An unusual late complication after SFA stenting: the artery rupture.

Peripheral artery rupture as a late complication of an endovascular stenting, due to the protrusion of a stent, has never been described in the literature in thigh arteries. Here we describe two anecdotic cases of artery rupture after superficial femoral artery (SFA) stenting. In both cases the endovascular procedure was performed as a reintervention at 2 and 27 months after a failed surgical or hybrid procedure for limb revascularization. The stent had been delivered in the first part of the SFA and the rupture occurred at the junction between the common femoral artery and SFA, which is one of the most flexible parts of the femoral artery. The cause of rupture was probably caused by an ulcer of the stent against the artery wall concomitant with a status of local or systemic infection. A huge pseudoaneurysm developed in both cases. The massive bleeding was stopped by an emergency surgical bypass, with the removal of the stented artery. These two cases show the possibility of SFA rupture after stenting. Previous surgical treatment, the site of stenting (first part of the SFA) and an active infection could predispose patients to this life-threatening complication.

Abdominal aortic aneurysm repair in octogenarians: myth or reality?

AIM: We studied the thirty-day mortality and morbidity rate to assess the value of conventional open repair vs endovascular aortic repair (EVAR) in an elderly population presenting with a ruptured, symptomatic or asymptomatic abdominal aortic aneurysm (AAA) undergoing emergency, urgent or elective repair. METHODS: During the period from January 2004 to May 2007, 329 consecutive patients were treated for AAA in our Department. Among these, 81 (24.6%) were aged >80 years (mean age 83.6, range 80-95 years). These older patients were divided into groups according to their clinical presentation: ruptured AAA group (rAAA) - 22 cases (4 emergency EVAR, 18 emergency open repair); symptomatic non-ruptured AAA group (sAAA) - 15 cases (11 urgent EVAR, 4 urgent open repair); asymptomatic AAA group (asAAA) - 44 cases (32 elective EVAR, 12 elective open repair). The main outcome measures were 30-day mortality and 30-day morbidity rate. RESULTS: The mortality rate following open surgery vs EVAR was 66.6% vs 50% (P=NS) in the rAAA group, 25% vs 0% (P=NS) in the sAAA group, and 9% vs 3.2% (P=NS) in the asAAA group. When comparing postoperative morbidities in the octogenarians, 3 of the patients that received EVAR (6.4%) and 15 of those that received open repair (48.4%) had a severe complication (P<0.01). CONCLUSION: The introduction of EVAR has considerably changed the balance of risks and benefits for AAA treatment. Our study confirms the high mortality rate for octogenarians with rAAA and haemodynamic instability, and supports the value of an active EVAR approach for octogenarians with AAA to prevent rupture. Moreover, the introduction of endovascular techniques as part of an overall treatment algorithm for ruptured AAAs appears to be potentially associated with improved outcomes in terms of mortality and morbidity as compared to open surgical repairs alone.

Purine catabolism in advanced carotid artery plaque.

This study was carried out on carotid artery plaque and plasma of 50 patients. We analyzed uric acid, hypoxanthine, xanthine, and allantoin levels to verify if enzymatic purine degradation occurs in advanced carotid plaque; we also determined free radicals and sulphydryl groups to check if there is a correlation between oxidant status and purine catabolism. Comparing plaque and plasma we found higher levels of free radicals, hypoxanthine, xanthine, and a decrease of some oxidant protectors, such as sulphydryl groups and uric acid, in plaque. We also observed a very important phenomenon in plaque, the presence of allantoin due to chemical oxidation of uric acid, since humans do not have the enzyme uricase. The hypothetical elevated activity of xanthine oxidase in atherosclerosis could be reduced by specific therapies using its inhibitors, such as oxypurinol or allopurinol.

Purine bases and atheromatous plaque.

In this work we determined hypoxanthine (HX), xanthine (X), uric acid (UA), allantoin (ALL) and free radicals in atheromatous plaques to improve the comprehension of oxidative stress, a phenomenon which characterizes the evolution of atherosclerotic lesions. Carotid artery plaque were obtained from subjects undergoing endoarterectomy. Pulverized plaque, extracted by water, was used for analysis of oxidative stress factors (allantoin, uric acid, xanthine, hypoxanthine, free radicals). The peroxidation UA-->ALL was very high in the plaque, as was the level of free radicals. The results show that oxidative degradation of nucleotides, such as LDL oxidation, plays a specific role not only in the progression of atherosclerotic lesions but also in the advanced plaque.

