Endovascular treatment of carotid injury.

This is a systematic review of the International Literature regarding the role of endovascular treatment in cases of carotid injury. Injury to the carotid artery is not very common but is a serious consequence associated with either blunt or penetrating cervical trauma. They are difficult to evaluate due to associated injuries. The frequent coexistence of traumatic brain injuries seems to obscure its presentation and concurrent systemic injuries make the management somewhat challenging from the perspective of both diagnosis and treatment. Although bleeding is a serious and potentially fatal complication of these injuries, the main concern should be the impairment of cerebral blood supply. In the modern era of increasing usage of minimally invasive treatment options and technological advances, endovascular approach seems to gain acceptance as a sufficient alternative treatment modality in carefully selected groups of these trauma population. Interesting issues facing this emerging technology include the adequate definition of the types of injuries ideally indicated for endovascular treatment. Those traumatic carotid lesions located proximal to aortic arch or near the skull base are particularly hazardous to approach and difficult to repair surgically and may benefit of an endovascular approach. Specifically, iatrogenic injuries of carotid vessels are often occur in patients with significant comorbidities that make their management challenging.

The role of aortouniiliac devices in the treatment of aneurysmal disease.

PURPOSE: Many studies have shown that aortouniiliac (AUI) devices have comparable outcome in high risk patients as the treatment with bifurcated devices. The purpose of this article is to review the relevant literature and discuss the outcomes. METHODS: A systematic search from 1991 until 2010 was performed on PubMed and Medline databases for studies evaluating the role of AUI devices accompanied with occlusion of one iliac artery and crossover femoral-femoral or iliac-femoral bypass, for the treatment of abdominal aortic aneurysmal disease. Keywords used were abdominal aortic aneurysms (AAA), endovascular aortic aneurysm repair (EVAR), aortouniiliac, aortomonoiliac, stent graft, outcome analysis, in various combinations. The reference lists of the gathered reports were also manually searched. Only articles with series of more than twenty (20) patients were included in this review. RESULTS: Seven articles were found referring to the results of endovascular aortic aneurysm repair with AUI stent grafts, three are comparing AUI, tube, bifurcated devices or between them or /and with open surgery repair, four are referring to the patency of the femoral-femoral bypass that couples the AUI stent graft deployment, and two are referring to the treatment of r-AAA with the AUI stent grafts. CONCLUSIONS: There is increasing evidence in the literature that the AUI configuration endoprosthesis placement is a safe procedure over the mid- and long-term period and compares well with the results of AAA endovascular repair with bifurcated endoprostheses that have been published.

Acute carotid stent thrombosis after carotid artery stenting.

BACKGROUND: Carotid artery stenting (CAS) is a reasonable alternative to carotid endarterectomy (CEA), especially in patients at high risk for surgery. Carotid artery thrombosis of the treated segment is a rare, early but potentially devastating complication of this endovascular procedure. The aim of this article is to identify and critically review cases of acute stent thrombosis reported in the literature. MATERIALS AND METHODS: Previous trials that compared CEA with CAS were rather heterogeneous and not large enough to allow reliable conclusions. Furthermore, because there is limited follow-up information to date, the long-term effect of CAS remains unclear. Acute carotid thrombosis after angioplasty and stenting is a very rare but potentially fatal complication, and there are very few reports in the literature. This article reviews twelve cases of acute carotid thrombosis published in the English literature from eight different Vascular and Radiology Departments around the world. RESULTS: The different ways of immediate treatment of this rare complication of acute carotid thrombosis after CAS are, open surgical procedure with thrombus removal and thromboendarterectomy with or without removing of the stent, selective local or facilitated thrombolysis with the rescue use of GPIs (glycoprotein IIb/IIIa receptor inhibitors), recanalization by instent percutaneous transluminal angioplasty with distal protection and additional stent placement on the stented portion of the internal carotid artery (ICA) in conjunction with the intravenous administration of recombinant tissue plasminogen activator (rtPA: 1300,000 IU). CONCLUSION: Carotid artery stenting has to be performed under specific pro- and post procedure protocol from experienced endovascular specialists. The treatment of acute carotid thrombosis after CAS must be urgent and immediate in order to regain restoration of blood flow and avoid major neurological adverse events.

