Management of concurrent colorectal cancer and vascular disease in the endovascular era.

UNLABELLED: Concurrent colorectal cancer (CRC) and vascular disease, such as abdominal aortic aneurysm, represents a challenging clinical situation. Both lesions may lead to the demise of the patient and therefore should be treated. Endovascular techniques may enhance decision-making and even permit single-stage treatment. PATIENTS AND METHODS: Retrospective review of patients in a university department with extensive endovascular experience. Between 2004 and 2010, seven patients with synchronous vascular disease and colorectal cancer were identified. RESULTS: The mean age was 73 years, and all patients were men. Five patients had concurrent CRC and aneurysmal disease. Two had synchronous critical carotid artery stenosis and CRC. All vascular lesions were treated with endovascular techniques. All CRC were resected with open techniques. In four patients, endovascular repair followed by staged CRC resection was performed. In three patients, single-stage procedures were performed. There was one perioperative death, for a mortality of 14.3% in our series. There were no graft infections. CONCLUSIONS: Priority of treating concurrent vascular disease and CRC remains a dilemma. Combined treatment with a single-stage procedure is feasible. Risk of graft infection may be lower than expected.

One stage carotid artery stenting and open heart surgery: a novel approach.

AIM: The optimal management of the patients requiring cardiac surgery with simultaneous severe carotid disease remains controversial. The traditional approach involves staged or combined carotid endarterectomy and cardiac surgery. This study evaluated the feasibility and safety of angioplasty and stenting for the treatment of carotid stenoses combined with cardiac operations in order to reduce the risk of perioperative stroke. METHODS: In a prospective, non-randomized study, we analyzed 70 consecutive patients requiring cardiac surgery with simultaneous severe carotid artery disease that underwent carotid artery stenting (CAS) and cardiac surgery in one stage. Symptomatic patients with ≥ 60% carotid stenosis, and asymptomatic patients with ≥ 70% stenosis, were treated using CAS under local anesthesia immediately before the open heart surgery. Cerebral protection devices were used in all cases. RESULTS: Despite the high baseline risk profile, our results were very encouraging. Carotid stenting was successful in all patients. No neurological complications occurred during the carotid stenting procedures. The 30-day death/stroke rate was 1.4% (no deaths, 1 contralateral minor stroke). No myocardial infarctions occurred. The carotid restenosis rate was zero during the long-term follow up. CONCLUSION: The low complication rate suggests that CAS and cardiac surgery in one stage offers a safer therapeutic option compared to combined carotid endarterectomy and cardiac surgery. It may also be safer than with the staged CAS and coronary artery bypass grafting approach as well.

Endovascular repair of a spontaneous ilio-iliac fistula presenting as pulmonary embolism.

Spontaneous rupture of a common iliac artery aneurysm into the common iliac vein is a rare phenomenon. We report the case of a 68 year old man admitted with acute cardiac failure and massive pulmonary embolism as a complication of a spontaneous ilio-iliac fistula, secondary to aneurysmal rupture. The aneurysm was successfully excluded using an aorto-uni-iliac stent graft. No complications were noted at 9 months follow-up. Arteriovenous fistulae should be considered in patients with aortic or iliac aneurysms who develop a pulmonary embolism or symptoms of venous congestion. Endovascular repair of these pathologies is a feasible therapeutic option; however long term results remain unknown.

Sacral nerve stimulation for fecal incontinence. First successful case in Greece.

INTRODUCTION: Sacral nerve modulation (SNM) is an established and successful treatment for fecal incontinence. We present the first successful case in Greece, performed in our department. PATIENTS AND METHODS: A 60-year-old female patient presented with a 5-year-old history of fecal incontinence. The Cleveland Clinic Florida (CCF) Incontinence Score was 15. Endoanal ultrasound did not show defects of the internal or external anal sphincter. Conservative and pharmacological therapy was unsuccessful. The patient subsequently underwent a total pelvic floor repair, which was also unsuccessful. After discussing further options, the patient gave consent for percutaneous nerve evaluation (PNE), for possible permanent stimulator implantation. RESULTS: A quadripolar lead was placed percutaneously through the dorsal S3 foramen under local anesthesia. This was connected to a test stimulator (Medtronic Interstim Model 3625, Minneapolis, MN). The stimulator was activated for a period of 4 weeks. At the end of the test period, the CCF Incontinence score was 5. This was considered successful. A permanent stimulator (Medtronic Interstim Implantable Pulse Generator Model 3058, Minneapolis, MN) was then implanted under local anesthesia. Two months after permanent implantation, the Wexner Score has not increased. CONCLUSION: SNM is a relatively simple, safe and minimally invasive technique for the treatment of fecal incontinence.

