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.

Soluble Fas and Fas-ligand levels in mid-trimester amniotic fluid and their associations with severe small for gestational age fetuses: a prospective observational study.

We aimed to determine the second-trimester amniotic fluid (AF) levels of soluble Fas (sFas) and Fas-ligand (FasL) and investigate their association with fetal growth. Therefore, sFas and FasL levels were measured by enzyme immunoassay in the AF of 21 small for gestational age (SGA), 13 large for gestational age (LGA), and 44 appropriate for gestational age (AGA) fetuses of pregnant women who underwent amniocentesis at between 15 and 22 weeks gestation. Our study results showed that sFas and FasL levels were detectable in AF. sFAS median (25th-75th centile) levels were 3.8 (2.8-4.6) ng/ml in SGA, 3.6 (3.1-4.5) ng/ml in AGA, and 4.0 (3.1-4.4) ng/ml in LGA. FasL median (25th-75th centile) levels were 26.0 (20.3-32.7) pg/ml in SGA, 22.7 (18.4-28.5) pg/ml in AGA, and 21.5 (15.8-30.9) pg/ml in LGA. The differences were not statistically significant. Nevertheless, statistically significant differentiation of FasL levels existed when SGA fetuses in the extremes of distribution (≤5th, ≤2.5th centile) were considered. This is the first study presenting sFas and FasL concentrations in early second-trimester amniotic fluid in AGA, SGA, and LGA fetuses. We found indications that severe and very severe SGA fetuses (≤5th and ≤2.5th centile) have high levels of FasL in the amniotic fluid. This finding probably reflects the increased rate of apoptosis that is assumed to exist in cases of extreme growth restriction.

Extracranial internal carotid artery stenting in Moya-Moya syndrome: a case report.

A 58-year-old Caucasian lady presented for severe left internal carotid artery (ICA) stenosis. Two months before she was operated for right carotid endarterectomy (CEA) in another Institution, complicated with internal carotid artery thrombosis and development of transient hemiplegia and aphasia. Postoperative selective DSA showed the development of an abnormal basal meshwork of collateral vessels with typical evidence for moyamoya disease. Preoperative workup in our Institution included cerebral MRI witch showed two ischemic right frontal and parietal lesions. The patient underwent successful stenting of the left ICA. This is the first report of extracranial ICA stenting in a patient with moyamoya syndrome.

Current knowledge on EVAR with the ultra-low profile Ovation Abdominal Stent-graft System.

Endovascular aneurysm repair (EVAR) has revolutionized the treatment of infrarenal abdominal aortic aneurysms (AAAs). The continuous collaboration of surgeons and bioengineers in the improvement of the devices the last two decades, lead to a continuous redesigning and improvement of the various endografts. In the last few years, the majority of companies have developed renewed models of grafts and have modified delivery systems tending to lower profile in order to deal with difficult anatomies. The ultra low profile 14F OD Ovation (Trivascular) Abdominal Stent-graft System with innovative sealing technology achieved through inflatable sealing rings, allows treatment of AAAs with small in diameter access vessels that might be unsuitable for EVAR with other currently available stent-grafts. The aim of the present paper was to analyze the technical characteristics and properties of this endograft and to review the current literature.

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.

Immediate conversion to CAS after neurological intolerance at cross-clamping test during CEA: a preliminary experience.

AIM: The aim of this preliminary study is to evaluate the feasibility and efficacy of CAS as treatment option to endarterectomy when carotid shunt cannot be used safely. METHODS: The medical records concerning 469 carotid stenosis treated between January 2006 and December 2009 were retrospectively reviewed, focusing on cross-clamp intolerance during CEA. Patients with cross-clamping intolerance were divided in two groups. Group 1: those that concluded the open procedure with the use of a shunt, and Group 2: those who experience immediate brain intolerance and coma and were immediately converted to an endovascular procedure. Mortality and neurological adverse event rate were compared between shunted CEA and cross-clamping intolerant cases converted into CAS. The secondary end-point was long-term survival. RESULTS: Carotid cross-clamp intolerance occurred in 30 cases (8.7%). CEA with Pruitt-Inahara's shunt was performed in 17 cases with a perioperative neurological adverse event rate of 23.5%. In 13 cases limitations to shunting due to quick onset of coma and/or an unfavorable anatomy were encountered. In these 13 cases the open intervention was immediately converted into endovascular procedure. Technical success was achieved in all the converted to CAS cases (100%), with a perioperative neurological adverse event rate of 7.7% (P=0.35 between the two groups). No significant difference emerges comparing patient's survival between the cases CONCLUSION: Nevertheless, the small dimension of this survey, immediate conversion to CAS resulted feasible with a lower risk of neurological adverse events if compared to CEA with shunt, and could be considered as an alternative to CEA when carotid shunt cannot be used safely.

