Left main coronary artery disease: percutaneous coronary intervention or coronary artery bypass grafting? A critical review of current knowledge and contemporary debates.

Significant unprotected left main (ULM) disease is the highest-risk coronary artery lesion, carries high morbidity and mortality related to a large amount of myocardium supplied, and should undergo prompt revascularization. Among recent randomized controlled trials (RCTs), NOBLE failed to demonstrate non-inferiority of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG). However, all the other RCTs have shown comparable outcomes. While CABG is associated with higher stroke rates at 30 days and 1 year, PCI is associated with increased spontaneous myocardial infarction (MI) events and the need for repeat revascularization. Furthermore, the benefit of CABG is more evident with the increased complexity of coronary artery disease. In current European and American guidelines, CABG is the standard of care for ULM disease. PCI is considered a reasonable alternative in selected patients (2a B-NR). There is still a great need for carefully designed RCTs with longer follow-up times to validate the role of recent technological and pharmacological regimens.

Secondary aortoenteric fistula: a narrative review of the view of the surgeon.

Aortoenteric fistula (AEF) is defined as the abnormal communication between the aorta and the gastrointestinal tract. AEFs are divided into primary and secondary usually after abdominal aortic aneurysm (AAA) recovery and are a rare but quite dangerous cause of gastrointestinal bleeding that the general surgeon may face during his/her career. Secondary AEF was first described in 1953 to a 44-year-old woman 3 months after an AAA operation. This review presents the role of the surgeon in the management of secondary aortoenteric fistulas. AEFs are a rare but fatal gastrointestinal bleeding cause that the general surgeon may be asked to manage. Diagnosis requires the combination of strong clinical suspicion and the presence of a history of AAA surgery. Although a vascular surgery case, general surgeons play a role in choosing the technique of restoring the intestinal tract, which seems to be significantly related to subsequent morbidity and mortality.

Demographic and clinical characteristics of patients with varicose veins in Albania: a retrospective, single-centre analysis.

Introduction: Chronic venous disease (CVD) constitutes a frequently underdiagnosed pathological condition that progressively diminishes patients' quality of life and imposes an escalating strain on healthcare resources. This study aims to comprehensively investigate the epidemiological landscape of varicose vein disease, examining age group distributions, gender patterns, residence influences, marital status correlations, weight considerations, educational impacts, and various aspects related to varicose veins. Material and methods: This was a single-centre retrospective analysis, in Albania from May 2018 to September 2023. Data were collected retrospectively through hospital records. Data collection involved administering a structured questionnaire to study participants, categorically organised into three sections. The first section focused on collecting demographic information, the second section involved self-perception of identifying risk factors associated with varicose veins, and the final section included inquiries about the history of variceal surgery. Results: The CEAP classification distribution in our cohort revealed a predominant presence of C2 (varicose veins) in 53.3% of patients, followed by C3 (oedema) at 29.2%, and C4 (changes in skin and subcutaneous tissue secondary to CVD) at 10.5%, whereas C5 (healed venous ulcer) and C6 (active venous ulcer) were less frequent. Based on the body mass index (BMI) scale, data from patients indicated that 9.7% were in the category of underweight, 54.8% had a normal BMI, and 35.5% were categorised as overweight. Conclusions: The study's thorough exploration of patient perspectives, risk factors, and treatment choices contributes to a holistic understanding of varicose vein management, emphasising the importance of personalised approaches that account for demographic variations and individual beliefs.

Vacuum-Assisted Thrombo-Aspiration for Paradoxical Embolism in Left Renal Artery: A Case Report and Literature Review.

Paradoxical embolism through the foramen ovale is a rare and devastating event requiring urgent treatment. Herein, we present the case of a 23-year-old male who presented with a pulmonary embolism complicated by a left renal artery paradoxical embolism. Urgent vacuum-assisted thrombo-aspiration restored normal perfusion of the left kidney within 5 hours. The patient had a patent foramen ovale and heterozygous thrombophilia. However, a radioisotopic scan performed 2 years later revealed an unexpected decrease in left renal perfusion. Therefore, despite the angiographic success, functional evaluation using a renal scan should be performed to assess renal function.

Arterial Stiffness and Aortic Aneurysmal Disease - A Narrative Review.

