The role of carotid plaque echogenicity in baroreflex sensitivity

ObjectiveThe baroreflex sensitivity is impaired in patients with carotid atherosclerosis. The purpose of our study was to assess the impact of carotid plaque echogenicity on the baroreflex function in patients with significant carotid atherosclerosis, who have not undergone carotid surgery.MethodSpontaneous baroreflex sensitivity (sBRS) was estimated in 45 patients with at least a severe carotid stenosis (70%-99%). sBRS calculation was performed noninvasively, with the spontaneous sequence method, based on indirectly estimated central blood pressures from radial recordings. This method failed in three patients due to poor-quality recordings, and eventually 42 patients were evaluated. After carotid duplex examination, carotid plaque echogenicity was graded from 1 to 4 according to Gray-Weale classification and the patients were divided into two groups: the echolucent group (grades 1 and 2) and the echogenic group (grades 3 and 4).ResultsSixteen patients (38%) and 26 patients (62%) were included in the echolucent and echogenic group, respectively. Diabetes mellitus was observed more frequently among echolucent plaques (χ2 = 8.0; P < .004), while those plaques were also more commonly symptomatic compared with echogenic atheromas (χ2 = 8.5; P < .003). Systolic arterial pressure, diastolic arterial pressure, and heart rate were similar in the two groups. Nevertheless, the mean value of baroreflex sensitivity was found to be significantly lower in the echogenic group (2.96 ms/mm Hg) compared with the echolucent one (5.0 ms/mm Hg), (F [1, 42] = 10.1; P < .003).ConclusionsThese findings suggest that echogenic plaques are associated with reduced baroreflex function compared with echolucent ones. Further investigation is warranted to define whether such an sBRS impairment could be responsible for cardiovascular morbidity associated with echogenic plaques

Three-Dimensional Geometric Analysis of Balloon-Expandable Covered Stents Improves Classification of Complications after Fenestrated Endovascular Aneurysm Repair

In balloon-expandable covered stent (BECS) associated complications after fenestrated endovascular aneurysm repair (FEVAR), geometric analysis may determine the cause of failure and influence reintervention strategies. This study retrospectively classifies BECS-associated complications based on computed tomographic angiography (CTA) applied geometric analysis. BECS-associated complications of FEVAR-patients treated in two large vascular centers between 2012 and 2021 were included. The post-FEVAR CTA scans of complicated Advanta V12 BECSs were analyzed geometrically and complications were classified according to its location in the BECS. BECS fractures were classified according to an existing classification system. In 279 FEVAR-patients, 34 out of the 683 included Advanta V12 BECS (5%) presented with a complication. Two Advanta V12 complications occurred during the FEVAR procedure and 32 occurred during follow-up of which five post-FEVAR CTA scans were missing or not suitable for analysis. In the remaining 27 BECSs complications were classified as (endoleaks (n = 8), stenoses (n = 4), occlusions (n = 6), fractures (n = 3), and a combination of complications (n = 6)). All BECSs associated complications after FEVAR with available follow up CTA scans could be classified. Geometric analysis of BECS failure post-FEVAR can help to plan the reintervention strategy

