Ferdinand Serracino-Inglott

A meta-analysis of endovascular versus surgical reconstruction of femoropopliteal arterial disease.

BACKGROUND Controversy exists as to the relative merits of surgical and endovascular treatment of femoropoliteal arterial disease. METHODS A systematic review of the literature was undertaken to identify studies comparing open surgical and percutaneous transluminal methods for the treatment of femoropopliteal arterial disease. Outcome data were pooled and combined overall effect sizes were calculated using fixed or random effects models. RESULTS Four randomized controlled trials and six observational studies reporting on a total of 2817 patients (1387 open, 1430 endovascular) were included. Endovascular treatment was accompanied by lower 30-day morbidity (odds ratio [OR], 2.93; 95% confidence interval [CI], 1.34-6.41) and higher technical failure (OR, 0.10; 95% CI, 0.05-0.22) than bypass surgery, whereas no differences in 30-day mortality between the two groups were identified (OR, 0.92; 95% CI, 0.55-1.51). Higher primary patency in the surgical treatment arm was found at 1 (OR, 2.42; 95% CI, 1.37-4.28), 2 (OR, 2.03; 95% CI, 1.20-3.45), and 3 (OR, 1.48; 95% CI, 1.12-1.97) years of intervention. Progression to amputation was found to occur more commonly in the endovascular group at the end of the second (OR, 0.60; 95% CI, 0.42-0.86) and third (OR, 0.55; 95% CI, 0.39-0.77) year of intervention. Higher amputation-free and overall survival rates were found in the bypass group at 4 years (OR, 1.31; 95% CI, 1.07-1.61 and OR, 1.29; 95% CI, 1.04-1.61, respectively). CONCLUSIONS High-level evidence demonstrating the superiority of one method over the other is lacking. An endovascular-first approach may be advisable in patients with significant comorbidity, whereas for fit patients with a longer-term perspective a bypass procedure may be offered as a first-line interventional treatment.

Endothelial microparticles as conveyors of information in atherosclerotic disease

Endothelial microparticles (EMPs) are complex submicron membrane-shed vesicles released into the circulation following endothelium cell activation or apoptosis. They are classified as either physiological or pathological, with anticoagulant or pro-inflammatory effects respectively. Endothelial dysfunction caused by inflammation is a key initiating event in atherosclerotic plaque formation. Athero-emboli, resulting from ruptured carotid plaques are a major cause of stroke. Current clinical techniques for arterial assessment, angiography and carotid ultrasound, give accurate information about stenosis but limited evidence on plaque composition, inflammation or vulnerability; as a result, patients with asymptomatic, or fragile carotid lesions, may not be identified and treated effectively. There is a need to discover novel biomarkers and develop more efficient diagnostic approaches in order to stratify patients at most risk of stroke, who would benefit from interventional surgery. Increasing evidence suggests that EMPs play an important role in the pathogenesis of cardiovascular disease, acting as a marker of damage, either exacerbating disease progression or triggering a repair response. In this regard, it has been suggested that EMPs have the potential to act as biomarkers of disease status. In this review, we will present the evidence to support this hypothesis and propose a novel concept for the development of a diagnostic device that could be implemented in the clinic.

Contralateral occlusion of the internal carotid artery increases the risk of patients undergoing carotid endarterectomy

BACKGROUND Controversy exists about whether occlusion of the contralateral internal carotid artery in patients undergoing carotid endarterectomy (CEA) is associated with a worse perioperative prognosis and outcome. METHODS A systematic review of electronic information sources was undertaken to identify studies comparing perioperative and early outcomes of CEA in patients with occluded and patent contralateral carotid arteries. The methodologic quality of selected studies was independently appraised by two reviewers. Fixed- and random-effects models were applied to synthesize outcome data. RESULTS Our literature search located 46 articles eligible for inclusion in the review and analysis. The total population comprised 27,265 patients having undergone 28,846 CEAs (occluded contralateral artery group, 3120; patent contralateral artery group, 25,726). Patients with an occluded contralateral carotid artery had increased incidence of stroke (odds ratio [OR], 1.65, 95% confidence interval [CI], 1.30-2.09), transient ischemic attack (OR, 1.57, 95% CI, 1.11-2.21), stroke/transient ischemic attack (OR, 1.52; 95% CI, 1.21-1.90), and death (OR, 1.76; 95% CI, 1.19-2.59) ≤30 days of treatment compared with those with a patent contralateral vessel. No difference in the incidence of myocardial infarction between the two groups was identified (OR, 1.45; 95% CI, 0.73-2.89). CONCLUSIONS Patients undergoing CEA in the presence of an occluded contralateral carotid artery had increased perioperative and early postoperative risk. Our analysis is limited by heterogeneity in symptom status and practices of intraoperative cerebral protection among the studies. Careful consideration should be given in this subgroup of patients with regard to selection and perioperative and postoperative care to minimize the risk.

