RESUMEN
Endovascular treatment of carotid artery stenosis is a valuable alternative to open surgery, and the evolution of stent materials and cerebral protection devices significantly decreased postoperative neurological complications. Among these, the introduction of nitinol double-layer micromesh stent seems to guarantee a reduced perioperative and postoperative cerebral embolization. Long-term results are however still not available to make a global evaluation of these stents. We present the case of a 66-year-old female patient treated for asymptomatic carotid stenosis complicated by a symptomatic partial stent thrombosis occurred three months after carotid artery stenting.
Asunto(s)
Aleaciones , Estenosis Carotídea/terapia , Dispositivos de Protección Embólica , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Stents , Mallas Quirúrgicas , Trombosis/etiología , Anciano , Anticoagulantes/administración & dosificación , Enfermedades Asintomáticas , Estenosis Carotídea/diagnóstico por imagen , Angiografía por Tomografía Computarizada , Femenino , Humanos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Diseño de Prótesis , Trombosis/diagnóstico por imagen , Trombosis/tratamiento farmacológico , Factores de Tiempo , Resultado del TratamientoRESUMEN
Serum is an abundant and accessible source of circulating extracellular vesicles (EVs). Serum-EV (sEV) pro-angiogenic capability and mechanisms are herein analyzed using an in vitro assay which predicts sEV angiogenic potential in vivo. Effective sEVs (e-sEVs) also improved vascular remodeling and prevented muscle damage in a mouse model of acute hind limb ischemia. e-sEV angiogenic proteomic and transcriptomic analyses show a positive correlation with matrix-metalloproteinase activation and extracellular matrix organization, cytokine and chemokine signaling pathways, Insulin-like Growth Factor and platelet pathways, and Vascular Endothelial Growth Factor signaling. A discrete gene signature, which highlights differences in e-sEV and ineffective-EV biological activity, was identified using gene ontology (GO) functional analysis. An enrichment of genes associated with the Transforming Growth Factor beta 1 (TGFß1) signaling cascade is associated with e-sEV administration but not with ineffective-EVs. Chromatin immunoprecipitation analysis on the inhibitor of DNA binding I (ID1) promoter region, and the knock-down of small mother against decapentaplegic (SMAD)1-5 proteins confirmed GO functional analyses. This study demonstrates sEV pro-angiogenic activity, validates a simple, sEV pro-angiogenic assay which predicts their biological activity in vivo, and identifies the TGFß1 cascade as a relevant mediator. We propose serum as a readily available source of EVs for therapeutic purposes.
Asunto(s)
Vesículas Extracelulares/metabolismo , Isquemia/sangre , Isquemia/patología , Músculo Esquelético/metabolismo , Músculo Esquelético/patología , Remodelación Vascular , Animales , Biomarcadores , Proliferación Celular , Modelos Animales de Enfermedad , Células Endoteliales/metabolismo , Vesículas Extracelulares/ultraestructura , Perfilación de la Expresión Génica , Regulación de la Expresión Génica , Miembro Posterior , Inmunohistoquímica , Ratones , Músculo Esquelético/irrigación sanguínea , Neovascularización Fisiológica , Regiones Promotoras Genéticas , Proteómica/métodos , Daño por Reperfusión/metabolismo , Daño por Reperfusión/patología , TranscriptomaRESUMEN
BACKGROUND: Many studies confirmed the role of early carotid endarterectomy (CEA) to prevent recurrent stroke or transient ischemic attack; however, the mid-long-term neurological benefit is still not completely investigated. The purpose of the study was to evaluate the role of early CEA on the perioperative and postoperative stroke/death complications of patients with a symptomatic carotid stenosis. METHODS: Ninety consecutive patients were referred to our center for a symptomatic carotid stenosis. They were divided into 2 groups according to the time to surgery: G1 within 2 weeks (39 patients) and G2 from 2 weeks to thereafter (51 patients). Neurological assessment was performed with the National Institutes of Health Stroke Scale (NIHSS) at presentation and at follow-up. Echo color Doppler ultrasound was performed at 1-6 months and then yearly. RESULTS: The presentation of neurological symptoms differed significantly between the 2 groups; in fact, minor stroke was more frequent in G1, whereas transient ischemic attack was more frequent in G2 (P value = 0.027). No significant differences emerged between the 2 groups on the surgical intervention or perioperative complications. The study showed a significant improvement of the neurological impairment (evaluated with a reduction of NIHSS score) of patients in G1 compared with G2 (P value = 0.01). CONCLUSIONS: Neurological recovery after a symptomatic carotid stenosis is strictly correlated to the variable "time to surgery." A higher sensitization of the general population on the early recognition of the symptoms and a strict collaboration with neurologists is mandatory to reduce time to CEA and improve clinical outcomes.
