Endovascular Management of Atherosclerotic Renal Artery Stenosis: Post-Cardiovascular Outcomes in Renal Atherosclerotic Lesions Era Winner or False Alarm?

Renal artery stenosis (RAS) is frequently associated with severe comorbidities such as reduced renal perfusion, hypertension, and end-stage renal failure. In approximately 90% of patients, renal artery atherosclerosis is the main cause for RAS, and it is associated with an increased risk for fatal and non-fatal cardiovascular and renal complications. Endovascular management of atherosclerotic RAS (ARAS) has been recently evaluated by several randomized controlled trials that failed to demonstrate benefit of stenting. Furthermore, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions study did not demonstrate any benefit over the revascularization approach. In this review, we summarized the available data from retrospective, prospective and randomized trials on ARAS to provide clinicians with sufficient data in order to produce useful conclusions for everyday clinical practice.

Preoperative Cardiac Assessment before Carotid Surgery: Should Perhaps Things Change?

Carotid endarterectomy has been associated with perioperative symptomatic or asymptomatic myocardial ischemia and cardiac mortality although it has been classified as a procedure of intermediate cardiac risk. Recent data indicate that the Cardiac Risk Index score for preoperative assessment by the latest guidelines is not suitable for vascular surgery procedures in general and carotid procedures in particular. This review aims to present and analyze all these results, concluding that current recommendations for this specific procedure should perhaps be reevaluated.

Absence of Clinical and Hemodynamic Consequences due to Posterior Tibial Artery Congenital Aplasia.

The exact knowledge of popliteal artery and its branches' anatomic variations is important for the clinical practice of angiology, vascular surgery, and interventional procedures. Congenital absence of the artery leads, in some cases, to early malformations of the extremity in the childhood; however, it may also remain asymptomatic. We present an unusual case of a 76-year-old male patient complaining of paraesthesia in both limbs and bilateral aplasia of posterior tibial artery (PTA). Physical examination, ankle-brachial indexes, before and after exercise, arterial duplex scan, and magnetic resonance arteriography were performed. Arterial pulses for PTA at the level of the ankle were normal; arterial duplex study showed biphasic arterial flow at the level of the ankle. Color duplex ultrasound as well as magnetic resonance arteriography revealed the absence of the PTA in both limbs. The vascularization of the fibula was bilaterally normal. The patient underwent also neurological examination and electromyography, which were normal. The evaluation of the possible clinical signs and symptoms and the hemodynamic consequences of this condition are further discussed.

Duplex Ultrasound versus Computed Tomography for the Postoperative Follow-Up of Endovascular Abdominal Aortic Aneurysm Repair. Where Do We Stand Now?

In the last decade, endovascular aneurysm repair (EVAR) has rapidly developed to be the preferred method for infrarenal abdominal aortic aneurysm repair in patients with suitable anatomy. EVAR offers the advantage of lower perioperative mortality and morbidity but carries the cost of device-related complications such as endoleak, graft migration, graft thrombosis, and structural graft failure. These complications mandate a lifelong surveillance of EVAR patients and their endografts. The purpose of this study is to review and evaluate the safety of color-duplex ultrasound (CDU) as compared with computed tomography (CT), based on the current literature, for post-EVAR surveillance. The post-EVAR follow-up modalities, CDU versus CT, are evaluated questioning three parameters: (1) accuracy of aneurysm size, (2) detection and classification of endoleaks, and (3) detection of stent-graft deformation. Studies comparing CDU with CT scan for investigation of post-EVAR complications have produced mixed results. Further and long-term research is needed to evaluate the efficacy of CDU versus CT, before CDU can be recommended as the primary imaging modality for EVAR surveillance, in place of CT for stable aneurysms.

Evaluation of apoptosis in varicose vein disease complicated by superficial vein thrombosis.

