Combined Type III and Type II Endoleaks after Endovascular Aneurysm Repair: Presentation of 2 Cases and a Literature Review.

Although endovascular aneurysm repair is a feasible option for high-risk patients resulting in lower perioperative mortality when compared with open repair, the need for reintervention and long-term follow-up affects its use. The aim of the current report is to present 2 cases of patients with type IIIa endoleak from limb disconnection (one patient with double-bilateral endoleak) combined with a late type II endoleak and symptomatic sac growth treated in our department. We also performed a literature review about type III endoleaks and their treatment options.

Comparative Study of Protein Expression Levels of Five Plaque Biomarkers and Relation with Carotid Plaque Type Classification in Patients after Carotid Endarterectomy.

Atherosclerosis is an inflammatory process resulting in local plaque deposition in the vessel wall of arteries with symptoms to various areas of vascular tree. Identification of patients with progressive advanced atherosclerotic disease is mainly based on the known characteristics of the vulnerable or recently ruptured plaque. Molecular and cellular features associated with the vulnerable plaque are considered potential diagnostic markers for plaque rupture and thrombosis. Here, protein expression levels of the metalloproteases MMP-1, MMP-9, osteopontin (OPN), and cytokines TNFα and IL-6 in tissue extracts of carotid plaques in patients after endarterectomy were estimated by Western immunoblotting, after SDS-PAGE analysis and evaluated based on the ultrasonographic plaque morphology. The gender and age effect was also examined. MMP-1, MMP-9, and IL-6 were expressed in higher levels compared to OPN and TNFa as well as in symptomatic (with type II and III carotid plaque classification) than asymptomatic (type IV) patients with differences considered statistically significant (P values <0.05). A significant positive correlation between MMP-1 and IL-6 (with Pearson correlation coefficient 0.748) is also notable. The data give further insight into the possible role of specific biomarker and enhance the need for further studies in order to clarify the proper one(s) for detection of the vulnerable plaque and help identify patients at risk for cardiovascular events.

Thrombolysis in Acute Lower Limb Ischemia: Review of the Current Literature.

BACKGROUND: Catheter-directed thrombolysis (CDT) is a therapeutic option with acceptable results in patients with acute limb ischemia (ALI) but with severe systemic or intracranial bleeding being the most significant clinical complication. The aim of the study is to collect and present direct results of CDT in patients treated for ALI. METHODS: Reports on CDT treatment in ALI until December 2016 were searched in PubMed using the keywords catheter direct thrombolysis, acute lower limb ischemia, and any combination. RESULTS: A total of 256 clinical trials were identified. After the exclusion criteria were applied, 10 articles were selected including 1,249 patients and 1,361 lower extremities treated for ALI. Acute thrombosis of a limb artery or bypass graft was the main cause of ischemia ranging from 77.7% to 98.0%. The overall technical success rate of the applied method reached 79.3% (1,079 successful cases). Complications of any type occurred in 358 (28.7%) patients. Of them, 72 (20.1%) experienced a minor complication while 286 (79.9%) had a major life-threatening complication. The need for secondary interventions was 77.8% (935 patients). The death rate during the first month was 4.2% (56 patients), while the percentage of patients who suffered amputation because of a failed thrombolysis during the same period was 11.5% (156 patients). Finally, the survival rate without amputation within 30 days was 88.5% (1.105 out of a total of 1,249 patients studied). CONCLUSIONS: Results confirm the high direct technical success rate of CDT and the high percentage of patients survived without amputation within 30 days, although major complications are a great disadvantage of the method.

Endovascular repair of ruptured abdominal aortic aneurysms with the endurant stent-graft: a combined experience from three centers.

BACKGROUND: Endovascular repair of ruptured abdominal aortic aneurysms (RAAAs) has been previously reported to reduce mortality rates compared to open repair. Newer stent-grafts may provide even better results with applicability in a larger number of patients. We present our experience with the Medtronic Endurant endograft over a three-year period. METHODS: Consecutive cases of RAAAs which have been managed with the Endurant stent-graft were recruited from three centers and were analyzed retrospectively. Twenty-three patients (22 males; mean age 74±9 years) were treated between June 2010 and May 2013. RESULTS: The technical success rate was 100% with no intraoperative endoleaks. Thirty-day mortality was 13% (3/23 patients). Two patients required prolonged hospitalization and mechanical ventilation. For the remaining 18 patients, the average hospitalization length was 5.5 days. Two major risk factors were found to be significantly associated with increased mortality: low systolic blood pressure on arrival at the hospital (63±6 vs. 99±22; P=0.01), and post-operative development of an abdominal compartment syndrome (Relative Risk - RR=13.3, 95% confidence interval - CI: 1.6-106; P=0.03). Other important clinical variables which did not significantly affect mortality included age (mean age 83±9 years in those who died vs. 73±9 years in the survivors; P=0.09), type of graft (bifurcated vs. aorto-uni-iliac; RR=2.2, 95% CI: 0.3-15; P=0.4), aneurysm diameter (11±4 cm vs. 9±2 cm; P=0.28), and proximal neck angulation (68±14 vs. 57±26 degrees; P=0.5). A proximal neck angulation >75° was not associated with a higher mortality rate (RR=1.33, 95% CI: 0.22-7.8; P=1). CONCLUSIONS: Endovascular repair of RAAAs resulted in high technical success and low mortality rates in this series of patients treated with the Endurant stent graft. Hypotension on arrival to the hospital and development of an abdominal compartment syndrome were predictive of increased risk of death. Patient age, aneurysm diameter and graft configuration did not negatively impact survival. Non-compliance with the device instructions for use (IFU) did not adversely affect results in this small patient series. Larger studies are needed to confirm our results.

