Open repair for ruptured abdominal aortic aneurysm: is it possible to predict survival?

The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAAA) and to assess the accuracy of the Glasgow Aneurysm Score (GAS) and the Acute Physiology Chronic Health Evaluation II (APACHE-II). From January 1998 to July 2006, 103 patients underwent operations for RAAA. For each patient, 44 variables were retrospectively recorded in a database. Data were analyzed with univariate and multivariate methods. In the univariate analysis significant predictors of death were hypotension (p=0.001), preexisting peripheral vascular disease (p<0.001), renal insufficiency (p=0.037), chronic obstructive pulmonary disease (p=0.028), level of HCO(3)(-) (p<0.001), intraperitoneal rupture (p=0.001), blood transfused (p<0.001), cardiac complications (p<0.001), and APACHE-II score (p=0.001). Multivariate analysis confirmed statistical significance for coexisting peripheral vascular disease (p<0.001), diastolic blood pressure at admission <60 mm Hg (p=0.039), APACHE-II score >18.5 (p=0.025), HCO(3)(-) <21 mg/dL (p<0.001), and intraperitoneal rupture of the aneurysm (p=0.011) as predictors of death. Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. APACHE-II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAAA.

Role of the genetic study in the management of carotid body tumor in paraganglioma syndrome.

Diagnosis of carotid body tumor (CBT) was made in a 36 years old woman. The pre-operative examination included genetic analysis of the succinate dehydrogenase that showed a mutation in his subunit D responsible of multiple paraganglioma at slow growth. Subsequently a thoraco-abdominal CT and indium(111) octreotide body scan were performed and another paraganglioma was detected in the anterior mediastinum. CBT was surgically removed; differently the thoracic lesion due to his benign genetic profile was not treated. During a 3-years follow-up the thoracic paraganglioma as expected, didn't increase. Genetic analysis of succinate dehydrogenase, should be performed in the management of CBT.

Endovascular treatment of asymptomatic popliteal aneurysms: 8-year concurrent comparison with open repair.

AIM: The aim of this prospective comparative study was to compare the results of 8-years experience of endovascular treatment (ET) of popliteal aneurysms (PAs) using the Hemobahn/Viabahn endograft with those achieved with open repair (OR). Endpoints were primary and secondary patency rate. METHODS: The study was a prospective randomized clinical trial from January 1999 to December 2003 and a prospective comparative study from January 2004 to December 2006. Patients with an asymptomatic aneurismal lesion in the popliteal artery 2 cm at angio-computed tomography were included in the study. Indication for ET was PA (proximal and distal neck length >1 cm); contraindications were: 1) age <50 years; 2) poor distal run-off; 3) contraindication to antiplatelet, anticoagulant or thrombolytic therapy. RESULTS: Between January 1999 and December 2006, of a total of 42 patients with 48 PA, 27 were treated with OR (group A) and 21 with ET (group B). The primary patency rate was 100% in group A and 80.9% in group B at 12 months and 71.4% and 88.1%, respectively, at 72 months; the secondary patency rate at 72 months was 88.15% and 85.9% in groups A and B, respectively. No statistical differences were observed at the log-rank test. During the entire study period, 3 (14.3%) patients in group B required conversion to open surgery because of endograft occlusion. CONCLUSION: Within the power limitations of this study, ET for asymptomatic PA in patients with suitable anatomy can be considered safe, with long-term results comparable with those of OR.

Glasgow aneurysm score predicts the outcome after emergency open repair of symptomatic, unruptured abdominal aortic aneurysms.

