR in the AAA treatment.

Identification of carotid 'vulnerable plaque' by contrast-enhanced ultrasonography: correlation with plaque histology, symptoms and cerebral computed tomography.

INTRODUCTION: Indication to carotid revascularisation is commonly determined by percent of stenosis as well as neurological symptoms and clinical conditions. High plaque embolic potential is defined as 'vulnerability'; however, its characterisation is not universally used for carotid revascularisation. We investigated the role of contrast-enhanced ultrasonography (CEUS) to identify carotid vulnerable plaque. METHODS: Patients undergoing carotid endarterectomy were preoperatively evaluated by cerebral computed tomography (CT) scan and CEUS. Contrast microbubbles detected within the plaque indicated neovascularisation and were quantified by decibel enhancement (dB-E). Plaques were histologically evaluated for five features: (microvessel density, fibrous cap thickness, extension of calcification, inflammatory infiltrate and lipid core) and blindly scored 1-5 to assess plaque vulnerability. Analysis of variance (ANOVA), Fisher's and Student's t-test were used to correlate patients' characteristics, histological features and dB-E. RESULTS: In 22 patients, dB-E (range 2-7.8, mean 4.85 ± 1.9 SD) was significantly greater in symptomatic (7.40 ± 0.5) vs. asymptomatic (3.5 ± 1.4) patients (p = 0.002). A higher dB-E was significantly associated with thinner fibrous cap (<200 µm, 5.96 ± 1.5 vs. 3 ± 1, p = 0.01) and greater inflammatory infiltrate (3.2 ± 0.9 vs. 6.4 ± 1.2, p = 0.03). Plaques with vulnerability score of 5 had significantly higher dB-E compared with those with vulnerability score of 1 (7.6 ± 0.2 vs. 2.5 ± 0.6, respectively, p = 0.001). Preoperative ipsilateral embolic lesions at CT were correlated with higher dB-E (5.96 ± 1.5 vs. 3.0 ± 1.0, p = 0.01). CONCLUSION: CEUS with dB-E is indicative of the extent of plaque neovascularisation. It can be used therefore as a marker for vulnerable plaque.

Ring-stents supported infrarenal aortic endograft fits well in abdominal aortic aneurysms with tortuous anatomy.

AIM: Abdominal aortic aneurysms (AAA) with severe angulation of the neck or of the iliac arteries are often unsuitable for endovascular repair with conventional endografts. We evaluated the performance of a ring-stent abdominal endograft (AnacondaTM Vascutek, Terumo, Scotland) in a consecutive series of infrarenal AAA. METHODS: Preoperative, procedural and follow-up data of patients treated with AnacondaTM endograft between September 2005 and September 2009 were prospectively enrolled. Patients were divided in Group A (proximal neck angle > or =60 degrees or iliac arteries angle > or =90 degrees ) and Group B (all others). Main endpoints were technical and clinical success (primary and assisted) and late outcome in the two groups. Results were compared by Kaplan-Meier life table analysis with log-rank test (Mantel-Cox). RESULTS: One hundred twenty-seven patients, with a mean age of 73.5+/-6.9 years, have been included in this series. Mean aneurysm size was 56.7+/-10.4 mm. A severe angulation of the proximal aortic neck or/and of the iliac arteries was present in 44 cases (Group A), absent in 83 cases (Group B). The mean follow-up was 18.2+/-16.3 months. Overall primary technical success was achieved in 100% of the patients. At twenty-four months survival, primary and assisted clinical success were 94.2%, 88.2% and 91.3% in Group A and 80.3%, 83.7% and 95.2% in Group B respectively. No significant differences were found between the two groups. The only factor significantly associated with decreased survival was preoperative renal insufficiency. Iliac limb patency 24 months after EVAR in severely and non-severely angulated iliac axis was 96.7% and 98.1% respectively, with no significant difference between the groups. Only one proximal type I endoleak was detected in a patient with severe angulation of proximal aortic neck. No significant correlation between proximal type I endoleak and severe neck angulation was found. CONCLUSION: Aneurysms with severe neck or iliac arteries angulation can be treated by a ring-stent endograft with results similar to those of AAA with more favourable anatomy.

The residual risk of cerebral embolism after carotid stenting: the complex interplay between stent coverage and aortic arch atherosclerosis.

