Carotid Restenosis Rate After Stenting for Primary Lesions Versus Restenosis After Endarterectomy With Creation of Risk Index.

PURPOSE: Carotid artery stenting (CAS) is an option for carotid restenosis (CR) treatment with favorable outcomes. However, CAS has also emerged as an alternative to carotid endarterectomy (CEA) for the management of patients with primary carotid stenosis. This study aimed to report CR rates after CAS was performed in patients with primary lesions versus restenosis after CEA, to identify predictors of CR, and to report both neurological and overall outcomes. MATERIALS AND METHODS: From January 2000 to September 2018, a total of 782 patients were divided into 2 groups: The CAS (prim) group consisted of 440 patients in whom CAS was performed for primary lesions, and the CAS (res) group consisted of 342 patients with CAS due to restenosis after CEA. Indications for CAS were symptomatic stenosis/restenosis >70% and asymptomatic stenosis/restenosis >85%. A color duplex scan (CDS) of carotid arteries was performed 6 months after CAS, after 1 year, and annually afterward. Follow-up ranged from 12 to 88 months, with a mean follow-up of 34.6±18.0 months. RESULTS: There were no differences in terms of CR rate between the patients in the CAS (prim) and CAS (res) groups (8.7% vs 7.2%, χ2=0.691, p=0.406). The overall CR rate was 7.9%, whereas significant CR (>70%) rate needing re-intervention was 5.6%, but there was no difference between patients in the CAS (prim) and CAS (res) groups (6.4% vs 4.7%, p=0.351). Six independent predictors for CR were smoking, associated previous myocardial infarction and angina pectoris, plaque morphology, spasm after CAS, the use of FilterWire or Spider Fx cerebral protection devices, and time after stenting. A carotid restenosis risk index (CRRI) was created based on these predictors and ranged from -7 (minimal risk) to +10 (maximum risk); patients with a score >-4 were at increased risk for CR. There were no differences in terms of neurological and overall morbidity and mortality between the 2 groups. CONCLUSIONS: There was no difference in CR rate after CAS between the patients with primary stenosis and restenosis after CEA. A CRRI score >-4 is a criterion for identifying high-risk patients for post-CAS CR that should be tested in future randomized trials.

IL-33/IL-33R in various types of carotid artery atherosclerotic lesions.

OBJECTIVE: Inflammation plays a crucial role in the progression of atherosclerotic plaques. The aim of the study was to investigate serum levels and expression of Interleukin-33 (IL-33) and ST2 receptor in atherosclerotic plaques and to analyze correlation with the type of the carotid plaques in patients with carotid disease. METHODS: This study included 191 consecutive patients submitted for carotid endarterectomy (CEA). Preoperative serum levels of IL-33 and soluble ST2 (sST2) were measured. Atherosclerotic plaques obtained during surgery were initially histologically classified and immunohistochemical analyzes of IL-33, IL-33R, CD68 and alpha-SMA expression was performed. Ultrasound assessment of the level of carotid stenosis in each patient was performed prior to carotid surgery. Demographic and clinical data such as gender, age, smoking status, blood pressure, glycaemia, hemoglobin and creatinine levels, and comorbidities were collected and the comparisons between variables were statistically evaluated. RESULTS: Serum levels of IL-33 (35.86 ±â€¯7.93 pg/ml vs.12.29 ±â€¯1.8 pg/ml, p < 0.05) and sST2 (183 ±â€¯8.03 pg/ml vs. 122.31 ±â€¯15.89 pg/ml, p < 0.05) were significantly higher in the group of CEA patients vs. healthy subjects. We demonstrated abundant tissue expression of IL-33 and ST2 in atherosclerotic carotid artery lesions. The levels of IL-33 and IL-33R expression were significantly higher in vulnerable plaques and significantly correlated with the degree of inflammatory cells infiltration in these plaques (R = 0.579, p = 0.049). Immunohistochemical analysis also revealed that cells responsible for IL-33 expression are not only mononuclear cells confined to inflammatory atherosclerotic lesions, but also smooth muscle cells which gained phenotypic characteristics of foam cells and were loaded with lipid droplets. CONCLUSION: The obtained results confirm the importance of IL-33/ST2 axis in the process of atherosclerosis, and indicate its ambiguous function in immune response, whether as proinflammatory cytokine in advanced atherosclerotic lesions, or as profibrotic, in early lesions.

