European Society of Vascular Surgery (ESVS) guidelines. Invasive treatment for carotid stenosis: indications, techniques

Europejskie Towarzystwo Chirurgii Naczyniowej (ESVS) zgromadziło grupę ekspertów zajmujących się patologią tętnic szyjnych (CAD) w celu stworzenia uaktualnionych wytycznych dotyczących inwazyjnego leczenia zwężenia tętnicy szyjnej. Zalecenia oceniano, przypisując im odpowiedni poziom dowodów. Wykonanie endarterektomii tętnicy szyjnej (CEA) zaleca się u pacjentów z objawami, u których zwężenie jest większe niż 50%, jeśli częstość występowania udaru mózgu/zgonu w okresie okołooperacyjnym wynosi mniej niż 6% [A]; najlepiej, aby CEA wykonano w ciągu 2 tygodni od wystąpienia ostatnich objawów [A]. Zabieg ten zaleca się także u mężczyzn, u których nie stwierdza się objawów, w wieku poniżej 75 rż., ze zwężeniem wynoszącym 70–99%, jeśli częstość występowania udaru mózgu/zgonu w okresie okołooperacyjnym wynosi mniej niż 3% [A]. Korzyści z przeprowadzenia CEA u kobiet, u których nie występują objawy, są istotnie mniejsze niż u mężczyzn [A], dlatego wykonanie tego zabiegu powinno rozważać się tylko u młodszych kobiet bez dodatkowych obciążeń. Preferuje się przeprowadzanie angioplastyki z użyciem łaty nad pierwotnym zamknięciem tętnicy [A]. Przed zabiegiem CEA, w jego trakcie i po nim chorym należy zalecić stosowanie kwasu acetylosalicylowego w dawce dobowej 75–325 mg i terapię statynami [A]. Zabieg stentowania tętnicy szyjnej (CAS) powinno się wykonywać jedynie u pacjentów, u których przeprowadzenie zabiegu CEA wiąże się z dużym ryzykiem, w dużych ośrodkach o udokumentowanym małym ryzyku wystąpienia zgonu i udaru mózgu w okresie okołooperacyjnym lub w ramach randomizowanych kontrolowanych badań klinicznych [C]. Zabieg CAS należy wykonywać, stosując jednocześnie podwójne leczenie przeciwpłytkowe z użyciem kwasu acetylosalicylowego i klopidogrelu [A]. Wykorzystanie systemów protekcji mózgu prawdopodobnie jest korzystne [C]. Acta Angiol 2010; 16, 4: 190–21