AIM: This study investigated the fate of the stent inner surface in carotid artery stenting (CAS). In addition, the occurrence of late cerebral micro-embolism after CAS has been studied in order to identify predictors and correlate it with a possible neo-intimal layer. METHODS: A series of patients were evaluated before CAS through aortic arch trans-oesophageal echocardiography. Six months after CAS, the stent coverage by neo-intima and the possible presence of uncovered plaques were determined by high-resolution duplex scanning (5-17-Hz probe and 3D reconstruction). Possible micro-embolic signals (MESs) were evaluated through transcranial duplex scanning (30-min analysis of ipsilateral middle cerebral artery with a 1-4-Hz probe) and correlated with patients' characteristics, intimal media thickness (IMT) (>0.9mm vs. <0.9mm) and uncovered proximal plaques, type of stent (closed vs. open cells) and aortic arch complicated plaques (>4mm). Fisher's and Wilcoxon tests were used to evaluate differences across groups for categorical and continuous variables, respectively. RESULTS: In the 68 CASs examined (40 closed cells and 28 open cells), the stent was completely covered by neo-intima in 52 cases (76.4%). Complete coverage was significantly correlated with IMT<0.9mm and the absence of a proximal plaque uncovered by the stent (100% vs. 0%, p<0.001). Hypertension was an independent predictor of complete intimal coverage (p=0.002), while the stent type did not influence this process. The MESs were significantly more frequent in patients with complicated aortic arch plaques (62.5% vs. 23.8%, p<0.012), independently from all other factors. CONCLUSIONS: The extent of the stent neo-intimal formation is independent of stent type, but it is correlated with proximal plaque coverage. Six months after CAS, MESs are still possible and are not prevented by complete neo-intimal stent coverage. Complicated aortic arch atherosclerosis is an independent predictor of late MES, thus underlying its importance in cerebral ischaemia onset.

The advantages of Anaconda endograft for AAA.

AIM: The Anaconda endograft (Vascutek, Terumo, Inchinnan, Scotland) is an infrarenal, trimodular stent-graft with peculiar characteristics in terms of implant, proximal sealing and fixation of the main body and iliac legs. This endograft can be used in infrarenal abdominal aortic aneurysm (AAA) with an aortic neck >or=15 mm in length. The authors evaluated the mid-term outcome of the Anaconda endograft in the treatment of infrarenal AAA also in cases with tortuous anatomy. METHODS: Between September 2005 and September 2008, 100 patients (94 males, 6 females) with mean age of 73.9+/-5.2 years (range 55-89) were considered eligible for treatment with Anaconda endograft (proximal neck length >or=15 mm). The mean aneurysm size was 55.2+/-3.4mm (range 45-99 mm). An angulation of the aortic neck greater than 60 degrees was present in 19 cases. The iliac arteries were severely angulated >60 degrees in 61 patients. The mean follow-up was 23.2+/-11.0 months (range 1.4-38.6). RESULTS: Primary technical success was achieved in 100% of the patients. Six patients died during follow-up, none for aneurysm-related causes. Survival rate was 87.9% at 24 months of follow-up. Primary and assisted clinical success were respectively 80.8% and 93.7% at 24 months with a freedom from reintervention of 88.8%. No cases of endograft migration were observed and only one case of type I proximal endoleak was recorded in the mid-term follow-up. The univariate and the multivariate analysis did not show an increased risk in patients with angulated proximal neck or iliac arteries. CONCLUSIONS: As evidenced in this clinical study, the mid-term outcomes of Anaconda endograft are satisfactory concerning the treatment of AAA with a minimum neck length of 15 mm. This device proved in the mid-term to effectively protect the patient treated from aneurysm rupture. Presence of even severe tortuosity of the proximal neck and of the iliac arteries did not affect outcomes. Considering these results showing the safety of Anaconda endograft, the authors suggest its employment also in cases with difficult anatomy.

Kissing balloon technique for angioplasty of popliteal and tibio-peroneal arteries bifurcation.

INTRODUCTION: Kissing balloon technique with two low-profile catheters (KBT) could be the treatment of choice for diseased infrapopliteal artery bifurcation in critical limb ischemia (CLI). REPORT: From April to December 2006, 8 patients with CLI and tibial artery disease located in the infrapopliteal bifurcation were treated with KBT. Technical success was achieved in all patients without major or minor complications. DISCUSSION: Angioplasty of the bifurcation of the popliteal and tibio-peroneal trunk using KBT is a safe and effective procedure in CLI.

Common carotid agenesis and internal carotid stenting.

