Chylous Ascites Following Open Abdominal Aortic Aneurysm Repair: An Unusual Complication.

Chylous ascites is a rare complication after abdominal aortic aneurysm repair. Accumulation of chyle within the close space of the peritoneal cavity may cause severe discomfort to the patient, complicating the postoperative course. Prompt diagnosis is needed to adopt measures for reducing lymph leakage and contributing to lymphatic fistula closure. Fortunately, conservative treatment is successful in the majority of cases. In the rare cases that do not respond to conservative treatment, surgery becomes mandatory. Accurate preoperative localization of lymph leakage is a prerequisite for a successful outcome. Postoperative chyloperitoneum has a benign course and an excellent prognosis.

Carotid endarterectomy in an asymptomatic patient with contralateral agenesis of the internal carotid artery.

A 64-year-old man was referred to the vascular surgery department with an incidental finding of right internal carotid artery stenosis during thyroid ultrasound imaging. Carotid artery color duplex revealed an ulcerated type III plaque producing stenosis of the right internal carotid artery of 70% and agenesis of the left internal carotid artery. Further imaging with computed tomography angiography confirmed the initial findings and excluded cerebral vascular malformations and ischemic cerebral infarcts. The patient was treated with endarterectomy of the right internal carotid artery with elective shunting and synthetic patch closure.

Rupture after endovascular abdominal aortic aneurysm repair: a multicenter study.

A total of 22 patients with ruptured abdominal aortic aneurysms (rAAAs) after previous endovascular aortic repair (EVAR; rAAAevar) were presented to 7 referral hospitals in Greece, between January 2006 and April 2012. Type Ia endoleak and endograft migration were identified in 72.7% and 50%, respectively. Compliance to follow-up protocol prior to rupture was 31.8%. In-hospital mortality was 36.4% (9.1% for those treated with secondary EVAR and 63.6% for those treated with open surgical repair, P = .02). An increase in the proportion of patients with rAAAevar among the total number of patients with rAAAs from 1.3% in 2007 to 18.2% in 2012 (P for trend = .04) was recorded, corresponding to an annual increase of 2.8% (b = 2.84, P = .04). Rupture after EVAR seemed to be a clinical entity encountered with increasing frequency over the past years. Type I endoleak and endograft migration were most frequently observed, whereas compliance to follow-up was low.

Predictors affecting in-hospital mortality of ruptured abdominal aortic aneurysms: a Greek multicenter study.

BACKGROUND: Endovascular aortic repair (EVAR) is being used with increasing frequency for the treatment of ruptured abdominal aortic aneurysms (rAAAs), although conflicting results have been reported concerning perioperative mortality. The aim of our study was to evaluate potential difference in mortality rates between EVAR and open surgical repair (OSR) and identify independent risk factors for in-hospital mortality in rAAAs. This study also aimed to evaluate the Glasgow Aneurysm Score (GAS) in predicting in-hospital mortality. A time-trend analysis of EVAR for ruptured AAAs was also performed. METHODS: Prospectively collected data from 7 public hospitals in Greece concerning rAAA repairs between January 2006 and April 2012 were analyzed. Primary outcome was in-hospital mortality. Multivariate logistic regression analysis was used to identify independent risk factors. The receiver-operator characteristic curve was used to determine the value of the GAS in predicting in-hospital death. Time-trend analysis, depicting annual changes (%), concerning EVAR for ruptured AAAs was also conducted. RESULTS: A total of 418 patients (92.3% men, mean age = 74.3 ± 8.8) with rAAAs were recorded during the study period. Among them, 113 patients (27%) underwent EVAR. Overall in-hospital mortality was 45.2%, whereas in-hospital mortality after EVAR and OSR was 20.4% and 54.3%, respectively (P < 0.001). Multivariate analysis evidenced that hemodynamic instability (P < 0.001), OSR (P < 0.001), age ≥80 years (P < 0.001), coronary artery disease (P < 0.001), and renal insufficiency (P = 0.02) independently increased in-hospital mortality. Area under the curve of GAS was 0.80 (95% confidence interval [CI] = 0.75-0.85, P < 0.001) for OSR and 0.64 (95% CI = 0.51-0.77, P = 0.04) for EVAR. Annual increase of proportion (%) of EVAR for rupture was 5% (P = 0.004). CONCLUSIONS: EVAR is being used with increasing frequency for the treatment of rAAAs and it appears to be associated with lower in-hospital mortality compared with OSR, after adjustment for hemodynamic instability and known atherosclerotic risk factors. Preoperative predictors of in-hospital mortality such as GAS should be probably modified in these patients.

Endovascular treatment of isolated iliac artery aneurysms with anaconda stent graft limb.

Isolated aneurysms of the iliac arteries are relatively rare conditions that traditionally have been treated by surgical reconstruction. We report our experience with endovascular treatment of iliac artery aneurysms (IAAs) with Anaconda stent graft limb. Two male patients were found to have 4.5 and 3.6 cm isolated common IAAs, respectively. The endograft was successfully advanced and deployed precisely to the intended position in both cases. In one case the internal iliac artery was embolized. No type I or II endoleak was observed immediately after the procedure. In one patient postimplantation fever (>38°C) and gluteal claudication occurred. After 2 years followup both iliac endovascular stent grafts are patent and without endoleak. Endovascular treatment with Anaconda limb stent graft seems to be a safe and feasible alternative to open surgery.

