Choosing the correct treatment for acute aortic type B dissection.

Acute type B aortic dissection is a life threatening disease process, which remains a clinical dilemma despite advances in technology, surgical technique and postoperative management. The variability of presenting symptoms, lack of a consensus on indications for treatment and differing opinions about the optimal timing for repair have added to the management confusion. Medical management has been the standard of care for acute uncomplicated type B dissection. Surgical repair and endovascular intervention are reserved for those who present with, or subsequently develop, dissection-related complications. Complicated dissections occur in 25% of cases and may include organ malperfusion, aortic rupture, periaortic hematoma, and uncontrolled hypertension. In the past decade thoracic endovascular aortic repair (TEVAR) has gained widespread acceptance as the modality of choice for the treatment of complicated type B dissection. This transition is representative of advances in technology, physician experience with aortic endografts and lower morbidity and mortality rates associated with TEVAR. The best medical therapy remains the standard of care for uncomplicated dissection, however this strategy fails to prevent long-term aortic-related morbidity and mortality. Recent data suggest that early TEVAR lowers aortic-related events and improves long-term aortic specific survival by covering the entry tear, promoting false lumen thrombosis and inducing aortic wall remodeling. The paucity of supporting data has created controversy surrounding the optimal treatment strategy for acute type B dissection. Nonetheless, recent healthcare trends show a paradigm shift towards the utilization of early TEVAR in acute type B dissection.

Vascular training profiles across Europe.

BACKGROUND: The European Vascular Surgeons in Training (EVST) were appointed by the European Society for Vascular Surgery to review the current status and developments regarding training and certification in vascular surgery (VS) across Europe. METHODS: An e-mail-based survey was distributed to EVST representatives in 33 countries. The questionnaire examined the current structure of vascular surgery training and certification (monospecialty, subspecialty, no specialty), as well as the evolving revisions of national curricula. Questionnaires were returned from 31 countries, two of which implement two training models. RESULTS: Vascular surgery (VS) as a monospecialty is the leading training model in 18 out of 31 countries, nine countries follow the subspecialty model, and six countries have no accredited vascular programs. The mean duration of dedicated VS training in monospecialty is significantly longer compared with subspecialty (3.8 vs. 2.9 years, p = .036) or no specialty models (3.8 vs. 1 years, p < .001). 83% of countries implementing an independent certification have recently updated their training curriculum; the respective rates for countries implementing a subspecialty or no specialty model are 56% and 17%. Among countries that offer VS certification, the endovascular logbook is mandatory in 78%, quality control of training centers or trainers is implemented in 62%, and training centers are reported as heterogeneous in 46%. The Working Time Directive is followed by vascular trainees in 10/24 EU countries. CONCLUSIONS: The results of this survey represent the most updated detailed record of the European training profiles in VS and document the diversity of vascular training across Europe.

Technical and patient-related characteristics associated with challenging retrieval of inferior vena cava filters.

OBJECTIVE: To identify patient-related and device-specific predictors of challenging and failed inferior vena cava (IVC) filter retrievals. METHODS: Retrospective single center review of consecutive retrievable IVC filters placed between 2004 and 2009. Retrieval was defined as challenging when it was unsuccessful owing to reported technical failure or when adjunctive endovascular maneuvers or access sites were recruited. Data regarding patient- and filter-specific information were collected. Logistic regression models were used to identify predictors of the reported outcomes. Statistical significance was set at p < .05. RESULTS: Four hundred and one patients underwent retrievable IVC filter placement-the majority indicated for prophylaxis (67%). Two hundred and fifty-nine retrievals were attempted and 237 filters were successfully retrieved (overall retrieval rate: 59.1%). Eleven out of 259 (4.2%) attempts were aborted owing to significant thrombus within the filter and 11 (4.2%) were technically unsuccessful. In 142 patients no attempt for filter retrieval was made-the major reason being physician oversight (44.3%). Thirty-eight out of 248 (15.3%) non-aborted filter retrievals were recorded as challenging. Failed retrievals were predicted by prolonged dwell time (96.9 ± 111.9 vs. 29.5 ± 25.1 days, odds ratio [OR] 1.034, 95% confidence interval [CI] 1.016-1.053, p < .001), therapeutic indication (OR 5.197, 95% CI 1.200-22.511, p = .028), and filter wall apposition (OR 11.857, 95% CI 2.069-67.968, p = .006). Challenging retrievals were predicted by dwell time (51.1 ± 69.8 vs. 29.1 ± 24.5 days, OR 1.017, 95% CI 1.005-1.029, p = .007), filter tilt (OR 2.607, 95% CI 1.045-6.508, p = .040) and filter wall apposition (OR 6.149, 95% CI 2.398-15.763, p = <.001). CONCLUSIONS: Physician oversight leads to poor IVC filter retrieval rates. Retrievals can be challenging or fail when the dwell time is >50 days and >90 days, respectively, and when the filter hook apposes the caval wall. Filter tilt increases retrieval difficulty but not failure rates.

