Infrarenal abdominal aorta aneurysm: a rare cause of anterior nutcracker syndrome with associated pelvic congestion

We present a rare case of anterior nutcracker syndrome caused by an abdominal aorta aneurysm (AAA). A 61-year-old woman was admitted to our institution for computed tomography angiography. It revealed an AAA 51 mm in diameter that was lifting off of the left renal vein toward the superior mesenteric artery, causing anterior nutcracker syndrome with consequent left renal vein compression and left ovarian vein congestion. Aneurysm resection was performed, followed by left ovarian vein ligation and left adnexectomy to prevent vein conglomerate rupture. This is the first case that describes anterior nutcracker syndrome caused by AAA, which was successfully treated by aneurysm resection.

In situ revascularisation for femoropopliteal graft infection: ten years of experience with silver grafts

Purpose

The purpose of this study was to analyze clinical outcome of patients for femoropopliteal graft infection who were treated by in situ reconstruction with a silver-coated prosthesis.

Basic methods

From December 2001 to December 2011, 27 patients were treated for femoropopliteal graft infection. Twenty patients (74%) were male and seven (26%) were female. Mean age was 65 years. The primary endpoint was recurrence of infection. Secondary endpoints were early and late mortality and morbidity, primary graft patency, major amputation rates and patient survival.

Principal findings

Early reinfection occurred in 11% and late in 8% of patients. Perioperative mortality was 7% and late was 4%. Above-knee amputation was performed in 4% of patients during early postoperative course and in 12% of patients during follow-up. Early and late graft patency was 96% and 72%, respectively.

Conclusions

Results of in situ implantation of silver-coated grafts for femoropopliteal prosthesis infection are according to our opinion acceptable, but the risk of reinfection remains.

Urgent carotid endarterectomy in patients with acute neurological ischemic events within six hours after symptoms onset

To analyze the outcome of urgent carotid endarterectomy (CEA) performed within less than six hours in patients with crescendo transient ischemic attack (TIA) and stroke in progression. From January 1998 to December 2008, 58 urgent CEAs were done for acute neurological ischemic events – 46 patients with crescendo TIA and 12 patients with stroke in progression. Brain computed tomography (CT) was done prior and after the surgery. Disability level was assessed prior to and after urgent CEA using modified Rankin scale. Median follow-up was 42.1 ± 16.6 months. In the early postoperative period stroke rate was 0% for the patients in crescendo TIA group while in patients with stroke in progression group 3 patients (25%) had positive postoperative brain CT, yet neurological status significantly improved. Mid-term stroke rate was 2.2% in crescendo TIA group and 8.3% in stroke in progression group. In the early postoperative period there were no lethal outcomes, mid-term mortality was 8.3% in stroke in progression while in crescendo TIA group lethal outcomes were not observed. In conclusion, based on our results urgent CEA is a safe and effective treatment option for patients with crescendo TIA and stroke in progression with acceptable rate of postoperative complications.

Percutaneous angioplasty of internal jugular and azygous veins in patients with chronic cerebrospinal venous insufficiency and multiple sclerosis: early and mid-term results

PURPOSE

To assess the safety of endovascular treatment of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS).

MATERIALS AND METHODS

A total of 72 patients with CCSVI and MS (44 with relapsing remitting--RR, 4 with primary progressive, 20 with secondary progressive and 4 with benign MS) underwent percutaneous angioplasty. Outcome measures were colour Doppler ultrasonography parameters, gradient pressure at the vein abnormality level, postoperative complications, re-stenosis, disease severity scored by means of Expanded Disability Status Scale (EDSS) and patients' assumption of disease status. Controls were done after one month on 72 patients, six months on 69 patients and one year on 61 patients, respectively (the average follow-up was 11 months).

RESULTS

There were no postoperative complications. Colour Doppler ultrasonography showed significant improvement in cross-sectional area parameters (P < 0.05) and significant decrease in confluence velocity values (P < 0.05). Postoperative gradient pressure decreased, in internal jugular vein (IJV) significantly (P < 0.05). Re-stenosis appeared in 5.3% of patients. EDSS score was significantly improved (P < 0.01) and about half of patients reported significant or mild improvement in disease status and none of them worsening of symptoms.

CONCLUSION

Endovascular treatment of the IJV and azygous veins in patients with CCSVI and MS is a safe procedure with no post-procedural complications followed by significant improvement of IJV flow haemodynamic parameters and decrease in the EDSS score. Whether CCSVI percutaneous treatment might affect clinical improvement in patients suffering from MS is yet to be seen after completion of major multicentric clinical trials, still it seems like that this procedure is not negligible.

Primary repair of internal carotid artery aneurysm secondary to kinking and cystic medial degeneration

INTRODUCTION

In this report, we aim to present a very rare case of internal carotid artery (ICA) aneurysm secondary to kinking and cystic medial degeneration.

