Dimitrios Karamanos

Endovascular Treatment of Popliteal Artery Aneurysms

OBJECTIVE To present the results of the endovascular treatment of popliteal artery aneurysms. METHODS From April 1999 to January 2002, 11 patients, aged 40-94 years, with 12 popliteal aneurysms were treated. Nine (75%) underwent an endoluminal repair, of whom three were done emergently due to an aneurysm rupture. Aneurysm diameter was 28-105 (mean 69) mm. A Hemobahn stent graft was inserted in six, Wallgraft in two and Passager in one case. RESULTS During a mean follow-up of 14 (3-31) months, four (44%) thromboses occurred: two in the early postoperative period (30 days) and two during the late postoperative period. Two of the four occluded grafts were successfully reopened, and in the one a stenosis of the distal end of the stent graft was treated with balloon dilatation. Patency rates at 1 and 12 months were 64/47% (primary patency) and 88/75% (secondary patency), respectively. CONCLUSION Initial experience with endovascular treatment of the popliteal aneurysm in high-risk patients yielded modest results. Larger number of patients and further follow-up time is necessary to evaluate the long-term results.

Impact of Endograft Material on the Inflammatory Response After Elective Endovascular Abdominal Aortic Aneurysm Repair

The purpose of this paper is to examine the impact of endograft material on the inflammatory response after elective endovascular abdominal aortic aneurysm repair. Consecutive patients (n=22, all men, 53 to 82 years old) were divided into 2 groups according to the graft material used: In group A (n=12) the endovascular device was made of polyester and in group B (n=10) the device was made of expanded polytetrafluoroethylene (ePTFE). All patients received antiinflammatory drugs in the perioperative period. Fever, white blood cells and platelet count, serum concentrations of cytokines (interleukin 6 [IL-6], tumor necrosis factor alpha [TNF-a], interleukin 8 [IL-8], acute-phase proteins high-sensitivity C-reactive protein [hsCRP] and alpha1-antitrypsin [a1-antitrypsin]), and complement protein (C3a) were measured preoperatively and 1, 3, 6, 24, 48, and 72 hours after aneurysm exclusion. One patient in each group had a systemic inflammatory response syndrome with 2 of the systemic inflammatory response syndrome (SIRS) criteria. No other complication associated with inflammation were present in any patient. Fever was more frequent in group A patients. Increases of white blood cells and serum concentrations of IL-6, TNF-a, hsCRP, a1-antitrypsin, and C3a and decrease of platelet count were recorded in both groups, but no statistically significant difference between them was recorded. However, serum concentrations of IL-8 were significantly higher in group A patients 24 hours postoperatively (p=0.01). No significant difference was apparent in the biological response between patients receiving a polyester or an ePTFE stent graft, except for fever and serum concentrations of IL-8.

Usefulness of the Hardman index in predicting outcome after endovascular repair of ruptured abdominal aortic aneurysms

OBJECTIVES The Hardman index, which has five variables, has been recommended as a predictor of outcome after open repair of ruptured abdominal aortic aneurysms (RAAAs). It has been reported that the presence of three or more variables is uniformly fatal. The aim of this study was to test the same model in an independent series of RAAA patients undergoing endovascular repair. METHODS A consecutive series of 41 patients undergoing endovascular repair for RAAA during an 8-year period was analyzed retrospectively. Thirty-day mortality and patient variables, including the five Hardman risk factors of age >76 years, serum creatinine >190 micromol/L, hemoglobin <9 g/dL, loss of consciousness, and electrocardiographic (ECG) evidence of ischemia, were recorded. The Hardman index and a revised version of the index with four variables (without ECG ischemia) were calculated and related to clinical outcome. RESULTS Operative mortality was 41% (17 of 41). On univariate analysis, only age >76 years (P = .01) and the use of local anesthesia (P < .0001) were statistically significant. Loss of consciousness (P = .05) showed a trend toward a higher mortality, albeit not statistically significant. On multivariate analysis, the use of local anesthesia was the only significant predictor of survival (odds ratio [OR], 0.03; 95% confidence interval [CI], 0.003-0.25, P = .001). Again, loss of consciousness showed an association with a higher chance of dying but did not achieve statistical significance (OR, 6.30; 95% CI, 0.93-42.51, P = .059). The original and revised versions of the Hardman index were both significantly associated with death (P = .02 and P = .001, chi(2) test for trend). The cumulative effect of 0, 1, 2, and >/=3 risk factors on mortality was 0%, 27%, 36%, and 71% for the original index, and 12.5%, 21%, 60%, and 78% for the revised version, respectively. Four and two patients with a score of >/=3 in each version of the index survived endovascular repair. CONCLUSIONS The Hardman index, with or without incorporating ECG ischemia, seems to be a simple and useful predictive tool in patients undergoing endovascular repair of RAAA, with the mortality rate increasing along with the Hardman score. However, the index cannot be used to accurately identify patients with no chance of survival after endovascular repair.