Cyanoacrylate Embolization: A Novelty in the Field of Varicose Veins Surgery.

In the past 2 decades, varicose veins surgery went through a great turbulence and various innovations. A number of new techniques have been introduced with a goal to increase the success rate, reduce the periprocedural complications and, overall, to improve patients' quality of life. The latest of them, named cyanoacrylate embolization (CAE) technique, threatens to shake the glory of the currently well-established endovenous methods. We have analyzed all previous studies by searching MEDLINE base using PubMed. Although the idea of using n-butyl cyanoacrylate (NBCA) glue in medical purposes was not new, the very first in vivo and animal experiments using NBCA for vein closure were conducted just at the beginning of this millennium. The results of these studies gave warranty to begin with the first interventions in humans. Early studies reported very high success rates of more than 90%, with the longest follow-up period of 36 months. There were no major adverse events reported, while the minor ones-mostly phlebitic reactions-were defined as mild to moderate. The newest head-to-head studies showed that CAE is a noninferior technique to other endovenous methods, with higher occlusion rates and fewer adverse events. Short procedure time and no need for tumescent anesthesia or compressive stockings reduce patients' discomfort to the minimum and definitely seem to be a step forward answering the modern "walk in-walk out surgery" demands. As an easily handling technique, CAE undoubtedly pierces its path to the top of varicose veins surgery but more head-to-head clinical trials with longer follow-up periods are necessary to obtain a plain picture.

Scoring system to predict early carotid restenosis after eversion endarterectomy by analysis of inflammatory markers.

BACKGROUND: Inflammation is one of the mechanisms that leads to carotid restenosis (CR). The aim of this study was to examine the influence of increased values of inflammation markers (high-sensitivity C-reactive protein [hs-CRP], C3 complement, and fibrinogen) on CR development after eversion carotid endarterectomy (CEA). METHODS: A consecutive 300 patients were included in the study, in which eversion CEA was performed between March 1 and August 1, 2010. Demographic data, atherosclerosis risk factors, comorbidities, and ultrasound plaque characteristics were listed in relation to potential risk factors for CR. Serum concentrations of hs-CRP, fibrinogen, and C3 complement were taken just before surgery (6 hours); 48 hours after CEA; and during regular checkups at 1 month, 6 months, 1 year, and 2 years. An "inflammatory score" was also created, which consisted of six predictive values of inflammatory markers (hs-CRP just before and just after CEA, fibrinogen just before and just after CEA, and C3 complement just before and just after CEA) with a maximum score of 6 and a minimum score of 0. At every follow-up visit to the outpatient clinic, ultrasound assessment of the carotid artery for restenosis was done. RESULTS: Our results showed an increased risk of early CR within 1 year in patients with increased hs-CRP before CEA (6 hours) and increased fibrinogen 48 hours after surgery and in patients not taking aspirin after CEA. Sex was determined to be an independent predictor of CR, with female patients having a higher risk (P = .002). Male patients taking aspirin with an inflammatory score >2 had an increased risk for restenosis compared with male patients with inflammatory score <2. Not taking aspirin after CEA and fibrinogen (48 hours) were the strongest predictors, and the Fisher equation incorporating these predictors was used to predict CR. A computer program was created to calculate whether the patient was at high or low risk for CR by selecting whether the patient was taking aspirin (yes or no) and whether fibrinogen was increased 48 hours after CEA (yes or no) and to display the recommended therapeutic algorithm consisting of aspirin, clopidogrel, cilostazol, and statins. CONCLUSIONS: Increased hs-CRP before CEA, increased fibrinogen 48 hours after CEA, and not taking aspirin were the main predictors of early CR. With the clinical implementation of the Fisher equation, it is possible to identify patients at high risk for early CR and to apply an aggressive therapeutic algorithm, finally leading to a decreased CR rate.

The Effect of Vacuum-Assisted Closure Therapy on Methicillin-Resistant Staphylococcus aureus Wound Biofilms.