It has been documented that large-artery stiffness is independently associated with increased cardiovascular risk and may potentially lead to heart and kidney failure and cerebrovascular disease. A systematic review of studies investigating changes in arterial stiffness in patients undergoing endovascular repair of aortic disease was conducted. In addition, a review of the available literature was performed, analyzing findings from studies using the cardio-ankle vascular index (CAVI) as a marker of arterial stiffness. Overall, 26 studies were included in the present analysis. Our research revealed a high heterogeneity of included studies regarding the techniques used to assess the aortic stiffness. Aortic stiffness was assessed by pulse wave velocity (PWV), elastic modulus (Ep), and augmentation index (AI). Currently a few studies exist investigating the role of CAVI in patients having an aortic aneurysm or undergoing endovascular aortic repair. The majority of studies showed that the treatment of an abdominal aortic aneurysm (AAA) either with open repair (OR) or endovascular aortic repair (EVAR) reduces aortic compliance significantly. Whether EVAR reconstruction might contribute a higher effect on arterial stiffness compared to OR needs further focused research. An increase of arterial stiffness was uniformly observed in studies investigating patients following thoracic endovascular aortic repair (TEVAR), and the effect was more pronounced in young patients. The effects of increased arterial stiffness after EVAR and TEVAR on the heart and the central hemodynamic, and an eventual effect on cardiac systolic function, need to be further investigated and evaluated in large studies and special groups of patients.

The choice of conduits in coronary artery bypass surgery.

Choosing appropriate bypass conduits is important in the consideration of long-term outcomes after surgical revascularization. When deciding on a grafting strategy, attention should be given to technical, anatomic, and angiographic determinants of conduit properties, as well as the clinical characteristics of the patient. The aim of the study was to present a current review of available choices of conduits in coronary artery bypass surgery. To date, only 4 conduits have proven to be effective: the saphenous vein (SVG), the internal mammary arteries (IMAs), the radial artery (RA), and the right gastroepiploic artery (RGEA). The IMA has unique biological properties that confer protection to intimal growth and atherosclerotic plaque formation, making it the conduit of choice for coronary artery bypass grafting. SVG exhibits a lower patency rate than those of IMAs. The RGEA allows revascularization of the inferior wall but is less commonly used, given that it is more prone to spasms.

Multifocal, biatrial, primary cardiac embryonal rhabdomyosarcoma.

Malignant primary cardiac tumors are rare, with atrial myxoma and rhabdomyosarcoma the common types in adult and pediatric populations respectively. Rhabdomyosarcomas are rare and are usually located in the atria; they present with symptomatology dependent on their location. A 63-year-old woman presented with the symptomatology of dyspnea, cough, and palpitations and was diagnosed with biatrial primary cardiac rhabdomyosarcoma, which required excision. The postoperative course was uneventful and the patient was discharged on the 5th postoperative day. Postoperative cardiac functional tests revealed an ejection fraction of 60%, consistent with the preoperative value, and no mitral valve dysfunction. Biatrial rhabdomyosarcomas are extremely rare, with only 3 cases reported, including ours, reported in the literature, to the best of our knowledge. Transthoracic echocardiogram is useful in the diagnosis. They require surgical excision along with chemotherapy or radiotherapy. Their prognosis is poor, with a median survival of almost one year. Primary biatrial rhabdomyosarcoma is an extremely rare diagnosis that can present with symptomatology based on the location, size, and number of masses. There is no consensus on how to manage them due to the scarcity of cases, but they are managed as single rhabdomyosarcomas. The majority require surgical excision, with subsequent chemotherapy or radiotherapy. The prognosis is very poor, with the majority of the patients not surviving longer than one year.

Endotension as a Rare Complication to Endovascular Abdominal Aortic Aneurysm Repair.

Endotension remains an enigmatic rare cause of endovascular abdominal aortic aneurysm repair failure leading to aneurysm growth and/or rupture. We present a patient with a long-standing endotension treated with open reconstruction and graft explantation. We also provide a unique clinical video, which gives a key view of the intrasac operative findings.

Current Clinical Knowledge on GORE EXCLUDER Conformable Abdominal Aortic Aneurysm Repair Endoprosthesis: A Case Series and Literature Review.