The critical role of the external carotid artery in cerebral perfusion of patients with total occlusion of the internal carotid artery.

AIM: The ipsilateral external carotid artery (ECA) can potentially provide an important collateral pathway for cerebral blood flow in the presence of occlusion or severe stenosis of the internal carotid artery (ICA), recovering up to 15% of the middle cerebral arterial flow. The aim of the study is to elucidate the role of ECA in cerebral flow of patients with total ICA occlusion. METHODS: Retrospective study of prospectively collected data of 139 patients with total ICA occlusions. The patients were divided to symptomatic and asymptomatic and were categorized in four subgroups according to the stenosis rates: A) ipsilateral ECA<70% and contralateral internal carotid artery stenosis <70%; B) ipsilateral ECA stenosis <70% and contralateral internal carotid artery stenosis ≥70%; C) ipsilateral ECA stenosis ≥70% and contralateral ICA stenosis <70%; D) ipsilateral ECA stenosis ≥70% and contralateral ICA stenosis ≥75%. RESULTS: Fifty eight (41.7%) patients were asymptomatic. The highest rate (48.2%) of asymptomatic patients was in Group A. Among patients with strokes, the highest rate belonged in groups C and D (44.4% and 50% respectively) where ipsilateral ECA stenosis was ≥70% irrespectively of the contralateral ICA patency. Ipsilateral external carotid artery stenosis ≥70% proved to be and independent risk factor for symptom presentation (P=0.013). CONCLUSION: The study reveals the significant role of ECA patency in cerebral flow in patients with ICA occlusion.

Adrenaline attenuates the acute lung injury after intratracheal lipopolysaccharide instillation: an experimental study.

Endotoxin is a major cause of endotoxinemia, sepsis, and pneumonia due to gram-negative bacteria. Experimental endotoxin administration via the tracheal route has been extensively used to study the biological and pathophysiologic pathways of inflammation. In particular, experimental endotoxin instillation in the respiratory tree has allowed an extended research with regard to the local response of the lungs to the pathogenic stimulus. This study aims (a) to define early events in the inflammatory cascade and (b) to evaluate the efficacy of adrenaline to ameliorate the acute pulmonary inflammation in vivo after administration of intratracheal lipopolysaccharide (LPS) in an in vivo animal model. Two groups of animals were used for that purpose, a control group (single LPS administration) and a study group (subcutaneous adrenaline infusion following LPS administration). We found that mononuclear recruitment, along with an increased population of CD4+ T lymphocytes, is an early event during the course of LPS-challenged inflammation. In the study group, we determined that adrenaline mediated the lung inflammation in a statistically significant degree. By the use of immunohistochemistry, we identified (1) an increased population of CD4+ T lymphocytes in the inflammatory infiltrate, further endorsing the hypothesis that T-helper lymphocytes, along with macrophages, secrete cytokines which amplify the inflammatory response, and (2) an upregulation of ICAM-1 expression, suggesting an important role in the early pathogenesis of LPS-induced acute lung injury. Our study establishes that systemic adrenaline administration after LPS instillation may ameliorate the inflammatory lung response in vivo.

Simultaneous venous gangrene in both lower and upper limbs. A case report.

Cancer-related venous gangrene is an extremely rare paraneoplastic syndrome. Here, we present the case of a woman, who suffered from cervical cancer of the uterus and was admitted to our Clinic with venous gangrene in both the right lower and upper limbs. Neither the anticoagulant therapy, nor thrombolysis, succeeded in improving her clinical condition. Cancer is one of the most important causes of venous thromboembolism. Venous gangrene is rarely seen in these patients. Despite adequate therapy, venous gangrene in some very rare occasions may progress to affect further limbs. Mortality in these patients remains very high.