Biofilm-associated wound infections are a major global health issue, and methicillin-resistant Staphylococcus aureus (MRSA) is among the greatest therapeutic challenges. Vacuum-assisted closure (VAC) therapy is now being revisited as an alternative treatment for both acute and chronic wounds. However, data supporting the concept of its antibiofilm effect remain limited. Using quantitative biofilm-forming assay and a range of genotypic methods (spa, SCCmec, and agr typing), study authors showed that VAC therapy can significantly prevent biofilm formation (P < .01) of a range of MRSA wound isolates differing widely in their biofilm-forming abilities and genetic background. The best effect was presented on CC5-MRSA-SCCmecI-agrII, a dominant MRSA clone among wound isolates worldwide. An assessment of effects of different protocols on dressing changes (1 or 2 times per week) demonstrated significantly greater antibiofilm activity (P < .05) of 3-day dressing changes. These findings support the use of VAC therapy as a topical antibiofilm treatment for the effective management of wound healing.

Genetic Markers for Coronary Artery Disease.

Coronary artery disease (CAD) and myocardial infarction (MI) are recognized as leading causes of mortality in developed countries. Although typically associated with behavioral risk factors, such as smoking, sedentary lifestyle, and poor dietary habits, such vascular phenotypes have also long been recognized as being related to genetic background. We review the currently available data concerning genetic markers for CAD in English and non-English articles with English abstracts published between 2003 and 2018. As genetic testing is increasingly available, it may be possible to identify adequate genetic markers representing the risk profile and to use them in a clinical setting.

A Novel Antegrade Approach for Simultaneous Carotid Endarterectomy and Angioplasty of Proximal Lesions in Patients with Tandem Stenosis of Supraaortic Arch Vessels.

BACKGROUND: To date, all published studies analyzing simultaneous treatment of carotid and proximal atherosclerotic lesions are describing retrograde approach and several technical variations. In the presented study, for the first time, antegrade approach is described for simultaneous carotid endarterectomy (CEA) and associated brachiocephalic trunk (BCT) or common carotid artery (CCA) angioplasty in the hybrid operating room. METHODS: From January 2012 till January 2016, antegrade hybrid procedures were performed in 18 patients. All patients were admitted to our institute for elective supraaortic arch multidetector computed tomography angiography when significant simultaneous proximal and distal supraaortic arch lesions were revealed. After surgical exposure of carotid arteries, proximal lesions were crossed by antegrade approach. Prior to stent placement, internal carotid artery (ICA) is clamped at its origin with the guidewire placed in the external carotid artery (ECA). After primary stenting and control arteriography, CCA and ECA are clamped and the ICA clamp moved more distally. An arteriotomy is performed in the CCA, with flushing of possible debris and thrombus before performance of the eversion CEA, once again flushing before completion of the anastomosis. Follow-up ranged from 6 to 36 months with average follow-up of 22.15 ± 11.31 months. RESULTS: All procedures went uneventfully. Out of 18 patients, 11 were males and 7 females, mean age 66.6 ± 3.82 years. In 10 patients (55.5%), simultaneous CEA and CCA angioplasty was performed, in 7 patients (38.9%) CEA and BCT angioplasty, and in 1 patient (5.5%) tubular graft interposition between the CCA and the ICA and CCA angioplasty. In 6 patients (33.3%), CCA/BCT balloon angioplasty alone was performed simultaneously with CEA. None of the patient had postoperative transient ischemic attack, stroke, hematoma, dissection, myocardial infarction, or ischemia in the early postoperative period and during the follow-up. There were no lethal outcomes, neither in the early postoperative course nor during the follow-up. CONCLUSIONS: Antegrade approach for simultaneous treatment of proximal CCA/BCT and distal carotid lesions with temporary ICA clamping is safe and feasible procedure that should be thought of in the future in addition to already described retrograde approach.

Vascular Age as a Predictor of Side Effects After Facial Lipofilling.