CASE REPORT

A 66-year-old female patient was admitted to our institution for multidetector computed tomography (MDCT) angiography of supra-aortic trunks. On admission, she complained of occasional dizziness; 2 months earlier ascending aorta reconstruction was done for aneurysmal disease. Color Doppler ultrasonography and MDCT arteriography revealed significant right ICA kinking associated with large aneurysm, 24.6 × 24.5 mm(2) in diameter. Aneurysm resection was done followed by ICA reconstruction by end-to-end anastomosis. Pathohistological findings of aneurysmal sac revealed cystical medial degeneration with inflammatory infiltrate mostly consisting of lymphocytes and fibrovascular proliferation.

CONCLUSION

This is the first case that describes mutual contribution of cystic medial degeneration and ICA kinking in carotid aneurysm disease etiology successfully treated by aneurysm resection.

Benefits, risks and complications of perioperative use of epidural anesthesia

Use of thoracic epidurals is widespread for intraoperative and postoperative analgesia. Thoracic epidural anaesthesia (TEA) reduces sympathetic activity and thereby influences perioperative function of vital organ systems. A results of recent studies suggest that TEA decreases postoperative morbidity and mortality. There is better pain control with TEA in a wide range of surgical procedures. Use of TEA is associated with the risk of harm, but also the other methods used to control perioperative pain and stress response carry specific risks. Timely diagnosis and treatment of spinal compression or infection are crucial to ensure patient safety with TEA. The benefits of TEA outweigh the risks with respect to the perioperative outcome and organ protection, if basic guidelines are followed.

Cell proliferation in the hippocampus and in the heart is modified by exposure to repeated stress and treatment with memantine

The present studies were aimed to verify the hypothesis that treatment with memantine, a low affinity NMDA glutamate receptor antagonist, can reduce possible stress-induced alterations in cell proliferation in the hippocampus and in the heart and has consequences on stress hormone release. Adult male Wistar rats were exposed to repeated hypokinesis (movement restraint, 2 h daily) or remained undisturbed and they were treated with memantine (5 mg/kg/day, s.c.) or vehicle for 8 days. On the day 7, all animals were injected with 5-bromo-2'-deoxyuridine (BrdU), a marker of cell proliferation. The mild form of chronic stress used resulted only in moderate decrease in BrdU incorporation into DNA in the hippocampus, while the same stimulus caused a pronounced reduction of the new cells formed in left heart ventricle. In both tissues, stress-induced reduction in cell proliferation was more evident in memantine-treated rats. Memantine failed to modify hormones of the hypothalamic-pituitary-adrenocortical axis, while the treatment increased plasma renin activity. The present study demonstrates that treatment with memantine potentiated rather than prevented stress-induced reduction of cell proliferation. We have shown that stress exposure may induce a reduction in cell proliferation in the heart, even in a higher extent than that in the hippocampus. Effects of memantine under stress conditions might be relevant with respect to clinical use of memantine, which is being used in the treatment of neurodegenerative diseases.

Distribution of risk factors in patients with premature coronary, supra-aortic branches and peripheral atherosclerotic disease

OBJECTIVE

The aim of this study was to determine the distribution of major risk factors among patients with atherosclerotic disease aged ≤50 years.

SUBJECTS AND METHODS

The study population comprised 944 patients aged ≤50 years with clinically significant manifestations of atherosclerotic disease compared with 350 consecutive (control) older patients (age >50 years).

RESULTS

The most significant risk factors for atherosclerotic disease of the supra-aortic branches were: smoking (87.5%, p < 0.001), family history of atherosclerosis (52.3%, p < 0.001), diabetes mellitus (28.5%) and being male (56.9%) (p < 0.05 for both). In patients with coronary artery disease, there was considerable disparity in the prevalence of smoking (85.4%), hyperlipoproteinemia (67.4%), and family history of atherosclerosis (68%) (p < 0.001). For peripheral artery disease, the most significant risk factors were smoking (97%, p < 0.001), hyperlipidemia (p < 0.01), and family history of atherosclerotic disease (p < 0.01). When compared to controls, patients with premature atherosclerosis smoked more frequently, had hyperlipidemia, had a family history of atherosclerosis, and were more frequently of male sex.

CONCLUSION

Premature atherosclerosis was most frequently associated with smoking, hyperlipidemia, family history of atherosclerotic disease, and male sex.

Color duplex sonography in the detection of internal carotid artery restenosis after carotid endarterectomy: comparison with computed tomographic angiography

OBJECTIVES

Internal carotid artery restenosis after carotid endarterectomy is a major postoperative event, but the clinically best suited means for diagnosis of restenosis are still debated. The objective of this study was to evaluate the sensitivity and specificity of color duplex sonography for detection of substantial internal carotid artery restenosis, verified by computed tomographic (CT) angiography.

METHODS

The study group consisted of 210 consecutive patients with internal carotid artery restenosis, defined as restenosis of 50% or greater, verified by color duplex sonography. The degree of restenosis was calculated according to the European Carotid Surgery Trial guidelines. All patients underwent CT angiography. The specificity, sensitivity, positive predictive value, and negative predictive value of color duplex sonography were calculated.