Agenesis of common carotid artery is rare and no report of stenting procedures (carotid artery stenting) for associated stenosis of the internal carotid have been published. We report a case of internal carotid stenosis associated with this anomaly. A 73-year-old male with left internal carotid artery originating from the arch, with significant stenosis, was referred to us. Wallstent was deployed with success. Carotid artery stenting should be reserved to uncomplicated arch anatomy and plaques with low fragmentation risk.

Vascular reactivity in patients with peripheral vascular disease.

Noninvasive techniques have been used to demonstrate a specific pattern of impaired vasoactive response in the normal brachial artery of patients with clinical atherosclerosis. This is a physiologic reflection of the systemic nature of atherosclerosis and may be useful as a marker for identifying patients with preclinical atherosclerotic disease.

Morphology of small aneurysms: definition and impact on risk of rupture.

BACKGROUND: Parietal characteristics of small aortic aneurysms predictive of increased risk of rupture are unknown. METHODS: Prospective morphologic evaluation was performed in 135 consecutive cases of small (< 5 cm) abdominal aortic aneurysm. Twelve cases (9%) were found to be ruptured and sent for emergency surgery. The remaining 123 patients were evaluated with ultrasonography, angiography, and intraoperatively during elective surgery. Ninety-six (78%) also underwent computerized tomography (CT) scanning. The evaluation assessed the thickness of the endoluminal thrombus and arterial wall as well as the presence of saccular outpouchings ("blisters"). Also noted were any areas of impending rupture, defined as discontinuity of the arterial wall with only a thrombus preventing rupture. RESULTS: Blisters were discovered intraoperatively in 12 aneurysms. Digital subtraction angiography (DSA) revealed 3 (25%) of these preoperatively. Eleven of the patients with blisters were examined preoperatively with CT scanning, which detected 3 blisters (27%). Both endoluminal thrombus and wall thickness were measurable by CT scan but not ultrasonography. The incidence of impending rupture was significantly greater in patients with blisters than in those without (71% versus 29%, P = 0.0001). The incidence of impending rupture was similar whether the amount of endoluminal thrombus was more or less than 2 cm (57% versus 40%, P = 0.386). Rupture was no more frequent when aneurysmal walls were thicker or thinner than 0.3 cm (14% versus 20%, P = 0.719). In an analysis using logistic regression, the presence of a blister was the only independent morphologic predictor of impending rupture (P = 0.001, Wald = 15). CONCLUSION: In patients with small aneurysms, increased attention should be directed to the preoperative detection of blisters.

Total excision and extra-anatomic bypass for aortic graft infection.

Reports of high mortality and amputation rates following total excision and extra-anatomic bypass for aortic graft infection have prompted the use of alternate approaches including local antibiotics, partial resection, in situ revascularization, and graft excision without revascularization. Experience with aortic graft infection was reviewed to establish current morbidity and mortality rates and evaluate our bias in favor of total excision and extra-anatomic bypass. Aortic graft infection was identified in 32 patients, 8 with aortoenteric fistulas. The mean interval between graft placement and infection was 34 months. History of groin exposure (75%) or multiple prior vascular surgery (50%) was common. Clinical signs included fever and/or leukocytosis (23 patients), false aneurysm (9 patients), graft thrombosis (6 patients), groin infection (11 patients), and gastrointestinal hemorrhage (6 patients). Microbiologic data, available in 26 patients, demonstrated gram-positive organisms in 15 patients and gram-negative in 9. Multiple organisms were seen in 11 patients. Patients were treated by partial removal with (8 patients) or without (4 patients) revascularization or total removal with (18 patients) or without (2 patients) revascularization. Revascularization was by an extra-anatomic route, either simultaneous or staged. Overall morbidity/mortality was less in the revascularized groups (p = 0.01), while late complications were seen only after partial removal (p less than 0.01). The best results were found after total excision with revascularization. No patient in this group experienced late infection or amputation during a mean follow-up of 34 months (range: 1 to 168 months). Complications after total excision and extra-anatomic bypass for aortic graft infection are lower than generally appreciated. This approach should remain the standard to which other approaches are compared.

Parietal inflammatory infiltrate in peripheral aneurysms of atherosclerotic origin.

