Editor's Choice \u2013 Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

2017 Clinical Practice Guidelines of the European Society for Vascular Surgery

Effects of Cyclic Strain and Growth Factors on Vascular Smooth Muscle Cell Responses

Under physiological and pathological conditions, vascular smooth muscle cells (SMC) are exposed to different biochemical factors and biomechanical forces. Previous studies pertaining to SMC responses have not investigated the effects of both factors on SMCs. Thus, in our research we investigated the combined effects of growth factors like Bfgf (basic fibroblast growth factor), TGF-β (transforming growth factor β) and PDGF (platelet-derived growth factor) along with physiological cyclic strain on SMC responses. Physiological cyclic strain (10% strain) significantly reduced SMC proliferation compared to static controls while addition of growth factors bFGF, TGF-β or PDGF-AB had a positive influence on SMC growth compared to strain alone. Microarray analysis of SMCs exposed to these growth factors and cyclic strain showed that several bioactive genes (vascular endothelial growth factor, epidermal growth factor receptor, etc.) were altered upon exposure. Further work involving biochemical and pathological cyclic strain stimulation will help us better understand the role of cyclic strain and growth factors in vascular functions and development of vascular disorders

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme

Eversion versus Conventional Carotid Endarterectomy: A Meta-analysis of Randomised and Non-randomised Studies

Background: To compare eversion (ECEA) and conventional (CCEA) carotid endarterectomy from randomised and non-randomised studies. Methods: Pooled odds ratios (ORs) with 95% confidence intervals (95%CIs) and numbers needed to treat (NNTs) were appropriately calculated. A sub-analysis was performed on studies directly comparing ECEA vs. patch CEA (PCEA). Meta-regression analysis was performed to examine the effect of potentially meaningful patient-related, procedure-related and definition-related modifiers. Power calculations were also conducted. Results: A total of 21 studies were deemed eligible (8530 ECEA and 7721 CCEA procedures), seven of which were randomised and 14 non-randomised. ECEA was associated with significant reduction in perioperative stroke (OR = 0.46, 95%CI: 0.35-0.62, NNT = 68, 95%CI: 56-96), death (OR = 0.49, 95%CI: 0.34-0.69, NNT = 100, 95%CI: 85 -185) and stroke-related death (OR = 0.40, 95%CI: 0.23-0.67, NNT = 147, 95%CI: 115 -270); the results were replicated at the sub-analysis on PCEA. Concerning long-term outcomes, ECEA presented with a significant reduction in late carotid artery occlusion (OR = 0.48, 95%CI: 0.25-0.90, NNT = 143, 95%CI: 100-769) and late mortality (OR = 0.76, 95%CI: 0.61-0.94, NNT = 40, 95%CI: 25-167); the sub-analysis on PCEA replicated only the finding on late mortality. Meta-regression analysis did not point to significant effects mediated by the examined modifiers. Power calculations suggested adequate statistical power. Conclusions: ECEA compared to CCEA may be associated with a lower incidence in both short-term and long-term outcomes, which does not seem to be hampered by potentially meaningful modifiers. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

Changes of the infrarenal aortic segment after conventional abdominal aortic aneurysm repair

Objectives: To delineate the natural history of the residual infrarenal aortic segment after conventional abdominal aortic aneurysm (AAA) repair. Design: Open prospective study. Patients and methods: Between 1990 and 1997, 100 patients, who underwent conventional infrarenal AAA repair at our department, were followed annually by means of colour duplex ultrasonography. Data from 76 patients who had at least 3 scans were analysed. Results: Mean duration of follow-up was 4.7 years (range: 3-8 years). The residual infrarenal aorta dilated a mean of 0.57 mm annually. No patient required reoperation. There was no significant correlation between dilatation and any of the recorded risk factors except for the initial neck diameter (p = 0.03). Conclusions: Conventional AAA surgery is durable so that surveillance, during the first 5 postoperative years, is not justified in terms of cost-effectiveness. The impact of such a dilatation on endovascular AAA repair requires further investigation

Inflammation and Chlamydia pneumoniae infection correlate with the severity of peripheral arterial disease

