Prognostic value of a low post-exercise ankle brachial index as assessed by primary care physicians.

OBJECTIVE: We aimed to investigate whether the post-exercise ankle brachial index (ABI) performed by primary care physicians offers useful information for the prediction of death or cardiovascular events, beyond the traditional resting ABI. An additional focus was on patients with intermittent claudication and normal resting ABI. METHODS: Using data from the 5-year follow-up of 6468 elderly patients in the primary care setting in Germany (getABI study) we used multivariate Cox regression models adjusted for age, gender and conventional risk factors to determine the association of resting ABI and/or post-exercise ABI and all-cause mortality/morbidity. RESULTS: Mean post-exercise ABI in the total cohort was 0.977 and resting ABI was 1.034. For post-exercise ABI, a threshold value of 0.825 had nearly the same sensitivity (28.6%) and specificity (85.7%) as the conventionally used resting ABI with a cut-off value of 0.9 to predict death. Compared to patients with normal post-exercise ABI, a low post-exercise ABI was associated with an almost identical risk increase for mortality (hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.30-1.86) as a low resting ABI (HR 1.65; CI 1.39-1.97) and/or myocardial infarction/stroke. Slight differences were observed for coronary/carotid revascularisation and peripheral revascularisation/amputation. In combined models it could not be shown that post-exercise ABI yielded relevant additional information for the prognosis of mortality and/or myocardial infarction/stroke, not even in the subgroup analysis of patients with intermittent claudication and normal resting ABI. CONCLUSIONS: It could not be shown that the post-exercise ABI is a useful tool for the prognosis of mortality and/or myocardial infarction/stroke beyond the resting ABI.

Postoperative neurological deficit after carotid endarterectomy: a mid-term outcome analysis.

BACKGROUND: To evaluate the neurological outcome of postoperative neurological deficit (PND) in patients undergoing carotid endarterectomy (CEA). METHODS: A total of 3.7% (n = 48) out of 1,290 consecutive patients developed PND and were assessed neurologically after a mid-term follow-up. RESULTS: After a 4-year follow-up, these patients were neurologically reevaluated. Clinical assessment revealed that 48% (n = 13) of the patients had a Rankin scale score of 0 or 1, 56% (n = 14) had a National Institutes of Health Stroke Scale score of 0 or 1, and 68.5% (n = 17) reached the maximum score on the Barthel index. CONCLUSIONS: The neurofunctional prognosis of PND is good. Four years after CEA, almost half of the patients had normal or near-normal neuroclinical findings.

Peripheral arterial disease as an independent predictor for excess stroke morbidity and mortality in primary-care patients: 5-year results of the getABI study.

BACKGROUND: There is controversial evidence with regard to the significance of peripheral arterial disease (PAD) as an indicator for future stroke risk. We aimed to quantify the risk increase for mortality and morbidity associated with PAD. METHODS: In an open, prospective, noninterventional cohort study in the primary care setting, a total of 6,880 unselected patients > or =65 years were categorized according to the presence or absence of PAD and followed up for vascular events or deaths over 5 years. PAD was defined as ankle-brachial index (ABI) <0.9 or history of previous peripheral revascularization and/or limb amputation and/or intermittent claudication. Associations between known cardiovascular risk factors including PAD and cerebrovascular mortality/events were analyzed in a multivariate Cox regression model. RESULTS: During the 5-year follow-up [29,915 patient-years (PY)], 183 patients had a stroke (incidence per 1,000 PY: 6.1 cases). In patients with PAD (n = 1,429) compared to those without PAD (n = 5,392), the incidence of all stroke types standardized per 1,000 PY, with the exception of hemorrhagic stroke, was about doubled (for fatal stroke tripled). The corresponding adjusted hazard ratios were 1.6 (95% confidence interval, CI, 1.1-2.2) for total stroke, 1.7 (95% CI 1.2-2.5) for ischemic stroke, 0.7 (95% CI 0.2-2.2) for hemorrhagic stroke, 2.5 (95% CI 1.2-5.2) for fatal stroke and 1.4 (95% CI 0.9-2.1) for nonfatal stroke. Lower ABI categories were associated with higher stroke rates. Besides high age, previous stroke and diabetes mellitus, PAD was a significant independent predictor for ischemic stroke. CONCLUSIONS: The risk of stroke is substantially increased in PAD patients, and PAD is a strong independent predictor for stroke.

