Endovascular treatment of a postlaminectomy arteriovenous fistula. A case report.

We report a case of iliac arteriovenous fistula (AVF) following disk surgery. A 51-year-old woman underwent hemilaminectomy for a slipped disk. Two weeks after surgery the patient experienced dyspnea and oedema of the lower limbs. Presence of a systolic murmur on the cardiac floor and on the abdomen was detected and abdomen CT scan which evidenced a AVF between the right common iliac artery and vein. The lesion, confirmed by angiography, was successfully treated with the endovascular technique. The endovascular technique appears to be a valid alternative to the traditional surgical treatment of postlaminectomy AVF.

Blood endothelin-1 levels before and after carotid endoarterectomy for atherosclerotic stenosis.

BACKGROUND: Elevated plasma levels of endothelin-1 (ET-1) have been reported in advanced atherosclerosis. Further in vivo demonstration of cause-effect relationship between atherosclerotic lesion and high levels of ET-1 needs to be carried out. The aim of this study was to determine whether circulating levels of ET-1 are influenced by removing haemodynamically significant atherosclerotic stenosis in selected patients with mono or bilateral carotid atherosclerotic stenosis. METHODS: Cubital venous ET-1-immunoreactive (IR) levels were measured in 20 patients: 11 (mean age+/-S.D. 63.1+/-5.36 years; range 53-70 years) were affected by monolateral, and nine patients (mean age+/-S.D. 64.7+/-9.8 years; range 52-78 years) by bilateral extracranial carotid artery atherosclerotic stenosis. ET-1-IR levels were evaluated before and 7 days after monolateral surgical endoarterectomy. Pre-surgery levels of ET-1-IR were compared with those obtained from 18 healthy younger volunteers (mean age+/-S.D. 27.8+/-2.7 years; range 20-50 years). FINDINGS: The mean cubital venous levels of ET-1-IR in the atherosclerotic patients before endoarterectomy (mean+/-S.D. 4.50+/-3.35 pg/ml; range 1.28-10.66 pg/ml) were significantly higher than those observed in healthy subjects (mean+/-S.D. 0.641+/-0.137 pg/ml; range 0.36-1.02 pg/ml) (P=0.000). The mean ET-1-IR level decreased significantly after endoarterectomy in the group of patients with monolateral stenosis (pre-surgery: mean+/-S.D. 4.35+/-3.11 pg/ml; range 1.28-10.66 pg/ml; post-surgery: mean+/-S.D. 3.05+/-2.94 pg/ml, range 0.28-8.86 pg/ml) (P=0.005), but not in patients with bilateral extracranial carotid stenosis submitted to monolateral endoarterectomy (pre-surgery: mean+/-S.D. 4.77+/-3.79 pg/ml; range 2.18-10.3 pg/ml; post-surgery: mean+/-S.D. 4.60+/-3.70 pg/ml; range 2.20-11.10 pg/ml). INTERPRETATION: The removal of a haemodynamically significant atherosclerotic vascular stenosis is associated with a decrease in the circulating ET-1-IR levels 7 days after surgery when haemodynamically significant atherosclerotic lesions are absent.

PYCNOGENOL in chronic venous insufficiency.

The aim of out study was to investigate the efficacy of Pycnogenol - a French maritime pine bark extract - in the treatment of chronic venous insufficiency (CVI). The study consisted of a double-blind phase - in which 20 patients were recruited and randomly treated with placebo or Pycnogenol (100 mg 2 3/day for 2 months) - and an open phase - in which other 20 patients were treated with Pycnogenol at the same dose schedule. In total, 40 patients were enrolled; 30 of them were treated with Pycnogenol and 10 with placebo. Pycnogenol significantly improved the legs' heaviness and subcutaneous edema; the venous pressure was also significantly reduced by the Pycnogenol treatment, thus adding further clinical evidence to its therapeutic efficacy in patients with CVI. Pycnogenol was effective, probably by either stabilizing the collagenous subendothelial basal membrane or scavenging the free radicals, or by a combination of these activities. Clinically, capillary leakage, perivascular inflammation and subcutaneous edema were all reduced. The safety of use of Pycnogenol is demonstrated by the lack of side effects or changes in blood biochemistry and hematologic parameters. Pycnogenol can be therefore recommended both for prevention and treatment of CVI and related veno-capillary disturbances.

Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial.