OBJECTIVE: To determine the predictor factors of in-hospital postoperative mortality in patients presenting with symptomatic but not ruptured abdominal aortic aneurysm (AAA) at our institution. PATIENTS AND METHODS: Forty-two patients who underwent urgent open repair for symptomatic, non-ruptured AAA were evaluated retrospectively. RESULTS: Five patients (11.9%) died during the in-hospital stay. History of coronary artery disease (p=0.014), cerebrovascular diseases (p=0.015), renal failure according to Glasgow Aneurysm Score (GAS) criteria (p=0.001), serum creatinine concentration (p=0.026), and the GAS (p=0.008) were predictive of postoperative death. The ROC curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.870 (95%C.I. 0.71-1, S.E. 0.08, p=0.008), and its best cut-off value in predicting postoperative death was 90.0 (specificity 89.2%, sensitivity 80.0%). The postoperative mortality rate of patients with a Glasgow Aneurysm Score below 90 was 2.9%, whereas it was 50% for those with a score >or=90 (p=0.003, O.R. 33.0). CONCLUSION: This study shows that the Glasgow Aneurysm Score is a good predictor of postoperative mortality and morbidity after urgent repair of symptomatic, non-ruptured AAA and can be useful in identifying those patients whose operative risk is prohibitive. Its simplicity makes it a clinically important tool, particularly, in the emergency setting. Patients having a score less than 90 can safely undergo urgent open repair. Thorough evaluation and improvement of preoperative status followed preferably by an endovascular repair is indicated for those with a score >or=90.

Hyaluronan biodegradable scaffold for small-caliber artery grafting: preliminary results in an animal model.

OBJECTIVE: To evaluate a new Hyaluronan-based graft. MATERIAL AND METHODS: Hyaluronan-based grafts (HYAFF 11trade mark tube, diameter 2 mm, length 1.5 cm) were implanted in an end-to-end fashion in the abdominal aorta of 15 rats. Histology, immunohistochemistry and electron microscopy were used to evaluate the results at 7, 21, and 90 days. RESULTS: At day 7, new tissue was observed in the graft coming from both the proximal and distal ends of the aorta. The luminal surface of the regenerating tissue was covered by endothelial cells (CD34(+), VEGFR-2(+), vWF(+)). At day 21, regenerating tissue joined at the centre of the tube. The neo-vessel was formed by smooth muscle cells (Myosin Light Chain Kinase) as well as elastic, and collagen fibres. At day 90 a stable artery segment was formed and the biomaterial was almost completely degraded. Infiltration of neutrophils and lymphocytes was not observed. All animals survived the observation period and there were no signs of stenoses or aneurysms. CONCLUSION: The hyaluronan-based graft allowed complete regeneration of a newly formed vascular tube in which all the cellular and extracellular components are present and organized in a well defined architecture similar to native artery.

Is carotid endarterectomy in octogenarians more dangerous than in younger patients?

AIM: The risk for developing stroke increases with the advancing age, peaking over age 80. In elderly patients, carotid endarterectomy may provide prophylaxis against stroke. Aim of our study was to compare patients 80 years or older with patients younger than 80 undergoing carotid endarterectomy. Endpoints were perioperative mortality and morbidity. METHODS: From January 1996 to December 2002, 1 659 patients underwent a 1 733 carotid endarterectomy for a symptomatic or asymptomatic significant carotid lesion. Among them, 125 patients were 80 years or older. We analyzed death and stroke rate from cerebrovascular accidents, TIA as well as non cerebrovascular complications and death rate postoperatively and in the long term follow-up. The Pearson's chi-squared(2) test was used for the statistical analysis on risk factors, morbidity and mortality. The Log rank test was used for cumulative stroke-free and survival rates between the 2 groups (level of confidence p<0.05). RESULTS: Risk factors were similar in both groups. No statistical difference was observed in the stroke, TIA, mortality and stroke free rates between the 2 groups. CONCLUSIONS: The results of our study show that perioperative and postoperative mortality and morbidity as well as the long-term stroke-free rate does not differ significantly in patients 80 years or older compared to patients younger than 80 undergoing carotid endarterectomy.

Synchronous carotid endarterectomy and retrograde endovascular treatment of brachiocephalic or common carotid artery stenosis.

OBJECTIVES: To retrospectively evaluate the safety and the long-term results of retrograde brachiocephalic and common carotid angioplasty and stenting (AS) performed for >70% stenosis synchronously with the carotid endarterectomy (CEA). PATIENTS: Sixteen patients operated between April 1999 and March 2002. RESULTS: 14/16 procedures were successful. There was no neurological morbidity or mortality. Per-operative angiography showed the optimal stent positioning and patency of both proximal and distal arteries in all patients. In the follow-up, all patients showed patency of the treated vessels without restenosis and the absence of any cerebrovascular symptoms. CONCLUSION: Intra-operative retrograde AS combined with CEA is an effective, safe and durable alternative to conventional surgery when a tandem significant proximal lesion is identified in a patient with an high grade carotid stenosis.