Mortality and vascular morbidity in older adults with asymptomatic versus symptomatic peripheral artery disease.

BACKGROUND: Our aim was to assess the mortality and vascular morbidity risk of elderly individuals with asymptomatic versus symptomatic peripheral artery disease (PAD) in the primary care setting. METHODS AND RESULTS: This prospective cohort study included 6880 representative unselected patients >or=65 years of age with monitored follow-up over 5 years. According to physician diagnosis, 5392 patients had no PAD, 836 had asymptomatic PAD (ankle brachial index <0.9 without symptoms), and 593 had symptomatic PAD (lower-extremity peripheral revascularization, amputation as a result of PAD, or intermittent claudication symptoms regardless of ankle brachial index). The risk of symptomatic compared with asymptomatic PAD patients was significantly increased for the composite of all-cause death or severe vascular event (myocardial infarction, coronary revascularization, stroke, carotid revascularization, or lower-extremity peripheral vascular events; hazard ratio, 1.48; 95% confidence interval, 1.21 to 1.80) but not for all-cause death alone (hazard ratio, 1.13; 95% confidence interval, 0.89 to 1.43), all-cause death/myocardial infarction/stroke (excluding lower-extremity peripheral vascular events and any revascularizations; hazard ratio, 1.18; 95% confidence interval, 0.92 to 1.52), cardiovascular events alone (hazard ratio, 1.20; 95% confidence interval, 0.89 to 1.60), or cerebrovascular events alone (hazard ratio, 1.33; 95% confidence interval, 0.80 to 2.20). Lower ankle brachial index categories were associated with increased risk. PAD was a strong factor for the prediction of the composite end point in an adjusted model. CONCLUSIONS: Asymptomatic PAD diagnosed through routine screening in the offices of primary care physicians carries a high mortality and/or vascular event risk. Notably, the risk of mortality was similar in symptomatic and asymptomatic patients with PAD and was significantly higher than in those without PAD. In the primary care setting, the diagnosis of PAD has important prognostic value.

Short and midterm results after left subclavian artery coverage during endovascular repair of the thoracic aorta.

BACKGROUND: To analyze the sequelae of the intentional left subclavian artery (LSA) coverage during thoracic endovascular aortic repair (TEVAR). METHODS: Retrospective analysis of prospectively collected data in a single center. Between March 1997 and October 2008, 88 of 220 patients (40%) had thoracic aortic lesions that required LSA coverage during TEVAR. Thirty-four of our patients (39%) were treated under urgent or emergent conditions for acute pathologies. The proximal landing zone was zone 0 in 10 patients (11%), zone 1 in 24 patients (27%), and zone 2 in 54 patients (61%). Debranching procedures of the supra-aortic vessels were performed in patients who were to undergo zone 0 or zone 1 deployment. Primary LSA revascularization was performed in 22 of the 88 patients (25%) at a median of 6 days before TEVAR. Median follow-up was 26.4 months (1-98 months). RESULTS: Technical success was achieved in 97%. Five primary (9%) and two secondary (4%) type Ia endoleaks in patients who underwent zone 2 deployment were observed and required further interventions. Fourteen (16%) primary type II endoleaks were observed; 10 of them fed by the LSA. Paraplegia rate was lower in patients with LSA coverage without revascularization than in other patients (1.5% vs 1.9%; odds ratio [OR], 0.774; 95% confidence interval [CI], 0.038-6.173; P = 1.000). Prior or concomitant infrarenal aortic replacement (P = .0019), renal insufficiency (glomerular filtration rate < 90 mL/min/1.73 m(2)) (P = .0024) and long segment aortic coverage (>200 mm) (P = .0157) were associated with significant higher risk of postoperative paraplegia. Stroke rate was lower in patients with LSA coverage without revascularization than in other patients (3% vs 3.9%; OR, 0.570; 95% CI, 0.118-2.761; P = .7269). Two patients (3%) developed left upper extremity symptoms and another two patients (3%) subclavian steal syndrome and required secondary LSA revascularization. The technical success rate for LSA revascularization was 94%. CONCLUSION: By using a selective approach to the LSA revascularization, coverage of the LSA can be used to extend the proximal seal zone for TEVAR without increasing the risk of spinal cord ischemia or stroke. Indications for revascularization include long segment aortic coverage, prior or concomitant infrarenal aortic replacement, and renal insufficiency. In addition, a hypoplastic right vertebral artery, a patent left internal mammary artery graft, and a functioning dialysis fistula in the left arm would also be indications to perform revascularization.