BACKGROUND: Vascular age (VA) represents chronological age adjusted for an individual's atherosclerotic burden. Keeping in mind the fact that facial vascularization could influence the success of esthetic interventions, we aimed to investigate the predictive value of VA in development of side effects following facial lipofilling. METHODS: In the period from October 1, 2014, to October 1, 2015, 106 consecutive subjects who underwent a facial lipofilling were included in the study. The VA was calculated using two approaches: Systematic Coronary Risk Evaluation (SCORE) project equations and means of vascular parameters assessed by color duplex sonographic examinations. The data regarding facial lipofilling-related complications (pain, edema and/or hematoma) have been collected during the regular checkups over 2 weeks after intervention. RESULTS: The average chronological age of the participants was 50.9 ± 9.4 years. Estimation of VA using vascular sonographic parameters revealed the value of 45.4 ± 29.1 years, whereas the assessment of VA using SCORE equations showed that the mean age was 53.7 ± 12.7 (p = 0.006). The total frequency of these complications was as follows: 6.6% for hematoma, 15.1% for edema (13.2% mild edema and 1.9% severe edema) and 20.8% for local facial pain (17.0% mild pain and 3.8% severe pain). The multivariate logistic regression models showed that VA had statistically significant (p < 0.01) independent prognostic value for facial lipofilling-related appearance of hematoma and pain. CONCLUSIONS: The results of our study revealed that advanced VA has an independent predictive role in the appearance of complications following facial plastic surgery. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Bilateral Eagle Syndrome with Associated Internal Carotid Artery Kinking and Significant Stenosis.

BACKGROUND: Eagle syndrome represents elongated styloid process characterized by calcification and ossification of the stylohyoid ligament rarely associated with the pathology of carotid arteries. We are presenting a very rare case of bilateral Eagle syndrome with associated internal carotid artery (ICA) kinking on the right side and significant ICA stenosis on the left side. CASE REPORT: A 62-year-old female patient was admitted to our Institution for multidetector computed tomography (MDCT) angiography. Two years ago, she experienced stroke with right-sided weakness, color Doppler scan of carotid arteries described left ICA stenosis of 75% and right ICA stenosis of 50%. MDCT arteriography revealed bilateral Eagle syndrome associated with significant left ICA stenosis of >90% and right ICA kinking. Left carotid endarterectomy was performed followed by elongated styloid process resection that was in close relationship to ICA. Even more significant relationship was seen on the right side involving right ICA kinking and elongated styloid process that was treated conservatively. Postoperative course was uneventful; after 6 months, the patient was doing well. CONCLUSIONS: This is the first case that describes bilateral Eagle syndrome associated with ICA kinking on one side and significant stenosis on the other. Although rare, this syndrome should be thought of in symptomatic patients with carotid pathologies in which case computed tomography angiography is of crucial importance.

The Impact of Facial Lipofilling on Patient-Perceived Improvement in Facial Appearance and Quality of Life.

An investigation of the effect of facial lipofilling on patient's satisfaction is a challenging and ongoing research area. Therefore, the aim of this study was to investigate the impact of aesthetic intervention on self-perceived improvement in facial appearance and quality of life (QoL) after 1- and 6-month follow-ups. In the period from October 1, 2014, to March 1, 2015, a total of 63 consecutive subjects who underwent a facial lipofilling were included in the study. The satisfaction with facial appearance was estimated by using the Satisfaction with Facial Appearance Overall scale. QoL was assessed by using the 36-Item Short Form Health Survey (SF-36). Severity of depressive and anxiety symptoms was quantified by using the Hamilton depression and anxiety rating scales. The self-esteem was assessed by Rosenberg self-esteem scale. The average Satisfaction with Facial Appearance Overall scale score at baseline was 45.5 ± 13.0, while this score reached values of 84.5 ± 16.2 after 1 month (Z = -6.744, p < 0.001) and 82.7 ± 12.6 after 6 months (Z = -6.545, p < 0.001) of follow-up. The mean change of Satisfaction with Facial Appearance Overall scale score from baseline to 1-month follow-up was 38.9 ± 21.2 and from baseline to 6-month follow-up was 37.1 ± 18.9. Statistically significant improvement in QoL at each subsequent time point, compared with those at baseline, was detected for all domains of the SF-36 except for subscales of physical functioning and pain. It has been highlighted that advanced social life was strongly associated with improvement in satisfaction with facial appearance, better self-esteem, and lower level of anxiety and depression during the period of follow-up after facial lipofilling. The results of this study supported the hypothesis that the level of self-confidence and mental health-related QoL could be significantly improved following facial lipofilling treatment.