Axillary artery transection after recurrent anterior shoulder dislocation.

Axillary artery transection after recurrent anterior shoulder dislocation is extremely rare. We present 2 such patients. The first, a 62-year-old man, presented with acute ischemia and a large hematoma in the axilla and chest wall. The second, a 63-year-old man, had a pseudoaneurysm and palpable peripheral pulses. Both underwent urgent computed tomography, which confirmed the clinical diagnosis, and the patients were taken to the operating room. In the first patient, intraoperative angiogram through both the brachial and the femoral route showed complete disruption of the axillary artery rendering an endovascular approach not possible. Proximal balloon occlusion was then undertaken through the femoral artery, controlling the bleeding and allowing easier dissection of the ruptured segment. Revascularization was performed with an interposition polytetrafluoroethylene (PTFE) bypass restoring normal blood supply to the upper extremity. The second patient had a Viabhan (W.L. Gore, Flagstaff, Ariz) stent-graft implanted through the brachial artery with an excellent clinical and angiographic result. As expected, both patients had significant neurologic morbidity due to associated brachial plexus palsy. Ruptured axillary artery after shoulder dislocation is very uncommon. Endovascular repair and hybrid procedures combining open and endovascular techniques can offer reliable solutions to these challenging problems.

Lack of an association between angiotensin converting enzyme gene polymorphism and peripheral arterial occlusive disease

Numerous factors have been reported to influence the pathogenesis of atherosclerosis. The angiotensin I converting enzyme (ACE) gene is a candidate gene for atherosclerotic-related disease. In the present study, the association between the polymorphism of the ACE gene and peripheral arterial occlusive disease (PAOD) was investigated. Using polymerase chain reaction techniques, 100 patients (age 66.7-7.7 years) with PAOD and 100 age-matched controls were divided into the three ACE genotypes: II, ID and DD (Insertion I and Deletion D). There was no evidence of any association between ACE gene polymorphism and the presence of PAOD (odds ratio 0.759; 95% confidence interval 0.418-1.377). These results indicate an absence of association between DD genotype and PAOD. Further evaluation in a larger population study is required to examine the possibility of an increased risk of PAOD in DD homozygotes.

The protective effect of oxygenated perfluorocarbons (PFCs) on intestinal ischemia reperfusion injury (I/R) in rabbits.

Objective: To evaluate the effect of intraluminal administration of oxygenated perfluorocarbons (PFCs) on small intestine’s viability in an experimental model of acute ischemia-reperfusion (I/R). Methods: Twenty rabbits were divided in four groups: sham-operated controls (group A), acute I/R (group B), acute I/R plus infusion of PFCs 30 min before ischemia (group C), and acute I/R plus infusion of PFCs 30 min before reperfusion (group D). Malondialdehyde (MDA) tissue levels and d-lactate blood samples were taken. All tissue sections were examined under light microscope. Results: Mean MDA levels in group A: 1.79 ± 0.97 at 0 min, 2.25 ± 1.76 at 120 min and 3.70 ± 1.76 nmols/g at 180 min. Group B: 2.60 ± 0.58 at 0 min, 4.20 ± 0.58 at 120 min and 5.48 ± 2.01 at 180 min. Group C: 1.54 ± 0.85 at 0 min, 1.14 ± 0.37 at 120 min and 0.59 ± 0.35 at 180 min. Group D: 2.12 ± 0.62 at 0 min, 3.97 ± 0.70 at 120 min and 2.32 ± 0.37 at 180 min (p < 0.05). Mean d-lactate levels in group A: at 0 min 36.45 ± 1.99, at 120 min 39.10 ± 2.37 and at 180 min 40.05 ± 2.13 mg/dl. Group B: 61.23 ± 11.03 at 0 min, 74.84 ± 10.70 at 120 min and 89.90 ± 9.29 at 180 min. Group C: at 0 min 51.05 ± 10.36, at 120 min 56.07 ± 11.27 and at 180 min 57.20 ± 11.19. Group D: 64.36 ± 5.26 at 0 min, 72.55 ± 7.19 at 120 min and 77.02 ± 9.41 at 180 min (p < 0.05). Histopathological analysis indicated a significant improvement in the groups of oxygenated PFCs compared with I/R group. Conclusion: Intraluminal administration of oxygenated PFCs seems that protect the intestine from the I/R injury.

Protective effect of antithrombin III against lung and myocardial injury in lower-limb ischemia-reperfusion syndrome.

