What the young physician should know about May-Thurner syndrome.

May-Thurner syndrome (MTS) is an anatomically variable condition resulting in compression of the left common iliac vein between the right common iliac artery and the underlying spine with subsequent development of a left deep vein thrombosis (DVT). Although this syndrome is rare, its true prevalence is likely underestimated. Mainly, clinical symptoms and signs include, but are not limited to, pain, swelling, venous stasis ulcers, skin pigmentation changes and post-thrombotic syndrome. Correct treatment is not well established and is based on clinical presentation. Staged thrombolysis with/without prophylactic retrievable inferior vena cava filter placement followed by angioplasty/stenting of the left iliac vein appears to be the best option in MTS patients with extensive DVT. The aim of this review is to present in a simple and didactic form all variable clinical presentations of MTS and to outline possible management within the current guidelines.

Carotid and vagal body paragangliomas.

Between 1972 and 2012, 25 patients presenting 32 paragangliomas of the neck were observed. Tumor locations included the carotid body (CBTs) in 21 patients and the vagus nerve in 4. Four patients had bilateral CBT and one a bilateral vagal tumor; a metachronous bilateral jugulare paraganglioma was diagnosed in one patient with bilateral CBT Shamblin type III. Five patients presented CBTs type II and three type III. Preoperative embolization was performed in 5 CBTs, with no significant difference in blood loss. Twenty-nine paragangliomas were resected (with three internal carotid artery resection): there were no cerebrovascular accident or perioperative death. Nine patients (36%) had cranial nerve palsy prior to surgery and a postoperative nerve dysfunction occurred in four other tumors (16%). Persistent nerve deficits occurred in 3 patients (12%). No evidence of malignancy was shown, intraoperatively or during a postoperative follow-up period (9 months to 18 years; mean: 8 years).

Kidney transplantation and large anastomotic pseudoaneurysm. Transplant management considerations.

AIM: Pseudoaneurysm (PA) at the anastomosis site in kidney transplantation is a rare but serious complication that usually requires graft nephrectomy. Literature reports are sporadic and usually focused on limb rather than graft salvage. In this paper we focus on this last point. MATERIAL OF STUDY: 6 patients presenting large PA at the anastomosis between iliac and graft artery were identified in our series. The diagnosis was performed with US, AngioTC scan and angiography. Blood cultures and labeled leukocyte scintigraphy were also performed. All patients underwent open surgery. RESULTS: Transplant nephrectomy was needed in all cases except one, in which it was possible to perform a graft replanting on hypogastric artery. Our perioperative mortality and morbidity rate was recorded. DISCUSSION: Etiology of PA is multifactorial, however an association with chronic rejection or infection must be also considered. Our mortality and morbidity rates are in accordance to literature. In our experience we observed only large PA so to require an open surgery but this approach has allowed the rescue of graft functioning just in a single case. Endovascular procedures are linked to higher rate of graft salvage than surgery but they can be used just in selected cases. CONCLUSIONS: Our experience and literature review led us to believe that the rate of graft salvage in patients with large PA at anastomosis site could be improved only by a planned therapeutic program that includes surgical and endovascular approach, taking the advantages of both technique and overcoming their limits.

Endovascular treatment of abdominal aortic anastomotic pseudoaneurysm. The experience of two centers.

INTRODUCTION: Abdominal aortic pseudoaneurysms are a rare but serious complication of aortic surgery. Treatment with traditional open surgery is associated with a high rate of perioperative mortality and morbidity. Endovascular treatment is less invasive and guarantees lower mortality and morbidity rates. The aim of this study was to evaluate the role of short-, medium- and long-term endovascular treatment of these pseudoaneurysms. MATERIALS AND METHODS: Over the past 10 years, 14 patients with abdominal aortic aneurysms, which developed after prior aortic surgery, underwent endovascular treatment involving implantation of an endoprosthesis at our institutions. Exclusion criteria were emergency treatment and suspicion of an infected prosthesis. A Cheatham-platinum covered stent mounted on a balloon catheter was implanted in one patient and self-expandable stent-graft in the other 13. No fenestrated or custom-made prostheses were used. RESULTS: The procedure had a 100% technical success rate. There was no postoperative mortality. Two type I endoleaks, observed at aortography at the end of the procedure, were not seen on the CT scan taken one month later. Three patients (21.4%) had major perioperative complications which consisted of early occlusion of a branch of the endoprosthesis, (treated with a femoro-femoral crossover bypass graft), a transient ischemic attack, and jaundice. The long-term mortality rate, at an average follow-up of 37.4 months, was 21.4%. None of the deaths was related to the procedure. CONCLUSIONS: Endovascular treatment of patients who develop anastomotic pseudoaneurysm after surgery of the abdominal aorta is safe and effective both in the short and long term. In our opinion it is the treatment of choice for this category of patients.