Gender-Specific Association between Angiotensin II Type 2 Receptor -1332 A/G Gene Polymorphism and Advanced Carotid Atherosclerosis.

BACKGROUND: The angiotensin II type 2 receptor (AT2R) -1332 A/G polymorphism has been denoted as functional and associated with certain cardiovascular disease phenotypes. However, there are no studies considering the association of this gene polymorphism with carotid atherosclerosis (CA) and cerebrovascular events. Therefore, the aim of our study was to investigate a possible association of the AT2R -1332 A/G polymorphism with the occurrence of carotid plaques (CPs) and history of cerebrovascular insult (CVI) in advanced CA. METHODS: The study group included 381 controls and 509 patients with CA consecutively admitted for endarterectomy. Genotyping was determined by polymerase chain reaction-restriction fragment length polymorphism method. The association was analyzed separately for males and females because the AT2R gene is located on the X chromosome. RESULTS: The AT2R -1332 GG genotype was associated with the advanced CA in the female study group (recessive model of inheritance, AA+AG versus GG; adjusted odds ratio [OR] = 2.25; 95% confidence interval [CI] 1.17-4.33; P = .01). In the male subgroup of patients with CA, the significant overrepresentation of G/- hemizygote was detected in patients with CVI compared to male patients without this event (crude OR = 2.05, 95% CI 1.20-3.50, P = .008). CONCLUSIONS: This study suggests a gender-specific association between the AT2R -1332 A/G polymorphism and the occurrence of CP and the history of CVI in advanced CA, but further replication studies are needed.

Oxidized low-density lipoprotein as a biomarker of cardiovascular diseases.

Atherosclerosis is a life-long illness that begins with risk factors, which in turn contribute to the development of subclinical disease, followed by the establishment of overt cardiovascular disease (CVD). Thrombotic-occlusive complications of atherosclerosis are among the most widespread and costly health problems. Oxidized low-density lipoprotein (OxLDL) plays an important role in atherogenesis by promoting an inflammatory environment and lipid deposition in the arterial wall. As cardiovascular events occur in individuals without common risk factors, there is a need for additional tools that may help in CVD risk assessment and management. The use of biomarkers has improved diagnostic, therapeutic and prognostic outcome in cardiovascular medicine. This review elaborates on the value of circulating OxLDL as a biomarker of CVD. Three enzyme-linked immunosorbent assays (4E6, DLH3 and E06) using murine monoclonal antibodies for determination of OxLDL blood levels have been developed. However, none of these assays are currently approved for routine clinical practice. We identified studies investigating OxLDL in CVD (measured by 4E6, DLH3 or E06 assay) by searching the PubMed database. Circulating OxLDL was found to be associated with all stages of atherosclerosis, from early atherogenesis to hypertension, coronary and peripheral arterial disease, acute coronary syndromes and ischemic cerebral infarction. The results of studies investigating the usefulness of OxLDL for CVD prediction were also summarized. Furthermore, OxLDL was found to be associated with pathologic conditions linked to CVD, including diabetes mellitus, obesity and metabolic syndrome (MetS). In addition, we have addressed the mechanisms by which OxLDL promotes atherogenesis, and the effects of antiatherogenic treatments on circulating OxLDL. Finally, we highlight the evidence suggesting that lipoprotein (a) [Lp(a)] is the preferential carrier of oxidized phospholipids (OxPL) in human plasma. A strong association between OxPL/apoB level (representing the content of OxPL on apolipoprotein B-100 particles, measured by E06 assay) and Lp(a) has been determined.

A rare case of large isolated internal iliac artery aneurysm with ureteral obstruction and hydronephrosis: Compression symptoms are limitation for endovascular procedures.

INTRODUCTION: In this report, we aim to present a rare case of isolated internal iliac artery aneurysm with associated left ureteric obstruction and consequent hydronephrosis. CASE REPORT: A 66-year-old male patient was admitted for occasional pain in the lower back that appeared one month earlier. CT arteriography revealed isolated internal iliac artery (diameter 99 mm) with ureteral obstruction, hydroureter and left kidney hydronephrosis occurrence. Aneurysm was resected, after six months the patient was doing well. Bearing in mind that 77% of the patients with isolated internal iliac artery have symptoms caused by aneurysmal compression on adjacent organs, we wanted to highlight that despite the amazing expansion of endovascular procedures in the last decades, its therapeutic effect in isolated internal iliac artery's treatment is to a great extent limited since compression symptoms cannot be solved. CONCLUSION: Open surgery remains the gold standard for isolated internal iliac artery's treatment considering significant limitations of endovascular procedures due to the inability to eliminate problems caused by compression.