The chimney graft technique for preserving renal arteries in stent-graft sealing zones.

Patients with juxtarenal aneurysms require complex surgical open repair, which is associated with increased mortality and morbidity. An alternative procedure that can be used is the "chimney graft" technique. Three cases of abdominal aortic aneurysms were successfully treated in our department with this technique. One type-Ia endoleak occurred which was successfully treated with coiling and biological glue infusion. All of the chimney grafts have remained patent for the period of observation. The "chimney" technique has good results as a bail out procedure in complex EVAR or in well planned difficult cases. Long-term data is necessary to determine the efficacy of this technique.

The European Society for Vascular Surgery guidelines for carotid intervention: an updated independent assessment and literature review.

BACKGROUND AND PURPOSE: Many medical societies now recommend carotid stenting as an alternative to endarterectomy which raises the question of whether the ESVS guidelines are still valid. This review addresses the validity of the ESVS guidelines that refer to carotid stenting based on the evidence available today. METHODS: We conducted a review and meta-analysis based on the original ESVS guidelines paper and articles published over the past 2 years. RESULTS: For symptomatic patients, surgery remains the best option, since stenting is associated with a 61% relative risk increase of periprocedural stroke or death compared to endarterectomy. However, centres of excellence in carotid stenting may achieve comparable results. In asymptomatic patients, there is still no good evidence for any intervention because the stroke risk from an asymptomatic stenosis is very low, especially with the best modern medical treatment. CREST and CAVATAS have verified that mid-term stroke prevention after successful stenting is similar to endarterectomy. EVA-3S, SPACE, ICSS and CREST have provided additional evidence regarding the role of age in choosing therapeutic modality. The role of the cerebral protection devices is challenged by the imaging findings of small randomised trials but supported by large systematic reviews. CONCLUSIONS: The ESVS guidelines that refer to carotid stenting not only remain valid but also have been further strengthened by the latest available clinical data. An update of these guidelines including all of the recent evidence is needed to provide an objective and up-to-date interpretation of the data.

Association between plaque echogenicity and embolic material captured in filter during protected carotid angioplasty and stenting.

OBJECTIVES/DESIGN: The aim of the study was to investigate debris captured in filter embolic protection devices (EPDs) during carotid artery stenting (CAS) and its possible correlation with plaque echogenicity and other risk factors. MATERIALS/METHODS: Between June 2010 and March 2011, 51 consecutive CAS patients (11 females, mean age 71.2 ± 7, 10 symptomatic) who underwent 53 procedures were included in this prospective study. Ultrasonographic Gray-Weale plaque type (I-V, echolucent to echogenic) characterisation was obtained in all cases. The same type of stent and filter EPD was used. Filters were collected and, after macroscopic evaluation, they were examined using the Thin-Prep(®) liquid-based cytology (LBC) technique. RESULTS: Technical success was 100%. Thirty-day stroke and death rates were 1.8% (1/53) and 0%, respectively. Visible debris was detected in eight (15%) filters, whereas LBC revealed the presence of embolic material particles in 30 filters (56.6%). The presence of embolic material into the filter EPD was 2.38-fold increased for every category change from type IV to type I carotid plaques (OR = 2.38, 95%CI = 1.15-4.93). This association remained robust even after adjustment for age, gender and known atherosclerotic disease risk factors (OR = 2.26, 95%CI = 1.02-5.02). In multivariate analysis for risk factors, hypertension was associated with increased presence of embolic material detection in filter EPD (OR = 20.4, 95%CI = 1.28-326.1). The time distance from symptom to CAS was inversely correlated with debris quantity in EPD (Spearman rho -0.716; p = 0.02). CONCLUSIONS: Echolucent plaques, smaller time frame from last symptom and hypertension were associated with increased presence of embolic material.

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.

Vascular surgery training and its relationship to other surgical specialties.