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.

Vascular tumors: rare neoplasms of the female genital tract.

BACKGROUND: Vascular tumors of the genital tract are rare entities. METHOD-RESULTS: We conducted a retrospective study of such tumors during the period January 1993 up to December 2007. During this period we identified thirteen patients with vascular tumors of the female genital tract. Their age ranged from 28 up to 76 years. More specifically, we identified one patient with angiomyxoma, five patients with angiokeratoma, one patient with vascular malformation, two with cervical hemangioma, two with hemangioma of the uterus and two with ovarian hemangioma. CONCLUSION: Our 15-year-old experience on the field is presented through description and images of such tumors.

The role of trans fatty acids in atherosclerosis, cardiovascular disease and infant development.

The process of partial hydrogenation converts vegetable oils in semisolid fats, like margarines, that contain high concentrations of trans fatty acids (TFA) and are commonly used in bakery, as well as for deep frying in fast food chains and other restaurants. Initially, these fats were considered the healthy solution, because they substituted butter and other cholesterol fats. However, in the last decades there has been continuing accumulation of evidence that TFA have potential harmful action in blood lipid metabolism, atherosclerosis development and cardiovascular disease, as well as in infant development. Consequently, many countries have enacted in order to reduce total TFA percentage in the daily fat intake, while others are waiting strongest evidence to enact. This article reviews the evidence of the effects of TFA, in relation to atherosclerosis, cardiovascular disease, inflammation and diabetes, and infant development.

Pathogenesis, diagnosis, and management of disseminated intravascular coagulation: a literature review.

BACKGROUND: Disseminated Intravascular Coagulation (DIC) is an acquired syndrome characterized by systemic intravascular activation of coagulation, leading to deposition of fibrin in the circulation, occurring in the course of severe diseases. OBJECTIVE: To review literature for articles that focus on the pathogenesis, diagnosis, and management of DIC. INFORMATION SOURCES: Selected articles from the Index Medicus data base. STATE OF THE ART: Recent studies have elucidate the pathogenic pathways that can trigger DIC. However, clinical and laboratory diagnosis of the syndrome remains difficult, as there is no single laboratory test, sensitive and specific enough, to allow a definitive diagnosis of DIC. Cornerstone for the treatment of DIC remains the optimal management of the underlying disorder. However, therapeutic interventions based on our present knowledge of the pathogenesis of DIC may be appropriate. CONCLUSION: Recent research on DIC, resulted in the development of diagnostic algorithms for the diagnosis of the syndrome and better supportive therapeutic strategies.

Inflammatory abdominal aortic aneurysms. A 20-year experience.

AIM: The aim of the study was to report a 20-year single Institution experience, with the early and late outcomes of surgical treatment of inflammatory abdominal aortic aneurysms. METHODS: In a 20-year period, 2 275 consecutive patients underwent elective surgical repair for non-rupture abdominal aortic aneurysm. Fifty-two patients (2.3%) were classified as inflammatory abdominal aortic aneurysms. Early and late outcomes were analyzed. RESULTS: One patient died in the perioperative period, giving a mortality rate of 1.92%. One patient died from a pseudoaneurysm rupture 7 months after operation. Three patients developed an aortic pseudoaneurysm in the follow-up period (mean 12.1 years, range 1-20 years) and underwent a redo operation. CONCLUSION: Overall surgical outcome of these patients, in terms of short-term and long-term is good. A high rate of pseudoaneurysm formation was observed.

Endovascular treatment of penetrating aortic ulcers: mid-term results.

OBJECTIVES: The aim of this study was to evaluate mid-term results of endovascular treatment of penetrating aortic ulcers. METHODS: Between February 2000 and November 2006, 18 consecutive patients underwent endovascular treatment of the descending thoracic aorta (N=16) and abdominal infrarenal aorta (N=2) for penetrating aortic ulcer, in a single University Hospital. Data were prospectively collected and retrospectively analyzed. Mean follow-up was 41 months (range 4 to 77 months). RESULTS: Technical success was achieved in all patients. No perioperative deaths occurred. No conversion to open repair or secondary procedures were required. Two patients died in the follow-up period for reasons not related to penetrating aortic ulcers. One type II endoleak was observed. It was still present, unchanged, twelve months after the procedure. CONCLUSION: Endovascular treatment of penetrating aortic ulcers of the descending thoracic and infrarenal aorta were safe and effective in the mid-term in this small series of patients.

