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Background-Aim: Limited data exist concerning the fluid dynamic changes induced by endovascular aortic repair with fenestrated and chimney graft modalities in pararenal aneurysms. We aimed to investigate and compare the wall shear stress (WSS) and flow dynamics for the branch vessels before and after endovascular aortic repair with fenestrated and chimney techniques. Methods: Modeling was done for patient specific pararenal aortic aneurysms employing fenestrated and chimney grafts (Materialise Mimics 10.0) before and after the endovascular procedure, using computed tomography scans of patients. Surface and spatial grids were created using the ANSYS CFD meshing software 2019 R2. Assessment of blood flow, streamlines, and WSS before and after aneurysm repair was performed. Results: The endovascular repair with chimney grafts leaded to a 43% to 53% reduction in perfusion in renal arteries. In fenestrated reconstruction, we observed a 15% reduced perfusion in both renal arteries. In both cases, we observed a decrease in the recirculation phenomena of the aorta after endovascular repair. Concerning the grafts of the renal arteries, we observed in both the transverse and longitudinal axes low WSS regions with simultaneous recirculation of the flow 1 cm distal to the ostium sites in both aortic graft models. High WSS regions appeared in the sites of ostium. Conclusions: We observed reduced renal perfusion in chimney grafts compared to fenestrated grafts, probably caused by the long and kinked characteristics of these devices. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM PUBLISHER]

Abstract: Hemodynamic forces, including shear stress and cyclic strain, have been recognised as important modulators of vascular cell morphology and function. However, the mechanism by which vascular cells sense and transduce the extracellular mechanical signals into the cell nucleus has not yet been clarified. The purpose of our study was to assess the involvement of the signal transducer and activator of transcription-3 (STAT-3) in the signaling pathway mediating the response of vascular smooth muscle cells (SMC) to cyclic strain. Embryonic A7r5 SMC derived from thoracic aortas of DB1X rats were seeded on flexible collagen I-coated plates. Cells were subjected to 10% average strain at 60cycles/min for various time periods. Activation of STAT-3, p38, extracellular signal-regulated kinase (ERK) 1/2 and Src was assessed by immunoblotting using phosphospecific antibodies. The interactions between STAT-3 phosphorylation and p38, ERK1/2, phosphatidylinositol-3 (PI3K), mammalian target of rapamycin (mTOR), Janus kinase (JAK) 2 and Src were evaluated by pretreating the cells with specific inhibitors including SB202190, PD98059, LY294002, wortmannin, rapamycin, AG490 and PP1. Serine phosphorylation of STAT-3 was increased by 2-fold after 15min of cyclic strain, while tyrosine phosphorylation was increased by 2.3-fold after 60min. Inhibition of ERK1/2 by PD98059 prevented serine phosphorylation of STAT-3, whereas inhibition of Src by PP1 prevented STAT-3 tyrosine phosphorylation. Pretreating the cells with SB202190, a specific inhibitor of p38, resulted in an increase in basal phosphorylation of ERK1/2 and a subsequent increase in basal serine phosphorylation of STAT-3. In conclusion, both serine and tyrosine phosphorylation of STAT-3 are involved in the signaling pathway mediating the effects of cyclic strain on vascular SMC. Serine phosphorylation of STAT-3 is mediated by ERK1/2, while tyrosine phosphorylation is mediated by Src. A negative feedback loop was also found between p38 and ERK1/2. [Copyright &y& Elsevier]

Hemodynamic forces, including shear stress and cyclic strain, have been recognized as important modulators of vascular cell morphology and function. The mechanism by which vascular cells sense and transduce the extracellular mechanical signals into the cell nucleus has only recently begun to come to light. Integrins, ion channels, platelet-derived growth factor receptors, and G proteins have been recognized as mechanosensors, converting the mechanical stimuli into chemical signals. Activation of second messengers, including mitogen-activated protein kinases, protein kinase C, and Akt, follows, leading to an increase in the activity of transcription factors such as activator protein (AP)-1, AP-2, cAMP-responsive element (CRE), early growth response (Egr)-1, and nuclear factor (NF)-n B. Binding of these factors to the DNA leads to activation of numerous genes that regulate cell proliferation, apoptosis, differentiation, morphology, migration, and secretory function. Understanding of these responses has provided new insights in the pathogenesis and treatment of vascular diseases, such as atherosclerosis and intimal hyperplasia. [ABSTRACT FROM AUTHOR]