Background: Our aim was to investigate the association of inflammation and Chlamydia pneumoniae infection with the presence and severity of peripheral arterial disease. Methods: Twenty-eight patients Whose initial claudication distance (ICD) in the traditional constant-load treadmill test was < 200 m, underwent femoral endarterectomy as part of their interventional treatment (group A). Group B consisted of 23 patients whose ICD was > 200 m and were put on medication and a daily exercise program. The control group consisted of 30 non-vascular patients of the Ophthalmology Department (group C). We measured the levels of C-reactive protein, fibrinogen, vascular cell adhesion molecule-1 and tumor necrosis factor-alpha, and the titers of IgA and IgG antibodies against C. pneunioniae in the serum of all the patients, Finally, the atheromas and vein segments of group A patients, were immunohistochemically (IHC) examined for the presence of C. pneumoniae. Results: Peripheral arterial disease (PAD) patients, had significantly higher CRP (p = 0.026) and anti-Cp TgA levels (p 0,001) when compared to control subjects, after a multiple linear regression analysis. The odds ratio for the prevalence of femoral atherosclerosis was 3.1.6 for IgA seropositive patients (Cl 1.15-8.67). When comparing group A and group B patients, CRP (p=0.003) and IgA (p=0.011), were significantly correlated with severe PAD. Group A patients with positive immunohistochemical examination of the plaque, had higher anti-Cp TgA levels (p=0.023) and TNF-alpha values (p= 0.031), compared to the IHC negative patients. C. pneumoniae was detected in 50% of the femoral atheromas, but in only 3.6% of the veins. Conclusion: This study supports the hypothesis that inflammation (CRP) and chronic C. pneumoniae infection (IgA seropositivity), have an important role in lower limb atherosclerosis and correlate with the severity of the disease

The European Society for Vascular Surgery Guidelines for Carotid Intervention: An Updated Independent Assessment and Literature Review

Background and purpose: Many medical societies now recommend carotid stenting as an alternative to endarterectomy which raises the question of whether the ESVS guidelines are still valid. This review addresses the validity of the ESVS guidelines that refer to carotid stenting based on the evidence available today. Methods: We conducted a review and meta-analysis based on the original ESVS guidelines paper and articles published over the past 2 years. Results: For symptomatic patients, surgery remains the best option, since stenting is associated with a 61% relative risk increase of periprocedural stroke or death compared to endarterectomy. However, centres of excellence in carotid stenting may achieve comparable results. In asymptomatic patients, there is still no good evidence for any intervention because the stroke risk from an asymptomatic stenosis is very low, especially with the best modern medical treatment. CREST and CAVATAS have verified that mid-term stroke prevention after successful stenting is similar to endarterectomy. EVA-3S, SPACE, ICSS and CREST have provided additional evidence regarding the role of age in choosing therapeutic modality. The role of the cerebral protection devices is challenged by the imaging findings of small randomised trials but supported by large systematic reviews. Conclusions: The ESVS guidelines that refer to carotid stenting not only remain valid but also have been further strengthened by the latest available clinical data. An update of these guidelines including all of the recent evidence is needed to provide an objective and up-to-date interpretation of the data. (C) 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

Factors Predisposing to Endograft Limb Occlusion after Endovascular Aortic Repair

Objectives: The aim of this study was to investigate risk factors for endograft limb occlusion after endovascular abdominal aneurysm repair (EVAR), using a case control design. Methods: All patients presenting with endograft limb occlusion after elective EVAR between January 2010 and June 2013, along with age, sex, and type of endograft matched controls were included in the study. The impact of atherosclerotic risk factors, anatomic characteristics of the aneurysm, procedural details, and antiplatelet therapy was investigated. Multivariate logistic regression analysis and conditional logistic regression analysis for 1:3 matched pairs deriving adjusted odds ratios (ORs) with 95% confidence intervals (Cis) in order to detect significant risk factors for endograft limb occlusion among cases and controls were modeled. Results: Of the 439 patients treated by EVAR, 18 patients (4.1%) presented with endograft limb occlusion. These patients were compared to 54 matched controls. Limb occlusion was associated with iliac artery angulation >60 (OR = 5.76, 95% Cl = 1.24-26.74; p =.03) or perimeter calcification >= 50% (OR = 5.87, 95% Cl = 1.10-31.32; p =.04). Limb occlusion was also associated with >= 15% endograft oversizing in the common iliac artery. (OR = 5.54, 95% Cl = 1.11-27.60; p =.04). No other risk factors for limb occlusion were recognized. Conclusions: The presence of significant angulation and calcification of the iliac arteries as well as excessive limb oversizing appear to be independent predictors of endograft limb occlusion after [VAR. (c) 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved