Biomechanic and Hemodynamic Perspectives in Abdominal Aortic Aneurysm Rupture Risk Assessment

Abdominal aortic aneurysms (AAAs) pose a significant source of mortality for the elderly, especially if they go on undetected and ultimately rupture. Therefore, elective repair of these lesions is recommended in order to avoid risk of rupture which is associated with high mortality. Currently, the risk of rupture and thus the indication to intervene is evaluated based on the size of the AAA as determined by its maximum diameter. Since AAAs actually present original geometric configurations and unique hemodynamic and biomechanic conditions, it is expected that other variables may affect rupture risk as well. This is the reason why the maximum diameter criterion has often been proven inaccurate. The biomechanical approach considers rupture as a material failure where the stresses exerted on the wall outweigh its strength. Therefore, rupture depends on the pointwise comparison of the stress and strength for every point of the aneurysmal surface. Moreover, AAAs hemodynamics play an essential role in AAAs natural history, progression and rupture. This chapter summarizes advances in AAAs rupture risk estimation beyond the “one size fits all” maximum diameter criterion

Μελέτη οξειδωτικού stress σε ασυμπτωματικούς και συμπτωματικούς ασθενείς με καρωτιδική νόσο

Σκοπός: Η παραοξονάση-1 (PON-1) είναι μια υδρολάση συνδεδεμένη με την υψηλής πυκνότητας λιποπρωτεϊνη (HDL), που φαίνεται να έχει προστατευτική δράση κατά της αθηροσκλήρωσης. Σκοπός της παρούσας μελέτης είναι να προσδιορίσει αν τα επίπεδα PON-1 μπορεί να σχετίζονται με την εκδήλωση νευρολογικής συμπτωματολογία σε ασθενείς με στένωση της καρωτίδας αρτηρίας. Μέθοδοι: Μελετήθηκαν όλοι οι ασθενείς που υποβλήθηκαν σε ενδαρτηρεκτομή καρωτίδας στο Τμήμα Αγγειοχειρουργικής του Γενικού Νοσοκομείου Αθήνας « Λαϊκό», από τον Ιούλιο 2012 έως τον Ιούλιο 2014. Καταγράφηκε το ιατρικό ιστορικό και οι διατροφικές συνήθειες των ασθενών και μετρήθηκαν τα επίπεδα PON-1, γλυκόζης, ολικής χοληστερόλης, HDL, χαμηλής πυκνότητας λιποπρωτεϊνης (LDL) και τριγλυκεριδίων. Οι μεταβλητές συγκρίθηκαν μεταξύ συμπτωματικών και ασυμπτωματικών ασθενών ενώ έγινε και μια ανάλυση καμπύλης λειτουργικού χαρακτηριστικού δέκτη, ή αλλιώς, ROC (Receiver Operating Characteristic curves),για να αξιολογήσει την ακρίβεια της PON-1 στην πρόβλεψη εμφάνισης συμπτωματολογίας. Αποτελέσματα: Συμπεριλήφθηκαν 74 ασθενείς στη μελέτη και οι 41 ήταν ασυμπτωματικοί. Η μέση ηλικία ήταν 68,5 έτη. Οι 2 ομάδες φαίνεται ότι διέφεραν σημαντικά σε σχέση με τα επίπεδα PON-1 με τη συμπτωματική ομάδα να παρουσιάζει χαμηλότερα επίπεδα (5,3 ± 1,19 έναντι 4,6 ± 1,36 ng / ml, p = 0,025). Η ανάλυση ROC έδειξε μια περιοχή κάτω από την καμπύλη 0,654 (p = 0,023). Συμπέρασμα: Η παρουσία μειωμένων επιπέδων PON-1 είχε στατιστικά σημαντική συσχέτιση με την εμφάνιση νευρολογικής συμπτωματολογίας, η οποία ήταν ανεξάρτητη από άλλους παραδοσιακούς καρδιαγγειακούς παράγοντες. Απαιτούνται περαιτέρω μελέτες για τη μελλοντική αξιολόγηση του ρόλου της PON-1 στην πρόγνωση εμφάνισης νευρολογικής συμπτωματολογίας σε ασθενείς με καρωτιδική νόσο.Objective: Paraoxonase-1 (PON-1) is a high-density-lipoprotein associated hydrolase that appears to have a protective action against atherosclerosis. The aim of our study is to identify whether PON-1 levels may be associated with the manifestation of symptoms in patients with carotid artery stenosis. Methods: We studied all patients who underwent carotid endarterectomy in the Vascular Surgery Department of Laikon Hospital, Athens, Greece, from July 2012 to July 2014. Medical history and dietary habits were recorded and PON-1 glucose, total cholesterol, high-density lipoprotein cholesterol, low-density-lipoprotein cholesterol and triglycerides levels were measured. Variables were compared between symptomatic and asymptomatic patients. A receiver operating characteristic (ROC) curve was constructed in order to evaluate accuracy of PON-1 to predict symptoms. Results: 74 patients were included, 41 were asymptomatic and mean age was 68.5 years. The 2 groups appear to differ significantly with regards to the PON-1 levels, with the symptomatic group showing lower levels (5.3±1.19 vs 4.6±1.36 ng/ml; p=0.025). ROC analysis demonstrated an area under the curve of 0.654 (p=0.023). Conclusion: Reduced PON-1 levels showed a significant association with symptomatic status, which was independent of other traditional cardiovascular factors. Further studies are required to prospectively assess the role of PON-1 in predicting cerebrovascular events in patients with carotid artery disease