Late outcome after surgical management of carotid body tumors from a 20-year single-center experience.

BACKGROUND AND AIMS: Surgical resection is the treatment of choice for carotid body tumors. The aim of this study was to assess not only the perioperative, but also the long-term outcome after surgical treatment. PATIENTS/METHODS: All patients that were operated on a carotid body tumor at our institution between 1986 and 2006 were reviewed. Data collection included patient profile, intraoperative findings and postoperative outcome. RESULTS: Seventeen patients (11 female, six male) with 17 carotid body tumors (12 right, five left sided) were identified. Mean patient age at treatment was 49 years (range 19 to 76 years). Eight patients (47.1%) had large Shamblin type III tumors. Complete tumor resection was achieved in 16 of 17 cases (94.1%). Malignacy could not be proven in any patient. The 30-day mortality and stroke rates were 0. The incidence of temporary and permanent cranial nerve deficit was 41.2% and 11.8%, respectively. Patients with type III tumors had significantly higher risk of neurologic complications than patients with smaller tumors (p = 0.0152). The median postoperative follow-up was 6.4 years (range 1.5 to 20 years). The overall survival rate was 82.4%; the disease-specific survival rate was 94.1% (16 of 17 patients). One patient (5.6%) died of local tumor recurrence 3 years after a R1 resection. All the other patients showed no signs of local recurrence or metastases. CONCLUSIONS: The surgical therapy of carotid body tumors shows low long-term morbidity, mortality, and recurrence rates. Cranial nerve injury is mostly temporary but a relevant procedure-related complication. Surgical resection is indicated also for small, asympomatic tumors, because of the uncomplicated resectability of these tumors.

Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial.

BACKGROUND: The SPACE trial is a multinational, prospective, randomised study to test the hypothesis that carotid artery stenting is not inferior to carotid endarterectomy for treating patients with severe symptomatic carotid artery stenosis. We did not prove non-inferiority of carotid artery stenting compared with carotid endarterectomy for the 30-day complication rate, and we now report the results at 2 years. METHODS: Between March, 2001, and February, 2006, patients with symptomatic, severe (>or=70%) carotid artery stenosis were recruited to this non-inferiority trial and randomly assigned with a block randomisation design to have carotid artery angioplasty with stenting or carotid artery endarterectomy. 2-year endpoints include several clinical endpoints and the incidence of recurrent carotid stenosis of at least 70%. Clinical and vascular follow-up was done by a certified neurologist. Analyses were by intention to treat and per protocol. This trial is registered with ISRCTN, number 57874028.12. FINDINGS: 1 214 patients were randomly assigned (613 were randomly assigned to carotid angioplasty with stenting and 601 were randomly assigned to carotid endarterectomy). In both the intention-to-treat and per-protocol analyses the Kaplan-Meier estimates of ipsilateral ischaemic strokes up to 2 years after the procedure and any periprocedural stroke or death do not differ between the carotid artery stenting and the carotid endarterectomy groups (intention to treat 9.5%vs 8.8%; hazard ratio (HR) 1.10, 95%CI 0.75 to 1.61; log-rank p=0.62; per protocol 9.4%vs 7.8%; HR 1.23, 95%CI 0.82 to 1.83; log-rank p=0.31). In both the intention-to-treat and per-protocol populations, recurrent stenosis of 70% or more is significantly more frequent in the carotid artery stenting group compared with the carotid endarterectomy group, with a life-table estimate of 10.7% versus 4.6% (p=0.0009) and 11.1% versus 4.6% (p=0.0007), respectively. Only two incidences of recurrent stenoses after carotid artery stenting led to neurological symptoms. INTERPRETATION: After 2 years' follow-up, the rate of recurrent ipsilateral ischaemic strokes reported in the SPACE trial is similar for both treatment groups. The incidence of recurrent carotid stenosis at 2 years, as defined by ultrasound, is significantly higher after carotid artery stenting. However, it cannot be excluded that the degree of in-stent stenosis is slightly overestimated by conventional ultrasound criteria.