Κριτήρια για διασφάλιση εφαρμογής ανάστροφης ενδαρτηρεκτομής της καρωτίδος

Σκοπός: Η ανάστροφη ενδαρτηρεκτομή της καρωτίδας έχει χαρακτηριστεί ως ασφαλής και αποτελεσματική χειρουργική θεραπεία για τη στένωση καρωτίδας, με σκοπό την πρόληψη του ισχαιμικού εγκεφαλικού επεισοδίου. Ενώ η μέθοδος διεθνώς απομακρύνεται από τη σκιά της κλασικής ενδαρτηρεκτομής, παραμένει ο προβληματισμός σχετικά με την πιθανή κεφαλική επέκταση της αθηρωματικής πλάκας μέχρι τη βάση του κρανίου, σε βαθμό απαγορευτικό για τοποθέτηση λαβίδας αποκλεισμού σε υγιές τμήμα του αγγείου. Σε μια τέτοια περίπτωση, η ανάστροφη ενδαρτηρεκτομή δεν μπορεί να πραγματοποιηθεί κατά κανόνα με ασφάλεια και θα πρέπει προ της διάνοιξης της καρωτίδας να επιλεγεί η κλασική επιμήκης ενδαρτηρεκτομή. Η ανάδειξη κριτηρίων, τα οποία θα επιτρέπουν ή θα απαγορεύουν τη μέθοδο της ανάστροφης ενδαρτηρεκτομής, λόγω της κεφαλικής επέκτασης του αθηρώματος, αποτελεί το στόχο της παρούσας διατριβής. Σχεδιάστηκε μια προοπτικού τύπου μελέτη ασθενών με συμπτωματική ή ασυμπτωματική σημαντική καρωτιδική στένωση, στην οποία έχουν μελετηθεί προεγχειρητικές και διεγχειρητικές μετρήσεις, οι οποίες συγκρίνονται με μετεγχειρητικές μετρήσεις, για την εκτίμηση της περιφερικής επέκτασης της αθηρωματικής πλάκας, προκειμένου να αποφασίσουμε την εκτέλεση -πριν από την διαίρεση των αγγείων - της τεχνικής της ανάστροφης ενδαρτηρεκτομής της καρωτίδας. Υλικά και μέθοδοι: Ογδόντα ασθενείς υποβλήθηκαν σε ανάστροφη ενδαρτηρεκτομή της καρωτίδας, χωρίς επιλογή ασθενούς. Η μελέτη περιλάμβανε 37 ασθενείς με συμπτωματική στένωση καρωτίδας άνω του 70% και 43 με ασυμπτωματική στένωση μεγαλύτερη από 80%. Η πρώτη ομάδα περιλάμβανε 10 γυναίκες και 27 άνδρες, ενώ η δεύτερη ομάδα περιλάμβανε 16 γυναίκες και 27 άνδρες. Έχουμε χρησιμοποιήσει τέσσερις μεθόδους για τον καθορισμό κριτηρίων: προεγχειρητική έγχρωμη υπερηχογραφική εξέταση Doppler που περιλάμβανε τη μέτρηση του μήκους τους αθηρώματος της έσω καρωτίδας (κατά τον κεφαλουραίο άξονα), ιδίως την περιφερική επέκταση από το ύψος του καρωτιδικού διχασμού και κεφαλικά, τη διεγχειρητική μέτρηση του ψηλαφητού αθηρώματος εξωτερικά του τοιχώματος της έσω καρωτίδας προ της διατομής της καρωτίδας, τη μετεγχειρητική μέτρηση του αθηρώματοςαμέσως μετά την αφαίρεσή του και τη μετεγχειρητική ιστολογική μέτρηση του μήκους του αθηρώματος. Όλα τα δεδομένα αναλύθηκαν, ενώ συσχετίστηκαν με τα κλινικά χαρακτηριστικά και τους παράγοντες κινδύνου των ασθενών. Αποτελέσματα: Οι μέθοδοι μέτρησης, διεγχειρητικά και μετεγχειρητικά, του αθηρώματος της έσω καρωτίδας δεν είναι τόσο αξιόπιστες για την επέκταση του. Η προεγχειρητική μελέτη με υπερήχους είναι μια αξιόπιστη, μη επεμβατική μέθοδος για την εκτίμηση της πραγματικής περιφερικής επέκτασης του αθηρώματος της έσω καρωτίδας, προκειμένου να αποφασιστεί με ασφάλεια να εκτελεστεί ανάστροφη ενδαρτηρεκτομή της καρωτίδας με τη διόρθωση, όπως υπαγορεύεται από τον τύπο: AL = 0,6704 + 0,7685 ∙ Doppler Σε αυτήν τη σειρά ασθενών με στένωση καρωτίδας δεν υπήρξε ανάγκη απόκλισης από την τεχνική της ανάστροφης ενδαρτηρεκτομής της καρωτίδας. Σε όλες τις περιπτώσεις, η προεγχειρητική υπερηχογραφική μέτρηση, καθώς και η διεγχειρητική εκτίμηση επιβεβαίωσαν τη σωστή απόφαση της επιλογής της χειρουργικής επέμβασης. Νοσηρότητα, θνητότητα μηδενική. Συμπεράσματα: Η περιφερική επέκταση της αθηρωματικής πλάκας στην έσω καρωτίδα μπορεί να εκτιμηθεί με μεγάλη ακρίβεια με προεγχειρητική μελέτη με υπερήχους και αυτή η εξέταση μπορεί να χρησιμοποιηθεί με ασφάλεια ως κριτήριο για την εκτέλεση ή την αποφυγή της τεχνικής της ανάστροφης ενδαρτηρεκτομής της καρωτίδας, προκειμένου να επιδιορθωθεί επιτυχώς μια στένωση της έσω καρωτίδας.Purpose: Eversion carotid endarterectomy has been characterized as a safe and effective surgical treatment for carotid stenosis, to prevent ischemic stroke. While the method is internationally moving away from the shadow of classical endarterectomy, the question remains about the possible cephalic extension of the atherosclerotic plaque. In such a case, eversion carotid endarterectomy cannot normally be performed safely and the classic longhitudinal endarterectomy should be chosen before the carotid artery is opened. The present dissertation aims to develop criteria that will allow or prohibit the method of eversion carotid endarterectomy due to the cephalic extension of the atheroma. A prospective study was designed in patients with symptomatic or asymptomatic significant carotid stenosis, in which preoperative and intraoperative measurements have been evaluated and in comparison, with postoperative measurements, we estimated the cephalic extension of the atherosclerotic plaque to decide to perform - before the vessel division - the technique of the eversion carotid endarterectomy. Materials and methods: Eighty patients underwent eversion carotid endarterectomy without patient selection. The study included 37 patients with symptomatic internal carotid stenosis greater than 70% and 43 with asymptomatic stenosis greater than 80%. The first group included 10 women and 27 men, while the second group included 16 women and 27 men. We have used four methods for establishing the criteria: preoperative doppler examination which included measurement of the length of the internal carotid atheroma (along the head axis), in particular the distal extension from the carotid bifurcation, intraoperative measurement of the palpated internal carotid atheroma before the carotid cross section, intraoperative measurement of the atheroma immediately after its removal, and postoperative histologic measurement of the atheroma length; all data were analyzed and correlated with the clinical features and risk factors of the patients. Results: The methods of measurement, intraoperatively and postoperatively, of atherosclerotic plaque of internal carotid artery are not so reliable for itsextension. Preoperative Doppler examination is a reliable, noninvasive method to estimate the actual distal extension of the internal carotid artery atheroma, to decide with safety to perform eversion endarterectomy with the correction as dictated by the formula: AL= 0.6704+0.7685∙Doppler In this case series of patients with carotid stenosis there was no necessity for deviation from the eversion carotid endarterectomy technique. In all cases, preoperative ultrasound measurement, as well as the intraoperative estimation confirmed the correct decision of the choice of the surgery. Morbidity and mortality were null. Conclusions: The cephalic extension of the atherosclerotic plaque in the internal carotid artery can be assessed with great accuracy by preoperative Doppler study and this examination can be used with safety as criterion for performing or avoiding the eversion endarterectomy technique in order to successfully repair an internal carotid stenosis