RESULTS

In 85 patients, internal carotid artery restenosis on color duplex sonography was 50% to 69%, whereas in 125 patients it was 70% or greater. When color duplex sonography was compared with CT angiography, only 2 patients in the group with restenosis of 50% to 69% were misclassified by color duplex sonography, in whom CT angiography showed stenosis of 70% or greater. No patient with stenosis of 70% or greater on color duplex sonography was shown to have a lesser degree of restenosis on CT angiography. When compared with CT angiography, color duplex sonography had specificity of 97.7%, sensitivity of 100%, a positive predictive value of 98.4%, and a negative predictive value of 100% for the detection of internal carotid artery restenosis.

CONCLUSIONS

Color duplex sonography can be effectively used as a primary diagnostic tool for evaluation of patients with suspected internal carotid artery restenosis after carotid endarterectomy.

Surgical reconstruction for unilateral iliac artery lesions in patients younger than 50 years

BACKGROUND

To evaluate safety, short and long-term graft patency, clinical success rates, and factors associated with patency, limb salvage and mortality after surgical reconstruction in patients younger than 50 years of age who had undergone unilateral iliac artery bypass surgery.

PATIENTS AND METHODS

From January 2000 to January 2010, 65 consecutive reconstructive vascular operations were performed in 22 women and 43 men of age < 50 years with unilateral iliac atherosclerotic lesions and claudication or chronic limb ischemia. All patients were followed at 1, 3, 6, and 12 months after surgery and every 6 months thereafter.

RESULTS

There was in-hospital vascular graft thrombosis in four (6.1 %) patients. No in-hospital deaths occurred. Median follow-up was 49.6 ± 33 months. Primary patency rates at 1-, 3-, 5-, and 10-year were 92.2 %, 85.6 %, 73.6 %, and 56.5 %, respectively. Seven patients passed away during follow-up of which four patients due to coronary artery disease, two patients due to cerebrovascular disease and one patient due to malignancy. Limb salvage rate after 1-, 3-, 5-, and 10-year follow-up was 100 %, 100 %, 96.3 %, and 91.2 %, respectively. Cox regression analysis including age, sex, risk factors for vascular disease, indication for treatment, preoperative ABI, lesion length, graft diameter and type of pre-procedural lesion (stenosis/occlusion), showed that only age (beta - 0.281, expected beta 0.755, p = 0.007) and presence of diabetes mellitus during index surgery (beta - 1.292, expected beta 0.275, p = 0.026) were found to be significant predictors of diminishing graft patency during the follow-up. Presence of diabetes mellitus during index surgery (beta - 1.246, expected beta 0.291, p = 0.034) was the only variable predicting mortality.

CONCLUSIONS

Surgical treatment for unilateral iliac lesions in patients with premature atherosclerosis is a safe procedure with a low operative risk and acceptable long-term results. Diabetes mellitus and age at index surgery are predictive for low graft patency. Presence of diabetes is associated with decreased long-term survival.

Morphological and haemodynamic abnormalities in the jugular veins of patients with multiple sclerosis

Objectives

Multiple areas of stenosis and different levels of obstruction of internal jugular and azygous veins (a condition known as cronic cerebrospinal venous insufficiency) recently emerged as an additional theory to the well-known autoimmune concept, explaining etiology of multiple sclerosis (MS). The aim of our study was to evaluate internal jugular vein (IJV) morphology and haemodynamic characteristics in patients with MS and compare it with well-matched healthy individuals and to evaluate the prevalence of venous flow abnormalities in both groups.

Methods

Sixty-four patients with clinically proven MS and 37 healthy individuals were included in our study. In all patients, IJV morphology and haemodynamic characteristics were evaluated by colour Doppler sonography as well as venous flow disorder. The patients were classified into four groups according to MS clinical form presentation. The prevalence of morphological and haemodynamic abnormalities in the IJV were assessed.

Results

The presence of stenosing lesion, mostly intraluminal defects like abnormal IJV valves, were observed in 28 patients (43%) in the MS group, and in 17 patients (45.9%) in the control group ( P = NS). By adding haemodynamic Doppler information in the IJV venous outflow was significantly different in 42% of MS patients showing flow abnormalities (27/64), as compared with 8.1% of the controls (3/37), P < 0.001.

Conclusion

In our group of patients, patients suffering from MS had significantly more IJV morphological changes and haemodynamic abnormalities when compared with healthy individuals not suffering from MS. These findings can be well demonstrated by non-invasive and cost-effective Doppler ultrasound.

Missed dissection as a result of the ascending pharyngeal artery arising from the internal carotid artery

Unlike high-grade stenosis, dissections of craniocervical arteries are a rare cause of cerebrovascular infarction. If the internal carotid artery (ICA) dissection is verified by duplex scanning or computed tomography angiography (CTA), the therapies of choice are antiplatelet and anticoagulation drugs, and surgical treatment is rarely performed. However, despite distinct clinical and radiological manifestation, carotid dissections are still under-recognized. In this study, we demonstrate the case of a 66-year-old man with dissection of ICA verified by duplex scanning and computed tomography angiography. The cause of missed diagnosis was an ascending pharyngeal artery originating from the ICA that runs parallel to it. Other than being a rare variation, this case may be interesting as a cause of misdiagnosis.