Endovascular stent grafting is becoming more common in treating complex thoracic aortic aneurysms and dissections. When it becomes necessary to cover the supra-aortic vessels, maintaining blood supply through the supra-aortic branches can be achieved by performing in situ needle fenestration. We present a case of a 65-year-old man with a type B aortic dissection that extended from the origin of the left subclavian artery. A stent graft was inserted into the thoracic aorta distally of the origin of the left common carotid artery. Due to the stent graft moving distally and not adequately sealing the subclavian artery, a second stent graft was placed more proximally. Both stent grafts were successfully in situ fenestrated using a needle, and a stent graft was inserted into the subclavian artery. In conclusion, during thoracic endovascular aortic repair, in situ needle fenestration can be successfully carried out on two overlapping thoracic stent grafts. [ABSTRACT FROM AUTHOR]

De novo carcinoma of the renal transplant is a rare but disastrous clinical entity. We report such a tumor developing 13 years after transplantation and describe its clinical presentation, diagnostic approach and therapy. The importance of a surveillance program allowing early detection of tumor developing in the renal transplant is emphasized. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The article presents case study of a 69-year-old male with a 4-month history of low back pain. It mentions that computed tomography (CT) scan illustrated an infrarenal abdominal aortic aneurysm (AAA) and magnetic resonance imaging (MRI) suggested a mesenchymal lesion of neurogenic origin as the most likely diagnosis. It adds elective AAA open repair followed in the posterior wall of the aneurysm was found.

An intraluminal thrombus (ILT) is present in the majority of abdominal aortic aneurysms, playing a crucial role in their growth and rupture. Although most computational studies do not include the ILT, in the present study, this is taken into account, laying out the whole simulation procedure, namely, from computed tomography scans to medical image segmentation, geometry reconstruction, mesh generation, biomaterial modeling, finite element analysis, and post-processing, all carried out in open software. By processing the tomography scans of a patient's aneurysm before and after rupture, digital twins are reconstructed assuming a uniform aortic wall thickness. The ILT and the aortic wall are assigned different biomaterial models; namely, the first is modeled as an isotropic linear elastic material, and the second is modeled as the Mooney–Rivlin hyperelastic material as well as the transversely isotropic hyperelastic Holzapfel–Gasser–Ogden nonlinear material. The implementation of the latter requires the designation of local Cartesian coordinate systems in the aortic wall, suitably oriented in space, for the proper orientation of the collagen fibers. The composite aneurysm geometries (ILT and aortic wall structures) are loaded with normal and hypertensive static intraluminal pressure. Based on the calculated stress and strain distributions, ILT seems to be protecting the aneurysm from a structural point of view, as the highest stresses appear in the thrombus-free areas of the aneurysmal wall. [ABSTRACT FROM AUTHOR]

Reports that a 63-year-old male, with history of hypertension, diabetes melitus and hypercholesterolemia, underwent an ultrasound scan for prostate hypertrophy, which revealed an abdominal aortic aneurysm (AAA) and disclosure duplication of the inferior vena cava (IVC). Result of the survey; Cause of the abnormality; Effect of the presence of double IVC.

Background: We investigated the relationship of matrix metalloproteinases (MMPs), cardio-ankle vascular index (CAVI), and Gray-Scale Median (GSM) score with the severity and vulnerability of carotid atherosclerosis and major adverse cardiovascular events (MACE) during follow-up of carotid artery revascularization. Methods: We enrolled 262 patients undergoing carotid revascularization therapy (GRT), 109 asymptomatic patients with low-grade carotid stenosis (40–70%) receiving conservative treatment (GCT), and 92 age- and sex-matched control subjects without carotid atherosclerosis (GCO). All participants underwent carotid ultrasound and we assessed at baseline clinical parameters, metabolic profile, CAVI, GSM, and circulating levels of hsCRP, MMP-3,-7,-9, and TIMP-1. Results: Both GRT and GCT presented with elevated CAVI, MMPs, and TIMP-1 levels compared to GCO (p < 0.001). The escalation highly correlated to the presence of symptoms or paralleled the degree of carotid stenosis (p < 0.001). During follow-up (mean duration: 55 months), 51 GRT patients experienced MACE unrelated to the revascularization procedure. Within GRT, diabetes (HR: 2.07; CI: 1.55–2.78, p < 0.001), smoking (HR: 1.67; CI: 1.35–1.95, p < 0.001), high CAVI (HR: 1.22; CI: 1.09–1.43, p = 0.023) and MMP-9 (HR: 1.44; CI: 1.29–2.15, p = 0.005), and low GSM (HR: 1.40; CI: 1.16–2.12, p = 0.002) independently predicted MACE occurrences, despite the optimum medical therapy. Conclusions: Novel imaging and biochemical biomarkers were positively associated with atherosclerosis severity, while CAVI, MMP-9, and low GSM showed a positive, independent relationship with MACE after carotid revascularization, describing "vulnerable patients". [ABSTRACT FROM AUTHOR]