The chimney technique in endovascular aortic aneurysm repair: late ruptures after successful single renal chimney stent grafts.

BACKGROUND The chimney graft technique has been proposed as an alternative endovascular treatment of juxtarenal aortic aneurysms, extending the landing zone and enabling successful exclusion of the aneurysm with standard endograft devices. METHODS A prospective observational study assigning patients with juxtarenal aortic aneurysm treated with single renal chimney grafts in a tertiary vascular center in the United Kingdom was conducted. Primary outcome endpoints were defined as technical success, perioperative morbidity and mortality, and freedom from any type of endoleak, reintervention, and aneurysm-related death. RESULTS Nine patients were enrolled. Successful aortic and chimney graft implantation was achieved in all patients. A proximal type I endoleak noticed on completion angiogram was treated with an aortic extension cuff. None of the patients died within 30 days of treatment. Two patients developed a type IA endoleak during follow-up, resulting in aneurysm rupture and death. Both patients had had uneventful chimney procedures, and no endoleak was evident on previous surveillance computed tomographic scans. All chimney grafts remained patent, and none of the patients developed renal impairment during the follow-up period. CONCLUSIONS Proximal type I endoleak constitutes a weak point of chimney graft interventions. Increased vigilance in surveillance of such patients to prevent late aneurysm-related complications is required. Additional research to identify potential poor prognostic morphologic indicators is expected.

A Comparative Study of Carotid Atherosclerotic Plaque Microvessel Density and Angiogenic Growth Factor Expression in Symptomatic Versus Asymptomatic Patients

OBJECTIVE A challenge facing clinicians is identifying patients with asymptomatic carotid disease at risk of plaque instability. We hypothesise that locally released angiogenic growth factors contribute to plaque instability. METHODS Carotid endarterectomy specimens from eight symptomatic and eight asymptomatic patients were interrogated for microvessel density and angiogenic growth factor expression histologically using immunofluorescence, and biochemically using quantitative real-time polymerase chain reaction (q-RT-PCR). Bio-Plex suspension array was used to assess circulating biomarkers in venous blood from the same patients and six healthy age-matched controls. RESULTS Immunofluorescence demonstrated significantly greater neovessel density in symptomatic plaques (P=0.010) with elevated expression of hepatocyte growth factor (HGF) (P=0.001) and its receptor MET (P=0.011) than in asymptomatic plaques. The q-RT-PCR demonstrated up-regulation of Endoglin (CD105), HGF (P=0.001) and MET (P=0.011) in the plaques of symptomatic versus asymptomatic patients. Bio-Plex suspension array demonstrated elevated HGF (P=0.002) serum levels in symptomatic versus asymptomatic patients and healthy controls, and decreased platelet-derived growth factor (PDGF) (P=0.036) serum levels in symptomatic versus asymptomatic patients. CONCLUSION Plaque instability may be mediated by HGF-induced formation of new microvessels, and decreased vessel stability resulting from decreased PDGF. Suspension array technology has the potential to identify circulating biomarkers that correlate with plaque rupture risk.

Inflammatory Abdominal Aortic Aneurysms (IAAA): Past and Present

Aim: The aim of the study is to determine whether presentation and outcomes of inflammatory abdominal aortic aneurysms (IAAA) have changed over the last five decades. Methods: Comparison of current outcomes (January 2001 to December 2007) with results of the earliest report from our unit in 1972. Results: In contemporary series, 421 patients underwent AAA repair; 38 (9%) were IAAA. In 58% patients, IAAA was an incidental finding, whereas 42% patients were symptomatic with abdominal or back pain. Of those, 32% were ruptured IAAA. Male-to-female ratio was 12:1. Thirty-day mortality was 13%; elective 11.5%; emergency 17%. Comparison with 1972 study showed no change in the incidence and gender predilection. Presentation as an incidental finding and rupture increased 4- and 2-folds, respectively. Conclusion: The incidence and gender predilection of IAAA have remained unchanged. The 4-fold increase in the presentation as an incidental finding reflects current trends in patient evaluation.