Altered expression of inflammation-related genes in human carotid atherosclerotic plaques.

OBJECTIVE: Inflammation is a pivotal process in atherosclerosis development and progression, but the underlying molecular mechanisms remain largely obscure. We have conducted an extensive expression study of atherosclerotic plaques to identify the inflammatory pathways involved in atherosclerosis. METHODS: We studied 11 human carotid plaques, their respective adjacent regions and 7 control arteries from different subjects. Expression of 92 genes was studied by TaqMan low-density array human inflammation panel. Human aortic endothelial and smooth muscle cells were used for in vitro experiments. RESULTS: The mRNA levels of 44/92 genes (48%) differed significantly between the tissues examined (13 up-regulated and 31 down-regulated). Dysregulated genes encode molecules belonging to different functional classes although most of them encode enzymes involved in the eicosanoid synthesis pathway. The expression of PTGIS and PTGIR genes was decreased in human aortic endothelial and smooth muscle cells stimulated with oxLDL and TNF-α. CONCLUSIONS: This study not only reveals several dysregulated genes in human lesions but also focuses the role played by the genes involved in the eicosanoid synthesis pathway during atherosclerotic development. The decrease of PTGIS and PTGIR expression after oxLDL treatment mirrors the decreased mRNA levels in atherosclerotic lesions versus control arteries, which suggests that oxidation is important for PTGIS and PTGIR regulation in human vessel cells during atherosclerosis development.

How should I treat concomitant post-endarterectomy carotid pseudoaneurysm and contralateral symptomatic stenosis?

BACKGROUND: A 74-year-old male patient complaining of crescendo TIAs, hypertension and hyperlipidaemia. INVESTIGATION: Duplex ultrasound scan MR angiography. DIAGNOSIS: Pseudoaneurysm stemming from the ICA. TREATMENT: An open or endovascular procedure for the right pECCA repair, or a left CEA or CAS.

External iliac artery pseudoaneurysm complicating renal transplantation.

OBJECTIVES: To assess the etiology, management and outcome of iliac pseudoaneurysms following renal transplantation. METHODS: Eleven patients who underwent repair between 1982 and 2007 were identified. Five (Group 1) presented pseudoaneurysm at the anastomosis of the donor renal and native iliac arteries, and six (Group 2) presented iliac pseudoaneurysm following transplant nephrectomy. Intraoperative cultures and immunohistochemical examinations were obtained from all surgical cases to determine the existence of a relationship between infection or transplant rejection and pseudoaneurysm formation. RESULTS: Endovascular repair (EVR) was used to treat three patients, while eight patients underwent open repair (OR). Transplant nephrectomy was needed in all cases but one after anastomotic pseudoaneurysm repair. After pseudoaneurysm excision, arterial reconstruction was performed in all cases, with a limb salvage rate of 100%. At 30 days, no patients died in the EVR subgroup. In the OR subgroup, one patient died of sepsis (12.5%). Cultures taken from the pseudoaneurysm wall and content grew Candida albicans and E. coli in two febrile patients. Pathologic evaluation of donor renal arteries revealed evidence of chronic rejection in three patients (60%) in Group 1, and in two (33.3%) in Group 2. No patients in either Group presented late infection, failure of vascular reconstruction nor pseudoaneurysm recurrence. The follow-up ranges from 20 to 89 months. CONCLUSIONS: The etiology of pseudoaneurysms in this location is multifactorial, however, an association with chronic rejection must be considered. Though rare, the development of pseudoaneurysms at the donor renal-external iliac artery anastomosis results in high rates of transplant nephrectomy. Less invasive endovascular techniques offer a new therapeutic option in this challenging scenario notwithstanding the fact that they require further validation.

Decreased paraoxonase-2 expression in human carotids during the progression of atherosclerosis.