Background and Objective: Venous thromboembolism (VTE), comprising deep-vein thrombosis (DVT) and pulmonary embolism (PE), is a major healthcare concern that results in substantial morbidity and mortality with great economic burden for healthcare systems. Hence, the need for effective and efficient treatment of patients with VTE is important for both clinical and economic reasons. The objective of this study was to evaluate the cost effectiveness of rivaroxaban compared to standard of care (SoC) with enoxaparin followed by dose-adjusted vitamin-K antagonists for the treatment of DVT and PE in Greece. Methods: An existing Markov model was locally adapted from a third-party payer perspective to reflect the management and complications of DVT and PE in the course of 3-month cycles, up to death. The clinical inputs and utility values were extracted from published studies. Direct medical costs, obtained from local resources, were incorporated in the model and refer to year 2017. Both costs and outcomes were discounted at 3.5%. The incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) gained was calculated. Probabilistic sensitivity analysis (PSA) was carried out to deal with uncertainty. Results: The base-case analysis showed that rivaroxaban in 3- and 6-month treatment duration for DVT and PE, respectively, as this is the common clinical practice in Greece, was associated with a 0.02 and 0.01 increment in QALYs compared to SoC, respectively. Rivaroxaban was associated with a reduced total cost in DVT (€85) but with an additional total cost in PE (€2) compared to SoC. Therefore, rivaroxaban was a dominant (less costly, more effective) and cost-effective (ICER: €177) alternative over SoC for the management of DVT and PE, respectively. PSA revealed that the probability of rivaroxaban being cost effective at a threshold of €34,000 per QALY gained was 99% and 81% for DVT and PE, respectively. Conclusion: Rivaroxaban may represent a cost-effective option relative to SoC for the management of DVT and PE in Greece. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented that focuses on a case study of a 33-year-old man with hypertrophic cardiomyopathy.

Arterial stiffness and its valid index, the cardio-ankle vascular index (CAVI), have emerged as predictors of adverse cardiovascular outcomes. We investigated the relationship of the CAVI with significant carotid stenosis (> 50%) and the related cerebrovascular symptoms or carotid plaque echogenicity, assessed by ultrasound gray-scale median (GSM) score, at baseline and after carotid artery stenting (CAS). We prospectively enrolled 113 patients with carotid stenosis (70-99% for asymptomatic and > 50% for symptomatic participants) eligible for CAS. Age- and sex-matched individuals (n = 38) served as controls (CON). Clinical data, CAVI, and biochemical profile were obtained at baseline. Clinical assessment and CAVI measurement were performed 6 months after CAS. Compared with the CON group, the CAS group had a higher incidence of co-morbidities (diabetes, hypertension, and hyperlipidemia), higher CAVI values (9.94 ± 2.14 vs 7.85 ±.97 m/sec, P <.001), but a better lipid profile due to increased prescription of statins. The symptomatic CAS subgroup showed higher CAVI (P <.001), high-sensitivity C-reactive protein (P =.048), and osteoprotegerin (P =.002) levels than the asymptomatic one. In multivariate analysis, CAVI at baseline was independently associated with the presence of significant carotid atherosclerosis (β =.695, P <.001), cerebrovascular events (β =.474, P <.001), and GSM score (β = −.275, P =.042). Raised CAVI values were independently associated with significant carotid stenosis and plaque vulnerability. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Soluble P selectin (sPsel), a member of the selectin family of cell adhesion receptors, has been proposed as a key molecule in hemostasis and thrombosis mediating platelet rolling, generating procoagulant microparticles and enhancing fibrin deposition. The aim of this study was to examine the role of sPsel in the diagnosis of venous thromboembolism (VTE). Materials and Methods: We performed a systematic review and we used meta-analysis to synthesize data from published studies reporting sPsel levels in patients with i) VTE (deep venous thrombosis; DVT or DVT and pulmonary embolism; PE) and ii) DVT only. Pooled Odds Ratios (ORs) with 95% Confidence Intervals (CIs) were appropriately calculated among patients and controls. Diagnostic performance of sPsel was tested with pooled sensitivity, specificity, Diagnostic Odds Ratio (DOR) and summary receiver operator characteristic (SROC) curve. Results: Eleven studies, comprising of 586 VTE patients and 1,843 controls were deemed eligible. The sPsel was significantly increased after VTE (OR=2.89, 95%CI=2.31-3.61, p<0.001), or DVT only (OR=2.64, 95%CI=1.95-3.56, p<0.001). Subgroup analysis evidenced that sPsel was also increased after VTE when evaluating only studies with patients that had no prior medical history (OR=2.88, 95%CI=1.98-4.19, p<0.001). Exclusion of studies including patients with solid organ tumor, HIV or lupus anticoagulants positive patients did not alter findings. Pooled sensitivity and specificity of sPsel was 0.57 (95%CI=0.30-082, p<0.001) and 0.73 (95%CI=0.51-0.90, p<0.001), respectively and DOR was 4.31 (95%CI=2.22-8.37, p<0.01). SROC curve yielded in significant accuracy of sPsel performance (AUC=0.74, p=0.05). Conclusions: The sPsel was significantly elevated in patients with DVT, both uncomplicated and complicated with PE and presented with high levels of diagnostic performance. sPsel is a plasma biomarker that may help in the diagnosis of VTE. [Copyright &y& Elsevier]

