EVAR and OPEN treatment of abdominal aortic aneurysm: What is the role of MMP-9 in the follow-up?

INTRODUCTION: The aim of our study is to verify the role of metalloproteinases in endovascular repair (EVAR) and OPEN surgery treatment for abdominal aortic aneurysm (AAA). Postoperatively, these enzymes could represent an important biomarker to adapt diagnostic tests and further investigations during follow-up. MATERIAL AND METHOD: From 2004 to 2008, 55 patients were considered with AAA. Of these, 33 patients (mean age: 70.1 years), (mean AAA diameter: 5.4cm) were treated with OPEN surgery (group A) and 22 (mean age: 74.1 years) (mean AAA diameter: 5.1cm) were treated with EVAR. In 17 of them, there were no signs of endoleak (group B1), while in 5 patients, a presence of endoleak (group B2) was detected. Plasma samples were collected in order to determine MMP-9 activity. Enzyme immunoassay was performed preoperatively at 1, 3, 6 and 12 months. Patients treated conventionally were clinically examined after 1 and 12 months by ultrasound. Patients undergoing EVAR treatment were clinically examined by CT scan after 1, 3, 6 and 12 months. The analysis was done by assessing the interaction over time of the MMP-9 value in B1 and B2 groups. RESULTS: The average values observed for MMP-9 were preoperatively and at 1, 3, 6 and 12 months, respectively: in group A 150.8ng/mL (SD=30.5), 252.5ng/mL (SD=25.2), 315.4ng/mL (SD=22.7), 295.3ng/mL (SD=26.8), 210.7ng/mL (SD=30.2); in group B1 105ng/mL (SD=10.8), 125.6ng/mL (SD=18), 85.8ng/mL (SD=19.9), 95ng/mL (SD=20.2), 80.4ng/mL (SD=15.6); in group B2 149ng/mL (29.2), 375.4ng/mL (SD=40.2), 215ng/mL (SD=35.9), 180ng/mL (SD=20.2), 175ng/mL (SD=33.4). The MMP-9 level was higher in group B2 compared to group B1 (P=0.01), suggesting a correlation with the presence of the endoleak. CONCLUSIONS: This preliminary study shows that MMP-9 may be a biomarker of the presence of endoleak. Other further investigations and larger series are needed to show that metalloproteases could play a role in the follow-up of EVAR treated patients.

Vascular injuries in supracondylar humeral fracture: an active approach to diagnosis and treatment.

AIM: The strategy with vascular complications of supracondylar humeral fractures (SHF) is under scrutiny since modern diagnostic techniques, particularly ultrasound investigations, provide earlier and more precise assessment and updated vascular surgical procedures, particularly microvascular ones, obtain excellent results. The purpose of this study was to look prospectively at what could be achieved by early systematic diagnostic investigations and, when appropriate, immediate arterial exploration and repair. METHODS: Sixty-three pediatric patients with SHF were admitted and treated in our Service between January 2007 and February 2014. Besides clinical examination, they were all investigated by color-coded Duplex scanning (CCDS) and ultrasound velocimetry (UV) of the hand. Eighteen patients were pulseless at first observation. Seven of them presented without signs of ischemia and regained their pulse post-reduction; only dislodgement and compression of the brachial artery (BA) was found in those children. In 11 patients, with pink hand in 7 and severe ischemia (white pulseless hand) in 4, lesions of the BA were detected. All were operated upon by various forms of arterial repair. CCDS and UV were used also intraoperatively and during follow-up (1 m-13 y). RESULTS: All patients had favorable early and long-term results: 8 came back to normal conditions, 2 had persistent paresthesia and weakness of the hand and 1 remained with partial disability of forearm and hand. All BA remained patent. CCDS correctly detected all the lesions preoperatively and showed the patency of the arteries after repair. CONCLUSION: Early assessment, use of ultrasound investigations and BA prompt repair seem to be the most logical and fruitful strategy at present time.

Open surgery of infrarenal aortic aneurysms with iliac involvement: repair should be entirely intra-abdominal.

AIM: A review of the literature on the surgical treatment of abdominal aortic aneurysms (AAAs) reveals that aortofemoral bypass (AFB) is used frequently in some centers. The latter series are characterized by higher rates of graft-related complications than in those in which AFB is used less frequently. The aim of our study was to evaluate the relative frequency and outcome of different types of bypass grafts in the surgical treatment of AAAs with iliac involvement, in our center and in others. METHODS: Between 1994 and 2004, 190 AAA patients with involvement of the iliac axes underwent elective repair in our department. Surgery was performed via median transperitoneal access. RESULTS: The AAAs extended to the common iliac artery (CIA) in 90.5% of patients. The remaining 9.5% extended to the external iliac artery (EIA). Aorto bi-iliac grafts were used in 159 cases, straight tube grafts in 13, aorto EIA grafts in 15, and AFBs in 3. Overall 30-day morbidity and mortality rates were 12.1% and 2.6%, respectively. At follow-up (mean: 5.6 years), one distal limb infection of an AFB and 4 CIA/EIA aneurysmal enlargements occurred and were repaired accordingly. Secondary patency and 5-year cumulative survival rate were 100% and 80%, respectively. CONCLUSIONS: In this series of AAAs extending to the iliac axes, AFB was used selectively (1.6%), even when the AAA extended to the EIA. This allowed us to maintain direct vascularization of the hypogastric arteries and eliminate the risk of complications associated with inguinal access. We feel, therefore, that for the repair of aortoiliac aneurysms, AFB is rarely indicated.