The Coronary ARteriogenesis with combined Heparin and EXercise therapy in chronic refractory Angina (CARHEXA) trial: A double-blind, randomized, placebo-controlled stress echocardiographic study.

BACKGROUND: Coronary collateral circulation exerts protective effects on myocardial ischaemia due to coronary artery disease and can be promoted by exercise with heparin co-administration. Whether this arteriogenetic effect is accompanied by functional improvement of left ventricle during stress and lessening of angina symptoms remains unknown. AIMS: To evaluate the anti-ischaemic efficacy of heparin plus exercise in coronary artery disease. METHODS: In a prospective, single-centre, randomized, double-blind study we recruited 32 'no-option' patients (27 males; mean age 61 ± 8 years) with stable angina, exercise-induced ischaemia and coronary artery disease not suitable for revascularization. All underwent a two-week cycle of exercise (two exercise sessions per day, five days per week) and were randomized (n = 16 per group) to intravenous placebo (0.9% saline) versus unfractionated heparin (5.000 IU intravenously), 10 min prior to exercise. We assessed Canadian Cardiovascular Society angina class, stress electrocardiogram and echo parameters (wall motion score index) and computed tomography angiography for collaterals. RESULTS: After two-week cycle, Canadian Cardiovascular Society class statistically decreased in both groups (heparin plus exercise group: 2.6 ± 0.7 to 1.9 ± 0.7, p < 0.001, exercise group: 2.4 ± 0.7 to 2.1 ± 0.9, p = 0.046). Only the heparin plus exercise group improved time-to-ST segment depression (before 270, 228-327 s vs. after 339, 280-360 s, p = 0.012) and wall motion score index (before 1.38 ± 0.25 vs. after 1.28 ± 0.18, p = 0.005). By multi-slice computed tomography angiography, collaterals improved in 12/15 (80%) in the heparin plus exercise group versus 2/16 (12.5%) in the exercise group (p < 0.001). CONCLUSION: A two-week, 10-test cycle of heparin plus exercise is better than exercise in improving angina class, myocardial ischaemia and collaterals by computed tomography angiography.

Effect of Intra-operative Intra-arterial Thrombolysis on Long Term Clinical Outcomes in Patients with Acute Popliteal Artery Aneurysm Thrombosis.

OBJECTIVE: Acute lower limb ischaemia (ALI) as a result of popliteal artery aneurysm (PAA) thrombosis represents a significant problem. The aim of this study was to investigate outcome of intra-operative intra-arterial thrombolysis in the treatment of acute ischaemia due to PAA thrombosis in terms of major adverse limb events (MALE), overall survival, and intrahospital complications, especially those associated with bleeding. METHODS: A total of 156 patients with Rutherford grade IIa and IIb acute ischaemia resulting from PAA thrombosis were admitted between 1 January 2011 and 1 January 2017. The patients were divided into two groups, those who underwent additional treatment with intra-operative intra-arterial thrombolysis (20 patients), and those who did not (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intra-operative thrombolysis was matched to four patients from the non-thrombolysis group. Thus, comparable patient cohorts (20 in the thrombolysis and 80 in the non-thrombolysis group) were identified for further analysis. The primary end point was MALE and the secondary endpoint all cause mortality. RESULTS: After a median follow up of 55 months, the estimated MALE rate was significantly lower in the thrombolysis group (30% vs. 65%, chi square = 10.86, p < .001, log rank test). Also, patients in the thrombolysis group had a significantly lower mortality rate (20% vs. 42.65%, chi square = 3.65, p = .05, log rank test). The thrombolysis group had wound/haematoma related interventions performed more commonly (25% in thrombolysis vs 8%, in non-thrombolysis group), but the difference was not significant (p=.013). There were no cases of major (intracranial and gastrointestinal) bleeding in either group. CONCLUSION: The data suggest that intra-operative thrombolysis in the treatment of selected patients with ALI due to PAA thrombosis has long term MALE and overall survival benefits, without a significant risk of major, life threatening bleeding complications.

Endovascular treatment of different types of iliac occlusions-Results from an observational study.