The inflammatory response during elective open infrarenal abdominal aortic aneurysm repair and its impact on outcome is investigated. Twenty high-risk patients were enrolled, and blood samples were obtained at 8 perioperative time points. Endotoxin, cytokines (tumor necrosis factor-α and interleukin-1β, and interleukin-6), Cl)11b expression, and nitric oxide were measured. Peak enclotoxin levels occurred within 30 minutes of reperfusion and were higher among patients developing complications. Interleukin-6 levels increased during reperfusion, reaching a peak on the first postoperative clay. lnterleukin-6 increase correlated with aortic clamp time and morbidity. CD1 lb expression increased 30 minutes after reperfusion, and this effect was greater among patients who developed complications. Enclotoxin may be important in the pathogenesis of multiple organ dysfunction syndrome. Activated neutrophils may have a central role in tissue injury after reperfusion. I ntraopcrative CD 11b upregulation may be an early marker for PostoPerative complications after infrarenal abdominal aortic aneurysm repair. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the present study was to investigate a potential difference on the arterial stiffness among aneurysm patients and non-aneurysm controls, as well as to explore potential changes between patients treated either with endovascular or open repair. Materials and Methods: A 110 patients with an infrarenal AAA were prospectively enrolled in this study. Fifty-six patients received an EVAR, whereas 54 patients received an open surgical repair. Moreover, 103 gender and age-matched subjects without AAA served as controls. The cardio-ankle vascular index (CAVI) was applied for measurement of the arterial stiffness. Results: CAVI values were statistically higher in the AAA patients when compared with control subjects. Although at 48 hours postoperatively the CAVI values were increased in both groups when compared to baseline values, the difference in CAVI had a tendency to be higher in the open group compared to the endovascular group. At 6 months of follow up the CAVI values returned to the baseline for the patients of the open repair group. However, in the endovascular group CAVI values remained higher when compared with the baseline values. Conclusion: Patients with AAAs demonstrated a higher value of CAVI compared to healthy controls. A significant increase of arterial stiffness in both groups during the immediate postoperative period was documented. The increase in arterial stiffness remained significant at 6 months in EVAR patients. Further studies are needed to elucidate the impact of a decreased aortic compliance after stentgraft implantation on the cardiac function of patients with AAA. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the incidence of postoperative incisional hernias after elective open abdominal aortic aneurysm (AAA) repair versus aortofemoral reconstruction. In this open prospective study, 281 patients who underwent elective open AAA or aortofemoral repair were included. All patients were evaluated by clinical examination 1 month after the operation, every 6 months for the next 5 years, and every year thereafter for the presence of an incisional hernia. Mean duration of follow-up was 63.7 months (range, 12-144 months). Seventeen patients (6.2%) were lost to follow-up. The development of a postoperative incisional hernia was recorded and analyzed with regard to the demographic data and the traditional risk factors for atherosclerosis. Statistical analysis was performed using the Kaplan-Meier method and the Cox regression analysis. The development of a postoperative incisional hernia after AAA surgical repair had an incidence of 16.2 per cent versus 7.4 per cent after aortofemoral reconstruction. Patients electively operated on for AAA have a 3.8-fold increase of developing a postoperative incisional hernia over patients operated on for peripheral occlusive disease (POD). [ABSTRACT FROM AUTHOR]

