TEVAR and EVAR, the unknown knowns of the cardiovascular hemodynamics; and the immediate and long-term consequences of fabric material on major adverse clinical outcome.

This review discusses the impact of endovascular aneurysm repair on cardiovascular (CV) hemodynamics and the role of stent-graft material, i.e., polytetrafluoroethylene (PTFE) vs. polyester in post-procedural outcomes. Endovascular aneurysm repair has been widely employed in the last decades for thoracic and abdominal aneurysm repair. However, aortic endografts are stiff and alter the native flow hemodynamics. This failure to simulate the native aorta could lead to added strain on the heart, manifesting as increased left ventricular strain, higher pulse pressure, and congestive heart failure later. This could result in adverse CV outcomes. Also, evidence is mounting to support the implication of stent-graft materials, i.e., PTFE vs. polyester, in adverse post-procedural outcomes. However, there is an absence of level one evidence. Therefore, the only way forward is to plan and perform a randomised controlled trial to demonstrate the alterations in the CV hemodynamics in the short and long run and compare the available stent-graft materials regarding procedural and clinical outcomes. We believe the best solution, for now, would be to reduce the stented length of the aorta. At the same time, in the longer term, encourage continuous improvement in stent-graft materials and design.

Combined thoracic endovascular aortic repair and endovascular aneurysm repair and the long-term consequences of altered cardiovascular haemodynamics on morbidity and mortality: case series and literature review.

BACKGROUND: Thoracic and abdominal aortic stent grafts are firmer and more rigid than the native aorta. Aortic implanted devices have been implicated in the development of acute systolic hypertension, elevated pulse pressure, and reduced coronary perfusion. CASE SUMMARY: We report four cases of staged thoracic endovascular aortic repair (TEVAR) and then endovascular aneurysm repair (EVAR). All patients had TEVAR first for thoracic aortic aneurysm and later on developed infra-renal abdominal aortic aneurysm (AAA) that required EVAR. There were three males and one female with a median age of 74.5 years (range 67.5-78.5). None of the patients developed aortic-related major clinical adverse effects or required any aortic intervention during their follow-up. However, within 2 years, all patients developed symptomatic left ventricular hypertrophy with diastolic dysfunction. All patients had bilateral lower limb oedema, with on and off chest pain and shortness of breath (SOB), necessitating coronary angiograms, which showed no evidence of coronary artery disease. Three patients died from cardiovascular-related morbidities, and the fourth patient is still complaining of SOB despite a normal coronary angiogram. DISCUSSION: Aortic-endograft compliance mismatch is an invisible enemy, with troubling consequences for the aorta proximal and distal to the endograft. Aortic stiffness due to vascular endograft could lead to cardiovascular adverse events, even in the absence of direct aortic-related complications. After combined TEVAR and EVAR, the compliance mismatch and elasticity loss are even more pronounced than with TEVAR alone, which necessitates patient monitoring for the development of cardiovascular complications.

Hydration may reverse most symptoms of lower extremity intermittent claudication or rest pain.

BACKGROUND: Medical treatment of severe intermittent claudication or critical limb-threatening ischemia causing rest pain frequently achieves only partial relief or is not effective at all. METHODS: Patients with severe intermittent claudication or rest pain of the lower extremities who did not improve after control of risk factors, supervised exercises, and cilostazol medication were included in this study. All patients were treated with hydration. They were asked to drink 2500 mL of fluids (water, soup, milk) during a 24-hour period and to ingest 0.6 g/kg of albumin a day, as egg white or albumin powder. Total salt administered daily was 3.5 g. Symptoms, skin temperature, ankle-brachial index, albumin concentration in serum, and time and distance to claudication were recorded before treatment, at 6 weeks, and at 6 months. Electrolytes were measured monthly. No additional treatment was used during the study. Walking was encouraged but not supervised. The trial has continued indefinitely. For statistical analysis, SPSS software (IBM Corp, Armonk, NY) was used. The Ethical Committee approved the protocol, and an informed consent was signed by all patients. RESULTS: There were 132 patients (94 male, 38 female) included in the study. Median age was 72.5 years (range, 67-77 years); all had severe claudication of a mean of 100 meters or rest pain. Symptoms had been present for >5 months in all patients; 22 (16.8%) had rest pain. Proper hydration, determined as drinking at least 2000 mL of water during 24 hours for a period of 6 months, was achieved in 131 compliant patients. Only one patient failed to drink 2000 mL of water or more. Ankle-brachial index in 131 compliant patients improved from 0.6 to 0.75 (P < .0001) after 6 months. Skin temperature of the feet increased from 29.4°C to 31.7°C (P = .009). Distance to claudication using the treadmill improved from 100 meters to 535 meters (P < .0001) at 6 weeks and remained stable at 6 month in 65.83% of the patients; in 34.17% of them, distance to claudication increased further by 200 (100-500) meters and time to claudication improved from 1.3 to 6.3 minutes (P < .0001) at 6 weeks, but the same group of patients (34.17%) that increased the distance to claudication further prolonged the time to claudication by 2.49 (1.24-6.23) minutes. All 131 compliant patients improved their status related to lower extremity ischemia; the noncompliant patient did not have any variation of symptoms, skin temperature, ankle-brachial index, or time and distance to claudication. All patients survived the initial 6 months of treatment; afterward, three patients abandoned the treatment and four died of unrelated causes. After the 6-month control, 49% of the patients continued to improve the time and distance to claudication as well as the ankle-brachial index. The rest of the patients conserved the initial improvement. Five patients who had significantly improved the time and distance to claudication were asked to decrease water intake for 3 days. No changes in time and distance to claudication were detected. Hydration was reinitiated. CONCLUSIONS: This study suggests that proper hydration by drinking ≥2000 mL of water daily and albumin complement orally to reach 4 g/dL in serum could be included in the armamentarium of physicians treating patients with disabling claudication or rest pain caused by peripheral artery disease. Further comparative studies to assess the benefit of hydration and increasing the serum oncotic pressure are warranted.