OBJECTIVE: The aim of this study was to evaluate the results of endovascular therapy on the treatment of different types of iliac occlusions. MATERIALS AND METHODS: A bi-center prospective, non-randomized study was conducted on 100 patients (mean age 59.14 ± 8.53; 64 men) who underwent endovascular treatment of iliac occlusive disease between January 2013 and November 2017. We evaluated baseline data, procedure, and follow-up results for the entire group, and according to Trans-Atlantic Inter-Society Consensus (TASC II) classification. The majority of patients (60%) were treated for severe claudication; 56 (56%) patients had TASC B occlusions, 28 patients TASC C, and 16 patients TASC D. RESULTS: The mean length of the occluded segments was 61.41 ± 35.15 mm. Procedural complications developed in 6 patients (6%). Mean ankle-brachial pressure index increased from 0.40 ± 0.12 preoperatively to 0.82 ± 0.16 postoperatively. The mean follow-up was 33.18 ± 15.03 months. After 1 and 5 years, the primary patency rates were 98% and 75.1%, and the secondary patency rate was 97% respectively. Regarding occlusion complexity there were no statistical significant differences in primary patency rates (TASC B vs. C vs. D: p = 0.19). There were no statistically significant differences in primary patency rates between patients in different clinical stages, as well as between the type of stents, and location of the occlusion. CONCLUSION: In our study, endovascular treatment for iliac artery occlusions proved to be a safe and efficient approach with excellent primary and secondary patency rates regardless of the complexity of occlusions defined by TASC II classification. This study is aligned with the notion that in well selected patients, endovascular therapy can be the treatment of choice even in complex iliac lesions if performed by experienced endovascular interventionists in high volume centers.

Transient Acute Leg Ischemia in a Professional Athlete Caused by Isolated Popliteal Artery Dissection Mimicking Popliteal Entrapment Syndrome.

Exertional leg pain includes a broad range of conditions induced by different vascular, musculoskeletal, and neurological disorders. We report a case with isolated popliteal artery dissection as a cause of a transient acute lower limb ischemia. We report a patient with popliteal artery dissection which occurred during squatting exercise. After initial signs of transient acute limb ischemia, physical and ultrasound examination pointed to entrampment syndrome as a likely cause. However, digital subtraction angiography showed possible dissection of popliteal artery, which was confirmed intraoperatively. Popliteal artery was resected and reversed saphenous vein bypass was performed. Isolated popliteal artery dissection in professional athletes is a rare entity, which can be manifested with exertional leg pain. Clinical findings can sometimes be similar to those of popliteal entrapment syndrome. Clinical suspicion and timely patient referral to a vascular specialist are crucial for optimal treatment of this limb-threatening condition.

Simultaneous Endovascular Treatment of Tandem Internal Carotid Lesions: Case Report and Review of Literature.

The incidence of concomitant extracranial carotid artery stenosis and ipsilateral intracranial carotid aneurysm has been reported to vary between 2.8% and 5%. These complex lesions may present a challenge for treatment decision-making. This case report describes an asymptomatic male patient with severe carotid bifurcation stenosis, coupled with an unruptured supraclinoid internal carotid aneurysm. Both lesions were treated simultaneously. Patient underwent carotid stenting followed by aneurysm coiling in the same setting without any complication.

Endovascular Treatment of Traumatic Pseudoaneurysm of the Superficial Temporal Artery.

Pseudoaneurysms of the superficial temporal artery (STA) are rare vascular lesions that mainly occur after blunt head trauma. Diagnosis can be made on clinical grounds and is confirmed by ultrasonography. They are usually treated by open surgery procedures, but when the aneurysm is located in inaccessible areas, catheter embolization can be an alternative therapeutic option. We describe a case of a traumatic pseudoaneurysm of the STA which was treated with the vascular plug embolization. We conclude that endovascular embolization can be an option in the treatment of STA pseudoaneurysms.

Chronic complete thrombosis of abdominal aortic aneurysm: an unusual presentation of an unusual complication.

