Synchronous abdominal aortic aneurysm and colorectal cancer. The therapeutic dilemma in the era of endovascular aortic aneurysm repair.

The incidence of synchronous abdominal aortic aneurysm (AAA) and colorectal cancer (CRC), although quite rare, still represents an issue of controversy regarding the optimal treatment. This study attempts a historical review of the surgical practice during the past decades by reviewing the existing English literature on this topic. The dilemma between one or two stage treatment has remained as both options offer advantages but also carry some substantial risks. The current practice gives priority to the life threatening disease (AAA>5.5 cm, symptomatic or complicated CRC) (two stage treatment) or suggest simultaneous management (one stage) when both diseases require urgent surgical treatment. The evolution of vascular endografts and the reported efficacy of endovascular aortic repair (EVAR) provide an alternative method for treating these high risk patients, by surpassing some significant obstacles. If the anatomical criteria are satisfied, EVAR could become the optimal solution for the concomitant AAA and CRC patients, especially those who require one stage treatment.

The systemic inflammatory response in coronary artery bypass grafting: what is the role of the very low ejection fraction (EF < or = 30%)?

AIM: Patients with depressed left ventricular function are more susceptible to develop postoperative complications after cardiac surgery. The aim of the present study was to examine the effect of severe left ventricular dysfunction on the activation of systemic inflammatory reaction during and after coronary artery bypass grafting (CABG). METHODS: Clinical prospective study; 32 selected patients underwent CABG; 16 patients had depressed left ventricular function before the operation (low ejection fraction [EF] <30%)--Low EF group (study group). Sixteen patients had normal left ventricular function (normal EF, >50%)--Normal EF group (control group). The levels of inflammatory mediators TNF-alpha, IL-6, IL-8 and IL-10 were measured preoperatively, during and after cardiopulmonary bypass (CPB) and 24 hours postoperatively. RESULTS: Higher levels of almost all of inflammatory mediators were detected in patients with depressed left ventricular function compared with patients of normal EF group. IL-6 levels were found statistically significant higher in Low EF group before the induction of anesthesia (P=0.039) and after the administration of protamine (P=0.02). IL-8 levels were found statistically significant higher in Low EF group before the induction of anesthesia (P=0.05), 30 min after the start of CPB (P=0.02), after the administration of protamine (P=0.015) and 24 hours after the end of the operation (P=0.05). No statistically significant differences were demonstrated between the 2 groups of study relative to TNF-alpha and IL-10. CONCLUSION: A greater activation of systemic inflammatory reaction occurred in patients with depressed left ventricular function than in patients with normal cardiac function when they underwent CABG with extracorporeal circulation.

Incidence, complications, and management of Meckel's diverticulum.

OBJECTIVES: To elucidate the incidence of Meckel's diverticulum; to determine the correlation between the histologic type of the diverticulum's mucosa and its clinical presentation; and to review our experience with Meckel's diverticulum. DESIGN: Case-control study. SETTING: University hospital in Ioannina, Greece. PATIENTS: A total of 2074 patients undergoing an appendectomy were examined intraoperatively for Meckel's diverticulum (subgroup A1). In addition, Meckel's diverticulum was found incidentally in 15 patients who were undergoing intra-abdominal surgery (subgroup A2). An operation for a complicated Meckel diverticulum was performed in an additional 15 patients (group B). RESULTS: Thirty-three (1.59%) Meckel diverticulae were found incidentally among 2074 patients in subgroup A1. A positive correlation between Meckel's diverticulum and male sex was found (P < .004), but no difference was found in sex distribution between patients in group B and subgroup A1 (P < .6744). The histologic type of the mucosa (gastric) had significant positive correlation with the clinical presentation of the diverticulum (complicated) (P < .001). CONCLUSION: Resection of the unexpected Meckel diverticulum can be performed safely with a low complication rate, regardless of the patient's age.

Evolving techniques in the treatment of carotid artery kinking: the use of resected redundant arterial segment.