BACKGROUND: The factors contributing to superficial vein thrombosis (SVT) in patients with varicose vein disease are unclear. Differences in vein wall apoptotic activity could be associated with the pathogenesis of SVT. The aim of the study is to address the role of the programmed cell death in the vein wall by comparing varicose veins with history of SVT to uncomplicated varicose veins. PATIENTS AND METHODS: Vein segments from the proximal part of the great saphenous vein (GSV), the distal part of the vein and from a varicose tributary, from 16 patients with varicose vein disease and one episode of SVT, were evaluated for the immunohistochemical expression of pro-apoptotic (Bax, p53, Caspase 3, BCL-6, BCL-xs), anti-apoptotic (BCL-xl and BCL-2) and proliferation (Ki-67) markers. The results of this study were compared to the results from the evaluation of 19 patients suffering from uncomplicated varicose vein disease and 10 healthy GSVs as controls. RESULTS: Overall, there was increased apoptosis in the distal part of GSV compared to the proximal part documented by increased expression of Bax (p < 0.01), Caspase 3 (p = 0.01), BCL-xs (p < 0.01). The comparisons of the markers' expression between patients with varicose veins and patients with a history of SVT showed significant differences among the three different anatomic locations. In the proximal GSV, only BCL-xs was higher in patients with SVT (p = 0.029). In the tributaries, Bax, BCL-xl and Ki-67 were higher in patients with SVT (p < 0.01). In the distal GSV, increased Bax, BCL-xs, BCL-xl and Ki-67 staining was observed in the thrombosis group compared to uncomplicated veins (p < 0.01). CONCLUSIONS: The vein wall in SVT shows increased pro-apoptotic activity compared to uncomplicated disease and normal veins. Whether increased vein wall cell apoptosis is a causative factor for SVT in varicose veins disease or a repairing mechanism of the thrombosis itself needs further research.

Cardiac damage after carotid intervention: a meta-analysis after a decade of randomized trials.

PURPOSE: This study synthesizes evidence from randomized controlled trials of the past decade regarding the relative safety of carotid endarterectomy (CEA) versus carotid angioplasty and stenting (CAS) as concerns postoperative cardiac damage. METHODS: We searched Medline, Embase, and Cochrane Central through November 2013 to December 2013. We determined trial eligibility and extracted descriptive, methodological, and outcome data related to cardiac damage after open or endovascular treatment. Cardiac damage was defined as evidence of symptomatic or asymptomatic myocardial ischemia/infarction. RESULTS: Nine trials (5,959 patients) were eligible for enrollment in this review. CAS was associated with a decreased risk for cardiac damage in all trials (pooled RR = 0.37; 95% CI = 0.22-0.61, I(2) = 11%, P = 0.0001), and specifically in the latest two randomized trials that show fewer methodological flaws (RR = 0.39; 95% CI = 0.23-0.69, P = 0.03). CAS was associated with 11.5 fewer cardiac events (from 14.7 fewer to 6.3 fewer) compared to CEA. CONCLUSIONS: Compared to open surgery, CAS is associated with significantly decreased risk for symptomatic and asymptomatic cardiac damage postoperatively. Therefore, a standardized troponin measurement after CEA should be further evaluated in future studies.

Synovial cyst of the antecubital fossa mimicking a brachial artery pseudoaneurysm: report of a case.

Pseudoaneurysms of the brachial artery are common following a percutaneous cardiac catheterization. Synovial cysts are a commonly identified entity in patients with rheumatic diseases as well. We present a rare case of a synovial cyst in the elbow masquerading as an iatrogenic pseudoaneurysm of the brachial artery. A 51-year-old female patient presented with a pulsatile and painful mass in the right antecubital fossa. The medical history revealed a recent diagnostic cardiac catheterization at the same site and rheumatoid arthritis under oral treatment. Imaging investigations were not fully diagnostic. Because of the clinical suspicion of a thrombosed pseudoaneurysm, exploratory surgery was indicated. The pathologic examination of the specimen confirmed the diagnosis of a synovial cyst. Ultrasonography and computed tomography imaging are valuable in the everyday clinical practice but they do not always exclude an iatrogenic pseudoaneurysm, especially when the medical history is suspicious. Surgical removal is the proper treatment and pathologic examination sets the final diagnosis in such cases of diagnostic difficulty.