Investigation of the role of toll - like receptors in atherogenesis

Σκοπός της μελέτης: Η ανοσολογική απόκριση του οργανισμού και ιδιαίτερα ηφλεγμονή θεωρείται πλέον ότι παίζει κυρίαρχο ρόλο στη διαδικασία τηςαθηροσκλήρυνσης. Ποικίλοι τύποι υποδοχέων σε συνδυασμό με τους συνδέτες τουςενδέχεται να συμβάλλουν στην ανάπτυξη και κυρίως στην αποσταθεροποίηση τωναθηρωματικών πλακών με τελικό αποτέλεσμα την πρόκληση ισχαιμικού εμφράκτου πουστην περίπτωση της καρωτιδικής νόσου εκδηλώνεται ως ισχαιμικό αγγειακό εγκεφαλικόεπεισόδιο (ΑΕΕ). Οι υποδοχείς Toll-like (TLRs) οι οποίοι παίζουν κυρίαρχο ρόλο στηνανοσολογική απόκριση του οργανισμού σε περιπτώσεις λοίμωξης ή ιστικούτραυματισμού, έχουν πρόσφατα αναγνωρισθεί ως δυνητικοί διαμεσολαβητές τωνανοσολογικών αντιδράσεων που εμπλέκονται στο σχηματισμό και την πρόοδο τωναθηρωματικών βλαβών. Τα ανωτέρω περιγράφονται αναλυτικά στη ξενόγλωσσηανασκόπηση που δημοσιεύθυκε στο περιοδικό Expert Opin Ther Targets (Katsargyris A,Klonaris C, Bastounis E, Theocharis S.Toll-like receptor modulation: a novel therapeuticstrategy in cardiovascular disease?. Expert Opin Ther Targets. 2008 ;12:1329-46).Σκοπός της παρούσας διδακτορικής διατριβής ήταν η διερεύνηση του ρόλου των TLR-2και -4 στην αθηροσκλήρυνση των καρωτίδων αρτηριών και ιδιαίτερα στηναποσταθεροποίηση των καρωτιδικών πλακών. Ιδιαίτερη έμφαση δόθηκε στη διερεύνησητης επίδρασης των στατινών στην έκφραση των TLRs στις καρωτιδικές αθηρωματικέςπλάκες.Ασθενείς και Μέθοδοι: Στη μελέτη συμμετείχαν 157 ασθενείς που υποβλήθηκαν σεενδαρτηρεκτομή καρωτίδος στην ‘Α Χειρουργική Κλινική του Πανεπιστημίου Αθηνώνκατά το διάστημα Ιανουάριος 2007 – Δεκέμβριος 2008. Μελετήθηκε η ανοσοϊστοχημικήέκφραση του TLR-4 και -2 στα ενδοθηλιακά κύτταρα (ΕΚ), τα μακροφάγα (ΜΑΚ) καιτα λεία μυϊκά κύτταρα (ΛΜΚ) των καρωτιδικών αθηρωματικών πλακών σεσυμπτωματικούς και ασυμπτωματικούς ασθενείς με καρωτιδική νόσο και αναζητήθηκανσυσχετίσεις με κλινικές, επιδημιολογικές και βιοχημικές παραμέτρους του πληθυσμούτης μελέτης. Ιδιαίτερα για τη διερεύνηση της επίδρασης των στατινών στην έκφραση του141TLR-4 αναλύθηκαν στοιχεία 140 ατόμων από το σύνολο των 157, καθότι δεσυμπεριελήφθησαν ασθενείς οι οποίοι είτε λάμβαναν στατίνες προεγχειρητικά γιαπερίοδο μικρότερη των 4 εβδομάδων (ν=13), είτε δεν ακολουθούσαν συστηματικά τηναγωγή τους με στατίνες (ν=4).Αποτελέσματα: Παρατηρήθηκε στατιστικά σημαντική συσχέτιση της θετικής χρώσηςγια TLR-4 στα ΕΚ των καρωτιδικών πλακών με την παρουσία νευρολογικώνσυμπτωμάτων οφειλόμενων στην καρωτιδική νόσο (OR: 2.85, 95%CI 1.33-6.11, p =0.009). Η ανωτέρω συσχέτιση αφορούσε τόσο στο ποσοστό όσο και στην ένταση τηςχρώσης του TLR-4 (p<0.0001 και p=0.003, αντιστοίχως) και ήταν ισχυρότερη για ταμείζονα ΑΕΕ σε σύγκριση με τα παροδικά ισχαιμικά επεισόδια (ΠΙΕ) και την αμαύρωσηfugax. Η έκφραση του TLR-4 στα ΕΚ ήταν ενισχυμένη στις επαναστενωτικές πλάκες σεσύγκριση με τις πρωτοπαθείς αθηρωματικές βλάβες (p=0.012). Η έκφραση του TLR-4στα ΜΑΚ των καρωτιδικών πλακών ήταν επίσης αυξημένη στους συμπτωματικούςασθενείς συγκριτικά με τους ασυμπτωματικούς (OR 5.1; 95%CI: 1.8-14.3, p < 0.001).Αντίθετα δεν αναδείχθηκε συσχέτιση της έκφρασης του TLR-4 στα ΛΜΚ τωνκαρωτιδικών πλακών με την προεγχειρητική νευρολογική σημειολογία των ασθενών. ΟTLR-2 ανιχνεύθηκε μόνο στα ΜΑΚ των καρωτιδικών πλακών και η έκφρασή τουπαρουσίασε συσχέτιση με τις επαναστενωτικές αθηρωματικές πλάκες (p= 0.004).Οι ασθενείς που χρησιμοποιούσαν στατίνες παρουσίασαν ελαττωμένη έκφραση τουTLR-4 τόσο στα ΜΑΚ (p=0.03) όσο και στα ΕΚ (p=0.02) των καρωτιδικών πλακών ενώδεν ανιχνεύθηκε κανένα δείγμα με «αυξημένη ένταση χρώσης» ή «υπερέκφραση TLR-4»μεταξύ των ασθενών που λάμβαναν συστηματικά στατίνες. Η συχνότητα των αγγειακώνεγκεφαλικών συμπτωμάτων προεγχειρητικά ανήλθε σε 61.4% στην ομάδα των ασθενώνπου δεν έπαιρναν στατίνες και σε 18.6% στους ασθενείς που χρησιμοποιούσαν στατίνες(OR για λήψη στατινών: 0.14, 95% CI: 0.07-0.31, P<0.001).Συμπεράσματα: Ο TLR-4 εκφράζεται στα κύτταρα των καρωτιδικών αθηρωματικώνπλακών. Η έκφραση του TLR-4 στα ΕΚ και τα ΜΑΚ είναι αυξημένη στιςσυμπτωματικές-«ασταθείς» καρωτιδικές πλάκες, εύρημα που υποστηρίζει την πιθανήσυμμετοχή του TLR-4 στην παθοφυσιολογία και την κλινική εκδήλωση της αγγειακής142εγκεφαλικής νόσου. Τα ανωτέρω περιγράφονται αναλυτικά σε 2 ξενόγλωσσεςδημοσιεύσεις (1. Katsargyris A, Theocharis SE, Tsiodras S, Giaginis K, Bastounis E,Klonaris C. Enhanced TLR4 endothelial cell immunohistochemical expression insymptomatic carotid atherosclerotic plaques. Expert Opin Ther Targets. 2010;14(1):1-10. και 2. Katsargyris A, Tsiodras S, Theocharis S, Giaginis K, Vasileiou I, BakoyiannisC, Georgopoulos S, Bastounis E, Klonaris C. Toll-like receptor 4 immunohistochemicalexpression is enhanced in macrophages of symptomatic carotid atherosclerotic plaques.Cerebrovasc Dis. 2011;31(1):29-36.) Αντίθετα ο ρόλος του TLR-2 στηναθηροσκλήρυνση των καρωτίδων αρτηριών φαίνεται ότι είναι περιορισμένος.Η λήψη στατινών σχετίζεται με εξασθένιση της έκφρασης του TLR4 στις καρωτιδικέςπλάκες και με ελάττωση του κινδύνου για αγγειακά εγκεφαλικά συμβάματα, γεγονόταπου σε συνδυασμό υποδηλώνουν ότι η σταθεροποιητική δράση των στατινών στιςκαρωτιδικές πλάκες ενδέχεται να σχετίζεται με τη λειτουργία του TLR-4. Τα ευρήματααυτά δημοσιεύθηκαν επίσης στο περιοδικό Vascular.(Katsargyris A, Klonaris C,Tsiodras S, Bastounis E, Giannopoulos A, Theocharis S. Statin treatment is associatedwith reduced toll-like receptor 4 immunohistochemical expression on carotidatherosclerotic plaques: a novel effect of statins.Vascular. 2011)Περαιτέρω μελέτες είναι απαραίτητες προκειμένου να επιβεβαιωθεί η ισχύς τωνανωτέρω συμπερασμάτων και να καθοριστούν οι ενδεχόμενες κλινικές εφαρμογές του