Internal carotid artery kinking is frequently accompanied by atheromatous disease at the carotid bifurcation, and in this case both lesions may be treated simultaneously. Various surgical techniques have been used to correct carotid kinking but no particular one has been widely established. We conducted a retrospective review of 18 patients operated upon for internal carotid kinking during the last 5 years, which represents 4.1 per cent of the total carotid procedures performed during the same period. In 13 of the 18 patients carotid endarterectomy was performed before the repair of the kink. In four patients resection of the kinked segment with end-to-end anastomosis was performed combined with longitudinal arteriotomy at the carotid bifurcation. Two patients developed restenosis at the site of anastomosis requiring reoperation with patch angioplasty. Three patients were treated with eversion endarterectomy and end-to-side anastomosis, whereas in six patients we performed resection of the redundant internal carotid artery combined with longitudinal arteriotomy at the bifurcation. The posterior wall was reconstructed with interrupted sutures and the procedure was completed with patch angioplasty of the anterior wall. In four of these cases we used the autogenous resected arterial segment as patch material. None of these patients developed restenosis or symptoms in a follow-up period of 3 to 32 months. In cases in which significant carotid artery stenosis and internal carotid kinking coexist resection of the involved segment with end-to-end anastomosis of the posterior wall and patch angioplasty using the resected autogenous arterial segment constitute a convenient and satisfactory method of reconstruction.

Rupture of an abdominal aortic aneurysm following acute descending thoracic aortic dissection. Case report.

The coexistence of an abdominal aortic aneurysm and an acute aortic dissection seems to be rare and only a few reports are to be found in the literature. We report a case of a patient with acute aortic dissection of the descending thoracic aorta that caused rupture of a pre-existing abdominal aortic aneurysm. The literature is also thoroughly reviewed.

Outpatient treatment of venous thromboembolism using low molecular weight heparins. An overview.

The development of low-molecular-weight heparins (LMWHs) was a significant advance in the treatment of venous thromboembolism (VTE). Their better bioavailability and more predictable anticoagulant activity than unfractionated heparin (UFH) allow subcutaneous administration without close laboratory monitoring, and thus make outpatient treatment of deep vein thrombosis (DVT) feasible. The safety and efficacy of outpatient treatment in selected patients were established in randomized clinical trials comparing subcutaneous LMWH administered primarily at home with inpatient intravenous UFH. Furthermore, during the last few years a large number of studies have supported these findings in various clinical settings of every-day practice. It is also important that home treatment has lead to substantial cost reductions along with improvement in patients' satisfaction and quality of life. Thus, outpatient treatment of DVT provides an opportunity, rarely seen in medicine, to improve patient care while reducing the overall VTE health-care cost, and it is likely that will be the preferred regime for the majority of patients in the future. However, the implementation of a home treatment program is not simple, as the risks of insufficient or excessive anticoagulation would be considerable. A structured protocol is necessary to ensure that patient care is optimal, and the keys to a successful outpatient treatment program are patient selection, patient education, patient access to health care team, appropriate follow-up and health care team communication.

A renal artery aneurysm incidentally found at operation. Should it be resected?

A rare case of a patient with a ruptured abdominal aortic aneurysm (AAA) and an incidentally found left renal artery aneurysm (RAA) is presented. Successful repair of both aneurysms was simultaneously performed. The indications for such a surgical approach are also discussed.

The prevalence of factor V Leiden as a risk factor for venous thromboembolism in the population of North-Western Greece.

BACKGROUND: Many predisposing factors have been associated with the development of venous thromboembolism. Recently, Factor V Leiden has been described as a common genetic risk factor. The geographic distribution of this genetic abnormality in the general population greatly varies. The prevalence of the Factor V Leiden mutation in Europe is high, particularly in Greece, where according to some authors it is especially high. The purpose of this study was to estimate the prevalence of the Factor V Leiden mutation in patients presenting with at least one episode of venous thromboembolism and to compare it with that of the general population. METHODS: Blood samples were drawn from 388 subjects. 240 healthy blood donors (controls) and 148 unselected patients with a history of one or more episodes of venous thrombosis. DNA analysis was performed using the polymerase chain reaction to amplify the factor V gene exon 10, and to detect the Factor V Leiden point mutation. RESULTS: DNA analysis revealed Factor V Leiden mutations in eight (3.3%) control subjects (seven heterozygous and one homozygous) and in twenty-four (16.2%) patients, (twenty-two heterozygous and two homozygous). The difference between the two groups is statistically significant (p<0.0001; chi2 test). CONCLUSIONS: The prevalence of the Factor V Leiden mutation in the general population of North-Western Greece is 3.3%, which is within the same range as that reported for other European countries. The Factor V Leiden mutation is one of the most important predisposing genetic factors in the development of venous thrombosis and was present in 16.2% of our patients.

Symptomatic deep venous thrombosis of the lower limb.