OBJECTIVE: The durability of carotid endarterectomy (CEA) may be affected by carotid restenosis. The data from randomized trials show that the highest incidence of restenosis after CEA occurs from 12 to 18 months after surgery. The optimal CEA technique to reduce perioperative complications and restenosis rates is still undefined. This study examines the long-term clinical outcome and incidence of recurrent stenosis in patients who undergo eversion CEA. Previously published perioperative results of this study did not show statistically significant differences in study endpoints between the eversion and standard techniques. METHODS: From October 1994 to March 1997, 1353 patients with surgical indications for carotid stenosis were randomly assigned to undergo eversion (n = 678) or standard CEA (n = 675; primary closure, 419; patch, 256). Withdrawal from the assigned treatment occurred in 1.6% of the patients (in 13 assigned to eversion CEA, and in nine assigned to standard CEA). The clinical and duplex scan follow-up examination was 99% complete, and the mean follow-up interval was 33 months (range, 12 to 55 months). The primary outcomes were perioperative and late major stroke and death, carotid restenosis (stenosis >/= 50% of the lumen diameter detected at duplex scanning), and carotid occlusion. The primary evaluation of study outcomes was conducted on the basis of an intention-to-treat analysis. RESULTS: Restenosis was found at duplex scanning in 56 patients (19 in the eversion group, and 37 in the standard group). Within the standard group, the restenosis rates were 7.9% in the primary closure population and 1.5% in the patched population. Of the patients with restenosis, 36% underwent cerebral angiography that confirmed restenosis in all cases. The cumulative restenosis risk at 4 years was significantly lower in the group that underwent treatment with eversion CEA as compared with the standard group (3.6% vs 9.2%; P =.01), with an absolute risk reduction of 5. 6% and a relative risk reduction of 62%. Eighteen patients would have had to undergo treatment with eversion CEA to prevent one restenosis during the 4-year period. The incidence rate of ipsilateral stroke was 3.3% in the eversion population and 2.2% in the standard group. There were no significant differences in the cumulative risks of ipsilateral stroke (3.9% for eversion, and 2.2% for standard; P =.2) and death (13.1% for eversion, and 12.7% for standard; P =.7)) in the two groups. Of the 18 variables that were examined for their influence on restenosis, eversion CEA (hazard ratio, 0.3; 95% confidence interval, 0.2 to 0.6; P =.0004) and patch CEA (hazard ratio, 0.2; 95% confidence interval, 0.07 to 0.6; P =. 002) were negative independent predictors of restenosis with multivariate Cox proportional hazards regression analysis. CONCLUSION: The EVEREST (EVERsion carotid Endarterectomy versus Standard Trial) showed that eversion CEA is safe, effective, and durable. No statistically significant differences were found in late outcome between the eversion and standard techniques at the available follow-up examination.

[Magnetic resonance angiography with contrast media bolus in the evaluation of aneurysms of the abdominal aorta]. / Angiografia a Risonanza Magnetica con bolo di mezzo di contrasto nella valutazione degli aneurismi dell'aorta addominale.

PURPOSE: To investigate the potentials of 3D breath-hold contrast-enhanced Magnetic Resonance Angiography (MRA) in the diagnosis, follow-up and treatment planning of abdominal aortic aneurysms. MATERIAL AND METHODS: Twenty-four patients with infrarenal aortic aneurysm underwent MRA. We used a 1.5 T unit (GE Horizon, Echospeed 8.2), a phased array surface coil and 3D Fast SPGR T1-weighted sequences acquired on the coronal plane during patient breath-hold and after contrast agent i.v. administration. A bolus-test was done before angiography to optimize imaging delay time. After 3D MRA a Fast-SPGR T1-weighted sequence was acquired on the axial plane. The 3D MRA source images were processed with the MIP algorithm. Qualitative and quantitative analyses were carried out. Helical CT was performed in 6 cases and DSA in 7 cases. Surgery was the reference standard in 15 patients. RESULTS: MRA depicted aneurysm thrombosis in 22 cases, carrefour involvement in 18 cases and iliac arteries involvement in 3 cases. Accessory renal arteries were shown in 4 cases; iliac artery stenosis was associated in 5 cases. There was agreement between MR and Helical CT and DSA findings: surgery confirmed MRA results in 15/15 cases. CONCLUSIONS: 3D contrast-enhanced MRA can be considered the method of choice in the follow-up and treatment planning of abdominal aortic aneurysms, because it provides both angiographic and tomographic images: this allows to obtain more information, noninvasively and without the use of ionizing radiations.