Clinical and histological analyses were made of 18 consecutive cases of peripheral artery atherosclerotic aneurysms (PAAA) (common, deep femoral and popliteal arteries) and compared to a group of 10 specimens obtained from the atherosclerotic, non aneurysmal femoral arteries of 10 cadavers with similar characteristics to the 18 patients. Although neither the clinical nor the macroscopic morphological data indicated the presence of an inflammatory process in the PAAA, the histological examination revealed the presence of a considerable infiltrate (greater than 11 inflammatory cells/2116 microns2) in a surprisingly high percentage of cases (4 cases, 22.8%). In 5 other cases (27.7%) the presence of lymphomonoplasmonocytic cells, although less pronounced, was greater than normally seen in atherosclerotic arterial walls (greater than 4 and less than 11 inflammatory cells/2116 microns2). The median number of inflammatory cells present in the media and adventitia varied from 2.2 +/- 0.3 to 13.2 +/- 0.3 per 2116 microns2. These values are significantly different compared to the results of atherosclerotic arteries at the same level (P less than 0.001 Mann-Whitney's U test). These findings of lymphomonoplasmocytic infiltrates in the absence of other pathology, together with an analysis of the data in the literature, makes it possible to presume that the inflammation present is associated with atherosclerosis and is more common in aneurysmal rather than stenotic forms. The pathogenesis may be determined by immune reaction phenomena.

Inflammatory abdominal aortic aneurysms: does an early stage exist?

Inflammatory aneurysms are characterised by a peculiar clinical (i.e. abdominal-lumbar pain, weight loss and increased ESR) and morphological picture (whitish wall, adhesion to the surrounding organs and thickness greater than 0.5 cm). The lymphomonoplasmacellular infiltrate and the interstitial deposits of collagen define the histological picture of these lesions. The authors describe three abdominal aortic aneurysms macroscopically characterised by parietal edema, hyperemia and hypertrophy of the preaortic lymphnodes. Histological study revealed a conspicuous and widespread lymphomonoplasmacellular infiltrate and interstitial edema. The abdominal-lumbar pain, the increase in ESR and the reactive C protein defined the clinical and laboratory aspects. Serological tests for syphilis, rheumatoid arthritis and lupus erythematosis were negative. The question which arises from these observations is whether these forms represent separate entities or an early stage in the evolution of inflammatory abdominal aortic aneurysms with fibrosis.

Is carotid stenosis correlated with tympanosclerosis.

AIM: Tympanosclerosis and atherosclerosis seem to have a similar inflammatory origin despite the different tissues involved. We have investigated the possible relationship between tympanosclerosis and atherosclerosis by evaluating the incidence of tympanic plaques in patients with significant carotid disease. METHODS: Between September 1(st) 2002 and April 30th 2003, we have evaluated all patients undergoing carotid surgery for significant carotid stenosis (group A). If at least 1/5 of the eardrum was occupied by plaques, then the case was considered positive. A control group of patients of similar age and no history of otological nor vascular pathologies was enrolled (group B). The 2 groups were compared statistically by Fisher's test and significance was set at p=0.05. RESULTS: Group A consisted of 84 patients. In this group 32 patients (38.1%) had tympanosclerosis; it was bilateral in 12 cases. Group B had 84 patients. In this group tympanosclerosis was present in 11 cases (13%). The difference between the 2 groups was statistically significant (p=0.005). CONCLUSION: More studies are needed before we can understand the cause of the association between these 2 pathologies. However early screening of atherosclerotic disease in patients with tympanosclerosis seems justifiable on the basis of the data of both the literature and the present study.

Angiosarcoma in a limb with arteriovenous fistulas and elephantiasis.

Angiosarcoma is a rare malignant tumor of the soft tissues (less than 1% of sarcoma). It may affect various parenchymae (bones, liver, breast), the soft tissues or the skin. In the latter case it may be associated with lymphedema. Onset in the arm is typical with postmastectomy lymphedema (Stewart-Treves syndrome). The forms occurring in limbs with chronic lymphedema not associated with mastectomy are much rarer, with a total of 38 cases occurring in patients with an average age of 46.8 years and with lymphedema present for an average of 20 years. The survival rate for 5 years is 16.6%. The case observed by us had the characteristic onset of the malignant neoplasm on a pre-existing "angiomatosis lymphangiomatosis" pattern also featuring angiographycally detected arteriovenous fistula.

Multifocal diffuse glomus tumor. A case report of glomangiomyoma and review of the literature.

The case examined was a multifocal diffuse glomus tumor covering most of the right leg of a 24-year-old woman. The lesion, present at birth, had never caused any symptoms. Macroscopically, it had a simulangiomatous aspect, whereas histologically it was identified as a glomangiomyoma. The Authors have examined 26 (46.4%) of the 56 cases of multiple tumors reported to date. Multiple glomus tumors are benign lesions, which generally appear at an early age (70% by the age of 20), with no clear distinction between the two sexes. The lesions usually occur on the upper limbs, which account for 80% of the cases. Pain is reported in half of the cases. There are 3 histological types: "sensu strictu" glomus tumor, glomangioma and glomangiomyoma; the glomangioma being the most frequent (80.8%) as compared to 19.2% for the glomangiomyomatosis type. No case of "sensu strictu" glomus tumor was observed.