Reversal of Lower-Extremity Intermittent Claudication and Rest Pain by Hydration.

BACKGROUND: Medical treatment of disabling intermittent claudication or critical limb-threatening ischemia causing rest pain often fails or has partial response. METHODS: In this pilot study, 36 patients (12 females) affected by disabling intermittent claudication or rest pain of the lower extremities were exposed to a daily 3-L water intake for up to 6 weeks. Cutaneous foot temperature, ankle/brachial index, time and distance of claudication, and pain intensity were recorded before and at the completion of the hydration period. RESULTS: Patients with a mean ± SE age of 71 ± 2 years (range, 40-86) had disabling claudication (less than 100 meters) for more than 5 months while 11% reported pain at rest. A 6-week water intake of more than 2,500 mL/24 hr was achieved in 35 of the 36 patients enrolled in the study. Increased water intake was associated with significant improvements in median ankle/brachial index (from 0.60 to 0.76; P < 0.0001) and skin temperature (first dorsal right toe, from 29.95°C to 30.0°C, P < 0.001). Time and distance to report claudication of supervised treadmill exercise improved from 1.25 to 6.25 min (P < 0.0001) and from 100 meters to 535 meters (P < 0.0001), respectively. CONCLUSIONS: This study suggests that hydration attained by daily water consumption of more than 2.5 L has a robust impact on reducing the symptoms of disabling claudication and rest pain caused by peripheral vascular disease.

General utilities of multislice tomography in the cardiac field.

OBJECTS: To show all cardiac evaluations multislice computed tomography (MSCT) can perform. METHODS: MSCTs were performed on an MSCT scanner (Mx8000; Philips Medical Systems) with enhanced contrast acquisition. The reconstructed images were sent to a workstation for multiplanar reconstruction, volume rendering, and 3-D reconstruction. A total of 140 patients were studied with MSCT and conventional angiography (CA) to assess coronary artery stenosis. 30 of these patients were also evaluated by intravascular ultrasound (IVUS) for plaque characterization. A group of 20 patients were studied with MSCT, gated single-photon emission computed tomography (SPECT), and echocardiography for myocardial perfusion test and volumetric analysis. RESULTS: The results of MSCT versus CA showed a sensitivity of 79.2% and a specificity of 93.7%, whereas for MSCT versus IVUS the sensitivity was 84.4% and the specificity 91.6%. A total of 156 plaques were detected by both methods. 105 (67%) were soft, 14 (24%) were fibrous and 37 (9%) were calcified. In the evaluation of myocardial perfusion, the cardiac software showed a sensitivity of 55% and a specificity of 80%. However, general evaluation disclosed a sensitivity of 88.5% and a specificity of 96.4%. The volumetric analysis showed a good correlation between MSCT and echocardiography for end-systolic volume (ESV), rS = 0.874, and end-diastolic volume (EDV), rS = 0.828. There was also a good correlation for the evaluation of the left ventricular anatomy: septal wall rS = 0.96, posterior wall rS = 0.81, and diameter of left ventricle rS = 0.69. CONCLUSION: Nowadays, MSCT allows different cardiologic evaluations with the same acquisition as that for the coronary arteries. These data show a general view of the patient providing information that is obtained by the hand of multiple cardiologic methods such as DA, IVUS, gated SPECT, and echocardiography.

Endovascular treatment of aneurysmal disease.

Endovascular repair of abdominal aortic aneurysm using stent grafts that are delivered intraluminally by catheters is a less invasive alternative to open surgical repair. Endovascular surgery has been studied for over a decade, and early results are comparable to open repair. With extended follow-up care, however, postoperative complications and graft failures have been reported in some patients, resulting in reintervention, conversion to open repair, and death. The high incidence of secondary interventions causes some researchers to question the durability of endograft repair and emphasizes the need for detailed long-term follow-up care. This article describes the evolution of endovascular treatment of abdominal aortic aneurysm from its origin to its current state and discusses the future direction of endovascular therapy.