Open decompression, proximal banding, and aneurysm sac fenestration as an alternative to conversion in the management of endotension after EVAR.

PURPOSE: To present a technique to treat endotension and avoid surgical conversion after endovascular aneurysm repair (EVAR). TECHNIQUE: The surgical procedure is based on decompression, downsizing, and fenestration of the aneurysm sac combined with proximal aortic neck banding and transmural endograft fixation with sutures. Among 193 patients who underwent infrarenal EVAR between October 2001 and October 2007, 3 (1.5%) patients developed endotension without evidence of endoleak (increasing aneurysm diameter in 2 and a pulsating aneurysm with unchanged diameter in the third). This technique was applied successfully in uneventful procedures. Considerable shrinkage of the aneurysm sac has been observed over a 13- to 31-month follow-up. CONCLUSION: This open surgical procedure is a safe and effective treatment for endotension and can avoid conversion. More experience is needed for definitive evaluation.

Hybrid procedures for thoracoabdominal aortic aneurysms and chronic aortic dissections - a single center experience in 28 patients.

OBJECTIVE: We report our 6-year experience with the visceral hybrid procedure for high-risk patients with thoracoabdominal aortic aneurysms (TAAA) and chronic expanding aortic dissections (CEAD). METHODS: Hybrid procedure includes debranching of the visceral and renal arteries followed by endovascular exclusion of the aneurysm. A series of 28 patients (20 male, mean age 66 years) were treated between January 2001 and July 2007. Sixteen patients had TAAAs type I-III, one type IV, four thoracoabdominal placque ruptures, and seven patients CEAD. Patients were treated for asymptomatic, symptomatic, and ruptured aortic pathologies in 20, and 4 patients, respectively. Two patients had Marfan's syndrome; 61% had previous infrarenal aortic surgery. The infrarenal aorta was the distal landing zone in 70%. In elective cases, simultaneous approach (n = 9, group I) and staged approach (n = 11, group II) were performed. Mean follow-up is 22 months (range 0.1-78). RESULTS: Primary technical success was achieved in 89%. All stent grafts were implanted in the entire thoracoabdominal aorta. Additionally, three patients had previous complete arch vessel revascularization. Left subclavian artery was intentionally covered in three patients (11%). Thirty-day mortality rate was 14.3% (4/28). One patient had a rupture before the staged endovascular procedure and died. Overall survival rate at 3 years was 70%, in group I 80%, and in group II 60% (P = .234). Type I endoleak rate was 8%. Permanent paraplegia rate was 11%. Three patients required long-term dialysis (11%). Peripheral graft occlusion rate was 11% at 30 days. Gut infarction with consecutive bowel resection occurred in two patients. There was no significant difference between group I and II regarding paraplegia and complications. CONCLUSIONS: Early results of visceral hybrid repair for high-risk patients with complex and extended TAAAs and CEADs are encouraging in a selected group of high risk patients in whom open repair is hazardous and branched endografts are not yet optional.

Thoracic aortic endografting in patients with connective tissue diseases.