Aortic and iliac fixation of seven endografts for abdominal-aortic aneurysm repair in an experimental model using human cadaveric aortas.

OBJECTIVE: To evaluate the proximal and distal (iliac) fixation of seven self-expanding endografts, used in the endovascular treatment (EVAR) of abdominal-aortic aneurysm (AAA), by measuring the displacement force (DF) necessary to dislocate the devices from their fixation sites. METHODS: A total of 20 human cadaveric aortas were exposed, left in situ and transected to serve as fixation zones. The Anaconda, EndoFit aorto-uni-iliac, Endurant, Powerlink, Excluder, Talent and Zenith stent grafts were deployed and caudal force was applied at the flow divider, through a force gauge. The DF needed to dislocate each device ≥ 20 mm from the infrarenal neck was recorded before and after moulding-balloon dilatation. Cephalad force was similarly applied to each iliac limb to assess distal fixation before and after moulding-balloon dilatation. RESULTS: Endografts with fixation hooks or barbs displayed a significantly higher DF necessary to dislocate the proximal portion compared with devices with no such fixation modalities (p < 0.001). Balloon dilatation produced a significant increase in DF in both devices with (p < 0.001) or without (p = 0.003) hooks or barbs. Suprarenal support did not enhance proximal fixation (p = 0.90). Balloon dilatation significantly increased the DF necessary to dislodge the iliac limbs (p = 0.007). CONCLUSIONS: Devices with fixation hooks displayed higher proximal fixation. Moulding-balloon dilatation increased proximal and distal fixation. Suprarenal support did not affect proximal fixation.

Quantitative evaluation of the systemic effects of transposed basilic vein to brachial artery arteriovenous fistula: a prospective study.

BACKGROUND: The transposed basilic vein to brachial artery arteriovenous fistula (BBAVF) constitutes an alternative autogenous vascular access (VA) site for chronic hemodialysis (HD); however, the hemodynamic effects of this procedure have not been adequately studied. The purpose of this study is to evaluate the effects of BBAVF on systemic arterial pressure, cardiac function, and upper limb ischemia (ischemic steal syndrome) utilizing reproducible quantitative methods. METHODS: Ten consecutive patients (eight males; mean age: 65.10+/-2.87 yrs) scheduled to undergo a brachial-basilic vein transposition were included, excluding patients with cardiac failure. Blood flow volume at the level of the AVF, systemic arterial pressure (SAP), cardiac output (CO) and digital brachial index (DBI) were measured intra-operatively, before and after the creation of the BBAVF, and post-operatively on the 30th post-operative day and on the 3rd post-operative month. RESULTS: SAP and DBI at 30 days and 3 months post-operatively were significantly lower compared to baseline. CO at 30 days and 3 months post-operatively was significantly higher compared to baseline; however, none of the patients developed cardiac failure. DBI remained >or=0.6 at 3 months, except in one case (0.59). Blood flow volume at the level of the AVF was positively correlated with CO levels on the 30th post-operative day. Mean clinical follow-up was 12 months (range: 4-15 months). In two cases (20%) the AVF was thrombosed (4th and 10th post-operative month). CONCLUSION: This prospective quantitative study proves that the BBAVF does impact significantly upon SAP, CO, and DBI; however, it is safe in terms of high-output cardiac failure and ischemic steal syndrome. The authors state that they do not have any commercial, proprietary, or financial interest in any products or companies described in this article.

Midterm results of endovascular abdominal aortic aneurysm repair with Talent stent graft in a single center.