Pulse wave velocity (PWV) is a valid, clinically feasible marker of arterial stiffening, and a strong predictor of outcomes. The present study aimed to compare aortic elastic properties in patients with abdominal aortic aneurysms (AAA), with or without coronary artery disease (CAD), as well as healthy individuals. A total of 130 patients with AAA, eligible for interventional repair, and 30 healthy individuals, comprising the control group (HC), were enrolled. Presence of CAD was identified by coronary angiography. Aortic PWV (aPWV) was measured using the Arteriograph. aPWV was found considerably higher in AAA patients compared with HC group (11.5 ± 2.9 vs 7.3 ± 1.6 m/s, P < .001). Importantly, among patients with AAA, those with concomitant CAD (n = 41) had greater aPWV than those without CAD (12.5 ± 2.9 vs 11.0 ± 3.0 m/s, P = .03). In receiver operator curve (ROC) analysis, a value of aPWV above 12.8 m/s was identified to correlate with the presence of CAD in the AAA patient population. After adjustment for confounders, including hypertension which is one of the major risk factors for abdominal aneurysms, multivariate logistic regression analysis revealed that this aPWV cutoff remained independently associated with presence of CAD [odds ratio = 1.64, 95% confidence interval =1.19-4.08, P = .03]. The coexistence of CAD and AAA is characterized by a greater arterial stiffness. This finding should be taken into consideration when selecting endovascular stents with more favorable elastic properties. Moreover, AAA patients with high aPWV (>12.8 m/s) are more likely to also have CAD, and this may be considered by vascular surgeons when evaluating patients' cardiovascular risk. [ABSTRACT FROM AUTHOR]

The article discusses the importance of prophylactic thoracic endovascular aortic repair (TEVAR) in uncomplicated acute type B aortic dissection (ABAD) to prevent complications leading to the catastrophic event of aortic rupture. Topics discussed include identification of ABAD patients at high risk of aortic enlargement, issues realted to postimplantation syndrome (PIS) induced by the endovascular treatment of aortic pathologies and clinical impact of alterations in the inflammatory response.

Acute carotid stent thrombosis (ACST) is a rare complication that can lead to dramatic and catastrophic consequences. A rapid diagnosis and prompt recanalization of the internal carotid artery are needed to minimize the ischemic insult and the reperfusion injury. We reviewed the current literature on this devastating complication of CAS with the intention of investigating the potential causative factors and to define the appropriate management. According to our study discontinuation of antiplatelet therapy, resistance to antiplatelet agents and inherent or acquired thrombotic disorders are the main causes of thrombosis. Technical intraprocedural parameters such as dissection, atheroma prolapse, kinking of the distal part of internal carotid artery and embolic protection device occlusion can also result in early carotid stent thrombosis. Rapid reperfusion ensures an improved neurological outcome and a better prognosis in the short and long term. Thrombolysis, mechanical thrombectomy or thromboaspiration in combination with drug or thrombolytic therapy, surgical therapy and re-angioplasty are treatment options that have been used with encouraging results. In conclusion, optimal perioperative antiplatelet treatment as well as technical considerations regarding the carotid artery stenting plays a determinant role. [ABSTRACT FROM AUTHOR]

The treatment of infected iliofemoral pseudoaneurysms is challenging and controversial. We present our experience regarding the efficacy and outcome of endovascular treatment of infected iliofemoral arterial pseudoaneurysms with covered stents. Our experience with 5 cases showed that stent grafting combined with antibiotic therapy and provisional drainage may be a safe and effective option in patients with cancer, patients with history of multiple hip revisions, and drug-addicted users. In our small case series, the reinfection rate was null and no covered stent thrombosis occurred. These results are fairly encouraging, but further studies with longer follow-up in a larger number of patients are needed to confirm the efficacy and durability of the technique. [ABSTRACT FROM AUTHOR]

