Gino Gemayel

Prospective randomized trial comparing endovenous laser ablation and surgery for treatment of primary great saphenous varicose veins with a 2-year follow-up

BACKGROUND Endovenous laser therapy (EVLT) for ablation of the great saphenous vein (GSV) is thought to minimize postoperative morbidity compared with high ligation and stripping (HL/S). Only a few randomized trials have reported early results. This prospective randomized trial compared EVLT (980 nm) and HL/S results at 1 and 2 years after the intervention. METHOD Patients with symptomatic varicose veins due to GSV insufficiency were randomized to HL/S (100 limbs) or EVLT (104 limbs). Four EVLT procedures failed primarily and were excluded. Phlebectomy and ligature of incompetent perforators were performed whenever indicated in both groups. Patients were re-examined clinically and by duplex ultrasound imaging preoperatively and at 12 days and at 1 and 2 years after treatment. Closure rate, complication rate, time to return to normal activity, the Aberdeen Varicose Vein Symptom Severity Score (AVVSS), the Varicose Venous Clinical Severity Score (VVCSS), and the Medical Outcome Study Short Form-36 scores were also recorded. RESULTS There were no differences in patient demographics, CEAP class, Widmer class, or severity scores between the groups. Simultaneous interventions did not differ between the groups. Similar times for the return to normal activity and scores for postoperative pain were reported. No major complications after treatment were recorded. HL/S limbs had significantly more postoperative hematomas than EVLT limbs, and EVLT patients reported more bruising. Follow-up at 1 year was 100% for HL/S and 99% for EVLT. Two GSVs in the EVLT group reopened and three partially reopened. No open GSVs occurred in HL/S limbs. Ninety-eight percent of the limbs in both groups were free of symptoms. VCSS, AVVSS, and Short Form-36 scores did not reveal any group differences. At 2 years, no differences compared with 1-year results were observed, except that two more GSVs in the EVLT group were partially reopened. CONCLUSIONS Abolition of GSV reflux and improvement in quality of life was similar after HL/S and EVLT. After EVLT, however, two GSVs were found completely reopened and five were partially reopened, which was significantly higher than after HL/S. A prolonged follow-up is ongoing.

Human stem cell-based three-dimensional microtissues for advanced cardiac cell therapies

Cardiac stem cell therapy has been proposed as a therapy option to treat the diseased myocardium. However, the low retention rate of transplanted single-cell suspensions remains a major issue of current therapy strategies. Therefore, the concept of scaffold-free cellular self-assembly into three-dimensional microtissues (3D-MTs) prior to transplantation may be beneficial to enhance retention and survival. We compared clinically relevant, human stem cell sources for their ability to generate 3D-MTs with particular regards to formation characteristics, proliferation-activity, viability and extracellular-matrix production. Single-cell suspensions of human bone marrow- and adipose tissue-derived mesenchymal stem cells (hBMMSCs and hATMSCs), Isl1(+) cardiac progenitors derived from human embryonic stem cells (hESC-Isl1(+) cells), and undifferentiated human induced pluripotent cells (hiPSCs) were characterized before to generate 3D-MTs using a hanging-drop culture. Besides the principal feasibility of cell-specific 3D-MT formation, a detailed head-to-head comparison between cell sources was performed using histology, immunocyto- and histo-chemistry as well as flow cytometry. Round-oval shaped and uniform 3D-MTs could be successfully generated from all cell types starting with a loose formation within the first 24 h that fully stabilized after 3 days and resulting in a mean 3D-MT diameter of 194.56 ± 18.01 μm (hBMMSCs), 194.56 ± 16.30 μm (hATMSCs), 159.73 ± 19.20 μm (hESC-Isl1(+) cells) and 120.95 ± 7.97 μm (hiPSCs). While all 3D-MTs showed a homogenous cell distribution, hiPSC-derived 3D-MTs displayed a compact cell formation primarily located at the outer margin. hESC-Isl1(+) and hiPSC-derived 3D-MTs maintained their proliferation-activity which was rather limited in the MSC-based 3D-MTs. All four 3D-MT types revealed a comparable viability in excess of 70% and showed a cell-specific expression profile being comparable to their single-cell counterparts. Extracellular matrix (ECM) production during 3D-MT formation was observed for all cell-specific 3D-MTs, with hiPSC-derived 3D-MTs being the fastest one. Interestingly, ECM distribution was homogenous for hATMSC- and hiPSC-based 3D-MTs, while it appeared to be primarily concentrated within in the center of hESC-Isl1(+) and hBMMSC-based 3D-MTs. The results of this head-to-head comparative study indicated that 3D-MTs can be successfully generated from hESC-derived Isl1(+) cells, hiPSCs and MSC lines upon hanging drop culture. Cell-specific 3D-MTs displayed sufficient viability and instant ECM formation. The concept of 3D-MT in vitro generation prior to cell transplantation may represent a promising delivery format for future strategies to enhance cellular engraftment and survival.