Rationale of the surgical treatment of carotid kinking.

AIM: Elongation and tortuosity of the internal carotid artery (ICAET) is a common angiographic, angioMR or Duplex scanning finding: it can be "pure" and, in a great majority of cases, it is not correlated to neurological symptoms. It can be associated with atherosclerotic bifurcation plaque, therefore in this case, indications to surgery follow that of carotid stenosis. On the other hand in some patients ICAET seems potentially correlated to hemispheric or non hemispheric symptoms: ICAET may show as kinking with a wide or narrow acute angle, single (< shaped) or double (Z shaped), or less frequently as a coiling (S,U, or C shaped). Surgical indications are controversial. In the author's opinion, surgery may represent the safest tool in the prevention of a stroke due to carotid occlusion, in selected patients. The aim of this study is to describe the author's experience in the surgical treatment of carotid kinking not associated with significant atherosclerotic lesions. METHODS: From March 1994 to March 2001, 29 patients (11 male, 18 female) with a pure ICAET underwent surgery. Patients presented hemispheric symptoms (24.13%), non hemispheric symptoms (41.3%) or both (27.5 %). Two asymptomatic patients (6.9%) underwent surgery because of contralateral carotid occlusion. RESULTS: The postoperative (within 30 days from operation) results, no mortality was observed, 1 patient presented a stroke (3.4%), and 1 patient had a TIA at awakening (negative cerebral CT scan). All patients with hemispheric symptoms (15 patients) had complete remission, whereas only 6 out of 12 patients (50%) presenting non-hemispheric symptoms had remission (1 patient underwent a controlateral ICAET correction). CONCLUSIONS: The natural history of symptomatic and asymptomatic ICAET is practically unknown, but in some cases selected indication to surgery is justified. Surgery was indicated for patients with transient ischaemic attacks ( hemispheric symptoms); in asymptomatic patients presenting a kinking with an angle inferior to 30 degrees, and a contralateral carotid artery occlusion; in patients with non hemispheric symptoms, after a screening to exclude all other possible neurological or non-neurological causes with duplex scan positive for significant increase of flow velocity in ICA and positive cerebral CT scan or MR scan for ischaemic lesions in the homolateral hemisphere, and/or a flow inversion in anterior cerebral artery or flow reduction in the middle cerebral artery, according to different head positions (rotation and flex-extension).

Visceral artery aneurysms: a single center experience.

BACKGROUND: Splanchnic artery areurysm is a rare but clinically relevant disease, showing a high mortality rate in emergency surgery. Reports on splanchnic aneurysms are rare and often anecdotal. The aim of this study is to discuss data obtained from 16 patients in a single vascular surgery center. MATERIALS AND METHODS: Between January 1987 and December 2000, 16 patients underwent surgery for splanchnic artery aneurysms. In 13 patients the localization was single (in two associated with an infrarenal abdominal aortic aneurysm) and in 3 patients multiple. The arteries involved were: splenic (8), hepatic (4), celiac (3), superior mesenteric (3), ileocolic (2), and pancreatoduodenal (1). 13 patients were asymptomatic and 3 presentec with abdominal pain. All patients underwent CT scan, and abdominal aortic and selective visceral artery angiography. Before surgery, all patients underwent cerebral MR or cerebral CT scan. 13 patients underwent open vascular surgery; 3 patients (2 splenic and 1 hepatic) underwent endovascular procedure (angioembolization). Histological examination of the aneurysmal wall was obtained in 14 patients. Ultrasound examination was performed after 6 months, then yearly. 14 patients underwent abdominal CT scan during the long-term follow-up. RESULTS: Perioperative mortality was absent. 12 cases were classified as displastic, with minor or major secondary atherosclerotic changes, and in many cases severe calcications. 2 cases were classified as atherosclerotic. Cerebral MR did not show any cases of intracerebral displastric aneurismal disease. One patient was lost at follow-up after 9 years. One patient showed a recurrence at 6 years (superior mesenteric artery): the patient underwent a new surgical procedure and died 20 days after surgery for intestinal infarction. All abdominal follow-up CT scans show good results of the vascular reconstruction and escluded other new visceral or aortic aneurysms. CONCLUSIONS: Visceral artery aneurysms are an uncommon form of abdominal vascular disease showing a high postoperative mortality rate in emergencies. Surgery, and in selected cases, endovascular treatment, can successfully manage splanchnic artery aneurysms with few complications and low recurrence.

