Carotid artery plaque echomorphology and its association with histopathologic characteristics.

OBJECTIVE: The aim of the study was to determine the association of ultrasonic texture features (severity of stenosis, grey scale median, plaque area, juxtaluminal black area [JBA], and discrete white areas) previously shown to be independent predictors for stroke with established histologic features of plaque instability. METHODS: A cross-sectional study was performed involving 70 patients scheduled for carotid endarterectomy. Before surgery, carotid plaque texture features were obtained with ultrasound after normalization using commercially available software (LifeQ Medical, Nicosia, Cyprus). After carotid endarterectomy, histologic features (number of macrophages [CD68 staining], severity of angiogenesis [CD31 staining], smooth muscle cell [SMC] numbers, size of lipid core, thickness of the fibrous cap, presence of intraplaque hemorrhage, plaque rupture, and instability) also were studied. RESULTS: Symptomatic (n = 20) and asymptomatic (n = 50) patients were comparable in terms of internal carotid stenosis (mean stenosis, 86%; range, 60%-99%) and prevalence of risk factors except for total cholesterol (which was higher in the symptomatic group; P = .023). A low grey scale median and the presence of discrete white areas were associated with an increased number of macrophages (P < .001 and P < .001, respectively), increased neovascularization (P = .019 and P < .001, respectively), larger lipid core (P = .001 and P = .025, respectively), intraplaque hemorrhage presence (P = .001 and P = .001, respectively), plaque rupture (P = .001 and P = .025, respectively), and a decreased number of SMCs (P = .003 and P = .003, respectively). The presence of JBA was associated with a decreased number of SMCs (P = .042), larger lipid core (P = .013), and plaque rupture (P = .002). The combination of a thin fibrous cap with either a large lipid core or plaque rupture was associated with the highest (65%) prevalence of a JBA. Plaque area was not associated with any of the histologic features. After adjusting statin therapy for symptoms, statins were associated with a decreased number of macrophages (P = .038), decreased neovascularization (P = .019), and an increased number of SMCs (P = .023). CONCLUSIONS: A number of ultrasonic texture features previously shown to be independent predictors of stroke have been found to have a strong association with established histologic features of plaque instability. This finding provides insight into the mechanism of ultrasonic texture features in stroke prediction and validates the use of ultrasound in stroke risk stratification.

Selective Spleen Embolization of Splenomegaly to Improve Thrombocytopenia Facilitating Open Aortic Aneurysm Repair: A Staged Approach.

We present an 82-year-old man with a history of hairy cell leukemia, having an 11-cm abdominal aortic aneurysm, who also had severe thrombocytopenia (about 20 000 platelets/µL) and splenomegaly at presentation. The patient had unfavorable anatomy for endovascular aneurysm repair, and therefore, an open procedure was planned. To reduce risk for perioperative bleeding and optimize patient preoperative status, a staged approach was employed. Initially, several sessions of embolization of 2 splenic artery branches were performed with the intent to decrease spleen size and to increase platelet count thus decreasing the perioperative bleeding risk. Then, after successfully increasing platelet count (280 000 PLT/µL), open repair of the aneurysm was conducted. This case demonstrates that selective splenic embolization in patients with hypersplenism and subsequent thrombocytopenia who are in need for major surgery may achieve a significant rise in platelet count and optimize patient's preoperative status in order to avoid bleeding complications.

Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over open repair.

BACKGROUND: Despite the intuitive advantages of endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (AAAs), uncertainty remains about the optimal management in the absence of convincing high-quality evidence. Our objective was to undertake a comprehensive literature review and perform a meta-analysis of outcome data of treatment modalities for ruptured AAAs. METHODS: Systematic searches were conducted of electronic information sources to identify studies comparing perioperative outcomes of EVAR and open repair for AAA rupture. Summary estimates of odds ratios (ORs) or standardized mean difference and 95% confidence intervals (CIs) were obtained with a random-effects model. Meta-regression models were formed to explore potential heterogeneity as a result of changes in practice over time. RESULTS: We selected 41 studies for analysis. The entire meta-analysis population comprised 59,941 patients (8201 EVAR patients and 51,740 open repair patients). EVAR was associated with a significantly lower incidence of in-hospital mortality (OR, 0.56; 95% CI, 0.50-0.64; P < .01; meta-analysis of risk-adjusted observational studies and randomized controlled trials: OR, 0.58; 95% CI, 0.46-0.73; P < .01). EVAR patients had a significantly decreased risk of developing respiratory complications (OR, 0.59; 95% CI, 0.49-0.69; P < .01) and acute renal failure (OR, 0.65; 95% CI, 0.55-0.78; P < .01) and a trend toward a reduced incidence of cardiac complications (OR, -0.02; 95% CI, -0.03 to 0.00; P = .05) and mesenteric ischemia (OR, 0.66; 95% CI, 0.44-1.00; P = .05). Patients treated with EVAR had significantly less requirements of intraoperative blood transfusion (standardized mean difference, -0.88; 95% CI, -1.06 to -0.70; P < .01). Random-effects meta-regression revealed no statistical evidence for an association between death and year of publication (P = .19). CONCLUSIONS: Our analysis provides evidence to motivate the adoption of an EVAR-first policy in a nonelective setting and the establishment of standardized protocols for the management ruptured AAAs.