The GORE EXCLUDER Conformable abdominal aortic aneurysm (AAA) Endoprosthesis (CEXC), is currently the newest stent-graft system for treating patients with AAA. CEXC is approved for patients with proximal aortic neck angles ≤90° with a ≥15 mm aortic neck length or proximal aortic neck angles ≤60° with ≥10 mm aortic neck length. The present study describes a clinical series of 5 males with AAA, one of whom had a ruptured infrarenal AAA and a 90° proximal aortic neck angle. All patients were treated with 100% technical success using the CEXC device. Dosimetric data were recorded regarding the total kerma-area product and total fluoroscopy time. During the 30-day follow-up, no device migration or failure was detected, whereas type Ib and II endoleaks were observed in two patients. The type Ib endoleak required re-intervention with limb extension placement, and the type II endoleak was treated with lumbar artery embolization. This clinical series showed that CEXC has no technical defects or AAA-related mortality. We also reviewed the current knowledge on CEXC's clinical outcomes, showing promising technical and clinical results in some studies, even outside the instructions for use. CEXC expands the vascular surgeons' armamentarium against hostile neck anatomy, as it is the only repositionable endovascular aneurysm repair device available. Multicenter, long-term outcome studies should confirm the promising preliminary results of our case series and the literature review.

Correlation between gynecological tumors and atherosclerotic diseases.

Gynecological cancer is among the leading causes of cancer-related mortality worldwide, with malignancies of the ovary, uterus, fallopian tube, cervix, vagina, and vulva making up 10-18% of all cancers diagnosed in women globally. Gynecological cancer and atherosclerosis are two of the most frequent medical entities that afflict women worldwide; thus the possible correlations between them ought to be explored. Vulvar, cervical, vaginal, endometrial, and ovarian cancers have been found to have common points with atherosclerosis regarding their pathogenesis and predisposing factors. Obesity and metabolic syndrome, HPV infection, vitamin D deficiency, and increased telomere length constitute common ground between these two afflictions, which this article aims to analyze.

Endografts for the treatment of abdominal aortic aneurysms with a hostile neck anatomy: A systematic review.

Background: Endovascular aortic repair (EVAR) of abdominal aortic aneurysms (AAAs) has emerged as a better alternative to conventional open surgery for AAAs. The purpose of the review is to define the improvement in the clinical management of the patient with hostile neck AAAs due to the introduction of new endografts while giving a thorough description of their instructions for use (IFUs), main characteristics and part sizing, reporting their outcomes from clinical studies and categorizing their usability. Methods: A MEDLINE search was conducted using keyword-specific combinations. Clinical studies were searched via the clinicaltrials.gov website. Relevant articles' references were also hand-searched. Results: We retrieved 640 records describing Alto, Ovation iX, Treovance, Aorfix, Anaconda, Conformable, and Endurant II/IIs endografts. Aortic necks >60° can be managed with Anaconda, Aorfix, and Conformable, which can treat up to 90° necks requiring ≥15 mm (Anaconda ≥20 mm), and Treovance, which is eligible for necks ≤75° with ≥15 mm length. Ovation's innovation of combining polymer-filled O-rings with integral anchors can treat conical necked AAAs giving Ovation iX and Alto an advantage. Short-necked AAAs can be treated with Alto, eligible for necks as short as 7 mm, and Endurant II, which can treat ≥10 mm necks or 4 mm if used in conjunction with the EndoAnchors system, respectively. Alto and Conformable report a 100% technical success rate, absence of AAA-related death, migration, ruptures, and limb occlusion during follow-up. Endurant II and Ovation iX report >99% technical success rate and are almost free from the AAA mortality rate, ruptures, migration, and limb occlusion, while Ovation iX has a high rate of sac dilation (15.5%) in a 5-year follow-up. Anaconda is slightly better than Aorfix and Treovance, which are related to the lowest technical success rates, 98.3%, 96.3%, and 96%, respectively. Aorfix has the highest AAA mortality rate, 4% in a 60 month follow-up. Conclusion: Most new generation endografts described have comparable results. They broaden the eligibility of patients for EVAR due to their unique technical characteristics described. There is a lack of comparative studies for newer endografts and postmarket clinical studies with long-term results concerning the most recently approved devices described, Alto and Conformable.