Prospective comparative study of two cerebral protection devices in carotid angioplasty and stenting.

BACKGROUND: The aim of the study was to compare two of the available cerebral protection devices (CPD) PercuSurge, balloon type (group A) and Angioguard, filter type (group B) used in carotid stenting and angioplasty (CAS). METHODS: From September 1999 to February 2001, 26 consecutive patients undergoing CAS were alternatively assigned to group A and B. Postoperative disabling stroke and neurological mortality, nondisabling stroke, TIA and non-neurological mortality were examined. CPD features included time required, ease of handling, device rupture or malfunctioning, radiopaque markers evidence, abnormal major mobility of the opened system. RESULTS: RNCR was 0 and TIAs were not observed in either group. Four patients (3 in group A and 1 in group B) showed drowsiness in the immediate postoperative period. Perioperative carotid occlusion and surgical conversion were observed in 1 case of group A. Average time calculated from the beginning of set-up to complete removal was 46 min in group A versus 31 min in group B. Abnormal major mobility of the opened system was very often observed during endovascular maneuvers with both devices. CONCLUSIONS: CAS may protect against postoperative procedure-related neurological events. Common and specific disadvantages were observed in both systems showing they were not close enough to the ideal device.

Short-term arterial blood reperfusion of normothermic kidney in renal artery and abdominal aorta reconstructive surgery.

OBJECTIVE: to prevent kidney injury in renal artery and juxta-renal aortic surgery. After 30 min of cross-clamping ischaemia, renal arterial inflow is temporary re-established for 3 min. The aim of the study was to retrospectively analyse the results of this original technique. METHODS: between January 1987 and May 1999, 48 patients underwent kidney short-term arterial blood reperfusion, directly or through the Pruitt-Inahara shunt. The reperfusion was repeated every 30 min of ischaemia, whenever necessary. Fifty control patients underwent <30 min of kidney ischaemia. Patients were assessed by serum creatinine, digital angiography and radioisotope renography using technecium(99). RESULTS: in the study group one patient developed an acute renal failure and died (2% (-95% CI: 0-11%)). In both study and control groups patients showed a similar and moderate but temporary decline in renal function, which returned to preoperative levels after 1 week. CONCLUSIONS: the results of this study indicate that kidney short-term reperfusion may protect renal tissue from prolonged cross-clamping ischaemia (up to 100 min), also in patients considered at high risk for acute renal failure.

Carotid endarterectomy without angiography: a prospective randomised pilot study.

OBJECTIVES: to determine whether duplex ultrasonography alone is an adequate examination prior to carotid endarterectomy. DESIGN: prospective, randomised, single centre study. MATERIAL AND METHODS: all patients with carotid bifurcation stenosis greater than 70% - based on duplex scanning - were randomised to arteriography followed by carotid surgery (Group A n=96) or carotid surgery alone (Group B n=90). Study endpoints were neurological complications or death occurring between the day of randomisation and until 30 days after surgery. RESULTS: major neurological complications of death in 1 (1%) vs 3 (3.3%) patients in group A and B, respectively (n.s.). Minor neurological complications (only TIA) were observed in 0 and 3 (3.3%) patients, respectively. CONCLUSIONS: complication rates were low in both groups and within the generally accepted rate after carotid surgery in asymptomatic and symptomatic patients.

Specific cellular features of atheroma associated with development of neointima after carotid endarterectomy: the carotid atherosclerosis and restenosis study.