Is volume important in aneurysm treatment outcome?

Several studies have suggested that surgical procedures performed at high-volume centers may result in superior outcome. Technically more demanding procedures such as aortic aneurysm repair appear to demonstrate a stronger relationship with volume. The present chapter reviewed the literature using the MEDLINE database to identify studies investigating the effect of volume in aortic aneurysm repair outcomes. The great majority of studies identified shows an advantage for high-volume hospitals with regard to perioperative mortality of abdominal (AAA), thoracic (TAA) and thoracoabdominal (TAA) aortic aneurysm repair. A similar advantage is shown for high-volume surgeons. The volume advantage appears to be less evident for simple endovascular procedures (EVAR &amp; TEVAR), compared to more complex endovascular (F/BEVAR) and open surgical procedures. Superior outcomes observed in high-volume hospitals are not only explained by increased surgeons’ experience, but importantly also by a more effective management of intra-and postoperative complications. Confounding factors to be taken into account are the timing of the studies in relation to positive evolution of outcomes in several high-risk procedures, and patient cohorts selected in regions with very low-and very high-volume hospitals only

Use of the Nellix Endovascular Aneurysm Sealing System in Combination With Parallel Grafts for the Treatment of a Symptomatic Type V Thoracoabdominal Aortic Aneurysm

Purpose: To report endovascular treatment of a symptomatic type V thoracoabdominal aortic aneurysm (TAAA) using the combined techniques of endovascular aneurysm sealing and parallel stent-grafts. Case Report: A 70-year-old man was referred with a symptomatic type V TAAA. The Nellix EndoVascular Aneurysm Sealing (EVAS) System was used in combination with 2 chimney grafts for the celiac artery (CA) and the superior mesenteric artery (SMA); one periscope graft perfused the right renal artery. Completion angiography showed exclusion of the aneurysm and patency of all 3 parallel grafts but occlusion of the left renal artery (LRA) due to unintentional coverage of its ostium by the Nellix endobags. Antegrade catheterization of the LRA failed, requiring implantation of an aortorenal vein bypass. The postoperative course was complicated by acute kidney injury. Imaging at 6 months showed sustained exclusion of the aneurysm, patency of the CA and SMA parallel grafts and left aortorenal bypass but occlusion of the right renal artery periscope graft. Serum creatinine at 6 months was 1.5 mg/dL. Conclusion: The combination of EVAS with parallel grafts for preservation of the visceral vessels may be a feasible technique to treat selected TAAAs in the acute setting when other options are not applicable