During the last 50 years vascular surgery has met an enormous evolution, paving the way for the development of modern vascular and endovascular surgery. Although, vascular surgery (VS) has emerged from general (GS) and cardiothoracic surgery (CTS), the need for specialized training has been recognized and gradually practice patterns are shifting towards vascular independence, but yet not in all countries. In these countries VS training is either permitted only after prerequisite GS certification, or as a non accredited surgical specialty, VS might be included in GS or CTS training and certification. Such a policy raises two main issues: the efficiency of vascular training within the GS or CTS curricula and the performance of vascular interventions by general or cardiothoracic surgeons. Meanwhile, the explosion of endovascular procedures has brought new disciplines into play, each one wanting to maintain its stake in the future. Interventional radiologists and a significant number of cardiologists become increasingly involved in the treatment of vascular diseases. The question of which specialist among those qualified should carry out medical treatment, open, and endovascular procedures is still suspended. Under this prism, vascular training issues arise as an important component of the future of vascular surgeons.

Heparin-induced thrombocytopenia: what a vascular surgeon needs to know.

The use of unfranctioned heparin and low molecular weigh heparins is very common in general medical practice and moreover in angiology and vascular surgery. Heparin-induced thrombocytopenia is a rare, yet catastrophic complication, with an incidence of 1-5% of patients receiving heparin therapy. Clinical presentation may include deep vein thrombosis, pulmonary embolism, arterial thrombosis, and skin lesions. Hemorrhage may also be present as a result of thrombocytopenia. Current diagnostic criteria include clinical scoring systems as well as laboratory tests for the identification of the specific antibodies. Efficient new alternative anticoagulant agents have been developed and are currently indicated for the treatment of such patients. The syndrome curies up to 53% thrombosis risk in untreated patients, and 28% mortality risk in patients complicated with thrombosis. This article aims in a comprehensive review of the literature for newly emerged data in the pathogenesis, diagnosis and management of heparin-induced thrombocytopenia.

Abdominal scar endometriosis after caesarean section: report of five cases.

Scar endometriosis is an under-appreciated or misdiagnosed phenomenon in general surgery and may eventually be more common than reflected in the literature. We herein report five cases of scar endometriosis that were treated in our surgical department one to five years after Caesarean section. Scar endometriosis should be considered when the symptoms are present in a cyclic manner mostly after gynaecological operations and worsening during menstruation. Diagnosis is mainly based upon a high index ofsuspicion. The treatment of choice is surgical resection.

Current knowledge on E-vita abdominal endograft.

The field of endovascular abdominal aortic repair has changed remarkably compared to what it was prior to 1993, the year of the first commercial endograft deployment in the United States. Over the years of endovascular aneurysm repair experience, various companies have attempted to construct an ideal stent-graft for exclusion of an abdominal aortic aneurysm (AAA). However, it has become evident that not all abdominal aortic anatomies are amenable to endovascular treatment and that the rationale "one device fits all AAAs" can lead to disastrous results. Different endografts have dissimilar properties and characteristics. Type of graft material, configuration and type of stent structural support, modularity, type of transrenal fixation, are potentially influential factors of endograft behavior. The self-expanding E-vita abdominal stent-graft (JOTEC, Hechingen, Germany) is a relatively new infrarenal, modular stent-graft with suprarenal fixation designed for AAA reconstruction. The present paper analyzes the technical characteristics and properties of this device. We also analyze our experience with the endoprosthesis and review the current literature.

An update of the role of endovascular repair in blunt carotid artery trauma.

Blunt carotid injury (BCAI) is an increasingly recognised entity in trauma patients. Without a prompt diagnosis and a proper treatment, they can result in devastating consequences with cerebral ischaemia rate of 40-80% and mortality rate of 25-60%. Several applied screening protocols and continuously improving diagnostic modalities have been developed to identify patients with BCAI. The appropriate treatment of BCAI still remains controversial and strictly individualised. Besides anti-thrombotic/anticoagulation therapy and surgical intervention, continuously evolving endovascular techniques emerge as an additional treatment option for patients with BCAI. We provide an update on blunt carotid trauma, emphasising the role of endovascular approaches.

Beneficial changes of serum calcification markers and contralateral carotid plaques echogenicity after combined carotid artery stenting plus intensive lipid-lowering therapy in patients with bilateral carotid stenosis.