[Transcranial Doppler sonography in the pre- intra- and post-operative evaluation of 85 patients undergoing carotid endarterectomy]. / Valutazione pre-, intra- e postoperatoria con Doppler transcranico di 85 pazienti sottoposti ad endarterectomia carotidea.

PURPOSE: To evaluate the usefulness of transcranial Doppler sonography during carotid endarterectomy. PATIENTS AND METHODS: Pre-, intra-, and postoperative transcranial Doppler was performed in 85 patients who underwent carotid endarterectomy. Intracranial collateral pathways were evaluated preoperatively and continuous monitoring of middle cerebral artery flow velocity was performed during carotid surgery. Transcranial Doppler was repeated in each patient 1 and 7 days thereafter. RESULTS: Values of residual middle cerebral artery flow velocity during preoperative digital compression of the common carotid artery were significantly correlated (r = 0.56; P < 0.001) with those obtained during cross-clamping. Middle cerebral artery flow velocity was significantly lower during cross-clamping with respect to pre-clamping (P = 0.006), in patients with neurologic symptoms (P = 0.001), EEG alterations (P = 0.001), or defective collateral blood supply through the anterior communicating artery (P = 0.01). Postoperative flow velocity values of the MCA were significantly higher at day-1 examinations (P < 0.0001) with respect to preoperative values, and were no more significantly different at day-7. CONCLUSIONS: Transcranial Doppler is a useful method to evaluate the risk of cerebral ischemia during carotid endarterectomy cross-clamping, to identify those patients in which shunt insertion is mandatory, and to evaluate the postoperative effect of carotid endarterectomy on cerebral hemodynamics.

A randomized study on eversion versus standard carotid endarterectomy: study design and preliminary results: the Everest Trial.

PURPOSE: The EVEREST Trial was designed to determine whether the surgical technique influences the durability and complications of carotid endarterectomy (CEA). The current report focuses on the study design and preliminary results. METHODS: EVEREST is a randomized multicenter trial. A total of 1353 patients with carotid stenosis requiring surgical treatment were randomly assigned to received standard (n = 675) or eversion (n = 678) CEA. Primary end points included carotid occlusion, major stroke, death, and restenosis rate. RESULTS: The rate of perioperative major stroke and death (1.3 for each study group) and the incidence of early carotid occlusion (0.6% for eversion vs 0.4% for standard) were similar. No significant differences were found between eversion and standard CEA with respect to incidence of perioperative transient ischemic accident, minor stroke, cranial nerve injuries, neck hematoma, myocardial infarction, or surgical defects as detected with intraoperative quality controls. Clamping time was significantly shorter for eversion CEA compared with patch standard procedures (31.7 +/- 15.9 vs 34.5 +/- 14.4 minutes, p = 0.02). A shunt was inserted in 11% of patients undergoing eversion CEAs and in 16% of patients undergoing standard procedures. Overall 30-day events occurred in 13.3% of the eversion group and in 11.4% of the standard group (p = 0.3). At a mean follow-up of 14.9 months (range, 1 to 38 months), 16 (2.4%) restenoses occurred in the eversion group and 28 (4.1%) occurred in the standard group (odds ratio, 0.56; 95% confidence interval, 0.3 to 1.1; p = 0.08). CONCLUSION: The preliminary results of the EVEREST Trial suggest that eversion CEA is a safe and rapid procedure with low major complication rates. No significant differences in restenosis rates were observed between eversion and standard CEA at the available follow-up. Longer-term results are necessary to assess whether the eversion technique influences the durability of CEA.

Healing of aortic prosthetic grafts: a study by magnetic resonance imaging.

Thirty-six patients with aortoiliac reconstruction were studied by magnetic resonance imaging (MRI) to determine the diameter, baseline signal, and subsequent magnetic signal characteristics of postoperative periprosthetic collection (PPC). Our study confirmed the presence of PCC in most cases (32/36). The diameter was significantly (p < 0.05) correlated with the type of disease being treated, the type of proximal anastomosis created, and whether or not drainage and postoperative transfusion were used. PPC usually disappeared within 3 to 6 months postoperatively. Modifications of magnetic signals T1 and T2 require approximately the same amount of time to diminish. During follow-up investigations in this series, there was one case of prosthetic infection characterized by the persistence of PPC and a strong T2 signal 6 months after surgery, the latter corresponding to incomplete or delayed healing. The MRI aspects of normal healing of aortic grafts were analyzed to correctly interpret the MRI aspects of complications in surgery of the aorta.