Although mural thrombosis frequently accompanies aneurysmal disease, complete thrombosis is distinctly unusual complication of abdominal aortic aneurysm (AAA). A case study of a patient with chronic, asymptomatic complete thrombosis of a large juxtarenal AAA is presented along with a literature review and discussion of the potential secondary complications, mandating aggressive management of this condition. A 67-year-old man with multiple atherogenic risk factors and unattended complaints consistent with a recent episode of a transient right hemispheric ischemic attack was referred to our clinic with a diagnosis of a thrombosed AAA established by computed tomography. Duplex ultrasonography and aortography confirmed the referral diagnosis and also revealed near occlusion of the left internal carotid artery. The patient underwent a two-stage surgery, with preliminary left-sided carotid endarterectomy followed three days later by an aneurysmectomy and aortobifemoral reconstruction. He had an uncomplicated recovery and was discharged home on postoperative day 7, remaining asymptomatic at the 42-month follow-up. Complete thrombosis is an uncommon presentation of AAA and may be clinically silent. It is frequently associated with other manifestations of generalized atherosclerosis. Radical open repair yields durable result and is the preferred treatment modality.

Coexistence of internal carotid artery stenosis in patients with abdominal aortic aneurysm.

BACKGROUND AND OBJECTIVES: Abdominal Aortic Aneurysm (AAA) and carotid disease have medical and social significance, considering their morbidity, disability, and economic consequences. The study objectives were to determine the prevalence of asymptomatic internal carotid artery (ICA) lesions ≥70% in patients with AAA, the correlation of AAA diameter with the degree of ICA stenosis and symptoms, and the importance of preventive ultrasound checkups. SUBJECTS AND METHODS: A prospective non-randomized controlled study including 740 patients, aged from 18-85 years, who were suitable for the inclusion and exclusion criteria and reported at the vascular laboratory of the Institute for Vascular and Endovascular Surgery, Clinical Center of Serbia from 1st of December 2011 to the 1st of November 2012. RESULTS: The prevalence of asymptomatic ICA stenosis ≥70% in patients with AAA is 10.8%. Male representatives have more symptomatic ICA stenosis ≥70%. Patients with small aneurysms more often have asymptomatic ICA stenosis ≥70%. The occurrence of symptoms of carotid disease was more prevalent among patients with ICA stenosis ≥70% compared to the group with stenosis <70%. There was no correlation found between the grade of ICA stenosis with the size of AAA. CONCLUSION: The prevalence of asymptomatic ICA stenosis ≥70% in patients with AAA is found to be 10.8%. Male patients with ICA stenosis ≥70% more often had symptoms of carotid disease. In the smaller aneurysms, ICA stenosis ≥70% occurs frequently, but without the symptoms of carotid disease, and there was no correlation between the size of AAA and the grade of ICA stenosis. Clinical implications of ICA imaging in patients with previously diagnosed AAA is necessary.

[Simvastatin influence on carotid atherosclerotic disease regression].

INTRODUCTION: The measurement of intima-media thickness (IMT) of carotid arteries has emerged as the method of choice for determining the anatomic extent of atherosclerosis and assessing cardiovascular progression. Statins are used in the primary and secondary prevention of cardiovascular and cerebrovascular disorders so as to reduce morbidity and mortality. OBJECTIVE: To evaluate the effects of treatment with simvastatin in patients with elevated cholesterol levels and increased values of carotid arteries IMT. METHODS: The study of 275 patients (155 male and 115 female, aged 37-79 years, mean 60.86 years) was performed from January 2008 - January 2010 at the Vascular and Endovascular Surgery Clinic of the Clinical Centre of Serbia. All patients were treated with simvastatin administered once a day for 6 months. RESULTS: Simvastatin treatment resulted in a statistically signuficant decrease of the IMT thickness of the right common carotid artery. There was no statistically significant reduction in the IMT of the left common carotid artery as well as in the IMT of the right and left internal carotid arteries. CONCLUSION: Long-term simvastatin treatment results in the regression or slowing down atherosclerosis in symptomatic, as well as in asymptomatic patients with a lower grade of carotid stenosis (IMT below 2.5 mm).