Evridiki Karanikola

Duplex Ultrasound versus Computed Tomography for the Postoperative Follow-Up of Endovascular Abdominal Aortic Aneurysm Repair. Where Do We Stand Now?

In the last decade, endovascular aneurysm repair (EVAR) has rapidly developed to be the preferred method for infrarenal abdominal aortic aneurysm repair in patients with suitable anatomy. EVAR offers the advantage of lower perioperative mortality and morbidity but carries the cost of device-related complications such as endoleak, graft migration, graft thrombosis, and structural graft failure. These complications mandate a lifelong surveillance of EVAR patients and their endografts. The purpose of this study is to review and evaluate the safety of color-duplex ultrasound (CDU) as compared with computed tomography (CT), based on the current literature, for post-EVAR surveillance. The post-EVAR follow-up modalities, CDU versus CT, are evaluated questioning three parameters: (1) accuracy of aneurysm size, (2) detection and classification of endoleaks, and (3) detection of stent-graft deformation. Studies comparing CDU with CT scan for investigation of post-EVAR complications have produced mixed results. Further and long-term research is needed to evaluate the efficacy of CDU versus CT, before CDU can be recommended as the primary imaging modality for EVAR surveillance, in place of CT for stable aneurysms.

Preoperative Cardiac Assessment before Carotid Surgery: Should Perhaps Things Change?

Carotid endarterectomy has been associated with perioperative symptomatic or asymptomatic myocardial ischemia and cardiac mortality although it has been classified as a procedure of intermediate cardiac risk. Recent data indicate that the Cardiac Risk Index score for preoperative assessment by the latest guidelines is not suitable for vascular surgery procedures in general and carotid procedures in particular. This review aims to present and analyze all these results, concluding that current recommendations for this specific procedure should perhaps be reevaluated.

Endovascular Management of Atherosclerotic Renal Artery Stenosis: Post-Cardiovascular Outcomes in Renal Atherosclerotic Lesions Era Winner or False Alarm?

Renal artery stenosis (RAS) is frequently associated with severe comorbidities such as reduced renal perfusion, hypertension, and end-stage renal failure. In approximately 90% of patients, renal artery atherosclerosis is the main cause for RAS, and it is associated with an increased risk for fatal and non-fatal cardiovascular and renal complications. Endovascular management of atherosclerotic RAS (ARAS) has been recently evaluated by several randomized controlled trials that failed to demonstrate benefit of stenting. Furthermore, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions study did not demonstrate any benefit over the revascularization approach. In this review, we summarized the available data from retrospective, prospective and randomized trials on ARAS to provide clinicians with sufficient data in order to produce useful conclusions for everyday clinical practice.

Management of a Common Iliac Artery Aneurysm Causing Contralateral Iliac Venous Thrombosis

A 73-year-old male patient was diagnosed with thrombotic obstruction of the left common iliac vein (LCIV). Computed tomography imaging revealed a known -under follow-up- isolated aneurysm of the right common iliac artery that seemed to directly obstruct the LCIV. Given the patient’s renal insufficiency as well as the size and anatomy of the aneurysm, the patient underwent open repair.

Synovial Cyst of the Antecubital Fossa Mimicking a Brachial Artery Pseudoaneurysm: Report of a Case

Pseudoaneurysms of the brachial artery are common following a percutaneous cardiac catheterization. Synovial cysts are a commonly identified entity in patients with rheumatic diseases as well. We present a rare case of a synovial cyst in the elbow masquerading as an iatrogenic pseudoaneurysm of the brachial artery. A 51-year-old female patient presented with a pulsatile and painful mass in the right antecubital fossa. The medical history revealed a recent diagnostic cardiac catheterization at the same site and rheumatoid arthritis under oral treatment. Imaging investigations were not fully diagnostic. Because of the clinical suspicion of a thrombosed pseudoaneurysm, exploratory surgery was indicated. The pathologic examination of the specimen confirmed the diagnosis of a synovial cyst. Ultrasonography and computed tomography imaging are valuable in the everyday clinical practice but they do not always exclude an iatrogenic pseudoaneurysm, especially when the medical history is suspicious. Surgical removal is the proper treatment and pathologic examination sets the final diagnosis in such cases of diagnostic difficulty.

Regarding "extent of COPD is associated with short and long-term adverse outcomes in patients undergoing elective AAA repair".

The article by Stone et al regarding the impact of chronic obstructive pulmonary disease (COPD) on short-term and longterm outcome after open abdominal aortic aneurysm (AAA) repair provides a landmark differentiation between oxygen-dependent and non-oxygen-dependent COPD patients. Oxygen-dependent COPD patients, operated for AAA, showed increased pulmonary complications and in-hospital and long-term mortality. Nonoxygen-dependent patients revealed to be an intermediate group between oxygen-dependent and non-COPD patients. Although the number of patients included is large and data are extremely valuable, retrospective analysis did not permit the evaluation of the impact of some crucial points concerning the optimization of the clinical results in these patients. First, the use of the appropriate preoperative pulmonary medication (bronchodilator treatment, preconditioning regular breathing exercises) has been shown to be important. Second, the use of epidural analgesia has been proved beneficial in patients with COPD undergoing AAA repair by reducing both the postoperative ventilator duration and intensive care unit stay, and therefore, epidural analgesia should be considered in all COPD patients undergoing elective transperitoneal AAA repair. Our team has recently published, in a prospective study, specific data, including postoperative values of forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), concerning COPD patients after open AAA repair. Although our series did not include any oxygen-dependent patient, the definition of moderate to severe COPD was defined according to international standards (Paco2>45 mm Hg, FEV1 <70% of the predicted value and FEV1/FVC <0.7). Epidural anesthesia with postoperative epidural analgesia was used for 4 days, a decision based on the protocol and increased FEV1 and FVC on the 1st and the 4th postoperative days, compared with intravenous analgesia. All COPD patients treated with epidural analgesia were extubated in the postanesthesia unit and transferred to the intensive care unit, whereas none were reintubated during the hospital stay. The theoretical benefits of epidural analgesia that reduce postoperative abdominal pain and potentially allow deeper inspiration and improve respiratory capacitance have been extensively reported. Our data added, with objective measurable results, a definite answer to the contribution of epidural analgesia in postoperative pulmonary function in COPD patients after open AAA repair. We agree with Stone et al that, even in the post-EVAR era, decisions on oxygen-dependent COPD patients with AAAs warrant extremely prudent risk/benefit assessments. However, for the large non-oxygen-dependent COPD group, data support that preoperative and postoperative dedicated clinical pathways may enhance the outcome.Whether epidural analgesia has a serious effect on oxygen-dependent patients, which remain the extremely high-risk group, has to be prospectively evaluated.

Acute limb ischemia in a patient with cardiac amyloidosis: a case report

IntroductionCardiac amyloidosis is a manifestation of several systemic diseases known as amyloidoses. Arterial thromboembolic complications have not been reported to occur frequently, although the pathophysiology of cardiovascular amyloidosis would theoretically predispose to such manifestations.Case presentationWe present the case of a 52-year-old woman, who suffered from cardiac amyloidosis and was admitted to our hospital for left acute limb ischemia. An urgent embolectomy was performed, improving her clinical condition and the pathologoanatomic examination of the embolus revealed deposition of amyloid.ConclusionPeripheral arterial thromboembolic events in patients with amyloidosis are rare. An antiplatelet treatment is recommended in such patients with cardiac amyloidosis for the prevention of embolism.