Transrenal E-XL stenting prior to EVAR in the case of abdominal aortic aneurysm associated to proximal aortic neck dissection.

Chronic dissection of proximal aortic neck is a rare occurrence in patients with abdominal aortic aneurysm (AAA) and a gold standard therapy has not been defined so far. Herein we report two successful cases of an original adjunctive procedure involving the transrenal placement of a self-expanding nitinol stent (E-XL aortic stent, Jotec GmbH, Germany) in order to fix a dissection flap in the aortic neck wall prior to the deployment of the bifurcated endograft. Primary technical success and midterm clinical success was achieved in both cases with freedom from any early or late reintervention. Scheduled follow-up angio-CT scans did not show any Type I endoleak, graft migration or renal/visceral arteries complications. According to these findings, patients with an AAA, presenting with a proximal neck with chronic dissection, can be safely and effectively treated by pre-emptive transrenal E-XL stenting and endovascular aneurysm repair.

An original technique for the treatment of symptomatic common carotid artery occlusion and concomitant ipsilateral internal carotid artery stenosis.

Successful hybrid treatment of the total symptomatic acute occlusion of a common carotid artery (CCA) concomitant to ipsilateral internal carotid artery (ICA) stenosis has only been described once in the literature to date. The management of this anatomic distribution of disease can be a challenge both to plan and perform. The aim of this paper is to report an original hybrid revascularization technique for the treatment of two patients with symptomatic CCA acute occlusion and ipsilateral ICA stenosis. Details of the surgical technique and mid-term follow-up are provided.

An accidental subclavian artery cannulation: successful catheter removal by percutaneous vascular stenting.

Central venous catheterisation may sometimes be associated with life-threatening complications. Of these, subclavian artery puncture (infraclavicular approach), though seldom, (incidence 1-2%) following accidental arterial cannulation, may lead to arterial occlusion, embolism, pseudoaneurysms, vessel laceration or dissection or fatal hemorrhaging. Such complications may be even more severe in critically ill patients requiring systemic anticoagulation therapy or those with acute coagulation dysfunction. The authors report a case of an accidental cannulation of the subclavian artery with a central catheter and its successful removal using an endovascular cover stent positioned via a percutaneous approach. The cover stent can be employed to occlude arterial lacerations. This device was preferred because of the patient's severe clinical condition (a 77-year-old woman with acute right heart thrombosis, atrial hyperkinetic arrhythmia, and cardiogenic shock requiring hemodynamic invasive monitoring and systemic thrombolysis) and because of the presenting anatomical and vascular characteristics (lack of space between introduction site and left ventricle, retroclavicular medial location) that did not permit a safe conventional surgical approach (thoracotomy). Echocolor Doppler sonography was a valuable aid in preoperative assessment, measurement of arterial diameter and cover stent sizing. The procedure was performed under general anesthesia 6 days after admission to the intensive care unit without sequelae. In conclusion, the endovascular procedure permitted safe removal of the arterial catheter without complications. A possible alternative to conventional procedures, the endovascular technique may offer an adequate choice for treating acutely ill patients ineligible for invasive interventions.

Cholesterol efflux from Fu5AH hepatoma cells induced by plasma of subjects with or without coronary artery disease and non-insulin-dependent diabetes: importance of LpA-I:A-II particles and phospholipid transfer protein.

We measured the capacity of human plasma to induce cholesterol efflux from Fu5AH rat hepatoma cells in four groups of men with or without non-insulin-dependent diabetes mellitus (NIDDM) and coronary artery disease (CAD). Plasma from men with both NIDDM and CAD (n = 47) had the lowest efflux capacity (17.3 +/- 3.6%) whereas healthy control subjects with neither diabetes nor CAD (n = 25) had the highest capacity (19.8 +/- 3.4%). The groups with CAD but no diabetes (n = 44) and with NIDDM but no CAD (n = 35) had intermediate efflux values (18.5 +/- 3.8 and 18.5 +/- 3.9%, respectively). In a 2 x 2 factorial ANOVA, the differences were significant with respect to the presence of CAD (P = 0.038) and NIDDM (P = 0.041), with no interaction between the factors. The concentration of HDL particles containing apolipoprotein (apo) A-I but no apo A-II (LpA-I) was not related to efflux capacity in univariate or multivariate analyses. A multivariate regression analysis showed that when controlled for the presence of NIDDM and CAD, the concentration of particles containing both apo A-I and apo A-II (LpA-I:A-II) and plasma phospholipid transfer protein activity were both positively, independently, and significantly (P < 0.001) related to cholesterol efflux capacity.

Routine ultrasound surveillance after carotid endarterectomy.

Ultrasounds (US) are employed in preoperative carotid disease diagnosis and in carotid endarterectomy (CEA) follow-up. The authors present their experience about postoperative modifications in CEA site with US evaluation with particular interest in restenosis. Clinical and instrumental examinations were performed at intervals 1, 3, 6, 12, and 24 months following surgery. Follow-up data were available on 189 CEAs. In 58 cases a primary closure was performed, whereas in the other 131 cases, a patch was applied. 15 restenosis (7.9%) were seen during the follow-up control period with 2 cases of haemodynamic restenosis (1%). Good results were recorded with PTFE patch angioplasty (restenosis 4.4%), instead of vein (restenosis 14.2%) and a biosynthetic material called Omniflow (restenosis 9.5%). A vein patch dilatation was encountered in 13 applications (30.9%). In conclusion the routine application of US after carotid endarterectomy allowed us to monitor the evolution of the repair processes and of the stenotic lesions from the very beginning.