BACKGROUND: Deep vein thrombosis (DVT) is a common problem in clinical practice causing severe complications. In this retrospective study, the distribution and extent of DVT in the lower limb in symptomatic patients were evaluated. Certain risk factors were also investigated. METHODS: The venograms of 187 symptomatic individuals (postoperative, medical, and out-patient) with suspected DVT and symptoms having been present for less than 6 days, were reviewed. Seventy-seven limbs of 76 patients had DVT. Twenty-seven were male (age range 14-82 years, mean 57) and 49 female (age range 12-82, mean 56). RESULTS: Age over 40 years and gender (female) were significant predisposing factors, (Z = 4.23, p < 0.001 and Z = 2.19, p < 0.05 respectively). Isolated calf DVT alone was the most common pattern (46%, 36 of 77 limbs), and no difference was seen between postoperative and medical patients (chi 2-test, p = 0.7). Postoperative DVT was found in 29 (38%) limbs. Prophylaxis with LMWH had been given in only 15 of them (52%). No difference was seen in the distribution and extent of thrombosis in relation to the prophylaxis with LMWH (chi 2-test, p = 0.34). CONCLUSIONS: Identification of the predisposing factors may enable us to distinguish patients at high risk of developing DVT. The majority of the thrombi commenced in the calf veins and thus meticulous investigation of these veins in symptomatic patients with suspected DVT is necessary.

Simultaneous endovascular stent-graft repair of descending thoracic and abdominal aortic pathologies. Report of four cases.

Four patients suffering from concomitant descending thoracic pathology and abdominal aortic aneurysms were treated with endovascular stent-grafts simultaneously. Graft deployment was successful and uneventful in all patients. Paraplegia was not observed. One patient developed an abdominal type Ib endoleak at 12 months which was repaired endovascularly. One patient died from multiorgan failure 3 days after the deployment of the grafts. After 18, 36 and 42 months follow up all the other patients are well without any graft related complication. Simultaneous endovascular repair for coexisting descending thoracic and abdominal aortic pathologies might be an acceptable alternative to open surgery or hybrid operations, at least for the high risk patients.

Successful cardiac and cerebral resuscitation with extracorporeal circulation and mild hypothermia.

Extracorporeal circulation could be effective for cardiac resuscitation in patients who do not respond to ''Advanced cardiac life support'' (ACLS), but cannot guarantee brain survival. A case of successful cardiac and cerebral resuscitation with extracorporeal circulation and mild hypothermia, in a 48 year-old man with cardiac arrest due to cardiac tamponade, is reported. The good long term neurologic outcome of the patient is also described.

The role of platelets in peripheral arterial disease: therapeutic implications.

Peripheral arterial disease (PAD) is associated with platelet hyperaggregability as well as an increase in morbidity and mortality from myocardial infarction and stroke. Enhanced platelet activation in PAD may substantially contribute to these adverse outcomes. A relative resistance to aspirin therapy has been reported in patients with PAD. Therefore, clopidogrel may be superior to aspirin in treatment of PAD. Furthermore, the aspirin + clopidogrel combination could be more effective than monotherapy but its risk-benefit ratio has yet to be evaluated. Clopidogrel is preferable to ticlopidine because of its safer profile and the convenience of once-daily administration. The glycoprotein (Gp) IIb/IIIa inhibitors may also find a place as short-term therapy after peripheral angioplasty. There is a need to consider the use of clopidogrel in patients who cannot tolerate aspirin. Patients who have an event while taking aspirin also present a problem. One possibility here is to substitute aspirin with clopidogrel or to add clopidogrel to the aspirin. Although these options are currently not evidence based in patients with PAD, there is emerging evidence showing that they are realistic choices.

Computer-assisted ultrasonographic analysis of carotid plaques in relation to cerebrovascular symptoms, cerebral infarction, and histology.

The objective of this study was to determine the relationship between plaque echogenicity as measured by computer and the incidence of cerebrovascular symptoms and cerebral infarction. The correlation between carotid plaque echogenicity and plaque histology was also evaluated. In this prospective nonrandomized study, 38 consecutive patients with 54 atherosclerotic carotid plaques producing 50-99% stenosis were reviewed. The ultrasonic images of the plaques were digitized and transferred to a computer. A histogram for each plaque representing its composition was obtained. The median of the gray scale (GSM) of each histogram was used as measure of plaque echogenicity. All patients had a computed tomography (CT) brain scan performed to determine the presence of cerebral infarction. Twenty-eight plaques were examined histologically to determine the deposition of calcium, hemorrhage, cholesterol, and amorphous granular material. It is possible to identify carotid plaques at high risk for development of cerebrovascular symptoms and cerebral infarction by the computerized measurement of plaque echogenicity. This method may be used to improve the criteria of patients selection for carotid endarterectomy.