A New Concept to Help Deal With Dissections in Peripheral Angioplasty

Peripheral Arterial Disease (PAD) affects nearly a fifth of those over the age of 60 in the Western World</div

Endovascular abdominal aortic aneurysm repair in the geriatric population.

Abdominal aortic aneurysm (AAA) is a relatively common pathology among the elderly. More people above the age of 80 will have to undergo treatment of an AAA in the future. This review aims to summarize the literature focusing on endovascular repair of AAA in the geriatric population. A systematic review of the literature was performed, including results from endovascular abdominal aortic aneurysm repair (EVAR) registries and studies comparing open repair and EVAR in those above the age of 80. A total of 15 studies were identified. EVAR in this population is efficient with a success rate exceeding 90% in all cases, and safe, with early mortality and morbidity being superior among patients undergoing EVAR against open repair. Late survival can be as high as 95% after 5 years. Aneurysm-related death over long-term follow-up was low after EVAR, ranging from 0 to 3.4%. Endovascular repair can be offered safely in the geriatric population and seems to compare favourably with open repair in all studies in the literature to date

Ilio-ureteric Fistula: A Rare Cause of Haematuria

Ilio-ureteric Fistula: A Rare Cause of Haematuri

Overview of Primary and Secondary Analyses From 20 Randomised Controlled Trials Comparing Carotid Artery Stenting With Carotid Endarterectomy

Objectives Overview of primary and secondary outcomes from 20 randomised controlled trials (RCTs) comparing carotid endarterectomy (CEA) with carotid artery stenting (CAS). Methods Systematic review and meta-analysis of data from 20 RCTs (126 publications). Results Peri-operative death/stroke was significantly higher after CAS. Excluding procedural risks, ipsilateral stroke was about 4% at 9-years for CEA/CAS, ie CAS was durable. To improve 10-year survival; peri-operative stroke/myocardial infarction must be prevented, mandating greater emphasis on risk factor control and best medical therapy (BMT). Reducing procedural death/stroke after CAS may be achieved through emerging CAS technologies, but better case selection is essential; eg perhaps preferentially performing CEA in; (i) symptomatic patients aged >70yrs; (ii) interventions <14 days of symptom onset and (iii) situations where stroke risk after CAS is higher (segmental/remote plaques, plaque length >13mm, heavy burden of white matter lesions (WML), avoiding situations where 2 or more stents need to be deployed). New WMLs are significantly more common after CAS and may be associated with higher rates of late stroke/TIA, requiring better risk factor control and BMT in patients with new, post-operative WMLs. There is no evidence that new WMLs predispose to cognitive impairment. Restenoses are more common after CAS, but do not increase late ipsilateral stroke. CEA is associated with a small, but significant increase in stroke ipsilateral to 70-99% restenoses, but procedural risks need to be Conclusions Questions to be answered include; (i) can CAS be undertaken <14 days of symptom-onset with outcomes similar to CEA; (ii) will emerging stent technologies and improved cerebral protection prevent stroke after CAS; (iii) what is the optimal volume of CAS procedures to maintain competency; (iv) how to deliver better risk factor control and BMT, and (v) is there a role for CEA/CAS in preventing/reversing cognitive impairment? What this paper adds to the literature? This is the first paper to provide a comprehensive overview of primary and secondary outcome data from 20 RCTs comparing CEA with CAS. It includes separate meta-analyses for peri-operative risks and late ipsilateral stroke. Secondary analyses include risk factors for stroke after CEA/CAS and its prevention; the effect of peri-operative stroke or myocardial infarction on long-term survival; non-stroke complications after CEA/CAS (cranial nerve injury, haematoma, arrhythmias and hypertension/hypotension); the significance of new white matter lesions on late stroke and cognitive impairment and whether asymptomatic 70-99% restenoses increase the risk of ipsilateral stroke after CEA and CAS.</p