Study of oxidative stress in asymptomatic and symptomatic patients with carotid artery disease

Objective: Paraoxonase-1 (PON-1) is a high-density-lipoprotein associated hydrolase that appears to have a protective action against atherosclerosis. The aim of our study is to identify whether PON-1 levels may be associated with the manifestation of symptoms in patients with carotid artery stenosis. Methods: We studied all patients who underwent carotid endarterectomy in the Vascular Surgery Department of Laikon Hospital, Athens, Greece, from July 2012 to July 2014. Medical history and dietary habits were recorded and PON-1 glucose, total cholesterol, high-density lipoprotein cholesterol, low-density-lipoprotein cholesterol and triglycerides levels were measured. Variables were compared between symptomatic and asymptomatic patients. A receiver operating characteristic (ROC) curve was constructed in order to evaluate accuracy of PON-1 to predict symptoms.Results: 74 patients were included, 41 were asymptomatic and mean age was 68.5 years. The 2 groups appear to differ significantly with regards to the PON-1 levels, with the symptomatic group showing lower levels (5.3±1.19 vs 4.6±1.36 ng/ml; p=0.025). ROC analysis demonstrated an area under the curve of 0.654 (p=0.023). Conclusion: Reduced PON-1 levels showed a significant association with symptomatic status, which was independent of other traditional cardiovascular factors. Further studies are required to prospectively assess the role of PON-1 in predicting cerebrovascular events in patients with carotid artery disease.Σκοπός: Η παραοξονάση-1 (PON-1) είναι μια υδρολάση συνδεδεμένη με την υψηλής πυκνότητας λιποπρωτεϊνη (HDL), που φαίνεται να έχει προστατευτική δράση κατά της αθηροσκλήρωσης. Σκοπός της παρούσας μελέτης είναι να προσδιορίσει αν τα επίπεδα PON-1 μπορεί να σχετίζονται με την εκδήλωση νευρολογικής συμπτωματολογία σε ασθενείς με στένωση της καρωτίδας αρτηρίας. Μέθοδοι: Μελετήθηκαν όλοι οι ασθενείς που υποβλήθηκαν σε ενδαρτηρεκτομή καρωτίδας στο Τμήμα Αγγειοχειρουργικής του Γενικού Νοσοκομείου Αθήνας « Λαϊκό», από τον Ιούλιο 2012 έως τον Ιούλιο 2014. Καταγράφηκε το ιατρικό ιστορικό και οι διατροφικές συνήθειες των ασθενών και μετρήθηκαν τα επίπεδα PON-1, γλυκόζης, ολικής χοληστερόλης, HDL, χαμηλής πυκνότητας λιποπρωτεϊνης (LDL) και τριγλυκεριδίων. Οι μεταβλητές συγκρίθηκαν μεταξύ συμπτωματικών και ασυμπτωματικών ασθενών ενώ έγινε και μια ανάλυση καμπύλης λειτουργικού χαρακτηριστικού δέκτη, ή αλλιώς, ROC (Receiver Operating Characteristic curves),για να αξιολογήσει την ακρίβεια της PON-1 στην πρόβλεψη εμφάνισης συμπτωματολογίας. Αποτελέσματα: Συμπεριλήφθηκαν 74 ασθενείς στη μελέτη και οι 41 ήταν ασυμπτωματικοί. Η μέση ηλικία ήταν 68,5 έτη. Οι 2 ομάδες φαίνεται ότι διέφεραν σημαντικά σε σχέση με τα επίπεδα PON-1 με τη συμπτωματική ομάδα να παρουσιάζει χαμηλότερα επίπεδα (5,3 ± 1,19 έναντι 4,6 ± 1,36 ng / ml, p = 0,025). Η ανάλυση ROC έδειξε μια περιοχή κάτω από την καμπύλη 0,654 (p = 0,023). Συμπέρασμα: Η παρουσία μειωμένων επιπέδων PON-1 είχε στατιστικά σημαντική συσχέτιση με την εμφάνιση νευρολογικής συμπτωματολογίας, η οποία ήταν ανεξάρτητη από άλλους παραδοσιακούς καρδιαγγειακούς παράγοντες. Απαιτούνται περαιτέρω μελέτες για τη μελλοντική αξιολόγηση του ρόλου της PON-1 στην πρόγνωση εμφάνισης νευρολογικής συμπτωματολογίας σε ασθενείς με καρωτιδική νόσο