Endovascular treatment of symptomatic high-grade vertebral artery stenosis.

BACKGROUND: The purpose of this study was to evaluate the initial and long-term results of endovascular treatment (EVT) in patients with symptomatic high-grade extracranial vertebral artery (VA) origin stenosis. METHODS: From February 2001 to March 2013, 73 consecutive patients (33 men with a mean age of 61.7 ± 8.8 years) underwent EVT for symptomatic high-grade VA stenosis. Preoperative evaluation included Duplex ultrasonography and arteriography. After successful treatment, all patients were followed up at 1, 3, 6, and 12 months after the procedure and every 6 months thereafter. RESULTS: Successful EVT of the VA stenosis was achieved in 68 patients (93.2%). All procedures were performed without use of cerebral protection. The early complication rate was 5.5%, which included one periprocedural transient ischemic attack, two hematomas at the puncture site, and one allergic reaction to the contrast agent. No in-hospital deaths occurred. During follow-up (mean, 44.3 ± 31.2 months; range, 2-144 months), the primary patency rates at 1, 3, 5, and 7 years were 98.4%, 87.3%, 87.3%, and 87.3%, respectively. Ultrasound Doppler controls during follow-up detected seven VA restenoses (10.3%). Univariate analysis failed to identify any variable predictive of long-term patency of successfully treated VA stenosis. CONCLUSIONS: EVT of symptomatic VA origin stenosis is a safe and effective procedure associated with low risk and good long-term results, even without use of cerebral protection devices.

Carotid angioplasty and stenting is safe and effective for treatment of recurrent stenosis after eversion endarterectomy.

OBJECTIVE: This study was conducted to determine the efficiency and long-term durability of percutaneous transluminal angioplasty and carotid artery stenting in carotid restenosis (CR) treatment after eversion endarterectomy, with emphasis on variables that could influence the outcome. METHODS: We analyzed 319 patients (220 asymptomatic and 99 symptomatic) who underwent carotid angioplasty from 2002 until 2012 for CR that occurred after eversion endarterectomy. During this period, 7993 eversion endarterectomies were done for significant carotid artery stenosis. Significant CR was detected by ultrasound examination and confirmed by digital subtraction angiography or multidetector computed tomography angiography. After angioplasty (with or without stenting), color duplex ultrasound imaging was done after 1 month, 6 months, 1 year, and annually thereafter. End points encompassed myocardial infarction, stroke, and cardiovascular death (fatal myocardial infarction, fatal cardiac failure, fatal stroke), and also puncture site hematoma and recurrent restenosis. Primary end points were analyzed as early results (≤30 days after the procedure), and secondary end points were long-term results (>30 days). Variables and risk factors influencing the early-term and long-term results were also analyzed. Median follow-up was 49.8 ± 22.8 months (range, 17-121 months). RESULTS: All but one procedure ended with a technical success (99.7%). In the early postoperative period, transient ischemic attack occurred in 2.8% of the patients and stroke in 1.6%, followed by one lethal outcome (0.3%). Stent thrombosis occurred in one patient (0.3%) several hours after the angioplasty, followed by urgent surgery and graft interposition. In the long-term follow-up, there were no transient ischemic attacks or strokes, non-neurologic mortality was 3.13%, and the recurrent restenosis rate was 4.4%. The rate of non-neurologic outcomes during the follow-up was significantly higher in asymptomatic patients than in symptomatic patients (4.54% vs 0%; P = .034). The statically highest rate of transient ischemic attack was verified in patients in whom Precise (Cordis Corporation, New Brunswick, NJ) stents was used (12.2%) and a Spider Fx (Covidien, Dublin, Ireland) cerebral protection device (12.5%) was used. Female gender, coronary artery disease, plaque calcifications, and smoking history were associated with an adverse outcome after angioplasty. CONCLUSIONS: Carotid artery stenting is safe and reliable procedure for CR after eversion endarterectomy treatment, with low rate of postprocedural complications. Type of stent and cerebral embolic protection device may influence the rate of postprocedural neurologic ischemic events.