Cardiovascular risk in patients with small abdominal aortic aneurysms

Background: Abdominal aortic aneurysm (AAA) is a cardiovascular health problem. Ultrasound screening has been shown to reduce the risk of AAA-related, but not all-cause, mortality. The recent introduction of screening in several countries has meant that thousands of patients with a small AAA (<5·5cm) that does not require immediate treatment are diagnosed annually. We sought to investigate the cardiovascular profiles of patients with ectatic aortas and assess whether participation in screening reduces cardiovascular risk. Methods: We used three sets of data: from the National Health Service AAA Screening Programme (NAAASP) during the 2013–14 round that were linked with Health Episode Statistics (HES) (235 409 individuals); a subset of the Framingham Study population who had an abdominal CT scan in 2004–05 and were followed up for 10 years (1383 individuals); and data for patients with a small AAA who had been in surveillance for at least 1 year in the UK Aneurysm Growth Study (UKAGS) (384 individuals) or from a national UK audit (1538 individuals), to assess cardiovascular risk and events. Findings: In the linked NAAASP–HES cohort, cardiovascular mortality was 0·30% (95% CI 0·28–0·32) for individuals with an abdominal aortic diameter of less than 2·5 cm; 0·81% (0·51–1·11) for those between 2·5 and 2·9 cm; and 1·30% (0·90–1·71) for those less than 3·0 cm. Death from a cardiovascular event was more likely for individuals with a small AAA than for those without AAA (risk ratio 4·33, 95% CI 3·15–5·97). In the Framingham cohort, abdominal aortic diameter was independently associated with cardiovascular events (hazard ratio [HR] 1·1, 95% CI 1·02–1·18; p<0·0001). An abdominal aortic diameter of more than 2·5 cm was also associated with cardiovascular events (HR 7·6, 95% CI 5·1–11·3; p<0·0001). In the UKAGS and audit populations, patients were not more likely to take antiplatelet agents or statins after entering screening surveillance; cholesterol concentrations and blood pressure also increased. Interpretation: In these contemporary large cohorts of patients with small AAA, cardiovascular events and death were common and were the leading cause of death. The implication is that patients are not more likely to receive cardiovascular protection if they enter screening or surveillance with existing protocols. Cardiovascular risk reduction interventions should be implemented in screening programmes in the future

Endovascular Repair for a Ruptured AAA due to a Combined Type IIIb and Ia Endoleak.

We report a case of a ruptured abdominal aortic aneurysm (AAA) caused by a combined type IIIb and Ia endoleak. Also, we propose the mechanism that resulted in this combined endoleak. Specifically, a 71-year old-man, with a previous history of endovascular aneurysm repair (EVAR) for an AAA, was diagnosed with a contained rupture. CT scan depicted a type Ia endoleak and a migrated Talent endograft. A proximal aortic cuff sealed the endoleak, but intraoperative angiography revealed that a type IIIb endoleak coexisted due to fabric tear close to the Talent bifurcation. A second aortic cuff could not seal the fabric tear; so, in-lay parallel limbs were sequentially deployed as a "kissing endograft" technique inside the cuff. Simultaneous treatment of combined type IIIb and Ia endoleaks has not yet been described. Maybe the type IIIb endoleak is the primary entity causing sac enlargement, neck recontouring, proximal migration, and ultimately type Ia endoleak, which leads to huge enlargement and rupture. Placement of an aortic cuff to seal the proximal endoleak/migration and kissing endografts limbs for the fabric tear seems a safe option in such patients

A Systematic Review and Meta-Analysis of the Presentation and Surgical Management of Patients With Carotid Body Tumours.