Retroperitoneal semi-closed eversion ring endarterectomy of the left common iliac artery as a bridge for EVAR in a patient with a bilateral obstructive iliac disease

Concomitant abdominal aortic aneurysm (AAA) and bilateral iliac occlusive disease constitute a challenge for the application of endovascular repair of the aorta. We present the case of an 84-year-old man with an AAA, coronary disease, intermittent claudication of both legs, comorbidities including a hostile abdomen, and a stent protruding in the aneurysm sac following previous stenting of the right common iliac artery, and with a previous thrombosed axillobifemoral graft. We treated him with a hybrid retroperitoneal technique by placing an aortouniiliac (AUI) stent-graft via an intervening graft-conduit sutured to the bifurcation of the left common iliac artery following a semi-closed eversion ring endarterectomy of the left occluded common iliac artery. The intervening graft was then anastomosed to a new femoral-femoral bypass. The patient is in good condition with all vessels patent for twenty-one months following the operation

Surgical Considerations for the Management of an Ectopic Main Renal Artery Originating from an Abdominal Aortic Aneurysm

Ectopic major renal arteries are rare but anatomically important because they can complicate aortic surgery and make the operation challenging for vascular surgeons. A 68-year-old male was presented with a 5.5-cm aneurysm of the infrarenal abdominal aorta combined with an ectopic main right renal artery arising from the middle of the aneurysm sac, perfusing a normotopic right kidney. The patient also had small right common iliac artery aneurysm. Open repair was performed with reimplantation of the right renal artery on the aortic tube graft, the right kidney was perfused with cold heparinized lactated Ringer solution during operation. The right common iliac artery aneurysm was wrapped with a polyester band. The patient’s postoperative courses were uneventful, with normal renal function during 5 years of follow-up. Preoperative planning is important for achieving optimal results in treating complex aneurysms with ectopic main renal artery

Eversion endarterectomy under full prasugrel treatment

The third-generation thienopyridine prasugrel has much stronger antiplatelet effect compared to other current antiplatelet inhibitors and exhibits practically zero resistance in healthy people. Prasugrel is used as a pre- and post-treatment in percutaneous coronary or neurovascular interventions with parallel aspirin regime. However, as there is a higher reported bleeding with intraluminal interventions and meticulous technique is recommended, there is nearly non-existent international experience of open surgery under full prasugrel treatment. We present, herein, a case of open carotid endarterectomy with the eversion technique in an asymptomatic patient with carotid stenosis, who was receiving dual antiplatelet therapy with aspirin and prasugrel, due to a previous insertion of two newer drug-eluting stents at the left anterior descending artery and the right coronary artery. The resistance test to prasugrel showed complete inhibition of platelet function. Open surgery was performed under continuation of prasugrel treatment and interruption of aspirin for 3 days before surgery. No perioperative and postoperative neurologic or cardiologic event occurred. No bleeding at the cervical or cerebral area was noted

