Circulating biomarkers for abdominal aortic aneurysm: what did we learn in the last decade?

AIM: Abdominal aorta aneurysm (AAA) is a serious threat for human life, especially in such cases when it is asymptomatic until aneurysm rupture, which is a general cause of death in AAA subjects. We aim to give a conceptual description of the potential biomarkers that can correlate and predict the natural history of an AAA. METHODS: The MEDLINE/PubMed database was searched for publications with the medical subject heading "abdominal aortic aneurysms (AAA)" and the keyword "biomarkers". We restricted our search to English till January 2012. We focused on human studies that reported aneurysm size, expansion rates and/or rupture and the studied biomarkers. RESULTS: In this review we included 94 articles (4 reviews) that were accessible and available in English. We excluded articles referred exclusively to thoracic aneurysms and cardiac studies. CONCLUSION: There are no specific laboratory markers that would allow one to distinguish in a simple way between aneurysm bearers and the healthy population. Serum elastase peptides seem still to be sufficient biomarkers to predict expansion and rupture, but advanced techniques (ELISA) and larger studies are needed to establish its exact role. Plasmin-antiplasmin complexes (PAP) may also have clinical potential. Newer biomarkers may also have a role, not well established yet. Beyond that, there are many limitations related to the fact that many biomarkers related with AAA outcome are not disease specific, due to their established correlation with atherosclerosis. Future research is required to establish the underlying relations between these biomarkers and their role in AAA pathophysiology.

Guided remote endarterectomy for superficial femoral artery occlusions: a technical note.

The aim of this paper was to describe a new modification of the remote endarterectomy for the treatment of long superficial femoral artery (SFA) occlusions and to present our preliminary results. Through a subinguinal incision and arteriotomy over the SFA origin, a hydrophilic guidewire was introduced into the subintimal plane of the SFA and advanced distally until reentry into the distal patent popliteal artery. The hydrophilic guidewire is exchanged for an Ablatz wire to provide support for the advancement of the single endarterectomy ring. The MollRing Cutter was introduced in the SFA after the removal of the single endarterectomy ring and it was advanced until the re-entry point. The atherosclerotic core was removed and a nitinol self-expanding stent was placed at the peripheral end of the endarterectomy. Arteriotomy was closed with a patch. Guided subintimally-assisted remote endarterectomy seems to be a successful and safe modification of the traditional technique in the treatment of SFA occlusion, in patients with critical limb ischemia.

Surgical treatment of carotid body tumors without embolization.

AIM: Carotid body (CB) paragangliomas are rare neoplasms, usually benign. This study deals with our 10-year experience in their surgical treatment and the evaluation of its effectiveness, without preoperative embolization. METHODS: During a 10-year period, from 1995 to 2004, we studied the medical records of 11 patients with CB tumors, 8 males and 3 females, whom only one had bilateral tumors. Their age ranged from 23 to 65 years (mean 35 years) and all had a palpable neck mass. Only two of the patients were asymptomatic on admission to our department. Twelve tumors were surgically resected and no patient underwent preoperative selective embolism of his tumor. Two patients had carotid endarterectomies with venous patch angioplasty. No one of the patients underwent radiotherapy or chemotherapy. RESULTS: Perioperative mortality was zero. No stroke or any other cerebral event was observed. One patient, with a grade III tumor, had an injury of the internal carotid artery that was repaired with a vein patch. Three patients had temporal cranial nerve lesions that resolved within 3 months. No malignancy was found even in a 10-year follow-up. CONCLUSIONS: Early surgical treatment is strongly recommended in almost all patients. Their resection is a very challenging operation with good postoperative results. Preoperative embolism of the tumor does not need to be a routine procedure. To exclude malignancy, long term follow-up is necessary.

Simultaneous venous gangrene in both lower and upper limbs. A case report.

Cancer-related venous gangrene is an extremely rare paraneoplastic syndrome. Here, we present the case of a woman, who suffered from cervical cancer of the uterus and was admitted to our Clinic with venous gangrene in both the right lower and upper limbs. Neither the anticoagulant therapy, nor thrombolysis, succeeded in improving her clinical condition. Cancer is one of the most important causes of venous thromboembolism. Venous gangrene is rarely seen in these patients. Despite adequate therapy, venous gangrene in some very rare occasions may progress to affect further limbs. Mortality in these patients remains very high.

