Outcomes of segmental femoral artery pseudoaneurysm in patients with Behçet's disease: a single center's experience.

BACKGROUND: Behçet's disease (BD) is an autoimmune condition that involves multiple systems. The most common arterial manifestation in BD patients is pseudoaneurysm, which has higher frequency than aneurysm formation. OBJECTIVES: To clarify the importance of profunda femoris artery in BD pseudoaneurysm, and present a new method for identifying healthy segments for anastomosis. METHODS: Fifteen patients presented at a vascular department with pseudoaneurysms of the common femoral (CFA) and superficial femoral artery (SFA), were diagnosed with BD and underwent surgical intervention at Kasr al Ainy hospitals over 2 years. RESULTS: All patients were male. The patients ranged in age from 30 to 40 years (mean, 33.8±2.6 years). Mean duration of the disease was 5±3.4 years. Eight (53.3%) CFA graft interpositions, six (40%) mid SFA graft interpositions, and one (6.66) distal SFA graft interposition were performed. Eight (53.3%) of these operations were performed using Dacron graft and sartorius flap, three (20%) were performed with a polytetrafluoroethylene graft, and four (26.66) with a great saphenous vein graft. Two cases (13.33%) were accidentally discovered while four cases (26.66%) had short distance claudication, four cases (26.66%) had pain at rest, and five cases (33.33%) presented with pulsatile swelling correlated with pseudoaneurysm size (p = 0.005). Patients were followed-up over 1 year for new aneurysms and recurrence. CONCLUSIONS: Surgical repair with muscle flap coverage, with or without ligation of profunda femoris artery, does not affect prognosis. An alternative method for identifying healthy segments of femoral artery may be frozen section and examination of the artery to decrease the risk of recurrence at the site of anastomosis.

CONTEXTO: A doença de Behçet (DB) é uma enfermidade autoimune que envolve múltiplos sistemas. A manifestação arterial mais comum em pacientes com DB é o pseudoaneurisma, que tem uma frequência mais alta do que a formação de aneurismas. OBJETIVOS: Esclarecer a importância da artéria femoral profunda no pseudoaneurisma por DB e apresentar um novo método para a identificação de segmentos saudáveis para anastomose. MÉTODOS: Quinze pacientes se apresentaram em um departamento vascular com pseudoaneurismas da artéria femoral comum (AFC) e artéria femoral superficial (AFS), foram diagnosticados com DB e foram submetidos a intervenção cirúrgica em hospitais Kasr al Ainy ao longo de 2 anos. RESULTADOS: Todos os pacientes eram do sexo masculino. A idade variou de 30 a 40 anos (média, 33,8±2,6 anos). A duração média da doença foi de 5±3,4 anos. Foram realizadas oito (53,3%) interposições de enxerto na AFC, seis (40%) interposições de enxerto na AFS média, e uma (6.66) interposição de enxerto na AFS distal. Oito (53,3%) das cirurgias foram realizadas utilizando enxertos de Dacron e retalho sartório, três (20%) com enxertos de politetrafluoroetileno, e quatro (26,66) com enxertos da veia safena magna. Dois casos (13,33%) foram descobertos ao acaso, ao passo que quatro casos (26,66%) apresentaram claudicação em curta distância, quatro (26,66%) apresentaram dor em repouso, e cinco casos (33,33%) apresentaram com inchaço pulsátil correlacionado com o tamanho do pseudoaneurisma (p = 0.005). Os pacientes foram seguidos por 1 ano para novos aneurismas e recorrência. CONCLUSÕES: O reparo cirúrgico com cobertura de retalho muscular, com ou sem ligadura da artéria femoral profunda, não afeta o prognóstico. Um método alternativo para identificar segmentos saudáveis da artéria femoral pode ser o exame de congelação e a avaliação da artéria para diminuir o risco de recorrência no local da anastomose.

Management of Buerger's Disease in Endovascular Era.