BACKGROUND Restoration of blood flow to an acutely ischemic limb can trigger systemic inflammation. We investigated whether antithrombin III (AT-III) exerts a protective action against remote lung and myocardial injury in an experimental animal model of lower-limb ischemia-reperfusion. METHODS Ischemia was induced by lower-limb arterial occlusion for 6 hours in 60 male Wistar rats. Animals were divided into those receiving AT-III (dose, 250 mg/kg) 30 minutes before the reperfusion (group A, n = 30) and those receiving placebo (group B, n = 30). Animals were then sacrificed, and lung and myocardial tissue samples were taken at baseline, 30 minutes, and 4 hours after reperfusion. Levels of malondialdehyde (MDA), a compound used as indirect index of oxygen free radicals, were estimated in lung and myocardium, and the two groups were compared at different time points using the independent sample t test. RESULTS Animals administered AT-III had significantly lower levels of lung MDA compared with the placebo group at baseline and at 30 minutes, but not at 4 hours (P = 0.001, P = 0.01, and P = 0.9, respectively), indicating a protective action of AT-III against remote lung injury early in the reperfusion phase. With regard to myocardial MDA levels, no statistically significant differences existed between the AT-III and placebo groups at baseline, at 30 minutes, and at 4 hours (P = 0.07, P = 0.07, and P = 0.2, respectively) after reperfusion. CONCLUSIONS In this experimental animal model, AT-III appears to exert a protective effect against remote ischemia-reperfusion injury in the lung tissue, but not in the myocardium.

Ruptured pseudoaneurysm of the profunda femoris artery due to pellet injury: endovascular treatment by coil embolization.

We describe the endovascular management of a ruptured profunda femoris artery (PFA) pseudoaneurysm resulting from multiple buckshot pellet injuries. A 71-year-old man was referred with the diagnosis of ruptured pseudoaneurysm of the PFA. He had previously been in good health but, 6 months prior to the referral, had been accidentally shot while boar hunting. He suffered multiple shotgun buckshot pellet injuries to the lower abdomen and right thigh and underwent laparotomy, bowel resection, and colostomy. His postoperative course was stormy and complicated by two subsequent laparotomies for peritonitis, multiple organ failure, and stroke. After 6 months in the ICU and the medical ward, he was noted to have a pulsatile swelling in the right upper thigh. Ultrasound examination revealed a pseudoaneurysm of the PFA (Fig. 1). The patient gradually became hemodynamically unstable and developed shock, along with a further increase in the swelling. On arrival, urgent CT confirmed the diagnosis, showing a large ruptured pseudoaneurysm of the PFA with contrast extravasation (Fig. 2). Due to multiple comorbidities, he was considered too debilitated to tolerate a general anesthetic, and as a result, we opted for a minimally invasive approach. A crossover technique was employed, with the use of a 45-cm-long, 5-Fr sheath (Super Arrow-Flex; Arrow International, Reading, PA, USA). Selective catheterization of the PFA was done with a 5-Fr, 100-cm-long Headhunter1 catheter (Merit Medical Systems, Inc., Salt Lake City, UT, USA) and angiogram revealed a disruption of the PFA about 15–20 cm distal to its origin, a large ruptured pseudoaneurysm, and an associated arteriovenous fistula. It was decided to proceed with coil embolization (Fig. 3A– C). The PFA branch which was feeding the pseudoaneurysm was selectively catheterized (Fig. 3A) and the catheter was advanced, first, into the aneurysm itself and, then, into the outflow vessel (Fig. 3B). Subsequently, coils were delivered into the distal branch, the pseudoaneurysm sac, and, finally, the proximal branch (Fig. 3C), resulting in aneurysm thrombosis. The remaining branches of the PFA and the superficial femoral artery remained patent. A total of 16 coils (BALT; Croix-Vigneron, Mont Morency, France) were delivered. The procedure lasted 1 h 45 min, the total fluoroscopy time was 20 min, and a total of 75 ml of contrast was used. C. D. Karkos (&) D. G. Karamanos K. O. Papazoglou D. N. Papadimitriou I. N. Gerogiannis F. P. Demiropoulos T. S. Gerassimidis 5th Department of Surgery, Medical School, Hippocrateio Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 546 42, Greece e-mail: ckarkos@hotmail.com Fig. 1 Ultrasound of the inguinal and upper thigh region showed a pseudoaneurysm of the PFA measuring 5 cm in transverse diameter

Current therapeutic options in the management of superficial femoral artery occlusive disease.

Abstract The management of superficial femoral artery occlusive disease remains challenging for vascular surgeons. Despite the advances and dramatic changes we have seen in modern practice with the development and introduction of new endovascular techniques, long-term results with these interventions remain disappointing when compared to the “gold standard” of a vein bypass with a good run-off. Furthermore, there is little Level 1 evidence to guide us with regards to the best treatment strategy. In this article, we review some of the currently available open surgical and endovascular options for the management of superficial femoral artery disease.

An Unusual Complication of a “Blind” Femoral Embolectomy

Iatrogenic pseudoaneurysms after femoral embolectomy are unusual and have been described in the peroneal, posterior tibial, and popliteal arteries. We present an unusual case of such a pseudoaneurysm originating from a medial superior genicular collateral vessel that was coming off the proximal popliteal artery at an acute angle. It is likely that the embolectomy catheter had accidentally entered this branch, which ruptured when the balloon was inflated. Transcatheter coil embolization resulted in successful thrombosis of the pseudoaneurysm.