Asunto(s)
Estenosis Carotídea/cirugía , Endarterectomía Carotidea , Ataque Isquémico Transitorio/etiología , Accidente Cerebrovascular/etiología , Tiempo de Tratamiento , Anciano , Anciano de 80 o más Años , Estenosis Carotídea/complicaciones , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/mortalidad , Evaluación de la Discapacidad , Endarterectomía Carotidea/efectos adversos , Endarterectomía Carotidea/mortalidad , Femenino , Humanos , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/mortalidad , Italia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Recuperación de la Función , Recurrencia , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Doppler en ColorAsunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/métodos , Arteria Renal/cirugía , Anciano , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/instrumentación , Angiografía por Tomografía Computarizada , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Humanos , Masculino , Diseño de Prótesis , Arteria Renal/diagnóstico por imagen , Stents , Resultado del TratamientoRESUMEN
Aberrant right subclavian artery (ARSA) is a rare congenital anomaly characterized by the origin of the right subclavian artery from the aortic arch distally to the left subclavian artery. We describe the case of a young patient with symptomatic ARSA treated by mediastinoscopy-assisted ligation at its origin and subclavian-carotid transposition.
Asunto(s)
Aneurisma/cirugía , Anomalías Cardiovasculares/cirugía , Arteria Carótida Común/cirugía , Trastornos de Deglución/cirugía , Mediastinoscopía , Arteria Subclavia/anomalías , Adulto , Anastomosis Quirúrgica , Aneurisma/complicaciones , Aneurisma/diagnóstico , Anomalías Cardiovasculares/complicaciones , Anomalías Cardiovasculares/diagnóstico , Arteria Carótida Común/anomalías , Arteria Carótida Común/diagnóstico por imagen , Trastornos de Deglución/complicaciones , Trastornos de Deglución/diagnóstico , Femenino , Humanos , Ligadura , Arteria Subclavia/cirugía , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Primary aortoenteric fistula is a direct communication between the aorta and intestinal lumen and it represents a rare but potentially lethal complication of an abdominal aortic aneurysm. However, it may occur less frequently in a naive non-aneurysmatic aorta. Diagnosis is often difficult and delayed in most cases, unless there is a high level of clinical awareness. Urgent surgery is still the recommended treatment. We describe the case of primary aortoenteric fistula of a saccular aneurysm. A 55-year-old woman was referred to our center with hematemesis, melena, and severe anemia who was dignosed previously with unknown saccular abdominal aneurysm.
RESUMEN
The obstructive calcifying aortic disease refers to severe calcifications of the descending aorta that obstruct or slow blood flow. Here, we report the case of a 65-year-old woman with recent onset of a very tight intermittent claudication and concomitant severe and uncontrolled hypertension, treated with a bypass graft between the proximal descending thoracic aorta and the supravisceral abdominal aorta.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Abdominal/cirugía , Enfermedades de la Aorta/cirugía , Arteriopatías Oclusivas/cirugía , Implantación de Prótesis Vascular , Calcificación Vascular/cirugía , Anciano , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Enfermedades de la Aorta/complicaciones , Enfermedades de la Aorta/diagnóstico , Aortografía/métodos , Arteriopatías Oclusivas/complicaciones , Arteriopatías Oclusivas/diagnóstico , Femenino , Humanos , Hipertensión/etiología , Claudicación Intermitente/etiología , Índice de Severidad de la Enfermedad , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Calcificación Vascular/complicaciones , Calcificación Vascular/diagnósticoRESUMEN
Contrast-enhanced ultrasound (CEUS) has recently become one of the most versatile and powerful diagnostic tools in vascular surgery. One of the most interesting fields of application of this technique is the study of the carotid atherosclerotic plaque vascularization and its correlation with neurological symptoms (transient ischemic attack, minor stroke, and major stroke) and with the characteristics of the "vulnerable plaque" (surface ulceration, hypoechoic plaques, intraplaque hemorrhage, thinner fibrous cap, and carotid plaque neovascularization at histopathological analysis of the sample after surgical removal). The purpose of this review is to collect all the original studies available in literature (24 studies with 1356 patients enrolled) and to discuss the state of the art, limits, and future perspectives of CEUS analysis. The results of this work confirm the reliability of this imaging study for the detection of plaques with high risk of embolization; however, a shared, user-friendly protocol of imaging analysis is not available yet. The definition of this operative protocol becomes mandatory in order to compare results from different centers and to validate a cerebrovascular risk stratification of the carotid atherosclerotic lesions evaluated with CEUS.