Stroke and pulmonary embolism following manual and bandage compression after bleeding from a common femoral artery access site.

Manual compression (MC) is required to seal a common femoral artery (CFA) access site after endovascular intervention unless a mechanical closure device is used. Herein we report previously unpublished complications following MC of a CFA access site: stroke (embolism through a patent foramen ovale) and pulmonary embolism. These were a T thrombosis of the internal carotid artery combined with multi pulmonary embolisms and a case of pulmonary embolism. No thrombophilic conditions or other possible causes of venous emboli could be demonstrated in either case by laboratory tests or color-Duplex ultrasound. These were the only two cases of pulmonary and cerebral embolism seen at our university tertiary referral center, over a five-year period. This short report considers the potential risk factors as well as a prevention policy for these complications.

Proteomic analysis of atherosclerotic plaque.

Proteins play a fundamental role in the formation and progression of plaque, but proteomic analysis of plaque as a whole is difficult, due to its heterogeneous cellular composition and an abundance of plasma proteins. Several approaches to this problem are reported in the literature; they include proteomic analysis of vascular tissues, analysis of proteins released by normal and pathological arterial walls, proteomic analysis of vascular cells and proteomic analysis of blood. In a previous study, we proposed a new strategy for studying of proteome of plaque, which permits to select the proteins exclusive to plaque by the constructing of a reference synthetic gel. In the present work, we matched the spots of the reference synthetic gel with the spots of a pool of carotid plaque, in order to select only spots exclusive to plaque from the 2-dimensional electrophoresis of the pool of plaque. We selected some spots between those exclusive and identified them by mass spectrometry. Some proteins identified are involved in transport, others take part in elimination of toxic radicals, others are metabolic enzymes or structural proteins. This study represents an example of application of the new approach which we have proposed: the reference gel of proteome of plaque permits to select, on every sample of interest, only the spots exclusive to plaque; once selected, spots can be identified by mass spectrometry and, being typical of plaque composition, could represent novel markers of lesions and vascular risk.

The retrojugular route: the ideal exposure for carotid endarterectomy performed under locoregional anesthesia.

BACKGROUND: Scientific evidence exists to support the claim that either general o regional anesthesia can be safely used for CEA: each of the techniques has either theoretical and practical advantages or drawbacks. Since the issue of whether, for CEA, one anesthetic technique is better than another has not yet been explored by randomized trials, any contribution that could reduce the disadvantages of any of the two approaches may contribute to overcome individual diffidence and visceral antagonism. The proposed approach represents a technical improvement of locoregional CEA technique. METHODS: One hundred consecutive patients undergoing elective or urgent primary CEA under locoregional anesthesia were prospectively randomized in two equal size groups. In group 1 traditional (medial) approach to carotid bifurcation was employed; in group 2 the retrojugular approach (RJA) was used. Surgical and anesthesia scores were developed to assess the differences between the two groups in terms of surgical ease, the quality of exposure, patients comfort, level and quality of anesthesia. RESULTS: Demographic and clinical characteristics of group 1 and group 2 patients were comparable. No major complication or death was observed in this series. Significant score differences were observed in favour of the retrojugular route. Using this route an improved and wider exposure was obtained, moreover, we achieved a better analgesia, with lesser additional anesthetic doses requirements, a faster approach to the carotid bifurcation, an enhanced patient comfort and a reduced interference on the surgical procedure by deglutition movements. CONCLUSIONS: The retrojugular route represents the ideal route for locoregional CEA; this exposure, with respect to the traditional approach, minimizes many of the disadvantages commonly considered as major deterrents of regional anesthesia for carotid surgery.

Comparative determination of purine compounds in carotid plaque by capillary zone electrophoresis and high-performance liquid chromatography.

Allantoin, uric acid (UA), hypoxanthine (Hx) and xanthine (X) were determined on carotid plaque by capillary zone electrophoresis (CZE) and high-performance liquid chromatography (HPLC). Comparison of the results showed that capillary zone electrophoresis may have similar or even superior analytical performance to HPLC, especially for the determination of allantoin in biological samples.