BACKGROUND: The purpose of this study was to investigate whether some cellular and molecular features of tissue retrieved at carotid endarterectomy are associated with the extent of neointima formation at ultrasound follow-up. METHODS AND RESULTS: One hundred fifty patients were studied. Endarterectomy specimens were tested by immunocytochemistry with the use of (1) monoclonal antibodies that identify smooth muscle cells (SMCs) and fetal-type SMCs on the basis of smooth muscle and nonmuscle myosin content, (2) the anti-macrophage HAM 56, and (3) the anti-lymphocyte CD45RO. The maximum intima-media thickness (M-IMT) of the revascularized vessel was assessed by the use of B-mode ultrasonography 6 months after surgery. The M-IMT values were related positively to the number of SMCs (r=0.534, P<0.0005) and negatively to that of macrophages and lymphocytes (r=-0.428, P<0.0005, and -0.538, P=0.001, respectively). Patients were classified as class 1 (M-IMT 1.3 mm). An abundance of SMCs, mostly of fetal type, was found in the plaque of class 3 patients, whereas lesions from class 1 patients were rich in macrophages and lymphocytes. In the multivariate analysis, factors related to M-IMT were the number of SMCs and the percentage of fetal-type SMCs present in the plaque. CONCLUSIONS: Although the classic risk factors did not play a role, an abundance of SMCs and a scarcity of macrophages characterized the primary lesion of patients in whom neointima developed after surgery. In patients in whom neointima did not develop, lesions were rich in macrophages and lymphocytes. This approach can be useful in defining patients at risk of restenosis.

Clamping ischemia, threshold ischemia and delayed insertion of the shunt during carotid endarterectomy with patch.

BACKGROUND: Shunt insertion during carotid endarterectomy (CEA) is mandatory to avoid neurological damage due to clamping ischemia; however shunt insertion before plaque removal has many inconveniences (atheroembolism, intimal dissection, difficulty of endarterectomy). The aim of this study is to verify whether and how long shunt insertion may be safely delayed to permit plaque removal and ensure cerebral perfusion during the further time consuming manoeuvres of CEA (peeling, patch angioplasty). METHODS: From July 1990 to February 1996 383 patients underwent 411 CEAs under general anesthesia with EEG continuous monitoring and PTFE patch angioplasty. A Pruitt-Inahara shunt was routinely inserted only after atherosclerotic plaque removal. In 316 CEAs (76.9%) without EEG signs of cerebral ischemia (Group A) the mean clamping time was 10 min +/-4.8 (range 2-37 min). In 95 CEAs (23.1%) with EEG signs of cerebral ischemia (Group B) it was 7.3 min +/-3.5 (range 3-20 min). All patients had normal EEG signals after delayed shunt insertion and reperfusion (mean 21 min, range 5-45 min). RESULTS: In the short term results (within 30 days) there was a relevant neurological complication rate of 0.96% (2 major stroke and 2 lethal stroke); at awakening we observed 5 RINDs (1.21% of total) 1 in a patient of Group A (0.31%) and the other 4 in patients of Group B (4.21%). CONCLUSIONS: These data confirm the rationale of a delayed insertion of the shunt: actually the cerebral parenchyma may tolerate under general anesthesia a sufferance due to carotid clamping, EEG detectable, without neurological deficits for at least 7.3 min. This time is sufficient to perform the most difficult steps of CEA (plaque removal, distal intima checking) allowing shunt insertion in a clean operatory field, without inconveniences. Finally the shunt allows complementary time consuming steps, as patch angioplasty, with improvement of both short- and long-term results.

Successful surgical treatment of ''globus hystericus''.

We report the case of a 52-year old woman who presented with a 4-year history of depression associated with intermittent dysphagia and globus sensation for which she was admitted to a nursing home. Physical examination revealed a murmur on the right carotid artery, while the routine biochemical tests were normal. Chest computer tomography (CT) demonstrated the presence of an anomalous vessel departing from the aortic arch; angiography showed an aberrant right subclavian artery of large lumen and a severe stenosis at the origin of the right internal carotid artery. Surgical intervention was performed and dysphagia disappeared.

Surgical treatment of atherosclerotic lesions of subclavian artery: carotid-subclavian bypass versus subclavian-carotid transposition.