Open Versus Endovascular Repair of Inflammatory Abdominal Aortic Aneurysms: A Comparative Study and Meta-Analysis of the Literature.

OBJECTIVES: Open surgical repair (OSR) of inflammatory abdominal aortic aneurysms (IAAAs) can have significant morbidity. The aim of the present investigation was to compare IAAA outcome after OSR and endovascular aneurysm repair (EVAR) and perform a meta-analysis of the literature. METHODS: Twenty-seven patients with an intact IAAA operated on during a 21-year period were included. RESULTS: Nine patients were managed with EVAR and 18 with OSR. In the EVAR group, the number of transfused red blood cell units (P = .001), procedure duration (P < .001), and postoperative hospitalization (P = .004) were significantly reduced compared to OSR. A trend for decreased morbidity with EVAR (11% vs 33% for OSR, P = .36) was observed. On literature review and meta-analysis, morbidity after EVAR was 8.3%, significantly lower compared to OSR (27.4%, P = .047). Mortality for nonruptured IAAAs was 0% after EVAR and 3.6% after OSR (P = 1.00). CONCLUSIONS: Endovascular aneurysm repair of IAAAs is associated with decreased procedure duration, transfusion needs, hospitalization, and morbidity compared to OSR.

Rupture after endovascular abdominal aortic aneurysm repair: a multicenter study.

A total of 22 patients with ruptured abdominal aortic aneurysms (rAAAs) after previous endovascular aortic repair (EVAR; rAAAevar) were presented to 7 referral hospitals in Greece, between January 2006 and April 2012. Type Ia endoleak and endograft migration were identified in 72.7% and 50%, respectively. Compliance to follow-up protocol prior to rupture was 31.8%. In-hospital mortality was 36.4% (9.1% for those treated with secondary EVAR and 63.6% for those treated with open surgical repair, P = .02). An increase in the proportion of patients with rAAAevar among the total number of patients with rAAAs from 1.3% in 2007 to 18.2% in 2012 (P for trend = .04) was recorded, corresponding to an annual increase of 2.8% (b = 2.84, P = .04). Rupture after EVAR seemed to be a clinical entity encountered with increasing frequency over the past years. Type I endoleak and endograft migration were most frequently observed, whereas compliance to follow-up was low.

Predictors affecting in-hospital mortality of ruptured abdominal aortic aneurysms: a Greek multicenter study.

BACKGROUND: Endovascular aortic repair (EVAR) is being used with increasing frequency for the treatment of ruptured abdominal aortic aneurysms (rAAAs), although conflicting results have been reported concerning perioperative mortality. The aim of our study was to evaluate potential difference in mortality rates between EVAR and open surgical repair (OSR) and identify independent risk factors for in-hospital mortality in rAAAs. This study also aimed to evaluate the Glasgow Aneurysm Score (GAS) in predicting in-hospital mortality. A time-trend analysis of EVAR for ruptured AAAs was also performed. METHODS: Prospectively collected data from 7 public hospitals in Greece concerning rAAA repairs between January 2006 and April 2012 were analyzed. Primary outcome was in-hospital mortality. Multivariate logistic regression analysis was used to identify independent risk factors. The receiver-operator characteristic curve was used to determine the value of the GAS in predicting in-hospital death. Time-trend analysis, depicting annual changes (%), concerning EVAR for ruptured AAAs was also conducted. RESULTS: A total of 418 patients (92.3% men, mean age = 74.3 ± 8.8) with rAAAs were recorded during the study period. Among them, 113 patients (27%) underwent EVAR. Overall in-hospital mortality was 45.2%, whereas in-hospital mortality after EVAR and OSR was 20.4% and 54.3%, respectively (P < 0.001). Multivariate analysis evidenced that hemodynamic instability (P < 0.001), OSR (P < 0.001), age ≥80 years (P < 0.001), coronary artery disease (P < 0.001), and renal insufficiency (P = 0.02) independently increased in-hospital mortality. Area under the curve of GAS was 0.80 (95% confidence interval [CI] = 0.75-0.85, P < 0.001) for OSR and 0.64 (95% CI = 0.51-0.77, P = 0.04) for EVAR. Annual increase of proportion (%) of EVAR for rupture was 5% (P = 0.004). CONCLUSIONS: EVAR is being used with increasing frequency for the treatment of rAAAs and it appears to be associated with lower in-hospital mortality compared with OSR, after adjustment for hemodynamic instability and known atherosclerotic risk factors. Preoperative predictors of in-hospital mortality such as GAS should be probably modified in these patients.