This study was aimed to report data on the feasibility, safety, and effectiveness of endovascular procedures in a thromboangiitis obliterans diagnosed patients presenting with critical limb ischemia (CLI). Prospective study conducted on patients affected by Buerger's disease who presented to our center along 2 years. Clinical, radiological, and patient-based outcomes were recorded at 3, 6, and 12 months after the intervention. Total 39 patients were included in the study. Fifteen (38.5%) patients underwent percutaneous transluminal angioplasty, another 15 patients (38.5%) underwent follow-up on medical treatment, there are four other patients (10.3%) underwent surgical bypass, and five (12.8%) patients underwent lumbar sympathectomy. The 12 months' outcome showed 66.7% technical success in endovascular group with 46.7% patency rate ( p -value = 0.06), 86.7% limb salvage rate (LSR; p -value < 0.04), and 66.7% clinical improvement ( p -value = 0.005). The endovascular management of Buerger's disease is feasible, save, and effective with high rate of LSR and clinical improvement.

Using serum s100-ß protein as a biomarker for comparing silent brain injury in carotid endarterectomy and carotid artery stenting.

BACKGROUND: S100-ß protein has been introduced as a sensitive biomarker of silent cerebral injury. This study compares its serum levels before, during, and 24 hours after carotid artery stenting (CAS) and carotid endarterectomy (CEA). METHODS: We measured serum level of S100-ß in arterial blood before (S100Ba), during (S100Bb), and 24 hours after (S100Bc) CAS and CEA. We assessed differences in S100-ß levels using non-parametric tests. We analyzed the relationship between carotid plaque type (echolucency) and S100-ß protein level. We also examined its relation to the oximetry results in the CEA group (ipsilateral and contralateral). RESULTS: Thirty patients were enrolled, including 15 CAS and 15 CEA patients, with no significant differences in baseline atherosclerotic characteristics. There was no significant difference in S100Ba or S100Bb levels between CAS and CEA patients. However, a significant difference was found in S100Bc: 331.3 pg/mL (IQ range 56.4-583.5) for CAS vs. 76.3 pg/mL (IQ range 29.7-117.4) for CEA (P=0.01). Type I and II plaques were associated with the higher S100Bc levels in CAS (P=0.048). S100Bc was higher in CEA patients when the contralateral cerebral hemisphere had oximetry values less than 60% (P=0.043). CONCLUSIONS: Our study suggests that CAS might produce silent brain injury. Moreover, vulnerable plaques might be associated with higher levels of S100-ß protein, especially in CAS. This pilot study demonstrates that S100-ß is a useful biomarker for silent brain injury in carotid revascularization. Large scale studies are still needed to confirm these findings.

Oncovascular Surgery and the Making of the Oncovascular Surgeon.

Patients diagnosed with tumors that are located in vicinity of the major axial vessels are inconsistently managed because they are often considered unresectable. The management of these patients remains at the periphery of various established sub-specialties that are prevalent under the current medical specialty. These patients are required to be treated by an oncovascular surgeon. This article discusses some key points in understanding the reasons for establishing a specialty branch, oncovascular surgery, to treat complex tumors with vessel invasion. This article also reviews important issues about leadership and how to train and educate oncovascular surgeons.

Management of critical lower limb ischemia in endovascular era: experience from 511 patients.

