Very Early Carotid Endarterectomy After Intravenous Thrombolysis.

OBJECTIVE/BACKGROUND: The timing of carotid endarterectomy (CEA) after thrombolysis is still a matter of debate. The aim of this study was to analyse a cohort of patients undergoing urgent endarterectomy after intravenous thrombolysis for acute ischaemic stroke. METHODS: This was an observational study. Prospective databases were reviewed and matched to identify patients who underwent CEA early after intravenous thrombolysis (2009-14). The focus was carotid surgery performed within 12 hours of stroke onset in patients with a high grade (≥70%) symptomatic carotid stenosis, associated with vulnerable plaques or stroke in evolution, and evidence of a significant salvageable ischaemic penumbra on perfusion computed tomography scan. Demographic and clinical information, as well as data on relevant outcomes were extracted. RESULTS: Thirty four consecutive stroke patients who underwent CEA within 2 weeks of thrombolysis for acute ischaemic stroke and ipsilateral high grade carotid stenosis were identified. In 11 patients the surgical procedure was performed within 12 hours of the onset of symptoms. All patients showed a clinical improvement after combined treatment. The 3 month outcome was favourable (modified Rankin Scale ≤ 2) in 10 patients. No haemorrhagic complications were registered. There was neither peri-operative stroke nor stroke within 3 months of surgery. One patient died from acute myocardial infarction 3 days after intervention. CONCLUSION: This experience suggests that very early CEA after thrombolysis, aimed at removing the source of potential embolisation and restoring blood flow, may be safe and can lead to a favourable outcome.

Treatment of true superficial femoral artery aneurysms: the 15-year experience of a single centre.

OBJECTIVE: True superficial femoral artery aneurysms (SFAAs) are rare and traditionally treated by open repair. However, the endovascular approach excluding the aneurysm sac with a covered stent may be an alternative. This study aimed to compare the outcomes of the open and endovascular repair of SFAAs. METHODS: This is a retrospective, observational, monocentric study. The main endpoints were: technical success, limb salvage and primary patency rate, and hospitalisation time. RESULTS: We identified 49 SFAAs in 40 patients; the mean age was 73.3±10.1 years, the mean diameter of SFAAs was 5.41±3.64cm, and 61.2% were symptomatic for ischaemic or compression-related signs. The indication for open repair was given mainly for complex SFAAs involving the distal third of the superficial femoral artery and with an ipsilateral popliteal aneurysm. Among the 36 open-repair patients, 33 underwent ligation and revascularisation via bypass or graft interposition, and 3 patients underwent simple ligation without revascularisation. The endovascular approach was adopted mainly for aneurysms located in the medial third of the SFAA, which underwent covered stenting in 12 patients and coil embolisation in 1 patient. The technical success was 100% in all cases. There were no statistical differences in terms of primary patency and limb salvage rate between groups at two and four years. The mean hospitalisation time was 10±4 and 3±1 days after open and endovascular treatment, respectively. CONCLUSIONS: The endovascular approach may be a valid alternative for isolating SFAAs offering good results and shorter hospitalisation. Open repair remains a valid approach, particularly in complex aneurysms.

Revascularisation through the obturator foramen of lower limbs with a compromised ipsilateral groin due to infection.

INTRODUCTION: Infra-inguinal vascular reconstruction with active groin infection is a concerning issue. Using resistant grafts to infection is the most adopted approach. However, in absence of these materials in acute situations, the trans-obturator approach allows for limb revascularisation avoiding the infected site. We evaluated the effectiveness of this approach in patients who needed lower limb revascularisation with an ipsilateral groin infection. MATERIALS AND METHODS: A retrospective study was conducted over a four-year period. RESULTS: Over this period, 13 patients underwent trans-obturator reconstructions (13 external iliac-popliteal above-knee and one aortobipopliteal above-knee bypass). Seven patients had been previously revascularised and were admitted for graft infection (six infra-inguinal bypasses, one axillo-bifemoral bypass). Four presented with acute limb ischaemia, three with groin haematoma and one with a groin abscess. The remaining cases consisted of drug-addicted patients with injury of femoral vessels due to self-injection of drugs. The patients underwent reconstructions with autologous grafts which complicated early with groin haematoma. After transobturator revascularisation, the groin underwent debridement with applying vacuum-assisted wound closure device. CONCLUSION: The transobturator approach could be considered as a chance for lower limb revascularisation in case of ipsilateral groin infection. Moreover, avoiding the infected site allowed us to focus separately and safely on the treatment of the inguinal wound.

