Aortic Endarterectomy for Aortic Occlusive Disease: An Old Operation With a Re-emerging Role.

INTRODUCTION: Descending aortic complex atheromatous plaques can cause claudication, critical lower limb ischaemia (CLI), and are an independent risk factor for systemic embolization. Current practice involves dealing with most cases using endovascular techniques. However, open repair remains superior in terms of the patency rates and may be the only valid option in a subgroup of patients who are unsuitable for endovascular treatments. Most of the current data investigating open procedures are now historic. The aim of this study is to determine whether it is a feasible option in the current day practice. PATIENTS AND METHODS: Ten years data from 2010 to 2020 were collected retrospectively from the hospital records. Clinic letters, radiologic scans, operative records and discharge letters were reviewed. Death records were reviewed to identify patients who survived. RESULTS: Ten cases were identified. The average age was 55 and the mean BMI was 29.4. The mean hospital stay in days was 12 (range: 4 to 22). The mean follow-up period was 147 days (range: 30 to 360 days). Four of the patients were TASC B, four were TASC C and two were TASC D. Two cases had to return to theatres. One patient had transient post-op AF and another had transient post-op ileus. One patient was readmitted within 30 days of discharge for urosepsis. All cases are alive to date except one case which only survived three years after procedure. CONCLUSION: AE is a procedure that should be considered in selected cases where endovascular approach is not feasible. There is a trend towards lower mortality than the historic data available in literature. Larger case series or registry data may be required to accurately estimate the current day mortality and morbidity figures.

Early and Late Outcomes of Surgery for Neurogenic Thoracic Outlet Syndrome in Adolescents.

BACKGROUND: Neurogenic thoracic outlet syndrome is a condition that is both complex to diagnose and manage successfully. The aim of our study was to present our experience and outcomes of surgical management of thoracic outlet syndrome in adolescents. METHODS: We performed a retrospective analysis of a prospectively held database of consecutive adolescents (age 10-19 years) who underwent surgery for neurogenic thoracic outlet syndrome between 2005 and 2017 at our university hospital. RESULTS: Fourteen patients were identified (19 operations), with a mean age of 16.5 years (SD: 1.9). All patients had symptomatic relief with surgery with low complication rates (1 pneumothorax). Median hospital stay was 2 days (IQR: 1). There were no early recurrences but 5 late ones which occurred 2, 2.5, 3, 4 and 10 years after surgery (20%). None required a second procedure and were managed successfully with physiotherapy. CONCLUSIONS: Surgical intervention for thoracic outlet syndrome in the adolescent population results in excellent outcomes in the short term. However, we found that recurrence of symptoms in this population is common and patients need to be counseled clearly about this prior to surgical intervention. However in our experience these do not require further surgery.

Impact of Frailty on Outcomes in Patients Undergoing Open Abdominal Aortic Aneurysm Repair.

BACKGROUND: Frailty is a global state that does not relate directly to comorbidities and is prevalent among patients with vascular disease. The Clinical Frailty Scale (CFS) is a rapid assessment tool to identify vulnerable and frail patients. In this study, we sought to evaluate whether the preoperative CFS score could be used to independently predict mortality and morbidity after elective open abdominal aortic aneurysm (AAA) repair. METHODS: We retrospectively reviewed our institutional National Vascular Registry (NVR) data to identify all patients who underwent an elective open juxta or infrarenal AAA repair between January 2014 and December 2018. The NVR data set included preoperative risk factors, imaging findings, intraprocedural variables, and postprocedural outcomes. RESULTS: A total of 184 patients were assessed using the CFS before they underwent elective open AAA repair. Among 26 (14%) individuals categorized as vulnerable using the CFS, there was no significant difference in age or preoperative cardiac and respiratory testing compared with nonfrail patients. However, vulnerable patients were significantly more likely to have a longer length of stay (12.2 days vs. 8.8 days, P-value 0.044), suffer from respiratory complications (35% vs. 15%, P-value 0.022) and renal failure (23% vs. 6%, P-value 0.013), or die (23% vs. 2%, P-value 0.0003). The regression analysis identified a vulnerable frailty score to be the only significant predictor of mortality (odds ratio = 36.7, P < 0.001), all other factors were not shown to be independent predictors. CONCLUSIONS: The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective open AAA repair and can be used to predict mortality and morbidity after surgery.

The Transposed Femoral Vein Fistula: The Native Choice in Desperate Vascular Access.