Primary stenting for aortic lesions: From single stenoses to total aortoiliac occlusions

Purpose: This study evaluated the feasibility, safety, and efficacy of primary stenting in atherosclerotic stenoses and occlusions of the infrarenal aorta. Methods: Between January 2003 and December 2006, 12 patients (6 men) with a mean age of 66.3 +/- 4.1 years who had infrarenal aortic occlusive disease were treated with primary stenting (aortic stenosis, 8; chronic total aortobiiliac occlusion, 4). Reasons for referral were severe claudication in six patients (50%), ischemic rest pain in four (33.3%), and minor tissue loss in two (16.7%). Three patients (25%) had chronic renal failure and were on dialysis. Follow-up was performed in all 12 patients. Results: Technical success was 91.7% because one patient had a residual stenosis &gt;30% after stent placement and balloon postdilation owing to severe calcification of the aorta. However, clinical and immediate hemodynamic success was achieved in all 12 patients (100%). The preprocedural mean resting ankle-brachial index (ABI) values of 0.56 +/- 0.13 at the right side and 0.59 +/- 0.15 at the left were increased to 0.97 +/- 0.04 and 0.95 +/- 0.06, respectively, after treatment (P &lt;.01). At the end of the mean follow-up of 18.3 months (range, 6-37 months), the primary clinical and hemodynamic patency was 91.7% +/- 7.98%, and the mean resting ABI values were 0.96 +/- 0.04 for the right and 0.92 +/- 0.1 for the left side (P &lt;.01 compared with preinterventional values). None of the patients in the study underwent reintervention. An access-related groin hematoma developed in one patient, but no other major or minor complications occurred. One patient died 8 months after the procedure of chronic renal failure complications. Conclusion: Primary stenting is feasible, safe, and effective for the whole spectrum of aortic occlusive disease. Especially for patients with infrarenal aortic stenoses, it is recommended as the first-line treatment and should be considered as a viable alternative to surgery for total aortoiliac occlusions

Efficacy of protected renal artery primary stenting in the solitary functioning kidney

Background: Significant renal artery, stenosis (RAS) in a solitary functioning kidney (SFK) represents one of the most acceptable indications for renal revascularization. Percutaneous transluminal renal artery stenting (PTRAS) is increasingly being used as a first line treatment for renal revascularization, associated with renal function improvement or stabilization in the majority of the patients with solitary kidneys, but also with deterioration in tip to 38% of the cases. Atheroembolism during PTRAS has been postulated as a potential cause for this acute renal function worsening. The aim of this study was to report on the feasibility, safety, and early outcomes of PTRAS in a series of patients with SFK using distal embolic protection (DEP). Methods: All PTRAS procedures in SFKs performed under DEP between June 2002 and September 2007 were reviewed. Renal function, blood pressure, and the number of anti-hypertensive medications were assessed pre- and post-intervention. Renal function improvement and deterioration were defined as a 20% increase and decrease in serum creatinine, respectively compared with preoperative values. Primary and primary assisted patency rates were also calculated. Statistical differences between values before and after intervention were determined by the Student t test and statistical significance was taken at P &lt; .05. Results: Protected PTRAS was performed in 14 patients with a SFK (9 men, 6 women, mean age 65.6 +/- 6.8 years). All patients were hypertensive and had varying degrees of azotemia. Mean pre-intervention stenosis degree was 86.8% +/- 7.8%. Immediate technical success was obtained in 100% of the patients. Renal function was cured (7.1%), improved (50%), or stabilized (42.9%) in all 14 (100%) patients after the procedure and no deterioration was noticed ill any patient at 6-month follow-up. Pre- and postintervention serum creatinine levels were 3.01 +/- 1.15 mg/dL and 2.16 +/- 0.68 mg/dL, respectively, (P = .02). Hypertension was improved in 6 (42.9%) patients and stabilized in the remaining 8 (57.1%). Primary patency was 100% and 90% at 1 and 3 years, respectively, while primary assisted patency remained 100% for the whole follow-up period (mean, 31.8 +/- 19.4 months). Conclusion: These findings suggest that in patients with a SFK, protected PTRAS represents a safe and effective treatment for halting the progression of renal dysfunction to renal loss and warrants further investigation. (J Vasc Surg 2008;48: 1414-22.