OBJECTIVE: Many gene products involved in oxidation and inflammation are implicated in the pathogenesis of atherosclerosis. We investigated paraoxonase 2 (PON2), 5-lipoxygenase (5-LO), and 5-LO activating protein (FLAP) expression and malondialdehyde (MDA) levels in carotid lesions to assess their involvement in plaque formation. METHODS AND RESULTS: We measured gene expression and MDA levels in atherosclerotic plaques from 59 patients undergoing carotid endarterectomy, and in plaque-adjacent tissue from 41/59 patients. Twenty-three fetal carotids and 6 mammary arteries were also investigated. Real-time polymerase chain reaction and immunohistochemistry revealed decreased PON2 expression in plaques versus adjacent regions (P<0.005, P<0.001, respectively), mammary arteries (P<0.031, P<0.001, respectively), and fetal carotids (both P<0.001). mRNA levels of 5-LO and FLAP were higher (P<0.038, P<0.005, respectively) in lesions versus fetal carotids. MDA was higher in plaques versus plaque-adjacent tissue and fetal carotids. PON2 mRNA was downregulated by oxidative stress in 5 ex vivo experiments, thereby indicating its possible atheroprotection role. CONCLUSIONS: We demonstrate that PON2 mRNA and protein are decreased in plaques versus plaque-adjacent tissue, mammary arteries, and fetal carotids. Our data indicate that the protective effect of PON2 could fail during atherosclerosis exacerbation; this was confirmed by the increase of MDA levels. The increase of 5-LO and FLAP mRNA expression confirms their role as inflammatory markers associated to atherosclerosis.

Endovascular versus open surgical repair of abdominal aortic aneurysm with concomitant malignancy.

BACKGROUND: The management of patients with abdominal aortic aneurysm (AAA) and concurrent malignancy is controversial. This study retrospectively assessed the outcome of endovascular repair (EVAR) and open repair (OR) for the treatment of AAA in patients undergoing curative treatment for concomitant malignancies. METHODS: All patients who underwent surgery for a nonruptured infrarenal AAA of > or =5.5 cm and concomitant malignancy between 1997 and 2005 were retrospectively reviewed. RESULTS: Identified were 25 patients (22 men; mean age, 70.3 years) with nonruptured infrarenal AAA of > or =5.5 cm (mean size, 6.4 cm) and concomitant malignancy amenable for curative treatment. EVAR was used to treat 11 patients, and 14 underwent OR. The EVAR patients had a smaller mean aneurysm size (5.9 cm vs 6.8 cm; P = .006) than the OR patients. The mean cumulative length of stay for all patients who received treatment for both AAA and cancer was 12.8 days (range, 4 to 26) for EVAR and 18.2 days (range, 9 to 42 days) for OR. In the EVAR group, no patients died perioperatively; in the OR group, three patients died perioperatively (21.4%; P = NS). Postoperative complications occurred in one patient in the EVAR group and in seven in the OR group for a morbidity rate, respectively, of 9.1% and 50% (P = .04). One late complication (9.1%) occurred in the EVAR group. The mean follow-up was 37.7 months (range, 16 to 60 months) in the EVAR group and 29.6 months (range, 11 to 55 months) in the OR group. At 1 and 2 years, survival rates were 100% and 90.9% in the EVAR group and 71.4% and 49% in the OR group (log-rank P = .103) CONCLUSIONS: With low morbidity and mortality, EVAR is a safe technique for the treatment of AAA in patients with concomitant malignancy and could be considered as an alternative to OR.

Delayed diagnosis of leiomyosarcoma of the common femoral artery after endovascular repair.

PURPOSE: To describe a unique case of misdiagnosed leiomyosarcoma of the common femoral artery presenting with signs and symptoms of high-grade stenosis, which was treated with stent placement. CASE REPORT: A 31-year-old woman with a history of diabetes and hyperlipidemia had recurrent claudication and showed significant in-stent restenosis of the common femoral artery in a postoperative angiogram at 5 months. The patient's clinical stage remained unchanged after repeat percutaneous intervention, and leiomyosarcoma was diagnosed from surgical specimens. The patient underwent resection and repair of the involved artery. She has survived 30 months with no further evidence of local recurrence or systemic metastatic disease. CONCLUSIONS: Endovascular repair may cause a long delay in the diagnosis of an arterial leiomyosarcoma mimicking peripheral occlusive disease.

Intracardiac migration of nitinol TrapEase vena cava filter and paradoxical embolism.

The nitinol TrapEase inferior vena cava filter is a new device for pulmonary embolism prophylaxis. No cases of filter migration or filter-related complications with this type of device have so far been described. We report a case of intracardiac migration of this filter in a patient with a patent foramen ovale, resulting in severe cardiogenic shock, cerebral and right arm paradoxical embolism. Surgical treatment, results, causes of these complications are discussed.