Late diagnosis of silent thoracic aortic rupture presented as a right pleural effusion.

Patients with ruptured thoracic aortic aneurysm rarely present in a stable clinical condition. A man was referred to our hospital with the diagnosis of ruptured saccular aneurysm of the descending thoracic aorta. He successfully underwent both endovascular graft repair and open thoracotomy.

Patterns of in-stent restenosis after carotid artery stenting: classification and implications for long-term outcome.

OBJECTIVES: Factors predicting in-stent restenosis (ISR) and future need for target lesion revascularization (TLR) after carotid artery stenting (CAS) remain undetermined. We hypothesized that the patterns of restenotic lesions may provide prognostic information. In this study, we developed an ultrasound classification scheme for ISR based on lesion length and distribution and assessed factors that may predict the need for TLR. METHODS: Patients were followed up after CAS with B-mode ultrasound imaging, and ISR lesions (> or =40% stenosis) were classified into type I (focal < or =10 mm end-stent lesions), II (focal < or =10 mm, intrastent), III (diffuse >10 mm, intrastent), IV (diffuse >10 mm proliferative, extending outside the stent), and V (total occlusion). The frequency of lesion types was assessed. Accuracy of the ultrasound classification was confirmed with angiography. We recorded patient (age, gender, comorbidities), lesion (severity, etiology, symptomatic status) and procedural features (type, number, length of stents), and the need for TLR. RESULTS: Eighty-five ISR lesions developed after 255 CAS procedures. Their percentage distribution was type I, 40; type II, 25.9; type III, 12.9; for type IV, 20; and type V, 1.2. Accuracy of the ultrasound classification was confirmed by angiography (r(2) = 0.82). Inter-rater agreement for the assignment of lesion type based on ultrasound was 0.88 (very good). TLR was performed in 13 that were > or =80% diameter reducing. On univariate analysis, the need for TLR was highest in type IV lesions (0%, 0%, 27.3%, and 58.8% [types I to IV, respectively]; P = .001). History of ISR (2.9%, 0%, 0%, and 41.2% [types I to IV]; P = .003) and diabetes mellitus (20.6%, 22.7%, 45.5%, and 52.9% [types I to IV]; P = .02) occurred more frequently with type IV ISR lesions. On multivariate analysis of all patient, lesion, and procedural characteristics, only the type of ISR (odds ratio, 5.1) and a history of diabetes (odds ratio, 9.7) were independent predictors of TLR. CONCLUSIONS: The proposed classification accurately grades the magnitude of intimal hyperplasia after CAS and provides important prognostic information. Diffuse proliferative (type IV) ISR lesions and diabetes are important determinants of long-term outcome after CAS. This classification will facilitate a standardized description of recurrence after CAS and enable early identification of high-risk patients for additional monitoring, treatment, and investigation.

The association of carotid plaque inflammation and Chlamydia pneumoniae infection with cerebrovascular symptomatology.

OBJECTIVE: Inflammation and infection have been implicated in the pathogenesis of carotid artery atherosclerosis, but their role in cerebrovascular disease symptomatology is not so well defined. We hypothesized that carotid disease symptomatology was associated with specific serologic markers of inflammation and Chlamydia pneumoniae infection and the presence of the pathogen and concentration of tumor necrosis factor-alpha (TNF-alpha) on the atheroma. METHODS: In 2004, 78 patients underwent carotid endarterectomy in our department, 46 of whom were symptomatic (group A) and 32 were asymptomatic (group B). A detailed medical history, the presence of atherosclerosis risk factors, ankle-brachial index and boxy mass index were recorded. We measured preoperatively the levels of C-reactive protein, fibrinogen, TNF-alpha, and the titers of immunoglobulin (Ig) A and IgG antibodies against C pneumoniae in the serum. Finally, the atherosclerotic plaques of all patients were immunohistochemically examined for the presence of C pneumoniae and their TNF-alpha concentration was determined. RESULTS: Isolation of the pathogen on the atheromatous lesion was statistically correlated with several risk factors and some of the variables that were tested. After testing independence of association, using the multiple regression analysis, only male gender (P = .024), hypertension (P = .008), hypercholesterolemia (P = .001), and TNF-alpha plaque values (P = .008) remained significantly associated. Hypertension, serum levels of fibrinogen and anti-C pneumoniae immunoglobulin A, detection of C. pneumoniae on the plaque, and plaque TNF-alpha values were significantly correlated with carotid disease symptomatology. After multiple analyses, only the presence of the pathogen on the lesion (P = .008) and atheroma TNF-alpha levels (P = .025) remained significantly associated with cerebrovascular events. CONCLUSIONS: It seems that hypertensive hypercholesterolemic men are more likely to have C. pneumoniae infected carotid plaques and that these plaques have higher TNF-alpha concentrations. Cerebrovascular disease symptomatology is strongly correlated with both C. pneumoniae infection and TNF-alpha concentration of the atheroma.