Association between periodontal disease and vulnerable plaque morphology in patients undergoing carotid endarterectomy.

BACKGROUND: Periodontal disease (PD) is a chronic inflammatory oral condition with potentially important systemic sequelae. We sought to determine whether the presence of PD in patients with severe carotid disease was associated with morphological features consistent with carotid plaque instability. METHODS: A total of 52 dentate patients hospitalized for carotid endarterectomy (CEA) had standardized assessments of their periodontal status, including measurements of probing pocket depth (PPD), clinical attachment level (CAL) and bleeding on probing (BoP). Carotid plaque morphology was assessed by ultrasound using the gray scale median (GSM) score and by immunohistochemistry using anti-CD68 and anti-alpha-actin antibodies, markers for macrophages and smooth muscle cells (SMCs) respectively. RESULTS: In total 30/52 patients (58%) had PD. Significant associations were noted between low GSM on ultrasound and each mm in PPD (p = 0.001), each mm in CAL (p = 0.002) and with a 10% increase in BoP (p = 0.009). Using the standardized PERIO definition the association remained robust (aOR = 10.4 [95% CI:2.3-46.3], p = .002). Significant associations were also observed with high macrophage accumulation and each individual PD measure (p < 0.01 for PPD, CAL and BoP) and with the PERIO definition (aOR = 15 [95% CI:1.8-127.8], p = .01). Similarly, low SMC density was also significantly associated with individual measures of PD (p < 0.05 for PPD, CAL and BoP), but not with the PERIO definition (aOR 3.4 [95% CI:0.9-12.8], p = .07). CONCLUSIONS: The presence of PD was significantly associated with both ultrasound and immunohistochemistry features of carotid plaque instability in patients undergoing CEA.

New cerebral ischemic lesions after carotid endarterectomy.

BACKGROUND: We sought to investigate the incidence and location of new cerebral ischemic lesions after carotid endarterectomy (CEA) using diffusion-weighted magnetic resonance imaging (DW-MRI). METHODS: Sixty-six consecutive patients (50 males with a mean [±SD] age of 69 ± 9 years) who underwent CEA were included in this prospective study. Seventeen patients were symptomatic and 49 patients were asymptomatic. CEA was performed with patch closure without using a shunt. Carotid plaque echostructure was evaluated with the grayscale median (GSM) score. DW-MRI scanning of the brain was performed 24 hours before and 48 to 72 hours after the procedure. RESULTS: Thirty-day stroke and mortality rates were 0%. The mean GSM score for symptomatic patients was 27 ± 15; for asymptomatic patients, the mean GSM score was 39 ± 18 (P = 0.006). Patients were divided into 2 groups according to GSM score: GSM scores ≤25 (22 patients) and GSM scores >26 (44 patients). New brain lesions were detected after 6 endarterectomies (8.9%), and all were clinically silent. These lesions were ischemic in 5 cases (7.5%) and micro-hemorrhagic in 1 case (1.4%). In 3 cases, new ischemic lesions were located within the treated carotid artery territory. In 2 cases, new lesions on DW-MRI were located outside of the treated carotid artery territory. There was no significant difference in the incidence of ischemic lesions between the 2 groups (GSM scores ≤25, 2 lesions; GSM scores >26, 3 lesions; P = 0.544). CONCLUSIONS: New ischemic lesions on DW-MRI are detected in 7.5% of patients after CEA, and most of these lesions are clinically silent. Plaque echogenicity does not affect their incidence. New lesions seen on DW-MRI may be generated outside of the treated carotid artery territory.

Aortocaval fistula formation due to ruptured abdominal aortic aneurysms: a 12-year series.

