Myostatin mediates abdominal aortic atherosclerosis progression by inducing vascular smooth muscle cell dysfunction and monocyte recruitment

Myostatin (Mstn) is a skeletal muscle growth inhibitor involved in metabolic disorders and heart fibrosis. In this study we sought to verify whether Mstn is also operative in atherosclerosis of abdominal aorta. In human specimens, Mstn expression was almost absent in normal vessels, became detectable in the media of non-progressive lesions and increased with the severity of the damage. In progressive atherosclerotic lesions, Mstn was present in the media, neointima, plaque shoulder and in infiltrating macrophages. Mstn co-localized with α-smooth muscle actin (α-SMA) staining and with some CD45+ cells, indicating Mstn expression in VSMCs and bloodstream-derived leukocytes. In vitro, Mstn was tested in VSMCs and monocytes. In A7r5 VSMCs, Mstn downregulated proliferation and Smoothelin mRNA, induced cytoskeletal rearrangement, increased migratory rate and MCP-1/CCR2 expression. In monocytes (THP-1 cells and human monocytes), Mstn acted as a chemoattractant and increased the MCP-1-dependent chemotaxis, F-actin, α-SMA, MCP-1 and CCR2 expression; in turn, MCP-1 increased Mstn mRNA. Mstn induced JNK phosphorylation both in VSMCs and monocytes. Our results indicate that Mstn is overexpressed in abdominal aortic wall deterioration, affects VSMCs and monocyte biology and sustains a chronic inflammatory milieu. These findings propose to consider Mstn as a new playmaker in atherosclerosis progression.

Abdominal compartment syndrome: an underrated complication in pediatric kidney transplantation

The transplantation of a large kidney in small children can lead to many complications, including an underrated complication known as abdominal compartment syndrome (ACS), which is defined as intra-abdominal pressure (IAP)≥20 mm Hg with dysfunction of at least one thoracoabdominal organ. Presenting signs of ACS include firm tense abdomen, increased peak inspiratory pressures, oliguria, and hypotension. Between June 1, 1985, and September 30, 2013, our center performed 420 kidney transplants (deceased/living related donors: 381/39) in 314 pediatric recipients (female/male: 147/167). ACS occurred in 9 pediatric patients (weight<15 kg) who received a large kidney from adult donors. In 1 case, the patient underwent abdominal decompression with re-exploration and closure with mesh in the immediate postoperative period. In a second case, the patient developed a significant respiratory compromise with hemodynamic instability necessitating catecholamines, sedation, and assisted ventilation. For small children transplanted with a large kidney, an early diagnosis of ACS represents a critical step. From 2005 we have measured IAP during transplantation via urinary bladder pressure, and immediately after wound closure we use intraoperative and postoperative duplex sonography to value flow dynamics changes. We recommend that bladder pressure should be routinely checked in small pediatric kidney recipients who are transplanted with a large graft.

Sinus grafting and simultaneous removal of large antral pseudocysts of the maxillary sinus with a micro-invasive intraoral access

Large antral pseudocysts of the maxillary sinus (APCs) may hamper the elevation of the Schneiderian membrane during sinus grafting and may impair osteo-meatal complex patency after sinus augmentation. Therefore, these should be removed prior to or at the time of sinus grafting. This study presents a new technique that combines enucleation of large APCs during sinus grafting via a lateral approach with preservation of the Schneiderian membrane periosteal layer. Twelve patients underwent a sinus graft via lateral approach during the years 2004-2012. Simultaneous APC removal was achieved through a small additional bony access, preserving the integrity of the periosteal layer of the Schneiderian membrane. Nineteen implants were inserted at the time of sinus augmentation or during a second stage. Prosthetic rehabilitation was started at 4-6 months after implant placement. No patient developed surgical complications or APC recurrence. The survival rate of implants and related prostheses was 100% over a mean follow-up of 50 months (range 12-96 months) after completion of the prosthetic restorations. This technique may represent an effective procedure to achieve APC removal at the time of sinus grafting, preserving the integrity of the Schneiderian membrane periosteal layer.