Stress MR imaging for evaluation of popliteal artery entrapment.

The popliteal artery entrapment (PAE) syndrome has been recognized as a cause of arterial occlusion in young people. It is the result of an anomaly of the relationship between the popliteal artery and the gastrocnemius muscle. Eight young health volunteers (16 legs) and six patients (10 legs) with suspected PAE underwent magnetic resonance (MR) imaging. Gradient-echo images were obtained in axial planes with the leg at rest and during active plantar flexion against resistance. Imaging at rest allowed identification of PAE signs in only one leg, which had an anomalous medial course of the popliteal artery. In the other cases, only the stress technique was able to show signal loss in the popliteal artery due to muscular compression (two legs) or the presence of accessory muscle slip around the vessel (two legs), as confirmed at surgery. MR imaging is therefore a useful technique for the diagnosis of PAE because of its capability of combining information obtainable with other modalities.

Detection of internal carotid artery stenosis. Comparison of 2D-MR angiography, duplex scanning, and arteriography.

The purpose of this study was to compare digital subtraction angiography (DSA) and duplex scanning with 2D-Magnetic Resonance Angiography (MRA) to evaluate the accuracy of MRA in determining carotid stenosis. All three methods were applied to 101 carotid arteries in 51 patients. Diameter stenosis of the internal carotid artery was categorized as follows: 0 to 39%, 40% to 59%, 60% to 94%, 95% to 99%, and occlusion (100%). All images were read in blind fashion by different physicians. DSA is still considered the "gold standard" investigation. In 78 arteries the degree of stenosis according to MRA correlated exactly with that of conventional angiography. In the remaining 23, carotid arteries MRA upgraded the stenosis in 13 and downgraded it in 8. The principal problem is the overestimation of the lesion, which was particularly revealing in lesions of more than 60%. Furthermore to date MRA is not able to evaluate the presence of ulceration. For this reason 2D-MRA alone is not a reliable method for evaluating the presence of carotid artery stenosis.

Popliteal artery entrapment: MR findings.

A 35-year-old woman with a history of claudication was examined by means of echodoppler, angiography, and MR imaging using gradient rephased sequences, performed at rest and during stress. Magnetic resonance imaging allowed the evaluation of the relationships between the gastrocnemius muscle and the popliteal artery at rest and the evidence of the occlusion during stress. This combined morphological and functional evaluation makes MR a procedure of choice for assessment of young adults with intermittent claudication.

Evaluation of hematoma by MRI in follow-up of aorto-femoral bypass.

We selected a population of 20 patients with atherosclerotic disease, submitted to implantation of aorto-femoral bypass graft. These patients were studied by MRI with T1- and T2-weighted sequences (w.s.) using a 0.5 T superconductive magnet. Investigation was performed at 1 wk, 1, 3, and 6 mo after dacron implantation, to evaluate the normal evolution of hematoma and the potential development of complications. At the first week examination, hematoma presented medium signal intensity on T1 w.s. and high signal intensity on T2 w.s.; at 1 mo control the amount of hematoma was slightly reduced and we found persistence of high signal intensity on T2 w.s.; progressive reduction of size and signal intensity on T2 w.s. was noted at 3 mo control, in patients operated for peripheral vascular disease; on the other hand we found persistence of high signal intensity in T2 w.s. in patients treated for abdominal aortic aneurysms; only after 6 mo it was evident in all patients fibrotic evolution of the collection and low signal intensity in both T1 and T2 w.s. Thus, MRI study was useful in the evaluation of patency, morphology, and in detection of intraluminal thrombosis, but also in the characterization of periprosthetic hematoma.

Role of magnetic resonance imaging in the evaluation of aortic graft healing, perigraft fluid collection, and graft infection.