OBJECTIVES/DESIGN: In symptomatic patients treated with ipsilateral carotid artery stenting (CAS) plus intensive lipid lowering, we assessed the changes of osteopontin (OPN), osteoprotegerin (OPG) and the Gray-Scale Median (GSM) score contralateral to symptomatic carotid stenosis. MATERIALS/METHODS: Forty-six symptomatic patients (group A) with significant carotid stenosis (North American Symptomatic Carotid Endarterectomy Trial (NASCET): >70%) underwent ipsilateral CAS. Those patients had simultaneously contralateral low-grade carotid stenosis (NASCET: 30-69%). Group B included 67 symptomatic patients with low-grade bilateral carotid stenosis (NASCET: 30-69%), but without indications for revascularisation. All patients were treated with atorvastatin (10-80mg) to target low-density lipoprotein (LDL)<100mgdl(-1). Blood samples and plaques' GSM score contralateral to brain infarct were assayed at baseline and after 6 months. RESULTS: At baseline, there were no significant differences between groups (p>0.05). Six-month atorvastatin treatment equivalently improved lipid profile in both groups (p<0.05). The parameters hsCRP, OPN and OPG were significantly down-regulated within both groups, but to a greater extent in group A (p<0.05). Besides this, contralateral GSM score was significantly improved from baseline in both groups (p<0.01), but that increment was more pronounced in group A (vs. group B; p=0.041). These changes were inversely correlated with changes in OPN (p=0.014), OPG (p=0.011) and LDL (p=0.041). CONCLUSION: Ipsilateral CAS plus intensive lipid-lowering therapy was associated with enhanced contralateral carotid plaque stability and attenuated inflammatory burden and calcification inhibitors to a greater extent than atorvastatin therapy alone in patients with bilateral carotid stenosis.

Analysis of the evidence behind the ESVS guidelines for the invasive treatment of carotid stenosis.

The European Society for Vascular Surgery has recently published updated guidelines for the invasive treatment of carotid disease. The recommendations were rated according to the level of evidence (A: randomized controlled trials, B: well-conducted clinical studies, C: expert opinion). The following document summarizes the evidence on which these recommendations were based, in order to keep physicians from various disciplines updated on the advances in the field of the invasive management of carotid disease.

Urgent CAS for patients in high neurologic risk.

Patients with residual carotid stenosis discovered following an acute ischemic insult represent a new subset of patients eligible for early carotid intervention that may decrease the risk of recurrent stroke by new emboli and improve cerebral blood flow. Short-term clinical outcomes of patients undergoing urgent CAS appear favorable, indicating that endovascular management may be a reasonable treatment option, particularly when combined with endovascular interventions for intracranial lesions. Data on indication and complication profiles are still limited. This review focuses on current knowledge, advantages and pitfalls of urgent and/or early (up to 2 weeks) carotid stenting in those presenting with an acute neurologic event or recently symptomatic carotid stenosis.

Does Helicobacter pylori identification in the mucosa of the gallbladder correlate with cholesterol gallstone formation? / ¿Existe una correlación de la identificación de Helicobacter pylori en la mucosa de la vesícula biliar con la formación de cálculos biliares de colesterol?

OBJECTIVE: Helicobacter pylori (H pylori) represents a potential initiator of cholesterol crystallization and it has been proposed that it is related to gallstone formation. In this study, any possible association between the H pylori identification in the mucosa of gallbladder and cholesterol gallstone formation was evaluated. METHODS: Gallbladders containing pure or mixed cholesterol gallstones (cholelithiasis group, n = 89) and gallbladders without gallstones (control group, n = 42) were submitted to standard histopathological examination for H pylori detection, as well as to nested polymerase chain reaction amplification for H pylori DNA detection. RESULTS: Helicobacter pylori was identified in the gallbladder's epithelium in four patients with cholelithiasis and in two patients in the control group by histology. In all the cases which were found to be H pylori positive by histological examination, H pylori DNA were also detected. No correlation between gallstone formation and H pylori detection in the biliary epithelium was found. A higher incidence of acute inflammation in the cholelithiasis (22.5% vs 9.5%, p = not significant [ns]) and in the H pylori positive groups (33% vs 17.6%, p = ns) were histologically detected. A higher incidence (10% vs 0%), p = ns) of H pylori in gallbladders with gallstones and acute inflammation, compared to gallbladders with acute inflammation but without gallstones, was noticed. CONCLUSION: Helicobacter pylori is detectable in low frequency in the mucosa of the gallbladder and it does not seem to act as a lithogenic component for cholesterol gallstone formation. Its higher incidence in gallbladders with gallstones and acute inflammation, suggests a possible accessory role in a subset of patients with cholelithiasis.

