Carotid stenting and transcranial Doppler monitoring: indications for carotid stenosis treatment

BACKGROUND

Recently, angioplasty and stenting of carotid arteries (CAS) have taken the place of surgery. The aim of our study is to assess the role of transcranial Doppler (TCD) monitoring during CAS to address the embolic complications during the stages of the procedure, with or without embolic cerebral protection devices.

METHODS

A total of 152 patients were submitted to carotid stenting. All patients were submitted to carotid arteries Duplex scanning.

RESULTS

Neurological complications are related to TCD detection of corpuscolate signals in rapid succession. Even if no reduction of the overall incidence rate of microembolic signals (MES) was observed, a decrease in the number of corpuscolate emboli were recorded when a cerebral protection was working.

CONCLUSIONS

According to our study, even in selected patients on the basis of preoperative diagnostic criteria, CAS is burdened by a nonnegligible risk of subclinical embolic ischemic events detected at TCD and confirmed by diffusion-weighted magnetic resonance imaging (DW-MRI).

Accelerated atherosclerosis in systemic lupus erythematosus and other connective tissue diseases

Connective tissue diseases are associated with increased morbidity and mortality related to a higher rate of cardiovascular events and higher prevalence of subclinical atherosclerosis. Atherosclerosis is now considered a multifactorial process where autoimmunity and chronic inflammation play an important pathogenic role. In systemic autoimmune rheumatic diseases in general, and in systemic lupus erythematosus in particular, atherosclerosis cannot be explained by traditional cardiovascular risk factors alone. Cellular and humoral mechanisms, together with specific factors associated with the disease itself and/or its treatments, have been advocated to explain the acceleration of arterial wall organic damage in these patients. Endothelial dysfunction, carotid intima-media thickness and plaque evaluations provide accurate detection of atherosclerotic process at a preclinical stage, before appearance of clinical disease, allowing preventive measure introduction with the aim to modify the cardiovascular risk in subjects with systemic autoimmune rheumatic diseases.

Transcarotideal access for endovascular repair of descending thoracic aortic aneurysm with intentional coverage of celiac artery

Endovascular treatment of thoracic and thoraco-abdominal aortic aneurysm with celiac artery ostium coverage, seems to be safe according to the literature. We present a case in which the endograft deployement was achieved through a right common carotid artery access because four years before the patient was submitted to an axillo-bifemoral bypass with aortic graft removal and aortic stump ligature for infection. After endovascular repair the patient suffered from spinal cord ischemia, acute pancreatitis and spleen infarction. Probably, the new pancreatic event has been triggered by temporary visceral ischemia, acting on a pancreas damaged by a previous acute hemorrhagic pancreatitis.

Identification of regulatory T cells in systemic lupus erythematosus

The concept that regulatory T cells (Treg) play a key role in both development and maintenance of autoimmune response in rheumatic diseases is well accepted. In recent years, several studies analyzed Treg cell phenotype and function in systemic lupus erythematosus (SLE), the prototypical systemic autoimmune disorder in humans. Although qualitative and/or quantitative abnormalities of Treg cells have been shown, data are often conflicting. This may depend on the selection of patients with different degrees of disease activity or on immunosuppressive treatments that can alter Treg cell findings. Among several proposed surface or intracellular Treg cell markers, CD25 at high level of expression and the transcription factor Foxp3 are the two most investigated in SLE. Despite the glucocorticoid-induced TNF receptor-related protein (GITR) represents a reliable phenotypic marker of murine Treg cells, little is known about its role in humans, in particular in the course of systemic autoimmune disorders. Preliminary data seems to suggest that this marker may represent a good tool to identify cell populations included within Treg cell subsets.

Management of simultaneous abdominal aortic aneurysm and colorectal cancer: the rationale of mini-invasive approach

The concomitant occurrence of abdominal aortic aneurysm and malignancy represents a therapeutic dilemma. Both lesions should be treated to achieve best life expectancy; the main controversy remains whether to treat them simultaneously or as staged procedures. Recently, endovascular repair has been suggested as a potential alternative to open standard intervention. We present a case of synchronous abdominal aortic aneurysm and colorectal cancer treated simultaneously by minimally invasive surgery.

Classic and endovascular surgical management of isolated iliac artery aneurysms

AIM

Isolated iliac artery aneurysm is a rare pathology that is often asymptomatic for long periods; this late diagnosis exposes patients to a high risk of death following aneurysm rupture. The aim of this study was to establish the most suitable diagnostic approach, the correct indications for treatment, and the most appropriate tactics and surgical technique.

METHODS

Twenty-eight patients were observed over 13 years. Aneurysmal involvement was unilateral in 22 cases and bilateral in the remaining 6 patients. Preoperative diagnostic tests included eco-colour Doppler (ECD) and angio-CT in all cases, with angio-MR and angiography as more selective procedures. Seventeen patients underwent conventional open surgery with prosthetic replacement of the aneurysmatic tract, 7 patients were treated using endovascular exclusion, and lastly 4 were monitored over time.

RESULTS

There was no perioperative mortality for either treatment. During the postoperative period following conventional open surgery, complications included one case of severe respiratory failure, one microembolism of the lower limb, and 2 periprosthetic hematoma. During the follow-up, we observed one pseudo-aneurysm, 3 cases of retrograde ejaculation and one patient with erectile dysfunction after traditional surgery; there was one minor endoleak after endovascular exclusion.

CONCLUSIONS

Our experience suggests that ECD is a useful method for arriving at an early diagnosis, while angio-CT imaging is essential for a correct preoperative study. Aneurysms with a diameter equal or greater than 3 cm or that present annual increases in excess of 5 mm represent a correct indication for treatment. Conventional open surgery is the treatment of choice for young patients in good general conditions. Endovascular exclusion is indicated when the patient's clinical conditions contraindicate open surgery and the morphology of the aneurysmal arterial district allows the endoprosthesis to be safely implanted.