Contrast Enhanced Ultrasound (CEUS) Is Not Able to Identify Vulnerable Plaques in Asymptomatic Carotid Atherosclerotic Disease

OBJECTIVES: Contrast enhanced ultrasound (CEUS) has been suggested as an imaging tool for detection of asymptomatic carotid atherosclerotic disease (ACAD) at high risk of cerebral embolisation. The objective of this study was to evaluate CEUS and immunohistochemical (IHC) patterns in ACAD (i.e., without any neurologic symptoms in the last 6 months) and their correlations with histology. METHODS: CEUS analysis was classified on a semiquantitative basis using a three-point classification scale. Plaque morphology was assessed using the American Heart Association (AHA) classification of atherosclerotic plaques, then accordingly assigned as non-vulnerable (AHA Type IV/V) or vulnerable (AHA Type VI). IHC analysis for intra-plaque neo-angiogenesis (IPN) was identified by CD34/VEGF immunostaining and classified on a semiquantitative basis using a four-point classification scale. Both CEUS and IHC analyses were performed and scored by single observers. RESULTS: Fifty-eight consecutive asymptomatic patients (mean age 73 years, 33 males) undergoing carotid endarterectomy were included in the final analysis. Nineteen had AHA Class IV/V plaques, and the remaining 39 had AHA Class VI plaques. There were two main findings of the study: (a) histologically proven vulnerable plaques compared with histologically proven non-vulnerable plaques had denser IPN (p = .004), but did not show more pronounced contrast enhancement; (b) the correlation between IHC analysis and CEUS analysis was significant for both vulnerable and non-vulnerable plaques (p = .04 and p = .01, respectively), but it was direct for AHA Type IV/V plaques and inverse for AHA Type VI plaques. CONCLUSIONS: The main findings of the study were that histologically proven vulnerable plaques (i.e., AHA Class VI) as compared with histologically proven non-vulnerable plaques (i.e., AHA Class IV/V) had denser neo-vascularisation, but not more pronounced contrast enhancement

Ruptured abdominal aortic aneurysm: Endovascular treatment

Abstract Aim The elective endovascular treatment of abdominal aortic aneurysm (AAA) is nowadays a daily routine practice in selected patients. The traditional treatment of ruptured abdominal aortic aneurysm (rAAA) has a peri-operative mortality of 40–50% that has not changed in the last 20 years. Nowadays, the endovascular repair may reduce mortality, hospitalization and sanitary costs. Methods The study included 14 patients affected by AAA who came to the Emergency Department because of hemodynamic shock (nine patients) or back pain (five patients). All patients underwent a CT angiography before surgery. Forty-two percent of the patients presented with shock (systolic pressure ≤70 mm Hg) in the operating room, and they underwent an endovascular aortic repair (EVAR) as an emergency procedure. Five bifurcated endoprotesis and nine uniliac protesis making a femoro-femoral bypass to revascularize the excluded limb were made. Patients underwent a follow up with CT angiography one month and then six months after surgery and if no problems were detected, patients underwent a follow-up every year. Results Two cases were immediately converted to open surgery because of failed EVAR. Four patients (28%) died after surgery because of multi-organ failure (MOF). The mean hospitalization was 12 days (range 3–21 days). We observed only one case of first-type endoleak at the 1-month follow up and we successfully treated it with a proximal cuff. Conclusion In our experience, the intention-to-treat protocol for rAAA offered acceptable results in terms of mortality rates. Multicenter studies are necessary to establish the role of endovascular treatment in patients with rAAA

Handling preferences in student-project allocation

We consider the problem of allocating students to project topics satisfying side constraints and taking into account students’ preferences. Students rank projects according to their preferences for the topic and side constraints limit the possibilities to team up students in the project topics. The goal is to find assignments that are fair and that maximize the collective satisfaction. Moreover, we consider issues of stability and envy from the students’ viewpoint. This problem arises as a crucial activity in the organization of a first year course at the Faculty of Science of the University of Southern Denmark. We formalize the student-project allocation problem as a mixed integer linear programming problem and focus on different ways to model fairness and utilitarian principles. On the basis of real-world data, we compare empirically the quality of the allocations found by the different models and the computational effort to find solutions by means of a state-of-the-art commercial solver. We provide empirical evidence about the effects of these models on the distribution of the student assignments, which could be valuable input for policy makers in similar settings. Building on these results we propose novel combinations of the models that, for our case, attain feasible, stable, fair and collectively satisfactory solutions within a minute of computation. Since 2010, these solutions are used in practice at our institution

The balanced academic curriculum problem revisited

The Balanced Academic Curriculum Problem (BACP) consists in assigning courses to teaching terms satisfying prerequisites and balancing the credit course load within each term. The BACP is part of the CSPLib with three benchmark instances, but its formulation is simpler than the problem solved in practice by universities. In this article, we introduce a generalized version of the problem that takes different curricula and professor preferences into account, and we provide a set of real-life problem instances arisen at University of Udine. Since the existing formulation based on a min\u2013max objective function does not balance effectively the credit load for the new instances, we also propose alternative objective functions. Whereas all the CSPLib instances are efficiently solved with Integer Linear Programming (ILP) state-of-the-art solvers, our new set of real-life instances turns out to be much more challenging and still intractable for ILP solvers. Therefore, we have designed, implemented, and analyzed heuristics based on local search. We have collected computational results on all the new instances with the proposed approaches and assessed the quality of solutions with respect to the lower bounds found by ILP on a relaxed and decomposed problem. Results show that a selected heuristic finds solutions of quality at 9%\u201360% distance from the lower bound. We make all data publicly available, in order to stimulate further research on this problem