Simultaneous surgical treatment of abdominal aortic aneurysm and bilateral aneurysms of the internal iliac artery.

INTRODUCTION: The purpose of this study is to present our experience in the management of patients with abdominal aortic aneurysms (AAA) and aneurysms in both the internal iliac arteries (IIA) at the same time. METHODS: Between 2000 and 2005, a series of 13 patients with AAA and also aneurysms in both the IIA, were treated in our clinic. They were all men with a mean age of 74 years. The size of the IIA aneurysms (IIAA) ranged from 2.0 to 8.0 cm (mean, 3.4 cm). All patients underwent an aneurysmatectomy of the AAA and placement of a prosthetic bifurcated aorto-biiliac or -bifemoral bypass, by a transperitoneal approach. The management of one of the two IIAA was the aneurysmatectomy and the direct revascularization of the healthy peripheral portion of the remaining IIA with the ipsilateral leg of the aorto-biiliac bypass. The other IIAA was treated with proximal ligation of its neck and aneurysmorraphy. RESULTS: No patient died during the first 30 postoperative days. Morbidity was about 7.7% (one patient suffered from 'trash foot', which was treated successfully with conservative measures). Finally, the mean stay in hospital was 7 days and no patient clinically presented symptoms of pelvic or colonic ischaemia. CONCLUSIONS: Simultaneous treatment of AAA and bilateral IIA aneurysms is a technically difficult, but safe procedure, if it is performed meticulously. Revascularization of at least one internal iliac artery is strongly recommended in order to avoid dangerous complications, such as pelvic or colonic ischaemia.

Rupture of an aortic anastomotic aneurysm into a ureter.

A case of rupture of a false aneurysm of the distal aorta into the left ureter is reported. The patient presented with purulent hydronephrosis and hematuria. A left aorto-femoral graft had been inserted 3 years earlier, which became infected and was then removed. After 2 years a false distal aortic aneurysm developed, and in the last 6 months recurrent episodes of hematuria have occurred. An aorto-ureteric fistula was confirmed at surgery, and a left nephrostomy was performed with proximal and distal ligation of the ureter and then aneurysmectomy followed by aorto-bifemoral bypass.

Femoral-anterior tibial reconstructions using cuffed PTFE grafts: routing alternatives.

BACKGROUND: The anterior tibial is the less often used artery for distal anastomosis in infrapopliteal bypass with synthetic grafts; however, several investigators argue against even an attempt to use non-autologous material for such distal reconstructions. Only few studies report patency rates mixing-up popliteal below-knee and various crural bypasses. PATIENTS AND METHODS: Nineteen consecutive femoral-anterior tibial cuffed PTFE bypass grafts, either via the lateral (n = 15) or interosseous (n = 4) route, were inserted in a 10-years period. RESULTS: The 1-year and 2-year primary patency rate was 71% and 53%, respectively. It is noteworthy that in one patient a graft positioned via the lateral route remained patient for ten years. No complications were observed regarding the routing methods, whatever increased operating time was required in the interosseous route cases. The 3-year cumulative survival rate for this particular group of patients was 32%. CONCLUSIONS: Our data indicate that femoral-anterior tibial bypasses using cuffed PTFE grafts via the lateral route result in an acceptable medium-term patency. As such patients have a limited life expectancy, these procedures should be performed when an autologous vein is not available, as opposed to primary amputation.

Early disruption of proximal anastomosis of a PTFE axillofemoral bypass graft.

Exertional disruption of axillary anastomosis is a well documented, although rare, complication of axillo-femoral grafts. Comprehension of causative mechanisms is of great importance, so that precautions can be taken against it. Here, a case of an early disruption of proximal anastomosis of an axillofemoral graft is reported. Use of crutches was incriminated as the responsible mechanism.

Abdominal aortic aneurysm and hepatocellular carcinoma: a one-stage approach.