This study reports on the frequency and management of aortocaval fistulas (ACFs) in our department between 1998 and 2009. Overall frequency of ACFs among ruptured abdominal aortic aneurysms was 5.5%. Patients presented with low back pain (92.8%), abdominal tenderness (78.6%), hemorrhagic shock (28.6%), congestive heart failure (21.4%), dyspnea (42.8%), and palpitations (57.1%). The most reliable clinical sign was the presence of palpable pulsating abdominal mass (92.8%). Other clinical findings included increased central venous pressure (21.4%), lower extremity edema (71.4%), hematuria (21.4%), and scrotal edema (14.3%). Diagnosis was established preoperatively in 85.7% and intraoperatively in 14.3% of cases. Surgery was successful in promptly improving clinical signs and symptoms. Mortality rate was 7.1%. After a mean follow-up of 18.5 months, all surviving patients remained free from complications. In conclusion, ACFs represent a life-threatening emergency for vascular surgeons but can be successfully managed.

Insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations.

INTRODUCTION: Central venous catheter placement is an effective alternative vascular access for dialysis in patients with chronic renal failure. The purpose of this study was to evaluate the insertion of central venous catheters for hemodialysis using angiographic techniques in patients with previous multiple catheterizations in terms of efficacy of the procedure and early complications. MATERIALS AND METHODS: Between 2008 and 2010, the vascular access team of our hospital placed 409 central venous catheters in patients with chronic renal failure. The procedure was performed using the Seldinger blind technique. In 18 (4.4%) cases it was impossible to advance the guidewire, and so the patients were transported to the angiography suite. RESULTS: Using the angiographic technique, the guidewire was advanced in order to position the central venous catheter. The latter was inserted into the subclavian vein in 12 (66.6%) cases, into the internal jugular vein in 4 (22.2%) and into the femoral vein in 2 (11.1%) cases. There was only one complicated case with severe arrhythmia in 1 (5.5%) patient. CONCLUSION: Our results suggest that insertion of central venous catheters using angiographic techniques in hemodialysis patients with previous multiple catheterizations is a safe and effective procedure with few complications and high success rates.

Characteristics of patients presenting to the vascular emergency department of a tertiary care hospital: a 2-year study.

BACKGROUND: The structure of health care in Greece is receiving increased attention to improve its cost-effectiveness. We sought to examine the epidemiological characteristics of patients presenting to the vascular emergency department of a Greek tertiary care hospital during a 2-year period. We studied all patients presenting to the emergency department of vascular surgery at Red Cross Hospital, Athens, Greece between 1st January 2009 and 31st December 2010. RESULTS: Overall, 2452 (49.4%) out of 4961 patients suffered from pathologies that should have been treated in primary health care. Only 2509 (50.6%) needed vascular surgical intervention. CONCLUSIONS: The emergency department of vascular surgery in a Greek tertiary care hospital has to treat a remarkably high percentage of patients suitable for the primary health care level. These results suggest that an improvement in the structure of health care is needed in Greece.

Cardiovascular events in chronic dialysis patients: emphasizing the importance of vascular disease prevention.

Cardiovascular disease is the leading cause of death in both chronic kidney disease and peritoneal dialysis/hemodialysis patients. Vascular disease prevention in these patients is therefore important to reduce the incidence of cardiovascular events and the high morbidity and mortality. This Editorial discusses the traditional, (1) smoking, (2) dyslipidemia, (3) body mass index, (4) glycemic control and (5) blood pressure, and non-traditional, (1) anemia, (2) vitamin D/hyperparathyroidism, (3) calcium/phosphorus metabolism and (4) magnesium, risk factors in renal patients. Current evidence does not support routine statin use and antiplatelet medication to dialysis patients. Patient compliance and adherence to proposed measures could be essential to reduce cardiovascular events and mortality rates in this high-risk population.

Combined endovascular/surgical management of a ruptured para-anastomotic aneurysm of the left common iliac artery.

A 75-year old man presented with signs and symptoms of acute abdomen and a clinical picture of hypovolemic shock. An emergency CT scan revealed a ruptured para-anastomotic left common iliac artery aneurysm. The patient had undergone an elective abdominal aortic aneurysm repair operation and placement of an aortoiliac bifurcated graft 10 years before. Para-anastomotic aneurysms had developed in all 3 (aortic and the 2 iliac) anastomosis. As the patient was highrisk, a combined endovascular/surgical approach was undertaken. The patient was discharged 4 days later.This article discusses the applicability of endovascular procedures in emergency settings to high-risk patients.