Mirror Image Incision for Popliteal Aneurysm Repair Tailored to Patient Specific Anatomy

Percutaneous closure of atrial septal defects (ASDs) has emerged as an alternative to surgical treatment; however, several early and late complications have been reported. In this report, we present the case of a patient who underwent surgical removal of a migrated ‘Figulla Flex II’ ASD occlusion device at the aortic bifurcation 2 months after ASD occlusion

Late renal artery occlusion following endovascular repair of abdominal aortic aneurysm: a possible complication of mural thrombus formation within aortic endografts

Mural thrombus formation within aortic endoprostheses has been described to occur in up to one-third of aortic endografts depending on the device type. Data regarding the clinical significance of such a phenomenon are scarce, but in most cases it is considered to be clinically innocent. The authors describe a rare case of late renal artery occlusion due to intraprosthetic thrombus formation and extension into the right renal orifice 30 months after endovascular abdominal aortic aneurysm repair. Additionally, a brief literature review regarding the incidence and natural history of mural thrombotic deposits within aortic endografts is also conducted

Management of a Complicated Ruptured Infected Pseudoaneurysm of the Femoral Artery in a Drug Addict

Infected pseudoaneurysm of the femoral artery represents a devastating complication of intravenous drug abuse, especially in the event of rupture. Operative strategy depends upon the extent of arterial injury and the coexistence of infection or sepsis. Options range from simple common femoral artery (CFA) ligation to complex arterial reconstruction with autologous grafts (arterial, venous, or homografts). We report herein the management of a 29-year-old male patient who was urgently admitted with a ruptured pseudoaneurysm of the right CFA, extending well above the inguinal ligament. Multidisciplinary approach with multiple arterial reconstructions and subsequent coverage of the tissue defect with a rectus abdominis musculocutaneous flap transposition was performed

Multiple Aneurysms of the Inferior Pancreaticoduodenal Artery: A Rare Complication of Acute Pancreatitis

Inferior pancreaticoduodenal artery (IPDA) aneurysms are uncommon, representing nearly 2% of all visceral aneurysms, and sporadically associated with celiac artery stenosis. Multiple IPDA aneurysms have been rarely reported. We report a case of a 53-year-old female patient with a history of prior pancreatitis, who presented with two IPDA aneurysms combined with median arcuate ligament-syndrome-like stenosis of the celiac trunk. The patient was treated successfully with coil embolization under local anesthesia. The procedure is described and illustrated in detail and the advantages and technical considerations of such an approach are also being discussed