AIM: The aim of this study is to investigate the safety and efficacy of abdominal aortic aneurysm (AAA) repair with modular bifurcated Talent stent-graft. METHODS: Between September 2001 and September 2005, 85 patients with infrarenal AAA underwent treatment with Talent stent-graft. There were 83 men and 2 women with a median age of 69.3 years. Anatomy of the abdominal aorta and the iliac arteries was investigated with high resolution contrast CT together with digital subtraction angiography. The majority of patients had comorbid illnesses like arterial hypertension (60%), CAD (38%) and previous CABG (26%). Duration of follow-up period ranged from 1 to 48 months (median 18 months). RESULTS: Repair was performed with transrenal fixation of the bifurcated Talent stent-graft under regional anesthesia in 80% of all cases. Technical success rate was 97.6%. Aneurysm related mortality was 2.4% due to aneurysm rupture in the postoperative period. Overall mortality rate was 9.4%. Morbidity rate was 16.5%. Immediate conversion to open repair was necessary in 1 patient (1.2%). Endoleak rate was 4.8% at 1 month follow-up period. Secondary intervention was required in 1.2% of patients. Iliac limb occlusion was detected in 1 patient (1.2%). CONCLUSIONS: Talent stent-graft exhibits a high degree of technical success in AAA repair in patients with comorbid conditions with a low perioperative morbidity and mortality rate.

Mesenteric cyst of the descending colon: report of a case.

Mesenteric cysts are rare benign, lesions that are discovered accidentally or during the management of one of their complications (torsion, rupture, haemorrhage, obstruction of nearby organs). We present the case of a 56-year old female patient, with a mesenteric cyst of the descending colon, discovered accidentally during a routine gynaecological examination. Preoperative evaluation included U/S scan, IVP, CT scan and MRI scan. She underwent exploratory laparotomy and the cyst was enucleated intact. Postoperative period was uneventful and pathological examination showed a benign mesenteric lymphangioma. The patient is free of symptoms on 1-year follow-up. We also review the literature.

Experience from the use of absorbable type I collagen as haemostatic agent in obstetric and gynecological operations.

UNLABELLED: During the third stage of labour there are a lot of causes of significant hemorrhage. The commonest causes of acute hemorrhage are the uterine atony, the retained placenta, the lower tract lacerations, uterine rupture, placenta accreta, hereditary coagulopathy. Also, there could be significant bleeding, during caesarian section, usually at the time of removal of the placenta in cases of low lying placenta or placenta previa. A lot of times we have to confront serious hemorrhages in gynecological procedures like hysterectomies in cases of cervical, uterine or ovarian cancers. In order to deal with these problems successfully, general and specific measures are being taken. In cases of atonic uterus when all the other methods are unsuccessful we have to proceed to ligation of the internal iliac artery or even hysterectomy. MATERIAL-METHODS: We have tried to use the hemostatic type I collagen in obstetrical and gynecological cases in order to control the bleeding. We have used the collagen type I totally in 8 cases. Five of them were cases of atonic uterus after normal delivery or caesarian section and three of them were gynecological cases of uterine fibroids and ovarian cancer. RESULTS: By placing the collagen type I over the bleeding surfaces we have realized that in a very short period of time, there has been satisfactory control of the bleeding and immediate clinical improvement of the patient. In four out of five obstetrical cases that we have used the type I collagen, we have managed to avoid the hysterectomy.

Idiopathic renal arteriovenous fistula treated by transcatheter embolization.

Renal arteriovenous fistulas (RAVFs) are unusual lesions with a variety of clinical manifestations. Traditionally, these lesions have been treated surgically. We report on an idiopathic, high-flow RAVF and an aneurysm treated successfully with the embolization technique. The endovascular management of RAVFs in carefully selected patients is a safe and effective therapeutic technique.

ProCol vascular bioprosthesis for vascular access: midterm results.

BACKGROUND/AIMS: This study aimed to evaluate the safety and efficacy of the ProCol vascular bioprostheses as vascular access (VA) material, especially in patients with a history of prior failed access. METHODS: During a 20-month period, 25 arteriovenous (AV) bovine vein grafts were placed in 24 hemodialysis (HD) patients for VA. All patients presented with failed autologous access sites. RESULTS: Graft placement was successful in all patients with no procedure-related complications. Follow-up from 6-26 months gave primary 6-month, 12-month and 24-month patency rates of, respectively, 90%, 80% and 70%. Graft characteristics in cannulation and hemostasis were very satisfying. CONCLUSION: Our midterm results demonstrated that the ProCol vascular bioprosthesis was a promising material for VA with good patency and low complication rates.