OBJECTIVES: The aim was to determine the mode of presentation and 30 day procedural risks in 4418 patients with 4743 carotid body tumours (CBTs) undergoing surgical excision. METHODS: This is a systematic review and meta-analysis of 104 observational studies. RESULTS: Overall, 4418 patients with 4743 CBTs were identified. The mean age was 47 years, with the majority being female (65%). The commonest presentation was a neck mass (75%), of which 85% were painless. Dysphagia, cranial nerve injury (CNI), and headache were present in 3%, while virtually no one presented with a transient ischaemic attack (0.26%) or stroke (0.09%). The majority (97%) underwent excision, but only 21% underwent pre-operative embolisation. Overall, 27% were Shamblin I CBTs; 44% were Shamblin II; and 29% were Shamblin III. The mean 30 day mortality was 2.29% (95% CI 1.79-2.93). The mean 30 day stroke rate was 3.53% (95% CI 2.91-4.29), while the mean 30 day CNI rate was 25.4% (95% CI 24.5-31.22). The prevalence of persisting CNI at 30 days was 11.15% (95% CI 8.42-14.64). Twelve series (544 patients) correlated 30 day stroke with Shamblin status. Shamblin I CBTs were associated with a 1.89% stroke rate (95% CI 0.92-3.82), increasing to 2.71% (95% CI 1.43-5.07) for Shamblin II CBTs and 3.99% (95% CI 2.34-6.74) for Shamblin III tumours. Twenty-six series (1075 patients) correlated CNI rates with Shamblin status: 3.76% (95% CI 2.62-5.35) for Shamblin I CBTs, 14.14% (95% CI 11.94-16.68) for Shamblin II, and 17.10% (95% CI 14.82-19.65) for Shamblin III tumours. The prevalence of neck haematoma requiring re-exploration was 5.24% (95% CI 3.45-7.91). The proportion of patients with a neck haematoma requiring re-exploration was not reduced by pre-operative embolisation (5.92%; 95% CI 2.56-13.08) vs. no embolisation (5.82%; 95% CI 2.76-11.88). Pre-operative embolisation did not reduce drainage losses (639 mL vs. 653 mL). CONCLUSIONS: This is the largest meta-analysis of outcomes after CBT excision. Procedural risks associated with tumour excision were considerable, especially with Shamblin III tumours where 4% suffered a peri-operative stroke and 17% suffered a CNI

Additional file 1: of SMYD2 promoter DNA methylation is associated with abdominal aortic aneurysm (AAA) and SMYD2 expression in vascular smooth muscle cells

Supplemental material. (DOCX 592 kb

Renal Function is the Main Predictor of Acute Kidney Injury after Endovascular Abdominal Aortic Aneurysm Repair.

BACKGROUND: Postoperative acute kidney injury (AKI) may occur in up to 18% of elective endovascular abdominal aortic aneurysm repair (EVAR) and has been associated with poor outcome; however, it is not clear which patients are at highest risk, to target renoprotection effectively. We sought to determine the predictive factors of AKI after elective EVAR. METHODS: Overall, 947 patients undergoing elective EVAR between January 2004 and December 2014 were analyzed, using prospectively collected data. Postoperative AKI was defined by serum creatinine change within 48 hr, as per the Kidney Disease Improving Global Outcomes guidelines. Cardiovascular and kidney-disease risk factors were entered in univariate and multivariate analyses to assess influence on AKI development. RESULTS: Overall, 167 (17.6%) patients developed AKI but only 2 patients required dialysis perioperatively. At multivariate analysis, adjusted for established AKI-risk factors and parameters that differed between groups at baseline, preoperative estimated glomerular filtration rate (eGFR; as per the chronic kidney disease epidemiology [CKD] formula); odds ratio (OR): 1.02 (per unit decrease); 95% confidence interval (CI): 1.003-1.041; P = 0.025; and chronic kidney disease (CKD) stage > 2 (OR: 1.28; 95% CI: 1.249-2.531, P = 0.001) were associated with development of AKI. CONCLUSIONS: AKI was common after elective infrarenal EVAR and preoperative renal function appears to be the main factor associated with AKI. Patients with a low eGFR need to be targeted with more aggressive renal protection

Investigation of the effect of genetic polymorphisms on aortic growth in patients with abdominal aortic aneurysm (AAA)

Investigation of the effect of genetic polymorphisms on aortic growth in patients with abdominal aortic aneurysm (AAA