Acute aortic occlusion due to tumor embolism in a patient with lung malignancy

Objectives: Acute lower limb ischemia caused by tumor embolization is rare, despite the fact that cancer is a common cause of hypercoagulability predisposing to venous thrombosis. Arterial embolization is mostly associated with intracardiac tumors while lung malignancies are the second most common cause of tumor embolism. Methods: In this report, we present a male patient who developed acute bilateral lower limb ischemia in the immediate postoperative period after a thoracotomy for attempted left upper lobe resection for lung cancer. Results: The patient was treated with a subclavian-bifemoral bypass, since an initial attempted embolectomy was unsuccessful. Histopathological characteristics of thrombus obtained during embolectomy were consistent with the histopathology of the primary tumor. Conclusion: Acute ischemia is an emergency that should be diagnosed and treated immediately. Interestingly, in this case, the presence of epidural anesthesia masked the initial symptoms and delayed diagnosis. Preoperative assessment with transesophageal echocardiography may reveal patients at high risk for tumor embolism

Treatment paradigms for ductus arteriosus aneurysms in adults

We report two symptomatic cases of ductus arteriosus aneurysm (DDA) in adults treated in our department over a 5-years period. One patient underwent an open off-pump surgical procedure, while the second one was treated with partial aortic arch debranching and endovascular stent-grafting. DDA in adults is an uncommon condition and can present with rupture, hoarseness or symptoms of airway obstruction. Although indications for intervention are not clearly established, most authors advocate that DDAs should be treated regardless of their size, to avoid the risk of rupture, while others reserve intervention for symptomatic patients. We report on the management of these patients and provide an updated review of the current literature

Late open conversion after failed endovascular aortic aneurysm repair

ObjectiveEndovascular aortic aneurysm repair (EVAR) is widely used for the treatment of abdominal aortic aneurysms. Complications secondary to EVAR are also treated with endovascular techniques. When this is not applicable, open surgical repair is mandatory. This study aims to present our experience in open surgical repair after failed EVAR.MethodsWithin the period from 2004 through 2013, 18 patients (17 men; mean age, 73.9 years) were operated on because of EVAR failure due to persistent type II endoleak (n = 10), type I or III endoleak (n = 3), mixed-type endoleaks (n = 2), stent graft thrombosis (n = 2), and aortoenteric fistulae (n = 1). Stent grafts used for EVAR were Zenith (n = 8), Talent (n = 4), Excluder (n = 4), and Anaconda (n = 2).ResultsMean time interval between EVAR and open conversion was 36 months (range, 2-120 months). Fifteen (83.3%) operations were elective, and three (16.7%) were urgent due to aneurysm rupture (n = 2) and aortoenteric fistula (n = 1). Six (33.3%) patients with type II endoleak were treated with simple ligation of the culprit vessels, without aortic clamping and stent graft explantation. In six (33.3%) patients, the stent graft was partially removed except from the segment attached to the proximal neck, while in five (27.8%) patients, complete removal of the stent graft was necessary. Finally, in one patient, with type III endoleak, a hybrid endovascular and open repair was performed. Clamping of the aorta was necessary in 12 (66.7%) patients (infrarenal, n = 10 or suprarenal, n = 2). Overall operative mortality was 5.6%. Postoperative complications included one abdominal wall defect requiring surgical revision and paroxysmal atrial fibrillation both in the same patient, and one case of pulmonary infection, requiring prolonged intubation and intensive care unit stay for 6 days.ConclusionsLate open conversion after failed EVAR remains challenging. Avoidance of aortic cross-clamping and if possible, partial or total preservation of the stent graft may improve outcomes in terms of operative mortality and morbidity. Elective operations seem to be associated with better outcomes, prompting thus for close follow-up of EVAR patients and early decision for conversion if other options are doubtful