Pharmacological characterization of a vasopressin V1 receptor in the isolated human gastric artery.

Species-related specific differences in the pharmacological profile of vasopressin V1a receptors have been reported. Thus, the aim of the present study was to identify a vascular preparation of human origin expressing V1a receptors. Vasopressin was found to contract human gastric artery strips without endothelium with high affinity (pEC50 8.9). The maximal effect induced by vasopressin was inversely related to the diameter of the vessel. Oxytocin was found to contract the human gastric artery strips with low potency (pEC50 7.2). Contraction induced by vasopressin was competitively antagonized by the non peptide vasopressin receptor antagonists SR 49059 (pA2 9.2), OPC 21268 (pA2 6.2) and OPC 31260 (pA2 7.1). The order of potency of agonists (vasopressin > > oxytocin) and of antagonists (SR 49059 > > OPC 31260 > OPC 21268) indicate the contraction induced by vasopressin in the isolated human gastric artery is mediated by the V1a receptor type. The present data are similar to those obtained in different preparations expressing the native human V1a receptor as well as to those obtained in cell transfected with this receptor. The human gastric artery is a monoreceptor system of great utility for studying the effects of new drugs interacting with the human V1a receptor.

Intraoperative H/R echography for carotid surgery.

BACKGROUND: Intraoperative duplex examination can be used during carotid surgery to identify small technical defects (like anastomotic stenosis, intimal flaps or subintimal wall dissections) that cannot be easily found by palpatory manoeuvres. The objective of this clinical study is to correlate intraoperative duplex findings with early postoperative complications and with duplex data obtained during follow-up. METHODS: From January 1993 to January 1996 we compared early and late postoperative complications that occurred after carotid surgery in two groups of patients: a group of 120 patients undergone intraoperative duplex compared with a group of 100 patients not undergone intraoperative ultrasound. RESULTS: The percentages of early and late postoperative complications which occurred in the first group were respectively 7.5% and 4.2% contrary to 10% and 7% occurred in the control group. CONCLUSIONS: Duplex constitutes a selective intraoperative method for carotid surgery, easy to use, enable to identify and immediately correct technical defects.

Aneurysm dissection of the extracranial internal carotid artery.

Aneurysm of the extracranial internal carotid artery is a rare event. This is a pathology with an elevated mortality of 70%. The most important etiologic factor is atherosclerosis. Here we report a case of surgically treated extracranial internal carotid artery (ICA) aneurysm. A 77-year-old man noticed a laterocervical pulsatile mass. Color Doppler ultrasonography revealed an ICA aneurysm related to a parietal thrombosis. The ICA aneurysm was confirmed by intra-arterial digital subtraction angiography, and cerebral computer tomography (CT) was negative. Surgical treatment reconstruction with the interposition of a part of the great saphenous vein was indicated. Exploration of the aneurysmatic wall revealed a posterolateral dissection. In this paper are discussed clinical and therapeutic implications.

[Morphologic anomalies of the extracranial internal carotid artery. Our experience]. / Anomalie morfologiche dell'arteria carotide interna extracranica. Nostra esperienza.

Cerebro-vascular insufficiency may be caused by morphologic anomalies of the extracranial internal carotid artery (10-15% of symptomatic patients). These alterations are characterized by anomalous elongation which conditions particular attitudes of the carotid: tortuosity, coiling, kinking. In the first case the artery assumes an "S" or "C" shape; in the second the elongation is more emphasized and the artery develops one or more loops; kinking, the most frequent morphologic anomaly, is a sharp angulation of the first part of the internal carotid artery. The etiology of these anomalies seems to be related to congenital causes, that may be unmasked by arterial growing old process. Surgical correction, indicated for symptomatic patients or patients with important hemodynamic alteration, requires rectilinearisation of the internal carotid artery associated with TEA eversion of the same.