BACKGROUND: The aim of this retrospective study is to analyze the short and long term results of two different surgical treatments in patients with subclavian lesions: common carotid-subclavian artery bypass (CSB) versus transposition of subclavian artery on the common carotid artery (SCT). METHODS: From 1981 until 1995, 40 non randomized patients with symptomatic subclavian steal underwent 20 CSBs and 20 SCTs. Risk factor rates were equally balanced in the two groups. Surgery was carried out routinely under general anesthesia, with electroencephalic continuous monitoring. Patency of revascularization was assessed by physical examination, brachial blood pressure determinations, ultrasound sonography and angiography whenever recurrence of symptoms developed or when the function of repair was in doubt. Patients were examined every year. In Spring 1996 (range 9-189 mos, average 7 years) a general clinical-instrumental follow-up was performed. RESULTS: In the short term (<30 days) mortality was 5%: one death (5%) for pulmonary embolism in a patient with CSB and one for myocardial infarction in a patient with SCT. The early thrombosis rate was 5% (1 CSB and 1 common carotid artery distal to a patent SCT). During follow-up 10 patients (25%) died and 6 were lost. The six-year actuarial patency rate was 100% for SCT and 66% for CSB. Moreover there were 3 thromboses of the vertebral artery homolateral to patent CSBs. CONCLUSIONS: In conclusions SCT should be considered the surgical technical choice for the treatment of proximal subclavian artery lesions.

Carotid artery endarterectomy in patients with contralateral carotid artery occlusion: perioperative hazards and late results.

The aim of this study was to analyze and compare the perioperative hazards and late results of internal carotid endarterectomy (CEA) in patients with and without contralateral internal carotid artery occlusion. From March 1980 to April 1990, 375 consecutive patients underwent 439 CEAs at the First Department of Vascular Surgery of Padova Medical School. Patients were divided into two groups; group 1 (61 patients) had contralateral internal carotid artery occlusion and group 2 (314 patients) did not (378 CEAs, 64 bilateral). Indications for CEA were similar in both groups. The only significant difference in patient characteristics was a higher rate of previous stroke in group 1 (11% vs. 3%, p < 0.001). General anesthesia, continuous EEG monitoring, selective intraluminal shunt, and arteriotomy closure with a polytetrafluoroethylene patch (PTFE) were used routinely in both groups. An intraluminal shunt was inserted more frequently in group 1 than in group 2 (69% vs. 17%, p < 0.001). Major perioperative stroke occurred in one patient in each group (1.7% vs. 0.31%, respectively; NS). Early fatal stroke rates were 0% and 0.95% in groups 1 and 2, respectively (NS). All patients had neurologic examinations and duplex scans every 6 months (range 6 to 118 months; mean 42 months). Kaplan-Meier survival curves were virtually identical in the two groups; the majority of deaths were caused by myocardial infarction and cancer. There were no stroke-related deaths in group 1 as compared with 8.2% in group 2 (NS). New neurologic symptoms appeared in 4.7% of patients in group 1 and 6% in group 2 (NS) whereas the late stroke rates were 0% and 3.1%, respectively (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of high-grade stenosis of innominate artery.

Although pathology of the innominate artery (IA) is not frequent, it causes relevant impairment of extracranial circulation and sometimes cerebrovascular events. Definite differentiation of high-grade stenosis from occlusion of the IA has not been obtained until now with continuous-wave (C.W.) Doppler and duplex system ultrasound, and thus the direct evaluation of IA is not reliable by noninvasive methods. In this study the authors suggest an indirect method of evaluation of IA pathology based on the study of carotid, subclavian, and vertebral arteries (VA) with echo-Doppler-color-flow (EDCF) (with linear--phase array probes of 7.5 and 5 MHz). In the last two years they studied 6 patients with IA pathology (2 with occlusion (occ), 1 with stenosis of 80% and 3 with subocclusive stenosis > 90%). In both patients with occ, right VA flow was inverted, and also the right common carotid (CC) was involved (occ in 1 case and inverted flow in the other); in the 3 subocclusive stenoses a lowered systolic flow in the CC was recorded (48 vs 85 cm/sec, 41 vs 77, and 23 vs 109). In the 80% stenosis, besides the inverted flow in VA, only a reduced diastolic flow in CC was also recorded (19 vs 33 cm/sec measured in the left side). All patients with high grade stenosis were successfully confirmed by an angiographic study, including the different degree of stenosis. Five of the 6 patients underwent surgical correction with a restored flow in the previously involved artery. Only 1 patient with occlusion is waiting for surgical correction.(ABSTRACT TRUNCATED AT 250 WORDS)