Isolated Bilateral Profunda Femoris Artery Aneurysm

BACKGROUND Isolated bilateral profunda femoris artery aneurysm (PFAA) is a very rare entity. Most of the cases are unilateral and occur with synchronous aneurysms elsewhere. Symptoms range from none to limb ischemia or hemorrhage because of rupture. METHODS We present a rare case of PFAA. In contrast to the general rule, the patient had a bilateral PFAA which was isolated to the deep femoral artery. The aneurysm was discovered after signs of acute limb ischemia caused by distal embolization. The patient was treated surgically with open aneurysmectomy and ligation of a branch of the deep femoral artery. CONCLUSION PFAA are asymptomatic most of the time. Surgical repair is always recommended to prevent such life-threatening complications. Different treatment modalities are offered, including endovascular options. The presence of a PFAA should prompt screening for concomitant aneurysms.

Can bilateral varicose vein surgery be performed safely in an ambulatory setting

OBJECTIVES Surgery for varicose veins is still the method of choice worldwide. When varicose veins require bilateral surgery, a single procedure often is the preferred choice by the patient. Today, unilateral varicose vein surgery is frequently performed as an outpatient procedure, while in many institutions bilateral surgery is done as an in-hospital procedure. DESIGN Retrospective comparative study. METHODS Between 1 October 2004 and 31 October 2006, 433 patients underwent surgery for the great saphenous vein as in-patient procedure (303 unilateral and 130 bilateral), period 1. From 1 November 2006 until 31 December 2009, 825 patients had ambulatory great saphenous vein surgery (550 unilateral and 275 bilateral), period 2. We have compared unilateral and bilateral varicose vein surgery (high ligation and stripping of the great saphenous vein) and in-hospital procedures with ambulatory surgery, with regard to postoperative complications, postoperative pain and midterm follow-up. RESULTS Operation time and total length of stay in the institution following varicose vein surgery were significantly shorter for period 2 compared with period 1 for both unilateral and bilateral surgery, without other differences between the groups. There were few postoperative complications without differences between periods, and between unilateral and bilateral surgery (wound infection 0.5%, haematoma requiring drainage 0.2%, transient paraesthesia 1.1%, superficial localised thrombophlebitis 0.6% and deep vein thrombosis in one unilaterally operated case only). CONCLUSIONS Bilateral varicose vein surgery can be safely performed as an outpatient procedure, without increased risk of postoperative complications, increased postoperative discomfort or midterm adverse effects compared with unilateral surgery.

Ascending aorto-superior mesenteric artery bypass as a surgical option for revascularization in mesenteric ischemia associated with type B aortic dissection

We report the case of an acute ischemia of the superior mesenteric artery (SMA) after endovascular fenestration of a complicated acute type B aortic dissection. An initial attempt for endovascular revascularization of the SMA failed, and an ascending aorto-superior mesenteric artery bypass was urgently performed to salvage the small bowel. Surgery of patients in these specific settings is more complex because an adequate, more distal inflow vessel is often not present due to the dissected aorta and iliac arteries. This surgical option could be lifesaving and should be part of the vascular surgeons armamentarium.