This study aims at the assessment of the achievability of the endovascular treatment of patients with critical limb ischemia (CLI) and the role of bypass in such patient. This is a prospective study conducted on patients with chronic atherosclerotic critical lower limb ischemia presenting to us over a period of 3 years. Patients presenting with nonsalvageable limbs requiring primary major amputation and nonatherosclerotic causes of CLI were excluded. Endovascular treatment was the first choice modality of treatment in revascularization of all patients. Open surgery was offered selectively for patient whom endovascular failed or complicated and for long TransAtlantic Inter-Society Consensus (TASC) II lesions in fit patients. This study included 511 cases of CLI, and the mean age was 64.5 years. Patients with Rutherford IV, V, and VI were 19.25, 60.5, and 19.25%, respectively. The TASC II aortoiliac lesions were as follows: A, B, C, and D in 33.7, 12,15.7, and 38.6%, respectively, and infrainguinal lesions were A, B, C, and D in 3.7, 19, 35.4, and 68.3%, respectively. A total of 78.3% of patients were treated by endovascular totally, while 16% were treated by surgery from the start, 3.7% of endovascular cases were converted to open surgery after failure of endovascular treatment, and 2% was offered hybrid treatment. Crossing of lesions by subintimal and intraluminal was 12.5 and 87.5%, respectively. Technical success in endovascular was 94%; however, we could successfully revascularize 96.8% of all CLI presented in this study by either surgery or endovascular. On 24 months follow-up, primary patency, secondary patency, and limb salvage by percutaneous transluminal angioplasty are 77.8, 84.7, and 90.7%, respectively. Revascularization by endovascular achieves high technical success and limb salvage in CLI, hence should be considered as preferred choice of treatment. However, both endovascular and surgery should not be counteracting each other and using both can revascularize 96.6% of CLI.

Carotid body tumors: a review of 25 years experience in diagnosis and management of 56 tumors.

OBJECTIVE: To report our experience in the management of CBTs and review the literature. MATERIALS AND METHODS: 56 CBTs were operated upon over a period of 25 years. Surgical intervention was planned according to the Shamblin classification. Thirty-nine of the tumors were in males (69.64%), and 17 of the tumors were in females (30.36%). The average age was 42 (ages ranging between 32 and 47). Twenty-two tumors were diagnosed and treated with Shamblin type I, twenty-eight with type II and eight tumors with type III. All patients were unilateral except two had bilateral carotid tumors. Thirty-five lumps were de novo (group A), while 21 lumps were treated after a prior trial of removal (group B). RESULTS: The incidence of carotid reconstruction was lower among group A (1/35) compared to group B (9/21). Complications were less in group A than group B (23% vs. 30%). There were 4 cases with suspected malignancy and no recurrences during the follow-up period. CONCLUSION: There is an increased incidence of major vascular reconstruction in cases not properly investigated or diagnosed and in cases with prior attempts of removal in Primary Hospitals. Proper diagnosis of suspicious lumps is mandatory. Resection of CBTs by surgeons with experience in vascular reconstruction is recommended. Vascular reconstructions have to be performed safely without serious complications. Also today, prior attempts of removal are not so common, with preoperative evaluation using the latest diagnostic tools. Cranial nerves injury (especially the Hypoglossal Nv) continues to be the most common complication.

Low-grade endometrial stromal sarcoma with intravenous extension to the heart.

Endometrial stromal sarcoma (ESS) is a rare neoplasm of uterine origin. Intracardiac metastasis from this tumor is extremely infrequent. This report describes a 24-year-old woman from Yemen who had irregular vaginal bleeding shortly after spontaneous abortion. She developed left-lower-limb swelling, diagnosed by duplex scanning and magnetic resonance imaging as deep venous thrombosis in the inferior vena cava (IVC) that extended into the iliac veins on both sides, as well as the left femoral vein and right atrium. She developed acute respiratory distress, from which she recovered after transfer to the intensive care unit. Transesophageal echocardiography showed a large mass occupying the right atrium and ventricle and another mass in the right ventricular outflow tract with areas of cavitations. The tumor appeared to come from the IVC and extended through the right atrium and right ventricle into the pulmonary artery, ending in several digit-like projections. After surgical resection of the intracardiac mass, pathologic examination revealed a low-grade ESS that was confirmed by immunohistochemistry. The patient underwent panhysterectomy and IVC debridement. Pathologic examination revealed infiltrating low-grade endometrial sarcoma invading the myometrium and left adnexa, with intravenous extension into the pelvic veins and the IVC to the right side of the heart. This case shows that despite its well-known good prognostic nature, low-grade ESS may behave as an aggressive malignancy.