Leiomyoma of the Greater Saphenous Vein Mimicking Inguinal Lymphadenopathy

Introduction. Leiomyoma is a benign vascular tumor affecting the greater saphenous vein rarely. Proper histopathological examination sets the diagnosis after complete and wide surgical excision along with a normal portion of the GSV. Case Presentation. A 36-year-old woman was admitted to our hospital complaining of a dull ache on her right groin for the last three months, along with a palpable mass on the mentioned area. An ultrasound (U/S) scan revealed a solid mass measuring 3×2 cm. After wide surgical excision, pathological examination revealed a leiomyoma of the GSV. Discussion. Benign and mostly malignant tumors arising from the GSV are reported in the literature before. Diagnostic modalities and clinical examination cannot set a correct diagnosis preoperatively due to no specific characteristics of these tumors. Possible sarcomatous behaviour has to be kept in mind when treating tumors arising from a vessel wall and wide surgical excision as negative margins should be attempted

Complex common and internal iliac or aortoiliac aneurysms and current approach: Individualised open-endovascular or combined procedures

Objective. Bilateral internal iliac artery aneurysms constitute the utmost configuration of infrarenal aortoiliac disease. We detail characteristic aortoiliac disease patterns and reconstructive techniques we have used, along with a visualized decision-making chart and a short review of the literature. Material and Methods. A retrospective, observational study of twelve clinical cases of patients with aortoiliac disease are described. Two patients had a common iliac artery aneurysm and were managed by the application of inversed stent-grafts; another case was repaired by the insertion of a standard bifurcated stent-graft flared in the right common iliac artery and with an iliac branched device in the left iliac arterial axis. Open approach was used in 5 cases and in 4 cases a combination of aortouniliac stent-grafting with femoral-femoral bypass was applied. Results. Technical success was 100%. One endoleak type Ib in a flared iliac limb was observed and corrected by internal iliac embolism and use of an iliac limb stent-graft extension. We report 100% patency rate during 26.3 months of followup. Conclusion. Individualized techniques for the management of isolated iliac or aortoiliac aneurismal desease with special concern in maintaining internal iliac artery perfusion lead to elimination of perioperative complications and long-term durability and patency rates. © 2014 Thomas Kotsis et al

Insulin Metabolism and Assessment of Hepatic Insulin Extraction During Liver Regeneration. A Study in a Rat Model

Background: Liver regeneration is a complex procedure in which insulin metabolism has been implicated. The aim of this experimental study was to evaluate the role of insulin in rat hepatic regeneration following major hepatectomy (70%), employing an isolated perfused rat liver (IPRL) model to assess the extraction of insulin from the regenerating liver. Methods: Eighty-six male rats were randomized in 9 groups. A group of rats was studied at postoperative day (POD) 1 having a sham operation while control rats had no operation. All other animals were subjected to 70% hepatectomy. In phase B, at POD 1, 2, 3, 5, 7, and 14, the IPRL was applied. The regenerating liver was perfused with insulin (450 mu/ml) at a flow of 1.4 ml/gr liver/min for 20 min. Animal weight, liver weight, glucose, lactate, aspartate transferase (AST), alanine transferase (ALT), total bilirubin, albumin, prothrombin time (PT), insulin clearance, and tissue proliferating cell nuclear antigen (PCNA) expression were recorded. Results: We observed reduction of the liver's biochemical activities resulting in increase of AST (684%), ALT (532%), PT (27.7%), international normalized ratio (72%), and total bilirubin (82.8%) at first POD, while a normalization of the essential liver's functions occurs at fifth POD. Endogenous insulin concentration increased, while insulin extraction by the liver was reduced at the first POD in animals who underwent hepatectomy (13.94 ± 0.8 vs 7.97 ± 1.80 u/ml, p = 0.0005 and 71 ± 9.9 vs 165.88 µU/gr liver/min, respectively, p = 0.0005). Conclusions: Insulin seems to take part in hepatic regeneration, as the pancreas increases insulin production and the liver absorbs less despite the reduced hepatic mass and function

Global impact of the first coronavirus disease 2019 (COVID-19) pandemic wave on vascular services

This online structured survey has demonstrated the global impact of the COVID-19 pandemic on vascular services. The majority of centres have documented marked reductions in operating and services provided to vascular patients. In the months during recovery from the resource restrictions imposed during the pandemic peaks, there will be a significant vascular disease burden awaiting surgeons. One of the most affected specialtie