PURPOSE: To present midterm results after thoracic endovascular aortic repair (TEVAR) in patients with connective tissue diseases focusing on secondary endoleak and reintervention due to disease progression. METHODS: Between January 1997 and January 2007, 167 patients received 241 thoracic aortic stent-grafts. Eight patients (6 men; median age 48 years, range 32-67) with connective tissue diseases (6 Marfan and 2 Ehlers-Danlos syndrome) treated with stent-graft repair were retrospectively analyzed at a median follow-up of 31 months (range 3-79). Surveillance included postoperative computed tomographic angiography and/or magnetic resonance imaging exams prior to discharge, at 3, 6, and 12 months, and yearly thereafter. RESULTS: Technical success of endovascular placement was 88% due to 1 primary type I endoleak. There were no perioperative deaths, and there have been no conversions to open surgery so far. Perioperative complications occurred in 2 (25%) of the 8 patients. Endoleaks were observed in 3 patients (primary type I, secondary type I, and type II). The reintervention rate was 38%. Progression of disease resulting in de novo aneurysms or aortic expansion occurred in 4 (50%) patients. Seven (88%) patients are alive. There was no disease- or procedure-related death. CONCLUSION: TEVAR in patients with connective tissue diseases is feasible but still questionable regarding their young age and the rates of endoleaks and reintervention due to disease progression. Close surveillance is mandatory. Low morbidity and mortality rates may justify TEVAR in emergencies as a "bridging" method.

Clinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stent-protected angioplasty: a subanalysis of the SPACE study.

BACKGROUND: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are used to prevent ischaemic stroke in patients with stenosis of the internal carotid artery. Better knowledge of risk factors could improve assignment of patients to these procedures and reduce overall risk. We aimed to assess the risk of stroke or death associated with CEA and CAS in patients with different risk factors. METHODS: We analysed data from 1196 patients randomised to CAS or CEA in the Stent-Protected Angioplasty versus Carotid Endarterectomy in Symptomatic Patients (SPACE) trial. The primary outcome event was death or ipsilateral stroke (ischaemic or haemorrhagic) with symptoms that lasted more than 24 h between randomisation and 30 days after therapy. Six predefined variables were assessed as potential risk factors for this outcome: age, sex, type of qualifying event, side of intervention, degree of stenosis, and presence of high-grade contralateral stenosis or occlusion. The SPACE trial is registered at Current Controlled Trials, with the international standard randomised controlled trial number ISRCTN57874028. FINDINGS: Risk of ipsilateral stroke or death increased significantly with age in the CAS group (p=0.001) but not in the CEA group (p=0.534). Classification and regression tree analysis showed that the age that gave the greatest separation between high-risk and low-risk populations who had CAS was 68 years: the rate of primary outcome events was 2.7% (8/293) in patients who were 68 years old or younger and 10.8% (34/314) in older patients. Other variables did not differ between the CEA and CAS groups. INTERPRETATION: Of the predefined covariates, only age was significantly associated with the risk of stroke and death. The lower risk after CAS versus CEA in patients up to 68 years of age was not detectable in older patients. This finding should be interpreted with caution because of the drawbacks of post-hoc analyses.

Delayed diagnosis of a pseudoaneurysm with recurrent hemarthrosis of the knee joint.

This is a case report of recurrent hemarthrosis of the knee joint over 3 months. The patient, a 47-year-old male had three arthroscopic procedures with multiple joint punctures over a 3-month-period prior to our initial consultation. The first procedure (arthroscopic synovectomy) was done for suspected infection following a series of hyaluronic acid injections. Recurrent hemarthrosis developed subsequent to this. Upon further evaluation, a pseudoaneurysm of the superior middle genicular artery was detected and successfully treated with selective angiographic embolization.

Feeding arteries of the spinal cord at CT angiography before and after thoracic aortic endografting.