Infrarenal abdominal aorta aneurysm: a rare cause of anterior nutcracker syndrome with associated pelvic congestion.

We present a rare case of anterior nutcracker syndrome caused by an abdominal aorta aneurysm (AAA). A 61-year-old woman was admitted to our institution for computed tomography angiography. It revealed an AAA 51 mm in diameter that was lifting off of the left renal vein toward the superior mesenteric artery, causing anterior nutcracker syndrome with consequent left renal vein compression and left ovarian vein congestion. Aneurysm resection was performed, followed by left ovarian vein ligation and left adnexectomy to prevent vein conglomerate rupture. This is the first case that describes anterior nutcracker syndrome caused by AAA, which was successfully treated by aneurysm resection.

Quality of life in chronic venous disease patients measured by short Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-14) in Serbia.

BACKGROUND: This was a psychometric validation of the short Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-14) as quality of life (QOL) instrument for chronic venous disease (CVD) patients. METHODS: Patients aged >18 years who had CVD in CEAP C stages C0s to C6 were included in the study. Diagnosis was made by general practitioners according to CVD symptoms and visual examination of the lower extremities. QOL was assessed with the self-administrated CIVIQ-14. The reliability, construct, and convergent validity of the CIVIQ-14 was estimated as well as QOL of CVD patients according to CEAP C stages. RESULTS: The study comprised 2260 subjects who fully completed the CIVIQ-14. CIVIQ-14 had a high level of reliability, construct, and convergent validity, but the structure of its three dimensions (pain [P], physical [PHY], and psychological [PSY]) was suboptimal. After adjustment for age, body mass index, and number of CVD symptoms, CIVIQ -14 global, P, PHY, and PSY scores showed significant progressive reduction of QOL from CEAP class C0s to C6. These differences were present in both sexes. The progressive impairment of the QOL involved primarily the pain and the physical items. For all CEAP C classes, the P and PHY scores were lower than the PSY scores. Global scores for men and women were: 76.7 and 73.9 for C0s; 75.5 and 70.6 for C1; 67.8 and 64.5 for C2; 68.3 and 61.6 for C3; 60.7 and 54.6 for C4; 49.5 and 50.2 for C5; and 41.3 and 46.7 for C6. CONCLUSIONS: CVD in the lower extremities has a substantial effect on both physical and psychologic aspects of QOL, the physical aspects of QOL (P and PHY items) being more important. CIVIQ-14 is valuable in assessing QOL in CVD patients. Further investigations are necessary to confirm the stability of its two dimensions.

Health-related quality of life among patients with symptomatic carotid disease.

OBJECTIVES: To evaluate health-related quality of life (HRQoL) in patients with symptomatic carotid disease (amaurosis fugax, transient ischaemic attack, stroke); to compare it with that of the general population; to explore whether HRQoL depends on the severity of the disease and to investigate the possible association between some demographic and clinical characteristics of patients and HRQoL. METHODS: This cross-sectional study involved 175 patients with symptomatic carotid atherosclerotic disease who were referred for endarterectomy between January 2011 and December 2011. HRQoL was measured using Medical Outcome Survey Short Form 36 (SF-36). RESULTS: In comparison to both referent populations, patients with carotid disease had significantly lower mean SF-36 scores for role-physical (41.6 vs. 61.5 and 67.8), social functioning (65.4 vs. 73.8 and 80.0), role-emotional (48.2 vs. 68.6 and 80.5) and mental health (51.5 vs. 61.9 and 66.0). The SF-36 scores were significantly lower in female patients with carotid disease than in men (for role-physical 32.3 vs. 46.5; for bodily pain 57.0 vs. 73.0; for general health 55.6 vs. 61.5; for vitality 55.4 vs. 60.1; for social functioning 57.1 vs. 69.8 and for role-emotional 37.2 vs. 54.1). Significantly lower SF-36 scores were also found in patient with comorbidity (for physical functioning 68.1 vs. 77.7; for role-physical 35.1 vs. 52.3; for bodily pain 62.6 vs. 75.4; for general health 56.8 vs. 63.8; for social functioning 61.9 vs. 71.0, for role-emotional 41.6 vs. 59.1and for mental health 52.5 vs 49.8). In a multivariable analysis, education, occupation, body mass index, metabolic syndrome and severity of the disease had a weak influence on patients' HRQoL, while age, marital status, smoking, alcohol consumption, physical activity and the degree of carotid stenosis had no effect on patients' HRQoL. The SF-36 scores did not substantially change after adjustment for confounding variables. CONCLUSIONS: Patients with symptomatic carotid disease had poorer HRQoL, especially its mental components, than the general population. The severity of the disease was significantly associated only with the SF-36 role-physical subscale. HRQoL in patients with symptomatic carotid disease was poorer in women than in men, and was not affected by age and other demographic and clinical characteristics of patients.

