Banding for type IA endoleak after endovascular abdominal aortic repair: An underexposed treatment option.

More challenging abdominal aortic aneurysms with unfavorable proximal aortic neck anatomy are treated with endovascular means. As a consequence, proximal inadequate sealing may result in type IA endoleak, which in turn can lead to abdominal aortic aneurysm progression or rupture. The presence of type IA endoleak is an indication for secondary interventions. External aortic banding can be a good option to solve a type IA endoleak, but is underreported in literature; we present two cases and review literature.

Isolated hip fracture care in an inclusive trauma system: A trauma system wide evaluation.

INTRODUCTION: Elderly patients with a hip fracture represent a large proportion of the trauma population; however, little is known about outcome differences between different levels of trauma care for these patients. The aim of this study is to analyse the outcome of trauma care in patients with a hip fracture within our inclusive trauma system. MATERIALS AND METHODS: Retrospective cohort study. Data were collected from the electronic patient documentation of patients, with an isolated hip fracture (aged ≥ 60), admitted to a level I or level II trauma centre between January 2008 and December 2012. Main outcomes were time to operative treatment, complications, mortality, and secondary surgical intervention rate. RESULTS: A total of 204 (level I) and 1425 (level II) patients were admitted. Significantly more ASA4 patients, by the American Society of Anesthesiologists (ASA) classification, were treated at the level I trauma centre. At the level II trauma centre, median time to surgical treatment was shorter (0 days; IQR 0-1 vs 1 day; IQR 1-2; P < 0.001), which was mainly influenced by postponement due to lack of operation room availability (14%, n = 28) and co-morbidities (13%, n = 26) present at the level I trauma centre. At the level II trauma centre, hospital stay was shorter (9 vs 11 days; P < 0.001) and the complication rate was lower (41%; n = 590 vs 53%; n = 108; P = 0.002), as was mortality (4%; n = 54 vs 7%; n = 15; P = 0.018). Secondary surgical intervention was performed less often at the level II trauma centre (6%; n = 91 vs 12%; n = 24; P = 0.005). However, no differences in secondary surgical procedures due to inadequate postoperative outcome or implant failure were observed. CONCLUSION AND RELEVANCE: The clinical pathway and the large volume of patients at the level II centre resulted in earlier surgical intervention, lower overall complication and mortality rate, and a shorter length of stay. Therefore, the elderly patient with a hip fracture should ideally be treated in the large-volume level II hospital with a pre-established clinical pathway. However, complex patients requiring specific care that can only be provided at the level I trauma centre may be treated there with similar operative results.

Results of reinterventions for failed endovascular aortic repair: a single-center experience.

AIM: The aim of this paper was to review technical success and clinical outcome of reinterventions to treat complications after endovascular abdominal aortic aneurysm (AAA) repair (EVAR) in a tertiary vascular center. METHODS: The study enrolled 107 patients treated for post-EVAR complications between January 2005 and March 2014. Details of reinterventions, technical success, and midterm clinical outcome were analyzed for reinterventions. Radiologic follow-up after reinterventions was performed by computed tomography scans and duplex ultrasonography. RESULTS: Indications for reinterventions in the 107 patients were predominantly endoleaks type Ia, Ib, II, and III (55.1%). Endograft obstructions were observed in 39 patients (36.4%). The initial technical success rate for the 107 reinterventions was 93.5% (N.=100). Median follow-up postreintervention was 20 months (range, 1-107 months). During follow-up, 34 of 107 patients (31.8%) needed at least one renewed reintervention. Kaplan-Meier analysis of overall survival after the primary reinterventions was 85% at 1 year, and 78% at 3 years of follow-up. AAA/EVAR-associated mortality was 4% at 3 years. Kaplan-Meier survival estimation of freedom of recurrence was 88% at 1 year post-reintervention and 78% at 3 years. Renewed reintervention-free survival dropped to 78% at 1 year and 58% at 3 years. CONCLUSION: In this series of patients, the technical success rate of reinterventions to treat post-EVAR complications was high. During a median follow-up of 20 months, AAA-associated mortality is low, but the need for renewed (endovascular) reinterventions is substantial.

Spontaneous preoperative microembolic signals detected with transcranial Doppler are associated with vulnerable carotid plaque characteristics.

AIM: Carotid plaque composition is associated with ipsilateral cerebrovascular events. Among patients with carotid artery stenosis, presence of microembolic signals (MES) detected with transcranial Doppler (TCD) is associated with increased stroke risk. We aimed to investigate whether MES detected with TCD in the outpatient clinic among patients scheduled for carotid endarterectomy, was associated with underlying carotid plaque composition. METHODS: TCD was used to detect MES among 38 symptomatic patients scheduled for carotid endarterectomy. Measurements were performed for 30 minutes. Carotid plaques harvested during CEA were subjected to histopathological examination. Plaques from patients without spontaneous MES were compared with plaques from patients with ≥1 MES. RESULTS: Median time between TCD and surgery was 4 days. At least 1 MES was detected in 10/38 (26%) patients. Five of ten (50%) patients with spontaneous MES had lipid-rich plaques, compared with 5/28 (17.2%) plaques from patients without MES (P=0.048). Luminal thrombus was observed in 6/10 (60.0%) of plaques from patients with MES compared with 7/28 (25.0%) of plaques from patients without MES (P=0.045). CONCLUSION: Spontaneous MES were detected in 26% of symptomatic patients scheduled for CEA and were associated with unstable carotid plaque characteristics. TCD might be a useful tool to help identify patients with vulnerable plaques.