Inflammatory aspects in atherosclerotic abdominal aortic aneurysms. A case report.

An important inflammatory reaction was histologically observed in the wall of an abdominal aortic aneurysm in a 42 year-old patient suffering from multifocal atherosclerotic lesions. Histochemical and ultrastructural studies showed an active-stage wall lymphomonoplasmacellular component. The histological appearance and biochemical and microbiological studies excluded specific aortitis, a rheumatic disease or concomitant infectious processes. The morphological relationships between the atherosclerotic lesion and the infiltrate together with the immunophenotyping features of the infiltrate suggest the possibility of a close correlation between the inflammatory process and the atherosclerotic lesion of the wall.

Ischemia: reperfusion syndrome of the lower limbs.

The ischemia-reperfusion syndrome, first described by Haimovici in 1960, is a severe complication following surgery for acute ischemia. We evaluated the incidence of this complication in 264 patients operated on between 1972 and 1981 (1st group) and compared it with another of 392 patients operated on between 1982 and 1991 (2nd group), our aim being to assess the effects of pharmacological prophyiaxis based on preoperative overhydration followed by an intra-arterial bolus of 250 ml 14/1000 HCO3-, containing 1 g dexamethasone and 2500 I.U. sodium heparin, injected into the femoral artery before suturing the arteriotomy. This regimen was based on the measurement of myoglobin and glutathione levels respectively carried out in two subgroups of 25 patients. The results of experimental ischemia-reperfusion syndromes induced in animal using radical scavengers and membrane-protective compounds were also taken into consideration. Following experimental research on sheep, 5 patients in the second group with very severe ischemia due to aortic occlusion received local dialysis in the extracorporeal circulation using hemodialysis or hemofiltration techniques. Mortality was 6.3% in the first group and 5.4% in the second, while the amputation rate was 3% and 1.8% respectively. The overall incidence of the reperfusion syndrome was 3% in the 1st period and 1.8% in the second. Our findings confirm the protective effect of hyper-hydration, radical scavengers and dexamethasone in the ischemia reperfusion syndrome, and indicate that local hemodialysis is a useful adjunct in very severe ischemia.

[Treatment of aneurysm of the inferior pancreaticoduodenal artery associated with celiac axis occlusion]. / Trattamento di un aneurisma dell'arteria pancreaticoduodenale inferiore associato ad ostruzione del tronco celiaco.

A case of the inferior pancreaticoduodenal artery aneurysm, associated with occlusion of the celiac axis is reported. The aneurysm seemed to be related to a high-flow state secondary to the associated occlusion of the celiac axis. The occlusion was typical of the atheromatous disease. The aneurysm was atherosclerotic in origin and was treated with resection and PTFE patching. Eighty months later an angiogram was performed, demonstrating a normal patency of the pancreaticoduodenal arcades. The treatment of these aneurysms is discussed, and the literature on this uncommon disease is reviewed.

[Problems of indications for the treatment of aneurysm of the visceral arteries]. / Problemi d'indicazione al trattamento degli aneurismi delle arterie viscerali.

The authors report the clinical history and the treatment of 5 patients with visceral artery aneurysms. The celiac trunk, the common hepatic artery, the inferior pancreaticoduodenal artery and the splenic artery (in 2 different patients) were affected by the aneurysmal disease. Various techniques have been employed in the successful treatment of these patients: radiological embolization of the celiac trunk aneurysms, Dacron graft reconstruction of the common hepatic artery aneurysm, endosaccular ligature and PTFE patching of the inferior pancreatico-duodenal artery aneurysm, endosaccular ligature in one of the two splenic artery aneurysm and simple ligature and splenectomy in the remainder splenic artery aneurysm. Early diagnosis is important in these lesions, because of the trend toward rupture and subsequent high mortality rate. Ultrasonography (US), Computed Tomography (CT) and Magnetic Resonance (MR) are very helpful as diagnostic tools, however angiography represents the method of choice since it could be the first step of the embolization treatment. Furthermore angiography is useful for detection of associated visceral lesions and for the study of collateral blood supply. Treatment choice depends on visceral artery aneurysms localization, the presence of associate lesions and the possible general contraindications. In the latter case, radiological embolization could be the first-choice treatment.