BACKGROUND: The operative management of abdominal aortic aneurysm (AAA) and co-existing intra-abdominal malignancy has been a long-standing controversy. It is unclear whether a single-stage or a two-stage approach is the more appropriate therapeutic option and also which lesion should be treated first. CASE OUTLINE: An 82-year-old man with a 4 x 5-cm mass in the left liver (segment IV), suspected to be a hepatocellular carcinoma (HCC), had a concomitant 6-cm infrarenal AAA. At the same operation he underwent a left hepatectomy followed by repair of the aneurysm. He was discharged on the 17th postoperative day. To the best of our knowledge, this is the third report in the world literature of a patient who underwent a successful simultaneous resection of an AAA and HCC and the first in which the liver resection was performed first. DISCUSSION: We recommend liver resection and AAA repair in a single-stage procedure, regardless of the time sequence of the procedures. This approach can be considered safe, and the theoretical risk of graft infection can be kept to a minimum.

Paradoxical embolism. An old but, paradoxically, under-estimated problem.

The theoretical model of paradoxical embolism requires the presence of four parameters, namely, arterial embolism, venous thrombus, abnormal intracardiac communication and right-to-left shunt. Many aspects, however, of this well known entity are under consideration; diagnosis is often difficult to be established and the long term efficacy of preventive measures is undefined. We comment on a case report of recurrent paradoxical embolism with popliteal vein thrombosis and patent foramen ovale, and we briefly review the literature.

Late non-anastomotic false aneurysm formation in femoropopliteal polyethylene terephthalate grafts.

Despite the proven reliability of polyethylene terephthlate (PET) grafts, structural defects resulting in graft rupture and false aneurysm formation have been sporadically described. Two cases of late, non anastomotic, false aneurysms of PET femoropopliteal grafts, are reported. The diagnosis is readily apparent on clinical examination and imaging studies, which display an aneurysm along the course of the graft, remote from the anastomosis. The extent of the repair depends on the extent of the degenerative process.

Therapeutic efficacy of flavonoids in oedema following reperfusion on acutely ischaemic legs.

BACKGROUND: The aim of this study was to investigate the effect of a purified, micronised, flavonoid fraction (Daflon) in lower limb oedema developed after delayed embolectomy and successful reperfusion of acutely ischaemic legs. METHODS: Our series consisted of 19 patients with prolonged, acute ischaemia of the lower extremity caused by arterial embolism, who had undergone successful embolectomy. Patients were randomised into two groups; ten patients (group I) treated with flavonoids, were compared to nine given a placebo. Ankle and calf circumferences, venous capacitance and venous emptying time were measured preoperatively [T1], on the 2nd [T2], 5th [T3], 8th [T4] and 30th [T5] postoperative days. RESULTS: An increase of ankle and calf circumference up to 9% and 13.5% respectively, as compared with preoperative values was demonstrated. There was a reduction in oedema formation in patients with the Daflon group, which reached statistical significance only in the ankles (p=0.0276). Calf differences were statistically significant on the second and fifth postoperative days (p<0.05). Venous haemodynamics were considerably improved by Daflon (p<0.001). CONCLUSIONS: Daflon 500 mg had an inhibitory effect on moderate oedema developed after revascularisation of an ischaemic limb.

Incidence and patterns of iatrogenic arterial injuries. A decade's experience.

OBJECTIVE: To investigate the incidence and patterns of all iatrogenic arterial injuries (IAI) necessitating surgical repair in a ten-year period. DESIGN: Retrospective study. SETTING: Departments of Vascular Surgery a) Athens General Hospital "G. Gennimatas" and b) Red Cross Hospital of Athens, Greece. PATIENTS: Eighty-seven patients underwent surgical repair of an IAI, comprising 36% of the 237 patients treated surgically for various arterial injuries during the same period. RESULTS: Specific injury patterns were implicated in most cases. Cardiac catheterizations were the commonest cause of IAI (n=39). The second commonest source for IAI was the renal units' personnel accountable for 17 false aneurysms, which arose at arteriovenous grafts' puncture sites. Among the surgical specialties orthopaedic surgery was the most common source of IAI (n=13). A less common pattern of IAI was following radical operations for cancer (n=7). The mortality of the series was 4.6% (4/87) and the amputation rate 2.3% (2/87). No death or amputation was associated with IAI following cardiac catheterizations confirming that post-catheterization IAI have a benign prognosis. False aneurysm was the most frequent complication when the cardiac catheterization was via the femoral artery, when the catheterization was via the brachial artery the commonest complication was arterial thrombosis. The two amputations were due to delayed reconstruction of arterial injuries that were not recognised at first sight. CONCLUSION: Common patterns characterize most IAI. Understanding their exact causes is a first step towards prevention or timely repair if the latter is not feasible.