The authors report their preliminary experience in the use of Magnetic Resonance Imaging (MRI) in ten patients who underwent aortic reconstruction. Examinations were performed 1, 4, 12 and 24 weeks after surgery, to examine the presence, size, magnetic characteristics and evolution of periprosthetic collections. The results have shown that periprosthetic collection can be considered normal after aortic reconstructive surgery, because such a perigraft collection (PFC) was present in 90% of the patients studied 1 week after operation, and had disappeared within 24 weeks in all cases. The magnetic characteristics were evaluated by T1 [repetition time (TR) = 480 msec and echo time (TE) = 20 msec] and T2 weighted spin-echo sequences (TR = 1800 msec and TE = 70/120 msec). Variations in the magnetic characteristics, found in sequential examinations, correlated with modifications of the collection and suggested that it was originally blood. The MRI examination performed 24 weeks after surgery gave a low signal intensity in T1 and T2 weighted sequences (w.s.) suggesting periprosthetic fibrosis. These preliminary observations may constitute a starting point for better evaluation of the normal appearance and evolution of the periprosthetic fluid collections following aortic graft implantation and, may be useful for the early detection of infection especially in asymptomatic patients.

Abdominal aortic aneurysm evaluation: comparison of US, CT, MRI, and angiography.

We studied 26 cases of abdominal aortic aneurysm with magnetic resonance imaging (MRI), computed tomography (CT), ultrasonography (US), and angiography. Data acquired were compared to those obtained at surgery. Diameter of the aneurysm was correctly defined in all cases by CT and MRI, while angiography underestimated the diameter of lesions without peripheral calcifications. Involvement of renal arteries was present in four cases and correctly diagnosed with MRI and angiography in all of them. CT did provide this information in three cases and US were not useful. Also, iliac arteries involvement was depicted by CT, MRI, and angiography in 10 out of 10 patients. Coronal sections of MRI provided comparable images to those of angiography. By comparing these different techniques we verified the good reliability of MRI as investigation tool for an accurate evaluation of aneurysms; its only limit lying in the poor capability of detecting calcifications.

[Abdominal aortic aneurysms. Comparison of magnetic resonance, ultrasound, CT x-ray and angiography]. / Aneurismi aortici addominali. Risonanza magnetica a confronto con US, TC ed angiografia.

Twenty-four cases of abdominal aortic aneurysm were studied by means of MR Imaging, Computed Tomography (CT), Ultrasound (US) and Angiography. MR Imaging gave detailed information on the site and extension of the aneurysm. The extent of branches involvement, the presence of thrombosis, and the adjacent structures were also demonstrated. Major limitations of angiography were its morbility, and the difficult/impossible demonstration of eventual thrombi, and of the adjacent structures. CT, although extremely valuable in emergency cases and in the detection of calcifications, provided insufficient information on the involvement of the vessels originating from the aorta. US proved useful in the screening of abdominal aortic aneurysms, but lacked both the accuracy and the reliability necessary to a complete preoperative evaluation. MR Imaging proves thus to be a good investigation technique for a complete assessment of aneurysmatic lesions. Its major limitation is its inability to detect calcifications, while its major advantages are the accurate demonstration of both blood flow and eventual thrombi, and the multiplanarity and non-invasiveness of the methodology.

Clinical and therapeutical evaluation of inflammatory aneurysms of the abdominal aorta.

Unexpected anatomical and clinical features of abdominal aortic aneurysm (AAA) may be encountered by the vascular surgeon creating technical problems that increase the normally low mortality rates of this affection. One such variant is the so called inflammatory aneurysm (IA) as a characteristic fibrosis involving the arterial wall and thus surrounding structure scan be observed. In our series of 525 patients affected by AAA the incidence of IA was about 4% (19 cases). Two groups of patients were considered: group A, including all the atherosclerotic patients, and group B 19 patients affected by IA. The latter group referred to a typical painful symptomatology in 84% of the cases: this element is of interest as only 20% of the cases of group A complained of pain. No other significant clinical or laboratory data were recorded which could allow the surgeon to perform a pre-operative differential diagnosis. In all 19 cases that underwent surgical treatment there was a 2-3 cm thick aneurysmal wall with a shiny white surface adhering to the IV portion of the duodenum, vena cava and iliac vessels and in some cases to the ureters. Histological examination of specimens of the aortic wall showed evident signs of atherosclerosis of the media and marked fibrotic thickening of the adventitia with the presence of lymphocyte aggregates: a sign of chronic inflammation. As what concerns indications and surgical treatment, there are no substantial differences. Pre-operative differential diagnosis can be made with CAT scan and ultrasound and the usual operative manoeuvres of aneurysmorrhaphy should be modified.