PURPOSE: To study the visualization of spinal cord feeding arteries in patients with complex thoracic aortic pathology undergoing endovascular aortic repair (EVAR) using an optimized protocol for multislice computed tomographic angiography (MSCTA). METHODS: Eighteen consecutive patients (13 men; mean age 63 years, range 45-79) with aortic type B dissections (n=5), chronic expanding aortic dissections (n=5), thoracic aortic aneurysms (n=6), or penetrating aortic ulcers (n=2) underwent 16-slice CTA before and after (mean interval 9 days) EVAR. Pulse rate and neurological status were documented. Quantitative density measurements were taken at regions of interest (ROI) in the ascending thoracic aorta and at the level of the diaphragm. Two experienced radiologists qualitatively assessed the posterior intercostal arteries (PIA; fully visible, partially visible, non-visible), dorsal branches (DB; visible/non-visible), and artery of Adamkiewicz (AKA; visible/non-visible) on multiplanar reformations and maximum intensity projection reconstructions. RESULTS: MSCTA was performed successfully in 17/18 patients before and after EVAR (1 patient was excluded after EVAR owing to rising creatinine levels). Before EVAR, MSCTA revealed 197/203 PIAs within the stented area, of which 179 were fully and 18 partially visible. No significant (p=0.37) difference was noted for overall PIA detection within the stented area on post-EVAR MSCTA (185/203 PIA), although only 124 were fully and 61 partially visible. Similar results were obtained for DB visualization. The AKA were seen in 10/17 patients pre EVAR and 9/17 post EVAR. In 2 patients, the AKA was localized within the stented aortic segment. ROI analysis revealed contrast densities of 427+/-89 HU and 398+/-84 HU on pre- and post-EVAR MSCTA, respectively. No neurological events were observed. CONCLUSION: The majority of posterior intercostal arteries and dorsal branches remain open after EVAR due to retrograde perfusion. High-resolution MSCTA permits accurate pre- and post-EVAR visualization of spinal cord feeding arteries in patients with thoracic aortic pathology.

Late aneurysm rupture after repressurization of a thrombosed stent-graft.

PURPOSE: To report late abdominal aortic aneurysm (AAA) rupture after endovascular stent-graft repair despite complete thrombotic stent-graft occlusion. CASE REPORT: A 65-year-old man underwent successful endovascular aneurysm repair (EVAR) with a Stentor device in 1995. In the interim course, the patient developed complete thrombotic stent-graft occlusion, which was treated with an axillobifemoral bypass. After 8 years, the patient presented with a reperfused and ruptured infrarenal AAA. Open repair was performed, with a good clinical result and exclusion of the AAA. CONCLUSION: Thrombosed stent-grafts and aneurysms can transmit systemic arterial pressure and cause late rupture. Lifelong surveillance is mandatory in EVAR patients.

Early and midterm results after open and endovascular repair of ruptured abdominal aortic aneurysms in a comparative analysis.

PURPOSE: To compare early and midterm results of open versus endovascular aortic repair of ruptured abdominal aneurysms (rAAA). METHODS: A retrospective analysis was performed of 58 consecutive patients with rAAA who were treated with open or endovascular aneurysm repair (EVAR) at a single center between January 2000 and December 2005. Patients without definitive signs of rupture (symptomatic patients) were excluded from the study. Twenty-nine patients (21 men; median age 71 years) were treated using endovascular techniques (EVAR group) and 29 (28 men; median age 71 years) with open repair (OR group). The hemodynamic status at the time of admission was evaluated with respect to blood pressure, pulse rate, and hemoglobin level to reduce selection bias. Patients underwent follow-up by clinical examination and computed tomography. RESULTS: The 30-day mortality rate was 31% (9/29) in each group (p = 1.0); the morbidity rates also did not differ between groups [16 (55.2%) EVAR vs. 18 (62.1%) OR; p = 0.9]. There was 1 (3.4%) primary conversion in the EVAR group and 7 (24.1%) endoleaks [3 (10.3%) primary; 4 (13.8%) secondary]. There was no difference between the groups with regard to intensive care unit stay (4 days for EVAR vs. 3 days for OR, p = 0.98) or total hospital stay (9 days for EVAR vs. 12 days for OR, p = 0.69). After a mean follow-up of 40.25 months (range 1-70), the midterm mortality rates did not differ [5 (17.2%) EVAR vs. 3 (10.3%) OR, p = 0.41]. CONCLUSION: EVAR of rAAAs is feasible, with equal early and midterm mortality rates compared to open repair. When a defined patient selection is used for rupture, including hemodynamic status, there is no evidence of a better outcome with EVAR in emergency cases.

[Importance of the ankle-brachial index (ABI) in the prevention of cardiovascular diseases. Ten questions and answers]. / Stellenwert des Knöchel-Arm-Index (ABI) in der Prävention kardiovaskulärer Erkrankungen : Zehn Fragen und Antworten.