A simple booklet for patient follow-up after endovascular abdominal aortic aneurysm repair procedures.

Endovascular abdominal aortic aneurysm (AAA) repair (EVAR) procedures require lifelong patient surveillance for the detection of complications (eg, endoleaks or graft migration). This follow-up may be suboptimal. Between November 2010 and November 2011, a follow-up booklet was provided at hospital discharge to 42 consecutive patients undergoing EVAR for an infrarenal AAA. Each patient was given specific instructions for completion of the booklet at each follow-up examination whether this took place at our hospital or elsewhere. After a mean follow-up of 7 ± 3 months, all patients had fully complied with the instructions. This booklet may be useful for patients who find it difficult to attend follow-up appointments. Additionally, this booklet is useful for patients who move to another town/country or in cases of emergency when patients are admitted to another hospital.

Acutely bleeding aortoduodenal fistula: staged endovascular and open surgical repair.

Secondary aortoduodenal fistula is an uncommon but potentially fatal complication that can occur after aortic reconstruction surgery and usually presents with upper gastrointestinal hemorrhage. Taking into account the accompanying multiple comorbidities of those patients, conventional open surgical repair carries with it significant mortality and morbidity rates. The purpose of this case report is to describe the successful combined endovascular and open surgical repair of an acutely ruptured aortoduodenal fistula in a 67-year-old male patient. Four months after the procedure, the patient remains well.

Total occlusion of the common carotid artery: a modified classification and its relation to clinical status.

To investigate the hemodynamics and clinical presentation of common carotid artery occlusion (CCAO), we reviewed 6,415 patients with suspected carotid artery disease in whom a color Duplex imaging (CDI) examination was performed. According to distal vessel patency, the following CDI classification of CCAO was adopted: type I (patent both distal vessels); type II (isolated patency of external carotid artery); type III (isolated patency of internal carotid artery); and type IV (both distal vessels occluded). Thirty-five (0.5%) cases met the CDI criteria for CCAO. Twenty-nine of those (83%) had at least one patent distal vessel. Ten patients (29%) presented with stroke, 20 (57%) with transient ischemic attacks (TIAs) and five (14%) were asymptomatic. The incidence of stroke was higher in type IV (50%) vs. type II (30%) and in type II vs. type I (10%) lesions. Similarly, TIAs presented more often in type II (67%) and IV (50%) vs. in type I (40%) lesions (p = 0.002). Retrograde flow in the ophthalmic artery and concomitant severe contralateral carotid artery stenosis were more often related with type II and IV lesions (p = 0.02 and 0.04, respectively). CCAO is usually accompanied by patent distal vessel(s). The proposed CCAO classification correlates well with the patients' clinical status and may help to better clarify the outcome of this rare entity. Among the main arteries of the developed collateral circulation, only the flow direction in the ophthalmic artery may be of clinical value.

Renal-portal shunt ameliorates renovascular hypertension in pigs.

BACKGROUND: Renovascular hypertension is the most common curable form of secondary hypertension. Renin angiotensin system activation depends on the balance between renin production by the kidney and renin degradation by the liver. Thus, we aimed to examine whether deviation of renin-rich blood from the affected kidney into the portal circulation (portalization) can ameliorate renovascular hypertension. METHODS: We selected a porcine model of unilateral renal artery stenosis because the pig's anatomy and physiology are comparable to those of humans and because pigs have already been found capable of developing chronic renovascular hypertension. Angiography and ultrasonography were deliberately used to evaluate renal artery stenosis and the renal-portal shunt. Histology was used to examine the effects of portalization on the kidney and liver after a period of two months. RESULTS: As expected, following the creation of a left renal artery stenosis both renin activity and mean blood pressure measurements increased from 1.23 +/- 0.06 ng/mL/h and 85.6 +/- 0.5 mm Hg at baseline to 4.59 +/- 0.02 ng/mL/h and 126 +/- 1.76 mm Hg, respectively. After portalization renin activity returned to the normal range (1.59 +/- 0.07 ng/mL/h) followed by a concomitant reduction of mean blood pressure to 91 +/- 2 mm Hg. Moreover, a significant correlation was observed between changes in renin activity and blood pressure measurements during the two stages of the experiment. Both the kidney and liver remained macroscopically and microscopically intact at the end of the experiment. CONCLUSION: Portalization of the affected kidney can ameliorate renovascular hypertension and therefore, it might be of benefit in those individuals with fibromascular or atheromatous lesions in the renal artery or its branches not amenable to balloon angioplasty or surgical revascularization.