Priority of resection in concomitant abdominal aortic aneurysm (AAA) and colorectal cancer (CRC): review of the literature and experience of our clinic.

The concomitant occurrence of abdominal aortic aneurysm (AAA) and colorectal cancer (CRC), although rare, always represents a therapeutic dilemma. The incidence of coexistence ranges between 0.49 and 2.1%. Both lesions should be treated to achieve best life expectancy. But the main controversy revolves around whether to treat them simultaneously or as staged procedures. In our institution, we treated seven cases of concomitant AAA and CRC. In five of them, synchronous conventional resection was preferred. In the latest two, which we present, endovascular aortic repair was chosen. No graft infection was documented.

The effect of aspirin and high fibre diet on colorectal carcinoma: a comparative experimental study.

BACKGROUND: The aim of this study is to assess the role of high fibre diet and aspirin on dimethylhydrazine (DMH)-induced colorectal cancer in rats. MATERIALS AND METHODS: Colorectal tumours were induced with DMH. The animals were randomly divided into five groups (15 rats each): I, controls; II, rats receiving only the carcinogen; III, rats receiving the carcinogen and high fibre diet; IVA, rats receiving the carcinogen plus low dose aspirin; IVB, rats receiving the carcinogen plus high dose aspirin. RESULTS: Adenocarcinomas were detected in 100% of the rats in group II, 47% of the rats in group III (chi2, p<0.05), 100% of the rats in group IVA, but the incidence was reduced to 50% in the rats of group IVB (p<0.05). CONCLUSIONS: These data indicate that high fibre diet and aspirin suppress experimental colon carcinogenesis and the protective effect of aspirin is dose related.

Management of colorectal cancer: 20 years' experience.

Colorectal cancer is the second most common cause of cancer death in westernised countries. Its treatment is the subject of active, ongoing investigation within all treatment modalities, including surgery, chemotherapy and radiotherapy. We reviewed the charts of all patients treated in this university general surgical department for colorectal carcinoma, between January 1983 and December 2002. A total number of 494 patients with colorectal cancer were operated on, on an elective or emergency basis. Patients' demographics, clinical presentation, location of tumour, type of surgery, operative staging, pathology of tumour, outcome and follow-up were recorded and analysed.

Stenting of central venous stenoses and occlusions to maintain hemodialysis vascular access.

BACKGROUND/AIMS: The aim of the study was to evaluate the efficacy of stenting for the treatment of central arm vein obstructions in hemodialysis patients in order to maintain hemodialysis from the affected side. METHODS: Fifteen self-expanding (8) and balloon expandable (7) stainless steel stents were implanted in 10 hemodialysis patients for the treatment of symptomatic central arm vein obstructions. Thirteen lesions were treated: 6 subclavian, 4 innominate and 3 restenoses. RESULTS: Stent deployment was successful in all cases leading to resolution of symptoms by correcting the underlying cause of venous hypertension. Follow-up from 3 months to 4 years revealed four deaths from unrelated causes, three restenoses at 1, 3, 4 months and one occlusion at 6 months respectively for a cumulative primary one-year and two-year patency rate of 70%. CONCLUSION: Stenting of subclavian and innominate venous stenoses and occlusions effectively corrected the underlying lesions responsible for disturbed hemodynamics and, in most cases, prolonged available hemodialysis access from the affected side.

Histochemical and ultrastructural characteristics of leg muscle fibres in patients with repairative abdominal aortic aneurysm (AAA).