Objective We investigated the relationship of circulating novel adipokines, retinol-binding protein 4 (RBP4) and omentin-1, with advanced carotid atherosclerosis and ultrasound indexes of severity (total plaque area-TPA) and plaque echogenicity and vulnerability (Gray-Scale median - GSM score). Methods We enrolled 225 patients with high-grade carotid stenosis (HGCS) who underwent carotid revascularization (73 Symptomatic patients, 152 asymptomatic patients) and 75 age- and sex-matched, asymptomatic individuals with low-grade (<50%) carotid stenosis (LGCS). Seventy-three individuals without current manifestations of atherosclerotic disease served as control group (COG). All participants underwent carotid ultrasound with TPA and GSM score assessment. Moreover, clinical parameters, metabolic profile, and circulating levels of hsCRP and adipokines were assessed. Results RBP4 was significantly elevated in HGCS (51.44 ± 16.23 mg/L) compared to LGCS (38.39 ± 8.85 mg/L), independent of symptoms existence, whereas RBP4 levels in COG were even lower (25.74 ± 10.72 mg/L, p < 0.001 compared to either HGCS or LGCS). Inversely, serum omentin-1 levels were significantly lower across HGCS (490.41 ± 172 ng/ml) and LGCS (603.20 ± 202.43 ng/ml) than COG (815.3 ± 185.32, p < 0.001). Moreover, the considerable difference between HGCS and LGCS (p < 0.001) was exclusively attributed to the excessive suppression of omentin-1 concentrations in symptomatic versus asymptomatic (p = 0.004) patients. HGCS and LGCS did not differ in the rest of clinical and biochemical parameters. In multiple regression analysis, RBP4 (beta = 0.232, p = 0.025) and hsCRP (beta = 0.300, p = 0.004) emerged as independent determinants of TPA in patients with carotid atherosclerosis. Low serum levels of omentin-1 correlated with GSM score and symptoms but that association was lost in multivariate analysis.. Conclusion RBP4 serum levels were significantly elevated in patients with established carotid atherosclerosis and were positively associated with atherosclerosis severity. The association of low serum omentin-1 with carotid plaque echolucency requires further investigation. [ABSTRACT FROM AUTHOR]

Abstract: Carotid atherosclerosis is the main cause of fatal cerebral ischemic events, thereby posing a major burden for public health and state economies. We propose a web-based platform named CAROTID to address the need for optimal management of patients with carotid atherosclerosis in a twofold sense: (a) objective selection of patients who need carotid-revascularization (i.e., high-risk patients), using a multifaceted description of the disease consisting of ultrasound imaging, biochemical and clinical markers, and (b) effective storage and retrieval of patient data to facilitate frequent follow-ups and direct comparisons with related cases. These two services are achieved by two interconnected modules, namely the computer-aided diagnosis (CAD) tool and the intelligent archival system, in a unified, remotely accessible system. We present the design of the platform and we describe three main usage scenarios to demonstrate the CAROTID utilization in clinical practice. Additionally, the platform was evaluated in a real clinical environment in terms of CAD performance, end-user satisfaction and time spent on different functionalities. CAROTID classification of high- and low-risk cases was 87%; the corresponding stenosis-degree-based classification would have been 61%. Questionnaire-based user satisfaction showed encouraging results in terms of ease-of-use, clinical usefulness and patient data protection. Times for different CAROTID functionalities were generally short; as an example, the time spent for generating the diagnostic decision was 5min in case of 4-s ultrasound video. Large datasets and future evaluation sessions in multiple medical institutions are still necessary to reveal with confidence the full potential of the platform. [Copyright &y& Elsevier]

We report a case of postarthroscopic popliteal artery pseudoaneurysm (PSA) with arteriovenous fistula (AVF; PSA-AVF) in a 53-year-old woman who presented with limb edema, pain, and bruit 1 year after arthroscopic meniscectomy. She was treated percutaneously by covered stent deployment. After 6 months of follow-up, the patient was asymptomatic, with patency of the stent and occlusion of the AVF. A review of the literature was also performed to investigate the prevalence of postarthroscopic PSAs and highlight the endovascular approach of treatment. Endovascular approach with covered stent appears to be less invasive and might be an effective and feasible way of treatment of postarthroscopic popliteal PSA-AVF. [ABSTRACT FROM PUBLISHER]