OBJETIVO: Helicobacter pylori (H pylori) representa un iniciador potencial de la cristalización del colesterol, y se ha propuesto que guarda relación con la formación del cálculo biliar. En este estudio, se evaluó cualquier posible asociación entre la identificación de H pylori en la mucosa de la vesícula y la formación del cálculo biliar de colesterol. MÉTODOS: Las vesículas que contienen cálculos biliares de colesterol puros o mixtos (grupo de colelitiasis, n = 89) y vesículas sin cálculos biliares (grupo control, n = 42) fueron sometidos a un examen histopatológico estándar con el fin de detectar el H pylori descubrimiento, así como a la amplificación de la reacción en cadena de polimerasa para la detección de ADN H pilori. RESULTOS: El Helicobacter pylori fue identificado mediante histología en el epitelio de la vesícula en cuatro pacientes con el colelitiasis y en dos pacientes en el grupo de control. En todos los casos que resultaron ser H pylori positivo por el examen histológico, se halló también DNA H pylori. No se halló correlación ninguna entre la formación del cálculo biliar y la detección de H pylori en el epitelio biliar. Se detectó histológicamente una incidencia más alta de inflamación aguda en la colelitiasis (22.5% contra 9.5%, p = no significativo [ns]) y en los grupos H pylori positivos (33% contra 17.6%, p = ns). Se observó una incidencia más alta (10% contra 0%), p = ns) de H pylori en las vesículas con los cálculos biliares e inflamación aguda, en comparación con las vesículas con la inflamación aguda pero sin cálculos biliares. CONCLUSIÓN: Helicobacter pylori es detectable en baja frecuencia en la mucosa de la vesícula y no parece actuar como un componente litogénico en la formación del cálculo biliar de colesterol. Su mayor incidencia en las vesículas con cálculo biliar e inflamación aguda, hace pensar en un posible papel auxiliar en un subconjunto de pacientes con colelitiasis.

Vascular training and endovascular practice in Europe.

OBJECTIVE: To evaluate the influence of the status of vascular surgery (VS) training paradigms on the actual practice of endovascular therapy among the European countries. METHODS: An email-based survey concerning vascular surgery training models and endovascular practices of different clinical specialties was distributed to a VS educator within 14 European countries. European Vascular and Endovascular Monitor (EVEM) data also were processed to correlate endovascular practice with training models. RESULTS: Fourteen questionnaires were gathered. Vascular training in Europe appears in 3 models: 1. Mono-specialty (independence): 7 countries, 2. Subspecialty: 5 countries, 3. An existing specialty within general surgery: 2 countries. Independent compared to non-independent certification shortens overall training length (5.9 vs 7.9 years, p=0.006), while increasing overall training devoted specifically to VS (3.9 vs 2.7 years, p=0.008). Among countries with independent certification an average of 76% of aortic and 50% of peripheral endovascular procedures are performed by vascular surgeons, while the corresponding values, for countries with a non-independent certification, are 69% and 36% respectively. Countries with independent vascular certification, despite their lower average endovascular index (procedures per 100,000 population), reported a higher growth rate of aortic endovascular procedures (VS independent 132% vs VS non-independent 87%), within a four-year period (2003-2007). Peripheral endovascular procedures, though, have similar growth rates in both country groups (VS independent 62% vs VS non-independent 60%). CONCLUSIONS: In European countries with VS as an independent specialty, vascular surgeons have a shorter total training period but spend more time in VS training, although they may not undertake a greater proportion of the endovascular procedures their countries appear to have adopted endovascular technologies more rapidly compared to the ones with non-independent VS curricula. Whether such differences influence patient outcomes requires investigation in future studies.

Does Helicobacter pylori identification in the mucosa of the gallbladder correlate with cholesterol gallstone formation?

OBJECTIVE: Helicobacter pylori (H pylori) represents a potential initiator of cholesterol crystallization and it has been proposed that it is related to gallstone formation. In this study, any possible association between the H pylori identification in the mucosa of gallbladder and cholesterol gallstone formation was evaluated METHODS: Gallbladders containing pure or mixed cholesterol gallstones (cholelithiasis group, n = 89) and gallbladders without gallstones (control group, n = 42) were submitted to standard histopathological examination for H pylori detection, as well as to nested polymerase chain reaction amplification for H pylori DNA detection. RESULTS: Helicobacter pylori was identified in the gallbladder's epithelium in four patients with cholelithiasis and in two patients in the control group by histology. In all the cases which were found to be H pylori positive by histological examination, H pylori DNA were also detected. No correlation between gallstone formation and H pylori detection in the biliary epithelium was found. A higher incidence of acute inflammation in the cholelithiasis (22.5% vs 9.5%, p = not significant [ns]) and in the H pylori positive groups (33% vs 17.6%, p = ns) were histologically detected. A higher incidence (10% vs 0%), p = ns) of H pylori in gallbladders with gallstones and acute inflammation, compared to gallbladders with acute inflammation but without gallstones, was noticed CONCLUSION: Helicobacter pylori is detectable in low frequency in the mucosa of the gallbladder and it does not seem to act as a lithogenic component for cholesterol gallstone formation. Its higher incidence in gallbladders with gallstones and acute inflammation, suggests a possible accessory role in a subset of patients with cholelithiasis.