Aortocaval fistula formation due to ruptured abdominal aortic aneurysms: a 12-year series.

This study reports on the frequency and management of aortocaval fistulas (ACFs) in our department between 1998 and 2009. Overall frequency of ACFs among ruptured abdominal aortic aneurysms was 5.5%. Patients presented with low back pain (92.8%), abdominal tenderness (78.6%), hemorrhagic shock (28.6%), congestive heart failure (21.4%), dyspnea (42.8%), and palpitations (57.1%). The most reliable clinical sign was the presence of palpable pulsating abdominal mass (92.8%). Other clinical findings included increased central venous pressure (21.4%), lower extremity edema (71.4%), hematuria (21.4%), and scrotal edema (14.3%). Diagnosis was established preoperatively in 85.7% and intraoperatively in 14.3% of cases. Surgery was successful in promptly improving clinical signs and symptoms. Mortality rate was 7.1%. After a mean follow-up of 18.5 months, all surviving patients remained free from complications. In conclusion, ACFs represent a life-threatening emergency for vascular surgeons but can be successfully managed.

Characteristics of patients presenting to the vascular emergency department of a tertiary care hospital: a 2-year study.

BACKGROUND: The structure of health care in Greece is receiving increased attention to improve its cost-effectiveness. We sought to examine the epidemiological characteristics of patients presenting to the vascular emergency department of a Greek tertiary care hospital during a 2-year period. We studied all patients presenting to the emergency department of vascular surgery at Red Cross Hospital, Athens, Greece between 1st January 2009 and 31st December 2010. RESULTS: Overall, 2452 (49.4%) out of 4961 patients suffered from pathologies that should have been treated in primary health care. Only 2509 (50.6%) needed vascular surgical intervention. CONCLUSIONS: The emergency department of vascular surgery in a Greek tertiary care hospital has to treat a remarkably high percentage of patients suitable for the primary health care level. These results suggest that an improvement in the structure of health care is needed in Greece.

Combined endovascular/surgical management of a ruptured para-anastomotic aneurysm of the left common iliac artery.

A 75-year old man presented with signs and symptoms of acute abdomen and a clinical picture of hypovolemic shock. An emergency CT scan revealed a ruptured para-anastomotic left common iliac artery aneurysm. The patient had undergone an elective abdominal aortic aneurysm repair operation and placement of an aortoiliac bifurcated graft 10 years before. Para-anastomotic aneurysms had developed in all 3 (aortic and the 2 iliac) anastomosis. As the patient was highrisk, a combined endovascular/surgical approach was undertaken. The patient was discharged 4 days later.This article discusses the applicability of endovascular procedures in emergency settings to high-risk patients.

Hypercoagulable state due to alcohol-paracetamol syndrome producing acute limb ischemia.

The authors describe a man with alcohol-paracetamol syndrome and hepatic failure who presented with acute arterial thrombosis of the left limb. The patient has jaundice, increased serum transaminase levels, and significant coagulopathy, with elevated international normalized ratio and prolonged prothrombin time. A transient hypercoagulable state due to liver failure is documented, characterized by acquired deficiencies of antithrombin III, protein C, and protein S. Laboratory and molecular testing for inherited hypercoagulable disorders during the follow-up period is positive for increased levels of factor VIII. The patient undergoes successful thrombectomy and receives intensive symptomatic and causal treatment, resulting in complete recovery. The patient is discharged 20 days after admission on a regimen of acenocoumarol.

Covered stent-graft treatment of traumatic internal carotid artery pseudoaneurysms: a review.

OBJECTIVE: To review the literature concerning the management with placement of covered stent-grafts of traumatic pseudoaneurysms of the extracranial internal carotid artery (ICA) resulting from penetrating craniocervical injuries or skull base fractures. METHOD: We have reviewed, from the Medline database, all the published cases in the English literature since 1990 and we have added a new case. RESULTS: We identified 20 patients with traumatic extracranial ICA pseudoaneurysms due to penetrating craniocervical injuries or skull base fractures who had been treated with covered stent-graft implantation. Many discrepancies have been ascertained regarding the anticoagulation therapy. In 3 patients the ICA was totally occluded in the follow-up period, giving an overall occlusion rate 15%. No serious complication was reported as a result of the endovascular procedure. CONCLUSION: Preliminary results suggest that placement of stent-grafts is a safe and effective method of treating ICA traumatic pseudoaneurysms resulting from penetrating craniocervical injuries or skull base fractures. The immediate results are satisfactory when the procedure takes place with appropriate anticoagulation therapy. The periprocedural morbidity and mortality and the early patency are also acceptable. A surveillance program with appropriate interventions to manage restenosis may improve the long-term patency.

Death from spontaneous coronary artery dissection in a healthy postmenopausal woman.

Spontaneous dissection of the coronary arteries, in the absence of trauma, is an unusual but well-documented entity that occurs usually in middle-aged women. It is a rare cause of sudden death and myocardial infarction. Coronary eosinophilic arteritis is suggested to result in a predisposition to intimal disruption and dissection. We present the case of the sudden death of a previous healthy, 53-year-old postmenopausal female, while working, in a town of Thessalia in Greece. The cause of death was left anterior descending coronary dissection with histologic findings of eosinophilic arteritis and autoimmune thyroiditis.