Tibialis anterior (ta) muscle biopsies before and after elective abdominal aortic aneurysm (AAA) repair operation were obtained, in order to observe possible changes after the aortic declamping reperfusion. Open muscle biopsies were taken from each of eight patients (60-75 years old) which were processed for enzyme histochemistry, and for transmission electron microscopy (EM). Morphometric analysis was applied to estimate the number and the area of muscle fibres of each fibre type. Rectus abdominis muscle biopsies were served as controls. Before the operation the predominant elements found were the presence of atrophic muscle fibres, fibre size diversity, localised cellular reactions, increased extent of connective tissue, disappearance, in many cases, of the mosaic pattern, predominance of type I and oxidative fibres, and existence of fibres with core-like structures in the sarcoplasm. Type I fibres consisted of 66.95 +/- 9% of all muscle fibres, the mean cross sectional area of which was 3,372.8 +/- 1,016 microm(2) and of type II fibres was 3,786.5 +/- 6,046 microm(2). After the aortic clamping was performed mitochondrial swelling was found, as well as disorganisation of sarcomeres. After declamping of the aorta, there were also severe edema, local fibre necrosis, and adhesion of leucocytes, whereas muscle fibre areas became 3,935.18 micro 531 microm(2) for type I and 5,804 +/- 1,075 microm(2) for type II. The short ischemic period during aortic clamping and the subsequent reperfusion resulted mainly in ultrastructural changes.

The technique of eversion carotid endarterectomy.

Eversion endarterectomy of the Internal Carotid Artery (ICA) has been employed as a good alternative method to classical carotid endarterectomy. The details of this technique are presented. The main operative steps are: complete transection of the ICA from the carotid bifurcation, eversion endarterectomy of the ICA, endarterectomy of the External Carotid Artery, reimplantation of a the ICA to its normal position and reconstruction of a new bifurcation. The major advantages of this attractive technique are optimum correction of an elongated ICA in combination with stenosis, avoidance of patch material for arteriotomy closure and low restenosis rate.

Primary aortocaval fistula in association with ruptured aneurysms.

We report three cases in which ruptured aneurysm and aortocaval fistula went undetected until surgery was performed. Preoperative features suggestive of an arteriovenous fistula were not apparent in any of these patients; they all presented with cardiovascular collapse and all underwent emergency laparotomy after a ruptured abdominal aortic aneurysm was diagnosed. The fistula was discovered unexpectedly only after the aneurysmal sac was opened and the thrombus evacuated. In the first two patients the fistula was successfully sutured from within the aneurysmal sac. The first patient died 1 week postoperatively from rupture of a previously known associated thoracic aortic aneurysm and the second patient died during the operation from excessive blood loss. The third patient had a large fistula requiring an interposition synthetic graft to restore the continuity of the vena cava; the graft has remained patent 15 months postoperatively. Aortocaval fistula is an uncommon complication of aneurysmal aortic disease and may coexist with a rupture of the aneurysm into the retroperitoneum. In emergency cases such as ours it is usually discovered unexpectedly during the operation. The established method of treatment is to oversew the fistula from within the aneurysm; however, when the fistula is large reconstruction of the infrarenal inferior vena cava with an interposition synthetic graft is a good alternative to caval ligation.

Transposed basilic vein-brachial arteriovenous fistula: an alternative vascular access for hemodialysis.

Twenty-five brachial-basilic arteriovenous (AV) fistulas with transposed basilic vein for alternative vascular access were created in 22 chronic hemodialysis patients. This surgical procedure was performed under brachial block or general anesthesia. After a longitudinal skin incision that was made in the inner side of the arm, the basilic vein was exposed, transposed subcutaneously, and anastomosed end-to-side to the brachial artery. The follow-up was between 7 and 24 months. Early complications were hemorrhage, thrombosis, steal syndrome, and swelling of the arm. Among the late complications were failure of the fistula because of thrombosis and multiple stenosis at the site of venipuncture. The accumulated one-year patency rate of fistulas was 81%. The complications of high-output cardiac failure or local infection were not seen in our study. On the basis of our results, the brachial-basilic AV fistula with transposed basilic vein is a useful and safe second- or third-choice vascular procedure for hemodialysis patients, in particular for women without good quality of vessels.

Experimental acute and chronic vascular access through the femoral vessels: hemodynamic study in dogs.

In a side-to-side fistula between femoral artery and vein, an external "shunt" was created that simultaneously connected the distal femoral vein and the proximal femoral vein in 14 normal dogs with weight ranging from 14 to 28 kg. Blood flow and pressure alterations of different sites of this experimental model of vascular access were studied. The results showed that the degree of blood flow on these two vascular communications depends on the structural integrity of the femoral artery with adequate blood flow and blood pressure. Also, the correct connection of external shunt with the fistula is of equal importance. It is suggested that the blood pressure as well as the blood flow rate of these two vascular communications were adequate to allow performance of acute and chronic hemodialysis.