Effect of gemfibrozil treatment in hypercholesterolemia on low density lipoprotein (LDL) subclass distribution and LDL-cell interaction.

Gemfibrozil, a widely used fibric acid derivative, corrects hypercholesterolemia in a non-negligible fraction of patients. To investigate the mechanism of the cholesterol-lowering activity of fibric acids, a study was performed in 12 type IIa hyperlipidemic patients treated with gemfibrozil for 12 weeks. Changes in low density lipoprotein (LDL) structure and composition, agonist capacity of LDL against the LDL-receptor in human skin fibroblasts, LDL-receptor activity in mononuclear cells, lecithin:cholesterol acyltransferase (LCAT) and cholesterol ester transfer protein (CETP) activity, were evaluated. Plasma total and LDL cholesterol levels decreased by 17% and 20% after 12 weeks of treatment, the reduction being directly correlated with the baseline levels (r = 0.75 and 0.78, respectively). The mean LDL diameter increased significantly, from 25.5 to 26.1 nm, while the relative content of small LDL particles (< 25.1 nm) increased from 23.4% to 32.8% of total LDL. Neither the apolipoprotein (apo) B secondary structure nor the affinity of LDL for the LDL-receptor of fibroblasts were affected. The LDL-receptor activity in patients' mononuclear cells increased 3-fold, the rise being unrelated to the plasma cholesterol reduction. LCAT activity did not change, while CETP activity was reduced by 25% (P = 0.13) after treatment. These findings indicate that gemfibrozil causes significant changes in LDL structure that do not, however, affect the LDL interaction with peripheral cells.

Plasma triglycerides and lipoprotein(a): inverse relationship in a hyperlipidemic Italian population.

The relationship between plasma lipoprotein(a) (Lp(a)) levels and other clinical/biochemical variables was investigated in 1200 consecutive hyperlipidemic patients. Plasma Lp(a) concentrations were measured by a sandwich-ELISA method, while the patients were either on diet or diet plus lipid-lowering drugs; 38% of them had a plasma Lp(a) level > 30 mg/dl. The median plasma Lp(a) concentration and the frequency of Lp(a) > 30 mg/dl were significantly lower in individuals with severe hypertriglyceridemia vs. hypercholesterolemics (HC) or mixed hyperlipidemics (M-HLP), but similar to normolipidemic healthy controls. Patients with isolated moderate hypertriglyceridemia had Lp(a) levels intermediate between HC and M-HLP subjects. The in vitro addition of triglyceride-rich lipoproteins to normotriglyceridemic plasma did not affect the Lp(a) measurement. Plasma Lp(a) concentrations in the whole hyperlipidemic population correlated negatively with triglycerides and positively with total cholesterol, HDL-cholesterol and age, being unrelated to either body mass index or lipid-lowering treatment. In HC patients, the presence of tendon xanthomas was associated with twofold higher Lp(a) levels. These findings argue for a regulatory role of triglycerides on plasma Lp(a) levels in hyperlipidemic patients.

New devices for carotid reconstruction.

An analysis of the reason for re-exploration of the carotid bifurcation immediately after surgery has demonstrated that in the majority of cases it is a question of defects of the distal part of the seat of CEA. The aim of this paper is to illustrate the use of an originally planned catheter and shunt during carotid surgery that may obviate some of the problems faced daily by surgeons during carotid reconstruction.

Early and late results of biosynthetic ovine carotid angioplasty.

Recent major technical improvements in the field of carotid surgery have been related to anesthesiology and cerebral monitoring. However early embolic events and recurrent stenosis are, after intraoperative ischaemia, the main problems of carotid endarterectomy (CEA) and therefore technical improvements that reduce the incidence of these complications are required. The choice between primary closure and angioplasty is still debated. In the case of angioplasty, the choice of patching material seems to be important in preventing these complications. The Authors present their experience with a biosynthetic ovine patch in carotid surgery. In the period from January 1982 to November 1991, 1013 carotid endarterectomies were performed on 866 patients (659 men, 207 women) with atherosclerotic disease at the carotid bifurcation. In 147 cases a bilateral CEA was performed. Recently, in 37 cases of patch angioplasty, the Authors used the biosynthetic ovine patch. No deaths and no permanent neurological deficit were registered in this series either during awakening or the immediate postoperative period. Of these 37 patients, all except 4, had a minimum follow-up of 24 months. Two cases of non-hemodynamic restenosis were detected, one at 6 and one at 12 months; both were asymptomatic. In this series the total restenosis ratio was 5.5% (2/36), and the cumulative mortality rate 10.8% (4/37) (IMA 2, hepatic insufficiency 1, cerebral hemorrhage 1). The Authors' preliminary experience with this biosynthetic graft as a patching material has been satisfactory. They believe that this biosynthetic graft (Omniflow) on account of its handling and particularly its healing characteristics can be considered as a graft material for patching at the carotid level.