Asunto(s)
Enfermedades de las Arterias Carótidas/diagnóstico por imagen , Embolización Terapéutica/métodos , Placa Aterosclerótica/diagnóstico por imagen , Embolización Terapéutica/efectos adversos , Humanos , UltrasonografíaRESUMEN
OBJECTIVES: Cerebral microembolization, one of the most frequent complications of carotid artery stenting, is associated with an increased risk of peri- and post-procedural stroke and transient ischemic attack and a mid-term risk of neurocognitive decline. A valuable tool to evaluate carotid plaque instability and risk of embolization is contrast-enhanced ultrasound. With this prospective study we sought to determine the correlation between contrast enhancement of the plaque and cerebral microembolization after carotid stent deployment and to evaluate the clinical impact of the neurological injury. MATERIALS AND METHODS: Thirty-five consecutive patients with carotid artery stenosis and indications for endovascular stenting were enrolled. Before the procedure, patients were evaluated with contrast-enhanced ultrasound to define plaque enhancement (signal intensity). All endovascular procedures were performed under cerebral filter protection. Diffusion-weighted magnetic resonance imaging scans to detect microemboli were obtained before and 48 h after the stent deployment. The Ray auditory verbal learning test to assess neurocognitive function was administered before and 1 month after the procedure. RESULTS: Nineteen patients (54 %) developed new cerebral ischemic lesions after carotid artery stenting. Contrast enhancement of the plaque was greater in the patients with post-procedural microembolization than in those without it [maximum signal intensity 26 ± 7.7 vs. 21 ± 5.2, respectively, (p = 0.039), mean signal intensity, 20.7 ± 6.1 vs. 16.5 ± 5.3, respectively (p = 0.048)]. No correlation was found between neurocognitive test scores and microembolization or plaque enhancement. CONCLUSION: Contrast enhancement of the carotid plaque is strongly associated with post-procedural microembolization and for this reason it can be considered a reliable tool for an accurate selection of patients undergoing this endovascular treatment. However, the neurocognitive test scores performed in this study are not enough sensible to appreciate the impact of the neurological injury on the day life activities.
Asunto(s)
Estenosis Carotídea/diagnóstico por imagen , Estenosis Carotídea/cirugía , Embolia Intracraneal/diagnóstico por imagen , Complicaciones Posoperatorias/diagnóstico por imagen , Stents/efectos adversos , Anciano , Medios de Contraste , Imagen de Difusión por Resonancia Magnética , Dispositivos de Protección Embólica , Femenino , Humanos , Embolia Intracraneal/prevención & control , Masculino , Pruebas Neuropsicológicas , Complicaciones Posoperatorias/prevención & control , Valor Predictivo de las Pruebas , Estudios Prospectivos , Riesgo , UltrasonografíaRESUMEN
Pseudoaneurysms are a rare complication of carotid endarterectomy. We successfully excluded with 2 overlapping bare stents a distal carotid artery pseudoaneurysm very likely induced by a Pruitt-Inahara shunt 2 months after carotid endarterectomy.
Asunto(s)
Aneurisma Falso/terapia , Arteria Carótida Interna/cirugía , Estenosis Carotídea/cirugía , Endarterectomía Carotidea/efectos adversos , Procedimientos Endovasculares/instrumentación , Stents , Anciano , Aneurisma Falso/diagnóstico , Aneurisma Falso/etiología , Aneurisma Falso/fisiopatología , Arteria Carótida Interna/diagnóstico por imagen , Estenosis Carotídea/diagnóstico , Estenosis Carotídea/fisiopatología , Endarterectomía Carotidea/instrumentación , Humanos , Masculino , Diseño de Prótesis , Flujo Sanguíneo Regional , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Ultrasonografía Doppler en ColorRESUMEN
The superficial femoral artery (SFA) is a relatively rare location for lower limb aneurysmatic disease. In the literature, this disease is described an association between a relatively high growth rate and/or the rupture of aneurysms and chemotherapeutic agents. We report a case of the rupture of a giant SFA aneurysm in a patient during chemotherapy for acute lymphatic leukemia.
RESUMEN
BACKGROUND: Seminomatous and non-seminomatous Germ Cell Tumors (GCT) of the testis are a rare cancer, with an estimated incidence of 56.3 per million white males and 10 per million black males in the United States.The association between non-seminomatous GCT and horseshoe kidney is a rare event and is seen in about 1.3% of patients requiring retroperitoneal lymph node dissection. To our knowledge, no cases have been reported in which replacement of the IVC was also necessary. CASE PRESENTATION: We report the case of a 22-year-old man with horseshoe kidney and metastatic non-seminomatous germ cell tumor involving the wall of the inferior vena cava.Following post-chemotherapy retroperitonal lymph node dissection, the inferior vena cava was replaced with an expanded polytetrafluoroethylene graft.At 2-years follow-up, the patient was in good health and the graft was patent. No clinical or diagnostic signs of renal impairment or recurrence of neoplastic disease were noted. CONCLUSION: Radical surgery is warranted in patients with non-seminomatous germ cell tumor metastasizing to the retroperitoneal lymph nodes. When vena cava replacement is required, and the situation is further complicated by horseshoe kidney, as in this case, surgical technique will rely on multidisciplinary surgical treatment planning by a team composed of urologists, vascular surgeons and oncologists.
Asunto(s)
Prótesis Vascular , Riñón/anomalías , Seminoma/secundario , Seminoma/cirugía , Neoplasias Testiculares/cirugía , Vena Cava Inferior/cirugía , Humanos , Metástasis Linfática , Masculino , Implantación de Prótesis/métodos , Seminoma/complicaciones , Neoplasias Testiculares/complicaciones , Resultado del Tratamiento , Vena Cava Inferior/patología , Adulto JovenRESUMEN
Popliteal vein aneurysms (PVAs) are rare but may cause severe and even fatal complications, such as pulmonary embolism (PE). A woman at the eighth week of pregnancy came to our attention because of a thrombosis of a previously undetected left PVA, diagnosed after a PE episode. Surgery was delayed until after delivery and breastfeeding, during which anticoagulant therapy was established.