Popliteal artery entrapment syndrome: report of two cases

Popliteal artery entrapment syndrome accounts for an important part of correctible causes of claudication and limb ischemia in young people. It is caused by an abnormal relation between the popliteal artery (PA) and the medial head of the gastrocnemius muscle. The diagnosis should be considered in any patient under 50 with calf claudication. The mainstay of treatment is prevention of PA fibrosis because if left untreated, the syndrome leads to irreversible damage to the PA with thrombosis and limb ischemia. We describe two cases of different types in 21- and 27-year-old males, respectively, and we review the literature about the presentation, diagnosis, classification and management of this entity.

Surgical treatment of complications associated with the Angio-Seal vascular closure device.

Vascular closure devices are used to provide quick hemostasis and early ambulation after percutaneous interventions. The Angio-Seal (AS) vascular closure device forms a mechanical seal by closing the puncture site located between a bioabsorbable anchor within the lumen and a collagen sponge on the adventitia. Although morbidities associated with AS are reportedly infrequent, even the slightest inaccuracy in device implantation may result in displacement of these device components, leading to sudden and severe complications. We report the surgical treatment of complications associated with the use of AS in four patients, including acute limb ischemia, pseudoaneurysm formation, significant hemorrhage, and hypovolemic shock. A common factor in all these cases was that the components of the AS device were displaced from their original site of implantation, stressing the importance of proper device placement. All patients underwent successful surgical vascular repair. Our report highlights the need for exercising extreme care during device implantation, and also the requirement for vigilant inspection for any associated vascular complications commencing immediately after device implantation. It is vital that these device components are actively looked for and removed during surgical exploration so as to prevent future complications.

Somatostatin treatment of a persistent chyloperitoneum following abdominal aortic surgery

Chyloperitoneum is an uncommon but serious complication of abdominal aortic surgery. There are no optimal guidelines for the management of chyloperitoneum. We present here our experiences regarding the treatment of chyloperitoneum with somatostatin for three patients who underwent surgery for abdominal aortic disease. Milky, odorless liquid was observed in the abdominal drain of these patients. The conservative treatment with total parenteral nutrition failed; therefore, in parallel, we initiated a somatostatin treatment as a continuous perfusion. Drain loss decreased in all up to the second day of treatment. The probable mechanisms of the somatostatin decrease the intestinal absorption of fats via the specific receptors, decrease triglyceride concentration in the thoracic duct, and attenuate lymph flow in the major lymphatic channels. The presented cases showed successful treatment using somatostatin and may be a new generation of effective treatments for chyloperitoneum.

Off-label use of a reversed flared endurant iliac limb stengraft for the management of a life-threatening internal iliac artery aneurysm rupture

We report a case of a life-threatening internal iliac artery aneurysm rupture managed successfully with an on-table reversed flared iliac limb stentgraft and embolization. This easily off-the-shelf reproducible technique avoids using a more complex and expensive bifurcated aorto-iliac graft and could be a good solution in emergency situation where a custom graft is not available.

Embolization of a Large Rapidly Growing Aortic Pseudo-Aneurysm Not Amenable to Open or Endovascular Repair

BACKGROUND To report the case of a rapidly growing aortic false aneurysm because of Q fever infection that was managed by embolization. CASE REPORT An 80-year-old man was admitted to our unit for an aortic false aneurysm from a chronic Q fever infection. During his stay, the aneurysm showed rapid progression necessitating urgent treatment. The patient was unfit for surgical repair; moreover, the location of the aneurysm at the level of the superior mesenteric artery prohibited the use of an endovascular graft. He was managed by coiling of the aneurysmal cavity with multiple detachable coils after positioning of a bare aortic stent to lock the coils and prevent their migration into the aortic lumen. The false aneurysm was successfully thrombosed with no complications. The patient was then put on doxycycline and hydroxychloroquine to target Coxiella burnetii. CONCLUSIONS Aortic false aneurysm coiling is feasible in cases where an endograft is not possible or an open repair is contraindicated. The use of a bare metal stent may help as a barrier to prevent the coils from migrating into the aneurysm and thus avoiding embolization into the systemic circulation.