BACKGROUND: This is a review of our experience in creating transposed femoral vein (TFV) fistulas and some of the lessons we have learnt while performing this challenging procedure over the last 5 years. METHODS: This is retrospective review of patients who underwent TFV fistula formation between January 2013 and December 2017. RESULTS: Fifteen patients underwent FV fistula formation with 4 cases being excluded from analysis. Median follow-up was 1.17 years (interquartile range 0.19-3.59 years). Primary and primary-assisted patency rates were 75% and 100% at 6 months, respectively, and 66.7% and 100% at 1 year. CONCLUSIONS: Our patient group showed good fistula patency at 1 year and did not experience any incidence of ischemic steal syndrome. We believe this to be due to careful preoperative patient assessment and meticulous surgical technique. Our experience suggests that such procedures should be performed by surgeons with vascular expertise wherever possible to reduce the incidence of complications.

Expression of monocyte subsets and angiogenic markers in relation to carotid plaque neovascularization in patients with pre-existing coronary artery disease and carotid stenosis.

AIM: To characterize blood monocyte subsets in patients with different degrees of carotid atherosclerosis and pathological carotid plaque neovascularization. METHODS: Assessment of carotid plaque neovascularization using contrast ultrasonography and flow cytometric quantification of monocyte subsets and their receptors involved in inflammation, angiogenesis, and tissue repair was done in 40 patients with carotid stenosis ≥ 50% and CAD (CS > 50), 40 patients with carotid stenosis < 50% and documented CAD (CS < 50), 40 hypercholesterolaemic controls (HC group), and 40 normocholesterolaemic controls (NC). RESULTS: CS > 50 and CS < 50 groups had increased counts of Mon1 ('classical' CD14++ CD16-CCR2 + cells) compared to HCs (P = 0.03, and P = 0.009). Mon3 ('non-classical' CD14 + CD16++ CCR2- cells) were only increased in CS < 50 compared with HCs (P < 0.01). Both CS>50 and CS < 50 groups showed increased expression of proinflammatory interleukin-6 receptor on Mon1 and Mon2 ('intermediate' CD14++ CD16 + CCR2+ cells); TLR4, proangiogenic Tie2 on all subsets (P < 0.01 for all). In multivariate regression analysis only high Mon1 count was a significant predictor of carotid stenosis (P = 0.04) and intima-media thickness (P = 0.02). In multivariate regression analysis only the Mon1 subset was significantly associated with severe, grade 2 neovascularization (P = 0.034). CONCLUSION: In this pilot study classical monocytes (Mon1) represent the only monocyte subset predictive of the severity of carotid and systemic atherosclerosis, such as carotid intima-media thickness, degree of carotid stenosis, and presence of carotid intraplaque neovascularization.

The role of monocytes in angiogenesis and atherosclerosis.

New vessel formation inside the arterial wall and atherosclerotic plaques plays a critical role in pathogenesis of heart attacks and strokes. The 2 known mechanisms resulting in the formation of new vessels within the plaque are local ischemia and inflammation. Blood monocytes play an important role in both processes. First, they express receptors for vascular endothelial growth factor and some of them may serve as circulating ancestors of endothelial cells. Second, monocytes are associated with inflammation by synthesis of inflammatory molecules following their activation (e.g., after stimulation of Toll-like receptors). Neovascularization is a reparative response to ischemia, and includes 3 processes: angiogenesis, arteriogenesis, and vasculogenesis. Angiogenesis, the formation of new capillary vessels is known to occur in response to a hypoxic environment. The interaction between leukocytes and vascular wall via overexpression of various molecules facilitates the migration of inflammatory cells into the plaque microenvironment. Monocytes are intimately involved in tissue damage and repair and an imbalance of these processes may have detrimental consequences for plaque development and stability. Importantly, monocytes are comprised of distinct subsets with different cell surface markers and functional characteristics and this heterogeneity may be relevant to angiogenic processes in atherosclerosis. The aim of this review article is to present an overview of the available evidence supporting a role for monocytes in angiogenesis and atherosclerosis.

The effect of statin therapy withdrawal on monocyte subsets.