Cilostazol in the management of vascular disease.

Cilostazol is a potent type III phosphodiesterase inhibitor with pharmacological effects that include vasodilatation, inhibition of platelet activation and aggregation, inhibition of thrombosis, increased blood flow to the limbs, improvement in serum lipids with lowering of triglycerides and elevation of high density lipoprotein cholesterol, and inhibition of vascular smooth muscle cell growth. It operates through its action as endothelium-target antithrombotic therapy, achieving its effects by improving endothelial cell function and reducing the number of platelets partially activated by interacting with activated endothelial cells. Since receiving approval from the Food and Drug Administration in 1999 in the United States for the treatment on intermittent claudication secondary to peripheral arterial disease, new data on its role on the prevention of restenosis after percutaneous transluminal angioplasty and the secondary prevention of cerebral infarction have increased interest in the drug. The aim of this study is to review cilostazol's beneficial effects and adverse events, and to present the results of the major clinical trials.

Case report of adventitial cystic disease of the popliteal artery presented with the ''dog-leg'' sign.

Adventitial cystic disease of the popliteal artery constitutes an infrequent cause of claudication in non-atherosclerotic young or middle-aged population. Here, we report the case of a 43-year-old female with adventitial cystic disease of the popliteal artery causing left lower leg claudication, detected by duplex scanning. The angio-CT showed the "dog-leg" sign, typical of the aneurysm of the popliteal artery. Surgery was performed through the posterior approach. The cyst and the affected segment of the artery were successfully excised and replaced with an autogenous saphenous vein graft. In 1 year follow-up the graft is patent and the patient is completely asymptomatic.

Duplex scanning on admission prevents unnecessary carotid endarterectomies.

AIM: This retrospective single Institution study, aims to evaluate the performance of duplex scanning on admission of patients with carotid artery disease to avoid unnecessary carotid endarterectomies. METHODS: From 1 January 1997 until 31 Decem-ber 2004, 1 504 patients were admitted to our Institution to undergo carotid endarterectomy. A duplex scan on admission was performed in all of them. RESULTS: A total of 1 369 from these patients (91%) underwent surgery, while 135 (9%) were dismissed because there was no indication for surgical treatment. They were put in conservative treatment and periodic duplex control appointments. CONCLUSIONS: In 9% of the patients, unnecessary carotid endarterectomy was avoided.

Retrograde aorto-mesenteric by-pass grafting as treatment option of recurrent chronic mesenteric ischemia after thrombosed superior mesenteric artery stenting. Report of a case.

We report a case of early stent failure in a patient with chronic mesenteric ischemia and its treatment with a retrograde aorto-mesenteric by-pass. The patient was initially treated with angioplasty and stenting. Seven months after the procedure complete thrombosis of the stent was achieved. A retrograde aorto-mesenteric by-pass was performed. After two years the patient remains asymptomatic and color Duplex scan confirm the patency of the graft.

Mid-term results after endovascular repair of abdominal aortic aneurysms: a four-year experience.

OBJECTIVES: The purpose of this retrospective, single-institution study is to describe a 4-year experience of examining early and late clinical outcomes after endovascular repair of abdominal aortic aneurysm (AAA). MATERIALS AND METHODS: Between October 1998 and January 2003, 455 patients were submitted for AAA treatment, of whom 269 underwent open repair and 186 were treated with an endovascular procedure. All endovascular-treated patients underwent preoperative arteriography, contrast enhanced CT scanning or spiral-CT to define the morphological characteristics of the aneurysm, including precise diameter and length measurements. RESULTS: Technical success was achieved in 182 (98%) of the endovascular procedures, as intraoperative conversions to open repair and/or aborted procedures occurred in four patients. The perioperative (30-day) mortality rate was 1% (two patients). During the follow-up period (9-60 months) CT, duplex ultrasound scanning and plain abdominal X-ray evaluation were performed at 3, 6, 12 months, and annually thereafter. Type I endoleak occurred in 12 patients (6.6%), required a further endovascular procedure (11) or late conversion to open repair (1). Type II endoleak occurred in five patients (3%). CONCLUSIONS: In our clinical experience the endovascular repair of AAA is a safe and effective technique with good mid-term results in patients at standard and high risk.