Outcomes of Surgical and Endovascular Treatment for Arterial Lesions in Intravenous Drug Abusers

Background: The objective of this study is to report an 18-year single-center experience in the surgical and endovascular treatment of arterial complications due to self-injection in drug abuser patients. Methods: This retrospective single-center study was conducted analyzing a prospectively collected database including all endovascular or surgical procedures performed from January 2007 to December 2019 for any arterial complication due to self-injection in drug abuser patient. Collected data were patient demographic and comorbidity, site and type of arterial lesion (pseudoaneurysm [PA], arteriovenous fistula [AVF]), signs of systemic or local infection, and procedural data (endovascular/surgical treatment). End points were rate of postoperative complications, reintervention rate, limb salvage, and patients’ early and long-term survival. Results: In 11 patients (median age 36 years, range 27–47; male 73%), 13 arterial lesions were treated: 10 (77%) PA, 2 (15%) PA associated with AVF, and 1 (8%) isolated AVF. Arterial lesion involved common femoral artery in 5 (38%), superficial femoral artery in 4 (31%), profunda femoral artery in 1 (8%), brachial artery in 2 (15%), and subclavian artery in 1 (8%). Signs of infections were present in 9 of the 13 cases (69%). The treatment was surgical in 11 (85%) cases: 7 interposition graft (6 great saphenous vein, 1 arterial cryopreserved homograft), 2 direct reconstruction, 1 patch plasty with pericardium bovine patch, and 1 arterial ligation. Endovascular treatment was performed in 2 cases: 1 noninfected PA of the superficial femoral artery, and 1 55-mm PA of the postvertebral segment of the right subclavian artery with clinical sign of hemodynamic instability. At 1 month, postoperative complication rate was 8% (one lower limb claudication after superficial femoral artery ligation). Reintervention rate was 8% (interposition graft rupture for repeated self-injections). Limb salvage and patient survival were both 100%. Median follow-up was 5 years (range 1 month to 11.3 years); surgical group: median 8.2 years (range 2 months to 11.3 years); endovascular group: median 3.5 months (range 1–6). During follow-up, neither complications nor reinterventions occurred, and limb salvage was 100% for both groups. At 2, 4, and 6 years, overall estimated patient survival was 91%, 81%, and 81%, respectively, with no procedure-related death. Conclusions: After surgical or endovascular management of arterial lesions due to self-injection in drug abuser patients, complications occur mainly in the postoperative period. During follow-up, the surgical procedures have low rate of complications, reinterventions, and procedure-related mortality, whereas for the endovascular treatment the mid-term outcomes remain unknown

Role of valsartan, amlodipine and hydrochlorothiazide fixed combination in blood pressure control: an update

The treatment of moderate or severe hypertension in most cases requires the contemporaneous use of multiple antihypertensive agents. The most available two-drug combinations have an agent that addresses renin secretion and another one that is statistically more effective in renin-independent hypertension. The practice of combining agents that counteract different mechanisms is the most likely explanation for the fact that most available two-drug combinations have an agent that addresses renin secretion (beta-blocker, angiotensin converting enzyme inhibitor, angiotensin II receptor blocker or direct renin inhibitor) and another one that is more effective in renin-independent hypertension (diuretic, dihydropyridine or non-dihydropyridine calcium channel blocker). Based on these considerations, addition of hydrochlorothiazide to the combination of an antagonist of the renin-angiotensin system with a calcium channel blocker would constitute a logical approach. Inclusion of a diuretic in the triple combination is based on the evidence that these agents are effective and cheap, enhance the effect of other antihypertensive agents, and add a specific effect to individuals with salt-sensitivity of blood pressure. The benefit of triple combination therapy with amlodipine, valsartan and hydrochlorothiazide over its dual component therapies has been demonstrated, and the use of a single pill will simplify therapy resulting in better blood pressure contro

Carotid cross-clamping intolerance during carotid endarterectomy: The role of Willis' Circle variations

BACKGROUND: Several authors have emphasized that different anatomical features regarding the Willis Circle (CoW) may represent risk factors in the development of cerebral ischemia during carotid cross-clamping (CCC). The aim of this study is to determine if the incompleteness of CoW assessed by computed tomography angiography (CTA) represents a risk factor for CCC intolerance (CCCi) during carotid artery endarterectomy (CEA). METHODS: We have conducted a retrospective study evaluating patients with a preoperative CTA of the extracranial and intracranial cerebral circulation, who underwent CEA under general anesthesia with preserved consciousness from 2012 to 2017. We considered patients who required shunt for CCCi (group A). We selected a control group with patient who tolerated CCC, homogenous to group A cardiovascular risk factors, contralateral carotid and vertebral arteries disease and operative technique (group B). On CTA we evaluated type (aplasia/hypoplasia) and side of the variations. Endpoints: evaluating CCCi risk in patients with at least one CoW variation; identifying the most common variation associated with CCCi. Statistical analysis was conducted using Fisher's Exact Test. RESULTS: Group A was composed by 17 patients, group B by 37. All group A patients owned at least one CoW variation vs. 70.3% of group B patients (P=0.01). The CoW variations resulted statistically significant were an aplasia/hypoplasia of contralateral anterior cerebral artery (cAl) (P=0.009) and the combination between cAl and ipsilateral posterior communicating artery (iCoP) (P=0.008). CONCLUSIONS: By this preliminary experience it can be assumed that CCCi is more frequently associated with an incomplete CoW. In particular aplasia/hypoplasia of cAl alone or associated with iCoP variation is statistically correlated with CCCi