Asymptomatic carotid artery stenosis: identification of subgroups with different underlying plaque characteristics.

OBJECTIVES: Optimal surgical treatment of patients with asymptomatic carotid artery stenosis (ACAS) remains a matter of debate. Established definitions of ACAS include: (1) patients who never suffered from ipsilateral cerebrovascular events (group 1) or (2) patients who suffered from ipsilateral cerebrovascular events more than 6 months prior to revascularisation (group 2). Cerebrovascular symptoms are closely related to underlying carotid plaque composition and therefore we investigated potential plaque differences between these definition-based subgroups. DESIGN: Cross-sectional analysis of a longitudinal prospective biobank study. MATERIAL AND METHODS: Carotid atherosclerotic plaques from 264 asymptomatic patients were harvested during endarterectomy, and subjected to histopathological examination. Patients were divided into two groups: group 1: truly asymptomatic (n = 182), and group 2: patients with ipsilateral events more than 6 months before carotid endarterectomy (CEA) (n = 82). RESULTS: Patients in group 1 had relatively more stable plaque characteristics as compared with patients in group 2, with a higher median plaque smooth muscle cell content (2.1 (0.0-18.7) vs. 1.6 (0.0-14.4); P = 0.036), a higher proportion of heavily calcified plaques (67.7% (123/182) vs. 48.8% (40/82); P = 0.005) and less frequently intraplaque haemorrhages (11.5% (21/182) vs. 30.5% (25/82); P = 0.001). CONCLUSION: Different plaque characteristics within subgroups of ACAS patients can be identified based on reported past ipsilateral events, which might result in adjusted future treatment strategies.

Radiation-induced carotid stenotic lesions have a more stable phenotype than de novo atherosclerotic plaques.

OBJECTIVE: To identify plaque characteristics of carotid artery radiation-induced stenosis. MATERIALS AND METHODS: Nineteen carotid plaques were obtained during carotid endarterectomy (CEA) in 17 consecutive patients with prior cervical radiation therapy (XRT) (median interval 10 years) and compared with 95 matched control carotid plaques of patients without a history of XRT. The following histopathological factors were assessed: calcification, collagen, macrophages, smooth muscle cells, atheroma, microvessels and intraplaque haemorrhage. Association of individual histological parameters with XRT plaque was analysed through a multivariable regression model. RESULTS: Less infiltration of macrophages (6/19 versus 60/95, adjusted p = 0.003) and a smaller lipid core size (Atheroma >10%: 10/19 versus 80/95, adjusted p = 0.006) were independently associated with XRT plaque, compared to non-XRT plaques. CONCLUSIONS: Carotid stenotic lesions in patients with previous cervical radiation are less inflammatory and more fibrotic than carotid atherosclerotic lesions in non-radiated patients.

Endothelial insulin receptor expression in human atherosclerotic plaques: linking micro- and macrovascular disease in diabetes?

OBJECTIVE: Exogenous insulin use in patients with type 2 diabetes (DM2) has been associated with an increased risk of cardiovascular events. Through which mechanisms insulin may increase atherosclerotic plaque vulnerability is currently unclear. Because insulin has been suggested to promote angiogenesis in diabetic retinopathy and tumors, we hypothesized that insulin enhances intra-plaque angiogenesis. METHODS: An in vitro model of pathological angiogenesis was used to assess the potential of insulin to enhance capillary-like tube formation of human microvascular endothelial cells (hMVEC) into a three dimensional fibrin matrix. In addition, insulin receptor expression within atherosclerotic plaques was visualized in carotid endarterectomy specimens of 20 patients with carotid artery stenosis, using immunohistochemical techniques. Furthermore, microvessel density within atherosclerotic plaques was compared between 68 DM2 patients who received insulin therapy and 97 DM2 patients who had been treated with oral glucose lowering agents only. RESULTS: Insulin, at a concentration of 10(-8)M, increased capillary-like tube formation of hMVEC 1.7-fold (p<0.01). Within human atherosclerotic plaques, we observed a specific distribution pattern for the insulin receptor: insulin receptor expression was consistently higher on the endothelial lining of small nascent microvessels compared to more mature microvessels. There was a trend towards an increased microvessel density by 20% in atherosclerotic plaques derived from patients using insulin compared to plaques derived from patients using oral glucose lowering agents only (p=0.05). CONCLUSION: Exogenous insulin use in DM2 patients may contribute to increased plaque vulnerability by stimulating local angiogenesis within atherosclerotic plaques.

New predictors of adverse cardiovascular events following vascular surgery.

With the aging population and the increasing number of patients suffering from diabetes, the incidence of clinical manifestations of atherosclerotic disease is rising. Risk factors for development of atherosclerosis have been described and it is a challenge to develop risk scores that can be applied for individual patients. Specific predictors for progression of atherosclerosis and secondary manifestations of the disease are lacking. The search for new serological and genetic markers predictive for cardiovascular events is an emerging research field. Local plaque instability can give rise to thromboembolic cardiovascular events, which suggests that certain information might be enclosed in local atherosclerotic tissue. Because of the systemic character of atherosclerosis, it can be hypothesized that local plaque characteristics encompass information of other atherosclerotic lesions throughout the vascular tree. Biobank studies with a longitudinal design have been initiated to investigate the link between characteristics of local atherosclerotic tissue and outcome during follow up. These studies might reveal new insights in predictors for cardiovascular outcome for vascular patients at an individual level.