Systemic vascular inflammation in abdominal aortic aneurysm patients: a contrast-enhanced PET/CT study

AIM

The aim of this paper was to investigate the presence of systemic vascular inflammation and its relationship with risk factors and biomarkers of systemic inflammation related to atherosclerosis in asymptomatic abdominal aortic aneurysm (AAA) patients.

METHODS

Thirty AAA patients and 30 age-matched controls underwent contrast-enhanced 2-deoxy-2-[18F]fluoro-D-glucose (FDG) PET/CT. C-reactive protein, erythrocyte sedimentation rate, white blood cell count and differential, serum fibrinogen, D-dimer and full lipid panel were also evaluated. Region of interest analyses were performed to obtain target-to-background (TBR) metabolism of aorta, subclavian, carotid, iliac arteries and AAA. CT-based arterial calcium load (CL) was evaluated. Arterial Metabolism and CL intergroup differences were tested (unpaired t-test). Linear regression analysis was performed only between blood biomarkers on one side and both TBR and ACL of the arterial districts that resulted significantly different between patients and controls on the other. In all the analyses P values <0.05 were considered significant.

RESULT

FDG-uptake was higher with respect to controls in aorta, carotid and iliac arteries (P<0.01, P<0.007, P<0.04 respectively). AAA and aorta metabolism showed an inverse correlation with HDL-chol (P<0.02 and P<0.01, respectively) while only aorta showed a direct correlation with lymphocytes' count (P<0.02). Carotid metabolism was directly correlated with monocytes' count and C-reactive protein concentration (P<0.02 and P<0.004, respectively).

CONCLUSION

The present findings support the relevance of systemic vascular inflammation in all phases of atherosclerosis-related disorders. Moreover they confirm the concept that acute ischemic syndromes might represent the local result of a systemic inflammation rather than the focal involvement of a single arterial lesion.

Early and long-term outcomes after open or endovascular repair for abdominal aortic aneurysms in high-risk patients

AIM

The aim of our study was to evaluate the earlier and long term survival as well the postoperative complications in high-risk patients who received endovascular aortic repair (EVAR) as first choice, or open repair when anatomical requirements for EVAR were not met.

METHODS

Between January 2005 and January 2010, 593 patients underwent procedures for elective abdominal aortic aneurysm (AAA) repair; 172 of these were considered at high risk according to the American Society of Anesthesiology (ASA) score (ASA III and IV): 150 high-risk patients were males (mean age 72.7, range 53-93 years) and 22 females (mean age 72.9 years, range 60-90 years). The median AAA diameter was 64 (53-75) mm in the open repair group and 62 (55-70) mm in the EVAR group. 121 patients underwent open repair and 51 EVAR, respectively.

RESULTS

The 30-day mortality rate was 0% in the EVAR group and 2.4% (3/121) in the open repair group (P=0.26). Long-term results showed: no EVAR-related mortality, no late conversion to open repair in the EVAR group was required during follow-up. No aneurysmal expansion was observed. In the open repair group, no graft-related events were observed during follow-up. The mean follow-up for survival analysis was 1542 days. Overall 5-year survival was 71.7% (SE=4.2%). Survival during follow-up was 92.2%, 86.1%, 76.2%, 65.9% and 61.8% at 12, 24,36,48,60 months respectively in EVAR Group. Open Group present long term survival of 95%, 88.9%, 83.9%, 79.7%, 76% at 12, 24, 36, 48, 60 months respectively.

CONCLUSION

Our results in open repair surgery show a perioperative low mortality rate with high survival rate in long term. This result could be successfully achieved even in high-risk patients unsuitable for EVAR.

Use of health-related quality-of-life measurements to estimate individuals' health on screening

OBJECTIVES

to investigate the utility of assessing Health-Related Quality of Life (HRQoL) in a large group of subjects participating in a screening program for aneurysm and the relationship between HRQoL, diagnosis of aneurysm and related risk factors.

METHODS

subjects involved in this screening program were submitted the EQ-5D questionnaire to report their own HRQoL. HRQoL was reported also a second time by the subjects who were diagnosed with aneurysm during screening and who returned for a monitoring follow up visit a few months later. We evaluated compliance with HRQoL data collection and performed multiple regression analyses in order to investigate the possible relationship between demographic and clinical data with HRQoL.