Background--Many authors using a hybrid debranching strategy for the treatment of thoracoabdominal pathologies have reported disappointing results and the initial enthusiasm for the technique has given way to criticism and ambiguity. The aim of the present meta-analysis study was to assess the safety and efficacy of the technique in patients with thoracoabdominal aortic aneurysms or other aortic pathologies. Methods and Results--A multiple electronic search was performed on all articles describing hybrid open endovascular repair. Separate meta-analyses were conducted for technical success, visceral graft patency, spinal cord ischemia symptoms, renal insufficiency, and other complications as well as 30-day/in-hospital mortality. Nineteen publications with a total of 507 patients were analyzed. The pooled estimates for primary technical success and visceral graft patency were 96.2% (95% CI, 93.5%-98.2%) and 96.5% (95% CI, 95.2%-97.8%) respectively. A pooled rate of 7.5% (95% CI, 5.0%--11.0%) for overall spinal cord ischemia symptoms was observed; whereas for irreversible paraplegia the pooled rate was 4.5% (95% CI, 2.5%-7.0%). The pooled estimate for renal failure was 8.8% (95% CI, 3.9%--15.5%). The pooled 30-day/in-hospital mortality rate was 12.8% (95% CI, 8.6%-17.0%). During the mean follow-up period of 34.5 (95% CI, 31.5-37.5) months, a total of 119 endoleaks were identified in 111 patients (22.7%). Conclusions--The repair of thoracoabdominal pathologies by means of hybrid procedures in patients who are poor surgical candidates is still associated with significant morbidity and mortality rates. Future studies may substantiate whether the technique is amenable to amelioration and improvement. [ABSTRACT FROM AUTHOR]

Purpose: Aim of this study is to present our initial experience with the use of the retrograde popliteal artery access in patients with certain anatomic lesions. Methods: Between September 2008 and September 2010, 24 patients underwent a transpopliteal retrograde subintimal recanalization. Instead of its usage when antegrade recanalization failed, the “facedown” technique was preferred as a first choice in patients with common femoral artery stenosis or occlusion, proximal lesions of the superficial femoral artery (SFA) with no stump, severe obesity, tandem iliac, and SFA lesions. Results: Technical success was achieved in 91.7% of patients.The complication rate was 12.5%. The primary patency at 6, 12, and 18 months was 86.4%, 65.8%, and 65.8%, respectively. Conclusions: The retrograde popliteal artery approach can be considered as the primary SFA recanalization strategy in carefully selected patients, with competitive immediate and midterm results. [ABSTRACT FROM PUBLISHER]

Background: Thoracoabdominal aortic aneurysm open surgery is accompanied by a significant incidence of renal failure due to renal ischemia. The effect of remote ischemic preconditioning (RIPC) in renal ischemia/reperfusion (IR) injury during a thoracoabdominal aortic aneurysm open repair approach was examined on an animal model. Materials and methods: Three groups of rats underwent the following operations respectively: (a) Sham operation in control group; (b) Renal IR injury produced by subphrenic aortic cross-clamping (45/45 min IR), in IR group; (c) The same renal IR injury following RIPC produced by a brief occlusion of the infrarenal aorta (15/15 min IR) in RIPC group. Levels of lactate, base excess, and malondialdehyde (MDA) were measured in selective blood samples from the left renal vein, while levels of MDA were measured in samples of kidney tissues. Results: Renal blood base excess was significantly reduced in IR and RIPC groups as compared to sham group, but it was significantly higher in RIPC compared to the IR group (–7.69 ± 0.62 versus –15.15 ± 0.86, P < 0.001). Renal blood lactate was significantly increased in both IR and RIPC groups as compared to the sham group, but it was significantly lower in RIPC group compared to IR group (6.76 ± 0.19 versus 11.99 ± 0.33, P < 0.001). Renal blood MDA was increased in both IR and RIPC groups compared to the sham group, but it was significantly less compared in the RIPC group compared to IR group (1.55 ± 0.38 versus 2.94 ± 0.16, P = 0.002). Finally, kidney tissue MDA was increased in both IR and RIPC groups versus sham group, but it was significantly lower in RIPC group compared to the IR group (5.92 ± 0.82 versus 13.98 ± 2.41, P = 0.005). Conclusions: RIPC induced by a temporary infrarenal aortic occlusion decreased the IR renal injury caused by subphrenic aortic cross-clamping. [Copyright &y& Elsevier]

The case of a patient with gallbladder empyema initially drained through a minilaparotomy procedure under local anesthesia with a tube cholecystostomy is reported in this paper. Eight weeks later, the patient underwent an elective interval laparoscopic cholecystectomy. At laparoscopy, the gallbladder and the cholecystostomy tube were dissected free from the abdominal wall and the greater omentum, which was attached to the gallbladder. The tube was removed from the gallbladder fundus, and the operation was completed laparoscopically without any major problems. [ABSTRACT FROM AUTHOR]