Chimney technique in the endovascular management of complex aortic disease

The objective of this study was to systematically review the literature reporting on the chimney technique and perform an analysis of the outcomes. A search of electronic databases was undertaken to identify all studies reporting on the outcome of the chimney technique. The selected articles were divided into those reporting on the treatment of aortic pathology involving the visceral and those involving the supra-aortic branches. Twenty-one articles reporting on the treatment of juxta/supra-renal aorta and aortic arch disease in 102 and 37 patients, respectively, were identified. In the visceral group, an overall technical success rate of 91% was achieved, the perioperative major morbidity and mortality rates were 17 and 5%, respectively, and an early type I endoleak developed in 13 patients (13%). During follow-up, one patient died of intestinal ischemia. In the supra-aortic group, the technical success rate was recorded in 95%, and three patients (8%) developed an early type I endoleak. Three patients (13%) required conversion to open surgery during follow-up. In conclusion, this technique may be viewed as a complementary technique in high-surgical-risk patients.

All patients benefit equally from a supervised exercise program for claudication

This study assessed the effect of gender, diabetic status, statin use, smoking, hypertension, cardiac status, and use of cilostazol on the outcome of a supervised exercise program for patients with claudication. Patient risk factors were prospectively recorded in a group of patients who had completed 1 year on a supervised exercise program. In 165 claudicant patients, maximum walking distance increased (P < .0001) from 67 meters (range, 17-196) to 122 meters (range, 43-409). Quality of life as measured by the Medical Outcome Study Short Form 36 increased (P < .0001) from a median of 78 (range, 55-110) to 99 (range, 71-154). The improvements in claudication distance, maximal walking distance, and quality of life after the exercise program were not dependent on any of the measured patient factors. Patients referred to exercise programs for claudication are a heterogenous group. Despite this, they benefit equally from such a program.

Outcomes of Endovascular Aneurysm Repair With 2 Different Endograft Systems With Suprarenal Fixation in Patients With Hostile Infrarenal Aortic Anatomy

Objective: To evaluate 2 different aortic endograft systems with suprarenal fixation in patients with unfavorable neck morphology. Methods: A prospective observational study assigning patients with abdominal aortic aneurysm with unfriendly neck anatomy treated with 2 different endograft systems (Endurant and Zenith) was conducted. The log-rank test was applied to investigate the differences in cumulative outcome parameters. Results: Successful endograft implantation was achieved in all patients. Requirement for troubleshooting techniques was similar in the 2 groups (P = .156 and P = .081, respectively). In-hospital procedure-related morbidity occurred in 7 patients (Zenith vs Endurant, P = .690). Freedom from any type of endoleak and overall mortality did not differ significantly between the groups (log-rank test, P = .068 and P = .087). Reinterventions were more commonly required in the Zenith group (log-rank rest, P = .041), and were all nongraft/aneurysm-related. Conclusions: Similar performances of the Zenith and the Endurant endograft systems were demonstrated.

Plasma matrix metalloproteinase 9 levels may predict endoleaks after endovascular aortic aneurysm repair.

A simple, noninvasive and cost-effective diagnostic test for the detection of endoleaks after endovascular aneurysm repair (EVAR) would complement (or even replace) current surveillance modalities. We reviewed the literature for studies correlating circulating levels of matrix metalloproteinases (MMPs)/tissue inhibitors of MMPs with the presence of endoleaks after EVAR. An electronic search of databases was performed to identify studies reporting circulating concentrations of MMPs in patients with and without an endoleak after EVAR. Four studies were identified. Patients with an endoleak had higher plasma MMP-9 levels compared with those without an endoleak. Two studies that also evaluated plasma MMP-3 levels after EVAR suggest that these levels may also be higher in patients with an endoleak. Preliminary evidence suggests that MMP-9 levels are increased in patients developing an endoleak after EVAR. Larger studies are required to confirm or refute our findings.