Laparoscopic adrenalectomy: where do we stand now?

Laparoscopic adrenalectomy (LA) has become the procedure of choice for the surgical removal of the vast majority of small sized adrenal tumors (

Acute limb ischemia in a patient with cardiac amyloidosis: a case report.

INTRODUCTION: Cardiac amyloidosis is a manifestation of several systemic diseases known as amyloidoses. Arterial thromboembolic complications have not been reported to occur frequently, although the pathophysiology of cardiovascular amyloidosis would theoretically predispose to such manifestations. CASE PRESENTATION: We present the case of a 52-year-old woman, who suffered from cardiac amyloidosis and was admitted to our hospital for left acute limb ischemia. An urgent embolectomy was performed, improving her clinical condition and the pathologoanatomic examination of the embolus revealed deposition of amyloid. CONCLUSION: Peripheral arterial thromboembolic events in patients with amyloidosis are rare. An antiplatelet treatment is recommended in such patients with cardiac amyloidosis for the prevention of embolism.

Short bowel syndrome: amelioration of diarrhea after vagotomy and pyloroplasty for peptic hemorrhage.

Acute mesenteric ischemia is a rare symptomatic manifestation of arteriosclerosis. Prognosis crucially depends on rapid diagnosis and surgical management to prevent or at least minimize the bowel infarction. The length of the small bowel is considered to be between 3 and 8 m, and a normal bowel function can be maintained even after resection of its one third. But loss of a major part (> 60%) can lead to malnutrition and death. However, patients, who survived an extended intestinal resection due to improved postoperative care (intensive care unit and parenteral nutrition), develop short bowel syndrome. This phenomenon is a medical problem, and several surgical techniques have been used to slow down intestinal transit time or to increase the area of absorption. All these procedures have controversial outcomes and are still on different experimental levels; namely, they cannot be recommended for routine use. In our report of a patient suffering from short bowel syndrome, vagotomy and pyloroplasty were performed to repair a sudden peptic hemorrhage. This operation cured bleeding peptic ulcer and also palliated the diarrhea, a main clinical manifestation of short bowel syndrome. In this study, our aim is to emphasize the favorable clinical outcome of vagotomy concerning a principal manifestation of short bowel syndrome, such as diarrhea. To the best of our knowledge, the present study is the first report showing the vagotomy as a possible procedure for the treatment of diarrhea, although this occurrence has no clear explanation. We also discuss the management of short bowel syndrome.

Serum CA 125 combined with transvaginal ultrasonography for ovarian cancer screening.

BACKGROUND: The aim of this study was to evaluate the combination of serum CA125 and Transvaginal Ultra Sonography (TVUS) score, as a screening procedure for ovarian cancer in premenopausal and postmenopausal women. PATIENTS AND METHODS: A retrospective case-control pilot study was conducted. The files of 120 women with ovarian neoplasia detected by TVUS and increased CA125 level, within the framework of a prevention program, were reviewed. The relationship between the above tests and epithelial malignancy was investigated using the SPSS-12 program for Windows. RESULTS: The combination of CA125 value exceeding 30U/ml and a TVUS score > or = 35 had a sensitivity of 81.7% and specificity of 100% in predicting ovarian cancer. Mathematical analysis of the logistic model of our variables revealed a mathematical model that can calculate the likelihood of ovarian cancer detection, by using a combination of CA125 > or = 30U/ml and TVUS score > or = 35. CONCLUSION: By combining TVUS and CA125, an accurate prediction for the presence of ovarian cancer may be achieved. Further investigation in a larger population is warranted.