SGLT-2 Inhibitors: The Next-generation Treatment for Type 2 Diabetes Mellitus.

Type 2 diabetes mellitus (T2DM) has become a worldwide concern in recent years, primarily in highly developed Western societies. T2DM causes systemic complications, such as atherosclerotic heart disease, ischemic stroke, peripheral artery disease, kidney failure, and diabetes-related maculopathy and retinopathy. The growing number of T2DM patients and the treatment of long-term T2DM-related complications pressurize and exhaust public healthcare systems. As a result, strategies for combating T2DM and developing novel drugs are critical global public health requirements. Aside from preventive measures, which are still the most effective way to prevent T2DM, novel and highly effective therapies are emerging. In the spotlight of next-generation T2DM treatment, sodium-glucose co-transporter 2 (SGLT-2) inhibitors are promoted as the most efficient perspective therapy. SGLT-2 inhibitors (SGLT2i) include phlorizin derivatives, such as canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin. SGLT-2, along with SGLT-1, is a member of the SGLT family of proteins that play a role in glucose absorption via active transport mediated by Na+ /K+ ATPase. SGLT-2 is only found in the kidney, specifically the proximal tubule, and is responsible for more than 90% glucose absorption. Inhibition of SGLT-2 reduces glucose absorption, and consequently increases urinary glucose excretion, decreasing blood glucose levels. Thus, the inhibition of SGLT-2 activity ultimately alleviates T2DM-related symptoms and prevents or delays systemic T2DM-associated chronic complications. This review aimed to provide a more detailed understanding of the effects of SGLT2i responsible for the acute improvement in blood glucose regulation, a prerequisite for T2DM-associated cardiovascular complications control.

The sex-specific association of Met62Ile gene polymorphism in P-selectin glycoprotein ligand (PSGL-1) with carotid plaque presence: preliminary study.

Atherosclerosis is known as an inflammatory disease in which a recruitment of leukocytes to the endothelium wall represents a preliminary step of the initiation and the development of disease. The P-selectin glycoprotein ligand (PSGL-1) seems to be the major molecule mediating leukocyte-endothelium interactions and leukocyte rolling on stimulated endothelium. There are limited number of studies reporting on association of Met62Ile SNP in PSGL-1 gene and the risk for atherosclerosis. The aim of this study was to analyze possible association of this polymorphism with an advanced carotid atherosclerosis and biochemical markers of inflammation and haemostasis. The 275 patients consecutively admitted for carotid endarterectomy with stenosis >70% and 256 controls of the same ethnic origin were included in the study. The Met62Ile genotypes were determined by PCR RFLP. The Ile/Ile homozygotes had significantly higher CRP compared to the other genotypes in patients. Female patients had Ile allele dose-dependent association with the carotid plaque presence (Met/Met vs. Met/Ile vs. Ile/Ile; OR 1, OR 2.02, CI 1.0-4.08, OR 4.08, CI 1.0-16.81, respectively, p = 0.04). Our results suggest the impact of PSGL-1 Met62Ile polymorphism on inflammation in advanced atherosclerosis. We observed the sex-differential association of Met62Ile with advanced carotid atherosclerosis. Studies in larger and different populations should validate and further examine the suggested role of genetic variations in PSGL-1 with atherosclerosis and thrombosis.