Safety maneuvers to prevent embolism complicating endovascular aortic repair.

The endoluminal approach of the diffusely atheromatous aorta (DAA) is an emerging tool to prevent further embolization. We treated one symptomatic patient with DAA. We designed a catheter with a balloon at the tip for occlusion of both common iliac arteries through which the antegrade flow was allowed by an iliac to femoral arterio-arterial shunt connected to an in-line filter. Filter wires were also placed in the superior mesenteric and both renal arteries' take-off, keeping their antegrade flow. The endograft was then introduced through these tubes. Endoluminal treatment of the primary source of atheromatous embolization is feasible, representing a new approach to be considered.

Angiografía coronaria no invasiva por tomografía computada multislice / Noninvasive coronary angiography using multislice CT

Objetivo: determinar la sensibilidad (S) y especificidad (E) de la TC multislice (TCMS) en la detección de estenosis coronaria (EC), comparándola con la angiografía digital (AD), considerada el gold standard. Material y métodos: entre marzo y junio de 2001, 50 pacientes con sospecha de enfermedad coronaria fueron estudiados por TCMS y AD. Las TC se realizaron con un equipo multislice (Mx8000; Marconi Medical Systems). Los parámetros técnicos utilizados fueron cortes de 1 mm de espesor y 0.6 mm intervalo de reconstrucción. Se realizaron los intervalos de confianza (IC) del 95 por ciento de las proporciones por el método de exacto binomial. Resultados: la S fue del 83,9 por ciento (IC: 75,5-89,9), la E del 91,2 por ciento (IC: 86,4-94,5), el valor predictivo positivo 83,2 por ciento (IC: 74,7-89,3) y el valor predictivo negativo del 91,6 por ciento (IC: 86,9-94,8). Conclusión: los resultados iniciales mostraron alta S y E de la TCMS en la detección y cuantificación de EC

Angiografía coronaria no invasiva por tomografía computada multislice / Noninvasive coronary angiography using multislice CT

Objetivo: determinar la sensibilidad (S) y especificidad (E) de la TC multislice (TCMS) en la detección de estenosis coronaria (EC), comparándola con la angiografía digital (AD), considerada el gold standard. Material y métodos: entre marzo y junio de 2001, 50 pacientes con sospecha de enfermedad coronaria fueron estudiados por TCMS y AD. Las TC se realizaron con un equipo multislice (Mx8000; Marconi Medical Systems). Los parámetros técnicos utilizados fueron cortes de 1 mm de espesor y 0.6 mm intervalo de reconstrucción. Se realizaron los intervalos de confianza (IC) del 95 por ciento de las proporciones por el método de exacto binomial. Resultados: la S fue del 83,9 por ciento (IC: 75,5-89,9), la E del 91,2 por ciento (IC: 86,4-94,5), el valor predictivo positivo 83,2 por ciento (IC: 74,7-89,3) y el valor predictivo negativo del 91,6 por ciento (IC: 86,9-94,8). Conclusión: los resultados iniciales mostraron alta S y E de la TCMS en la detección y cuantificación de EC (AU)

Hipertensión arterial en pacientes sometidos a endarterectomía carotídea. ¿La hipertensión es un factor predisponente o desencadenante de la hemorragia intraplaca carotídea? / Hypertension in patients submitted to carotid endarterectomy. Does hypertension predispose or trigger intraplaque carotid hemorrhage?

Para obtener información sobre el papel de la hipertensión en la génesis de las placas carotídeas complicadas, en 195 piezas de endarterectomías de 191 pacientes (143 hipertensos y 48 normotensos) se estudiaron la inmunofenotipificación celular, la apoptosis y las alteraciones de los cromosomas 7 y 11, y de la amplificación génica del FGF-3. Los hallazgos sugieren que la hemorragia intraplaca se debería a la ruptura de los vasos de neoformación en relación con los infiltrados inflamatorios y al desbalance entre el crecimiento celular clonal y el alto índice apoptótico, lo cual tendría un papel importante en la evolución de las placas complicadas, independientemente de la hipertensión

Hipertensión arterial en pacientes sometidos a endarterectomía carotídea. ¿La hipertensión es un factor predisponente o desencadenante de la hemorragia intraplaca carotídea? / Hypertension in patients submitted to carotid endarterectomy. Does hypertension predispose or trigger intraplaque carotid hemorrhage?

Para obtener información sobre el papel de la hipertensión en la génesis de las placas carotídeas complicadas, en 195 piezas de endarterectomías de 191 pacientes (143 hipertensos y 48 normotensos) se estudiaron la inmunofenotipificación celular, la apoptosis y las alteraciones de los cromosomas 7 y 11, y de la amplificación génica del FGF-3. Los hallazgos sugieren que la hemorragia intraplaca se debería a la ruptura de los vasos de neoformación en relación con los infiltrados inflamatorios y al desbalance entre el crecimiento celular clonal y el alto índice apoptótico, lo cual tendría un papel importante en la evolución de las placas complicadas, independientemente de la hipertensión (AU)