RESULTS

1,633 subjects screened (6.1% diagnosed with aneurysm) and 125 subjects diagnosed with aneurysm and attending a follow-up visit reported their HRQoL. Completion of the EQ-5D questionnaire was well accepted by both physicians and subjects undergoing screening. HRQoL was not significantly different between the screening and followup visits, on adjusting for age and sex. At the screening visit, HRQoL was associated with ASA class, heart condition, BMI and respiratory diseases. No associations were found at the follow-up visit.

CONCLUSION

Assessing HRQoL in screening programs is feasible and well accepted and add useful information on health of large numbers of subjects from general population. This could be considered as a routine approach to optimizing the informative role of screening programs in guiding other investigations or interventions.

Stent-graft and multilayer stent for treatment of type II thoracoabdominal aortic aneurysm in a high-risk patient

The aim of the present article was to present an alternative endovascular treatment for type II thoracoabdominal aortic aneurysm that would have the advantage of limiting the duration of the procedure and the use of contrast. A high-risk patient was admitted to our Vascular Unit for type II thoracoabdominal aneurysm according to Crawford's classification. Two thoracic stent-grafts (Valiant Captivia, Medtronic, Pewaukee, WI, USA), a bifurcated stent-graft (Endurant Medtronic) and two multilayer stents (Cardiatis SA, Isnes, Belgium) were deployed. No postoperative major complications were observed. Operative time and use of contrast material were 45 min and 80 mL, respectively. Computed angiography tomography at 1 and 6 months showed patency of visceral and renal arteries and progressive thrombosis of the aneurysmal sac. This stent-graft treatment in combination with multilayer stent could be an alternative treatment for thoracoabdominal aneurysm in high-risk patients.

Treatment of penetrating aortic ulcer by endoprosthesis: a single center experience

AIM

This is a retrospective study of a single center experience in the endovascular treatment of penetrating aortic ulcer (PAU).

METHODS

Sixteen consecutive patients aged 69.1±9.6 years presenting PAU (in the aortic arch in 2, the descending thoracic aorta in 11, and in the abdominal aorta in 3) undergone therapy. Nine patients presented symptomatic, while 7 were asymptomatic. All patients underwent computer tomography angiography (CTA) of the thoracic and the abdominal aorta. Endovascular therapy alone was carried out in 12 patients, while 4 received hybrid therapy.

RESULTS

One patient died of multiorgan failure after hybrid procedure. Complications consisted of type II endoleak from lumbar arteries in 1 case of endovascular procedure, and acute respiratory insufficiency in 1 patient treated by endovascular technique on the emergency basis for aortic rupture.

CONCLUSION

PAU involves more frequently the descending thoracic aorta. Endovascular treatment (alone or in hybrid therapy) can give good results in patients with severe concomitant diseases. Prognosis of these patients is not favourable in most cases (48-month survival rate 47.9%) due to severe concomitant diseases.

Treatment of penetrating aortic ulcer by endoprosthesis: a single center experience

AIM: This is a retrospective study of a single center experience in the endovascular treatment of penetrating aortic ulcer (PAU). METHODS:Sixteen consecutive patients aged 69.1±9.6 years presenting PAU (in the aortic arch in 2, the descending thoracic aorta in 11, and in the abdominal aorta in 3) undergone therapy. Nine patients presented symptomatic, while 7 were asymptomatic. All patients underwent computer tomography angiography (CTA) of the thoracic and the abdominal aorta. Endovascular therapy alone was carried out in 12 patients, while 4 received hybrid therapy. RESULTS:One patient died of multiorgan failure after hybrid procedure. Complications consisted of type II endoleak from lumbar arteries in 1 case of endovascular procedure, and acute respiratory insufficiency in 1 patient treated by endovascular technique on the emergency basis for aortic rupture. CONCLUSION:PAU involves more frequently the descending thoracic aorta. Endovascular treatment (alone or in hybrid therapy) can give good results in patients with severe concomitant diseases. Prognosis of these patients is not favourable in most cases (48-month survival rate 47.9%) due to severe concomitant diseases.