BACKGROUND: Three functionally distinct monocyte subsets have been identified. Statins are of undoubted effect in atherosclerosis and have numerous pleiotropic effects that contribute to their clinical success, but the effect of these drugs on monocyte subsets is unclear. We hypothesised a beneficial effect of statins on key receptor expression by monocyte subsets. MATERIAL AND METHODS: Effects of temporal (2 weeks) cessation of statin therapy by 66 patients with stable coronary artery disease on monocyte subsets [CD14++CD16-CCR2+ (Mon1), CD14++CD16+CCR2+ (Mon2) and CD14+CD16++CCR2- (Mon3)], their aggregates with platelets and their expression of a number of receptors involved in inflammation (IL-6 receptor), adhesion [vascular cell adhesion molecule (VCAM)], angiogenesis [vascular endothelial growth factor (VEGF)] and repair were assessed by flow cytometry. RESULTS: Statin cessation did not lead to any significant changes in absolute numbers of monocyte subsets or the degree of their aggregation with platelets. All monocyte subsets showed significant downregulation of expression of vascular endothelial factor receptor 2, Tie2 and Toll-like receptor-4 (TLR4; all changes P < 0·01). Expression of CXCR4 was only reduced in Mon1 cells (P = 0·013). There was no significant change in the expression of CD14, CD16, CCR4, IL6 receptor and VCAM (all P = NS). CONCLUSIONS: Statin withdrawal does not affect counts of any of monocyte subsets, but leads to downregulation of expression of TLR4 and receptors related to angiogenesis on all subsets, as well as a decrease in density of CXCR4 expression on 'classical' Mon1. These data provide further support of pleiotropic effects of statins and their effects on monocyte pro-angiogenic and proreparative characteristics.

Evaluation of carotid plaque neovascularization using contrast ultrasound.

Contrast-enhanced ultrasound (CEUS) is increasingly used to improve visualization of carotid arteries. However, its reproducibility and utility for clinical research are not well established. The aim of the present study was to assess reproducibility of detection of carotid artery wall neovascularization using CEUS. Complete sequenced CEUS images from 10 individuals were analyzed for the presence of carotid arterial wall neovascularization. The images were acquired using Philips CompactXtreme CX50 ultrasound unit with an L12-3 probe and Bracco SonoVue contrast agent. The carotid wall neovascularization was graded by 2 independent observers with inter-/intraobserver agreement (κ) calculated. Interobserver κ values for intraplaque neovascularization (mean [95% confidence interval]) were 0.67 (0.40-0.94) for the left side. Interobserver κ values for intraplaque neovascularization were 0.65 (0.38-0.92). No study-related complications were observed. The CEUS method although semiquantitative shows moderate-to-strong intra- and interagreement for the results and can be used for clinical research purpose.

The effects of exercise and diurnal variation on monocyte subsets and monocyte-platelet aggregates.

BACKGROUND: Monocytes are important mediators in the pathophysiology of cardiovascular disease, but only scarce data are available on biological and methodological factors affecting their levels. DESIGN: Three monocyte subsets, CD14(++) CD16(-) CCR2+ (Mon1), CD14(++) CD16(+) CCR2(+) (Mon2), CD14(+) CD16(+) CCR2(-) (Mon3), and monocyte-platelet aggregates (MPAs) were analysed by flow cytometry. The effects of treadmill exercise were assessed on 12 healthy volunteers. Diurnal variation was evaluated in 16 healthy volunteers, and the effects of delayed blood processing were measured in 12 samples. RESULTS: Mon1 were increased when measured 15 min after exercise followed by a reduction at 1 h (P < 0·05 for both). MPAs were significantly reduced at 15 min and 1 h (P < 0·05 for both). There was significant diurnal variation in the numbers of Mon2, which were highest at 6 pm and lowest at 6 am. There were also significant diurnal variations in phagocytic activity of Mon1 and Mon2, which were highest at 12 pm and lowest at 12 am. Monocyte counts remained stable up to 2 h after venipuncture. MPAs were significantly increased at 2 h and increased further by 4 h after sampling. CONCLUSIONS: Monocyte subset Mon2 and monocyte phagocytic activity undergo significant diurnal variation. A single bout of exercise causes a temporal increase in monocytes and a reduction in MPAs. Monocyte subset counts should be analysed within 2 h of blood sampling, whereas measurement of MPAs and monocyte CD14 and CD16 expression should be performed within 1 h.

Three stage axillary lymphatic massage optimizes sentinel lymph node localisation using blue dye.

AIMS: This paper describes a simple technique of axillary and breast massage which improves the successful identification of blue sentinel nodes using patent blue dye alone. METHODS: Patent blue dye was injected in the subdermal part of the retroaroelar area in 167 patients having surgical treatment for invasive breast cancer. Three stage axillary lymphatic massage was performed prior to making the axillary incision for sentinel lymph node biopsy. All patients had completion axillary sampling or clearance. RESULTS: A blue lymphatic duct leading to lymph nodes of the first drainage was identified in 163 (97%) of the patients. Results are compared with 168 patients who had sentinel lymph node biopsy using blue dye without axillary massage. Allergic reactions were observed in four patients (1.2%). CONCLUSION: Three stage axillary lymphatic massage improves the successful identification of a blue sentinel lymph node in breast cancer patients.