Cystic breast masses are very common in female patients attending breast clinics. Most of them are benign and managed by simple aspiration. We reviewed histology records for the last 12 years to find patients with cystic breast carcinomas and to evaluate special clinical signs that may help to identify patients with this rare entity. Eighteen patients with cystic breast carcinomas were found among 1510 new breast cancer patients (1.19%) who were seen at our Breast Unit during this period. Ten had intracystic papillary carcinoma (0.66% of all breast cancers), seven had cystic degeneration of ductal carcinoma, and one had a mucinous carcinoma. The diagnosis of intracystic papillary carcinoma was based on cyst fluid cytology and breast imaging in most patients and on open breast biopsy in two cases only. The prognosis of our cystic breast carcinoma patients was excellent regardless of the specific histologic type of the tumor. We conclude that cysts in postmenopausal women should be viewed with suspicion. Bloodstained aspirated cyst fluid should be sent for cytology and breast imaging should be carried out in all these cases. Residual mass after cyst aspiration is also an indication for open biopsy. [ABSTRACT FROM AUTHOR]

Perioperative neck hematoma (PNH) requiring re-intervention is an important complication after carotid endarterectomy (CEA). There are limited data regarding the potential risk factors associated with PNH. The aim of this prospective, multicenter study was to document the rate of PNH in symptomatic carotid artery stenosis (sCAS) patients treated with CEA within the first 14 days of cerebrovascular symptom onset and to identify possible predictors of this complication. Patients with non-disabling (mRS ≤ 2) acute ischemic stroke or transient ischemic attack due to sCAS (≥70%) underwent CEA at three stroke-centers during a seven-year period. PNH requiring surgical re-intervention or transfusion during a 30-day follow-up period was determined by the attending surgeon but was also confirmed by an independent neurologist. A total of 280 patients with sCAS underwent CEA within 14 days of ictus. PNH occurred in 10 cases (3.6%; 95%CI: 1.4%–5.8%). Pretreatment with therapeutic anticoagulation (TA) and history of atrial fibrillation were more prevalent in patients with PNH (20% vs. 3.1%, p = 0.047 & 30% vs. 8.2%, p = 0.05 respectively). Elapsed time between symptom onset and carotid surgery, pretreatment with dual antiplatelets, intravenous thrombolysis or prophylactic anticoagulation were not related to PNH in univariable analyses. Pretreatment with TA was independently associated with higher likelihood of PNH [OR: 10.69, 95%CI (1.74–65.72), p = 0.011] in multivariate logistic regression models adjusting for potential confounders. PNH is uncommon in patients with sCAS that are operated during the first 14 days of ictus. Pretreatment with TA appears to be associated with higher risk of PNH. • PNH is rare in patients undergoing CEA during the first 14 days of symptom onset. • PNH is not related to increased risk of cardiovascular or poor functional outcomes. • Treatment with therapeutic anticoagulation might be associated with a higher risk of PNH. • The role of anticoagulants in PNH after CEA needs further evaluation. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine factors associated with the incidence of axillary lymph node metastases (ALNM) in T[sub 1] tumors and cases in which axillary dissection could be omitted. Data from 195 patients with T[sub 1] primary invasive breast cancer (size less than or equal to 2 cm) who underwent either mastectomy or wide local excision of the tumor and axillary dissection were reviewed. ALNM was found in 59 of 195 patients with T[sub 1] tumors (30.3%). Tumor size was found to be the only independent predictor of ALNM, having a directly analogous relationship with the probability of invaded nodes: T[sub 1a] (less than or equal to 5 mm) tumors had 0 per cent ALNM, whereas T[sub 1b] (5 mm < T[sub 1b] less than or equal to 10 mm) and T[sub 1c] (10 mm less than or equal to T[sub 1c] less than or equal to 20 mm) tumors had 25.7 per cent and 33.8 per cent ALNM respectively. Among the other factors studied (patient age, tumor site, hormone receptor status, histologic type, and grade of the tumor) only the histologic grade of the tumor cells appeared to correlate with the incidence of lymph node involvement, but this was not statistically significant. In conclusion only tumor size has statistically significant correlation with the incidence of ALNM. Routine axillary dissection could be omitted only in patients at minimal risk of ALNM (ductal carcinoma in situ and T[sub 1a]) and when treatment decisions were not influenced by lymph node status (e.g., elderly patients with clinically negative axilla). Axillary dissection (at least levels I and II) should be performed in all cases with primary invasive breast cancer with tumor size >5 mm. [ABSTRACT FROM AUTHOR]