District-based abdominal aortic aneurysm screening in population aged 65 years and older

AIM

Screening for abdominal aortic aneurysms (AAAs) has been carried out in an area of Genoa (Italy) for subjects aged 65 years or more to evaluate prevalence of this disease.

METHODS

Between March 2007 and September 2009 8234 subjects were screened. Ultrasound examination of the abdominal aorta and the iliac arterial segments was carried out on each subject and all data related to risk factors were collected.

RESULTS

Five hundreds-twelve (6.2%) subjects were found to have an AAA: 469 (10.8%) males and 43 (1.1%) females (significant difference, P < 0.01). Based on the aortic diameter, 403 (4.9%), 80 (1.0%) and 29 (0.3%) had an AAA of 3.0-3.9 cm, 4.0-4.9 cm and ≥ 5.0 cm diameter, respectively. With regards to risk factors, family history of cardiovascular disease only resulted more frequent in subjects with AAA than in those without AAA.

CONCLUSION

The prevalence of patients with AAA (6.2%) was similar to previously published estimates. Nevertheless, AAA resulted very high in males. This observation is likely due to screening in a city with a very high percentage of elderly subjects. Family predisposition to cardiovascular disease resulted significant risk factor for AAA. Results of our epidemiological study provide evidence of the usefulness of AAA screening thanks to early diagnosis and appropriate treatment of AAA.

Carotid endarterectomy: results of the Italian Vascular Registry

AIM

The aim of this study was to evaluate the results of carotid endarterectomy (CEA) carried out in centers dedicated to vascular surgery.

METHODS

The study was supported by the Italian Registry for Vascular Activity, which collected the data of 89 centers of vascular surgery (almost all of the existing centers in Italy) during 2007. Data were collected for 5962 CEAs. A total of 5,809 patients (153 were operated bilaterally in two staged procedures), 3990 (68.7%) males and 1,819 (31.3%) females, whose ages ranged from 33 to 100 years (mean 72.7+/-7.78) underwent the surgery procedure. Several surgical techniques were used: i.e., standard CEA with direct suture (1477 cases, 24.8%), standard CEA with patch (2242 cases, 37.6%), and eversion technique (2243 cases, 37.6%).

RESULTS

Combined perioperative mortality and stroke rate were also evaluated (1.1% [stroke 0.9%, mortality 0.2%]).

CONCLUSIONS

These results are very good and are comparable to what has been reported in the literature during the last few years. This observation provides further proof of the effectiveness of CEA in the management of extracranial carotid disease. Moreover, these results have to be taken into account when evaluating any new therapeutic options, such as carotid stenting, before accepting them as valid alternatives.

Epidural plus general anesthesia vs general anesthesia alone for elective aortic surgery: effects on gastric electrical activity and serum gastrin secretion

BACKGROUND

The aim of this study was to evaluate differences in electrogastrographic activity and serum gastrin secretion in patients subjected to general anesthesia (GA) vs blended anesthesia (BA = GA plus epidural analgesia) for abdominal aortic surgery.

METHODS

Thirty-four patients (all males: 28 with abdominal aorta aneurysm, 6 with obstructive aorto-iliac disease; mean age: 68+/-7 years) were randomly assigned either to GA (N.=17) or to BA (N.=17) for abdominal aortic surgery. Each patient was evaluated for serum gastrin secretion at the time of electrogastrography (EGG) 24 h before and after surgery, using ambulatory equipment. Gastrin levels were tested under fasting conditions and after a standard meal. EGG shows gastric electrical activity that parallels gastric motor activity.

RESULTS

Before surgery, no significant difference was found for any of the EGG parameters or the serum gastrin integrated value (area under the curve [AUC]) between the two groups of patients. After surgery, an increased frequency of electrical waves (tachygastria) was observed in 22% of those undergoing GA and in 5% of patients undergoing BA. The power ratio (postprandial/fasting total power) was exceedingly high (>4) in 53% of the GA patients and in 11% of the BA patients (P<0.05). The gastrin AUC was 263+/-58 pg/mL in the GA group and 179+/-92 pg/mL in the BA group (P<0.01).

CONCLUSIONS

An excess of EGG activity and serum gastrin secretion was observed in patients undergoing GA vs those submitted to BA. Thus, the latter procedure seems to affect gastric function less than GA alone.