Leg artery stenoses often indicate generalized atherosclerosis of the arterial circulation. They can easily and reliably be diagnosed by the family physician or the nurse with Doppler ultrasound measurements and the calculation of the ankle-brachial index (ABI). A decreased value (< 0.9) is not only a sign of peripheral arterial disease, but is also associated with a doubled risk of future coronary or cerebrovascular events. Patients with a low ABI, even if yet asymptomatic, should receive intensive preventive measures in the same manner and intensity as patients with coronary heart disease.

Hybrid procedures as a combined endovascular and open approach for pararenal and thoracoabdominal aortic pathologies.

OBJECTIVES: to report our experience with hybrid vascular procedures in patients with pararenal and thoracoabdominal aortic pathologies. METHODS: 68 patients were treated for thoracoabdominal aortic pathologies between October 1999 and February 2004; 19 patients (16 men; mean age 68, range 40-79) with high risk for open thoracoabdominal repair were considered to be candidates for combined endovascular and open repair. Aortic pathologies included five thoracoabdominal Crawford I aneurysms, one postdissection expanding aneurysm, three symptomatic plaque ruptures (Crawford IV), five combined thoracic descending and infrarenal aneurysms with a healthy visceral segment, three juxtarenal or para-anastomotic aneurysms, and two patients with simultaneous open aortic arch replacement and a rendezvous maneuver for thoracic endografting. Commercially available endografts were implanted with standardized endovascular techniques after revascularization of visceral and renal arteries. RESULTS: Technical success was 95%. One patient developed a proximal type I endoleak after chronic expanding type B dissection and currently is waiting conversion. Nine patients underwent elective, five emergency and five urgent (within 24 h) repair. 17 operations were performed simultaneously, and 2 as a staged procedure. Postoperative complications include two retroperitoneal hemorrhages, and one patient required long-term ventilation with preexisting subglottic tracheal stenosis. Thirty-day mortality was 17% (one multiple organ failure, one secondary rupture after open aortic arch repair, one myocardial infarction). Paraplegia or acute renal failure were not observed. Total survival rate was to 83% with a mean follow-up of 30 months. CONCLUSIONS: Midterm results of combined endovascular and open procedures in the thoracoabdominal aorta are encouraging in selected high risk patients. Staged interventions may reduce morbidity.

Impaired Fas-induced apoptosis of T lymphocytes in patients with abdominal aortic aneurysms.

OBJECTIVE: Homeostasis of the immune system is maintained by apoptotic elimination of potentially pathogenic autoreactive lymphocytes. Emerging evidence shows that Fas-mediated apoptosis is impaired in activated lymphocytes from patients with autoimmune disease. The aim of this work was to assess apoptosis mediated by the cell death receptor Fas in peripheral T lymphocytes from patients with abdominal aortic aneurysms (AAA). METHODS: The apoptotic pathway was triggered by anti-Fas monoclonal antibodies in cultured and activated peripheral T-cell lines from 20 AAA patients with control groups of 15 patients with aortic atherosclerotic occlusive disease (AOD) and 25 healthy individuals. Cell survival and death (apoptosis) rate were assessed. RESULTS: Cross-linkage of Fas receptor exerted a strong apoptotic response on T cells from AOD patients and healthy controls, but a much less pronounced effect on T cells from AAA patients. The evaluation of cell survival rate showed a significantly higher percentage in AAA group (98.9% +/- 10.3%) than in the AOD subjects (58.9% +/- 15.2%) or the healthy group (59.4% +/- 12.9%; P < .001). Apoptosis assessment by annexin V and propidium iodide staining and flow cytometry showed similar results. The defect in AAA group was not due to decreased Fas expression, since Fas was expressed at normal levels. Moreover, it specifically involved the Fas system because cell death was induced in the normal way by methylprednisolone. Complementary DNA sequencing identified no causal Fas gene mutation, but two silent single nucleotide polymorphisms with higher frequency were found in the AAA group. CONCLUSIONS: Fas-induced apoptosis in activated T cells from AAA patients is impaired. This may disturb the normal down-regulation of the immune response and thus provide a new insight into possible mechanisms and routes in the pathogenesis of AAA.