Management of an Iatrogenic Pseudoaneurysm of the Superior Gluteal Artery by Percutaneous Ultrasound-Guided Thrombin Injection: A Case Report

We report the unusual case of a pseudoaneurysm of the superior gluteal artery (SGA) as a complication of a bone marrow biopsy. A 75-year-old man presented with pain and swelling of the left buttock 1 month after a bone marrow biopsy of the left iliac crest. The patient was treated by percutaneous ultrasound-guided thrombin injection (UGTI). The procedure was successful without any complication and the patient was discharged at home the same day. Follow-up at 3 months after the procedure confirmed the complete thrombosis of the pseudoaneurysm sac. At the best of our knowledge, UGTI of a pseudoaneurysm of the SGA has never been reported since now in the English literature

Endovascular Management of Infected Femoral Artery Pseudoaneurysms in High-Risk Patients: A Case Series

We report our experience with the urgent treatment of two high-risk patients with infected femoral artery pseudoaneurysms (IFAPs) with the placement of a self-expandable covered stent (SECS). In both cases, there was no perioperative mortality and the aneurysm exclusion was successful without early or late stent thrombosis/stent fracture nor acute or chronic limb ischemia or limb loss. There was no recurrence of local or systemic infection during the follow-up period. Endovascular therapy represents a feasible treatment option for IFAPs in those patients for whom the risk of open surgical repair would be prohibitive, especially under urgent circumstances

Multiple sites of vascular dilation or aneurysmal disease and matrix metalloproteinase genetic variants in patients with abdominal aortic aneurysm

OBJECTIVE: The objective of this study was to assess whether functional genetic polymorphisms of matrix metalloproteinases (MMPs) 1, 3, 9, and 12 are associated with arterial enlargements or aneurysms of the thoracic aorta or popliteal arteries in patients with abdominal aortic aneurysm (AAA). METHODS: The associations between MMP1 (-1607 G in/del, rs1799750), MMP3 (-1171 A in/del rs35068180), MMP9 (13-26 CA repeats around -90, rs2234681, rs917576, rs917577), and MMP12 (G/T missense variation, rs652438) polymorphisms and enlargements or aneurysms of the thoracic aorta and popliteal arteries were tested in 169 consecutive AAA patients. RESULTS: Thoracic aorta enlargement or aneurysm (TE/A; maximum diameter, >35 mm) was detected in 34 patients (20.1% prevalence). MMP9 rs2234681 microsatellite was the only genetic determinant of TE/A in AAA patients (P = .003), followed by hypercholesterolemia and antiplatelet use. Carriers of both alleles with 6522 CA repeats had a 5.9 (95% confidence interval, 1.9-18.6; P 10 mm) occurred in 55 patients (33.1% prevalence). Carriers of MMP12 rs652438 C allele showed an 18% (P = .006) increased diameter in popliteal arteries and a 2.8 (95% confidence interval, 1.3-6; P = .008) increased odds of popliteal artery enlargement or aneurysm compared with TT genotype. CONCLUSIONS: Among patients with AAA, carriers of homozygous 6522 CA repeats in MMP9 rs12234681 and of C allele in MMP12 rs652438 have a substantial risk of carrying thoracic and popliteal enlargements, respectively

Management of abdominal aortic prosthetic graft and endograft infections. A multidisciplinary update

Abdominal aortic graft infections (AGIs) occur in 1-5% of aortic prosthetic placements. It can result in limb amputation, pseudo-aneurysm formation, septic emboli, aorto-enteric fistulae, septic shock and death. The most frequently involved pathogens are methicillin-susceptible Staphylococcus aureus, methicillin-resistant Staphylococcus aureus and coagulase-negative staphylococci, followed by Enterobacteriaceae and uncommon bacteria. In case of gut involvement the presence of fungi has to be considered. Computed tomography angiography is actually the gold standard diagnostic imaging but magnetic resonance is a valid alternative. Nuclear medicine imaging is commonly used to improve sensitivity and specificity. Signs and symptoms are often aspecific and blood cultures can be negative, requiring alternative ways to detect the microorganism responsible for infection, such as 16S rRNA gene sequencing and molecular rapid diagnostic tests. Curative surgical intervention is the first choice approach, with in-situ reconstruction providing by far the best outcome and xenopericardial bovine patch as a promising option. For patients unable to undergo major surgery, the outcome of conservative approach remains uncertain but usually provides for life-long suppressive therapy. However, in selected cases an attempt of stopping antibiotic treatment after 3-6 months can be done. Given the difficulty in their management, we performed a review of AGIs, in order to raise awareness on clinical presentation, current available diagnostic tools, prophylaxis, surgical and anti-infective treatment of AGI