John C. Papakostas

Comparative Effects of Atorvastatin, Simvastatin, and Fenofibrate on Serum Homocysteine Levels in Patients with Primary Hyperlipidemia

Hyperhomocysteinemia is regarded as an independent risk factor for cardiovascular disease. Lipid‐lowering agents, such as fibrates, can modify homocysteine levels. However, less is known about the effect of statin therapy on homocysteine. The authors compared the effects of atorvastatin (40 mg/day), simvastatin (40 mg/day), and micronized fenofibrate (200 mg/day) on the serum concentrations of total homocysteine, vitamin B12, and folic acid in patients with primary hyperlipidemia. A total of 128 patients with primary hyperlipidemia (total cholesterol > 240 mg/dL and triglycerides < 350 mg/dL) were assigned to atorvastatin, simvastatin, or fenofibrate. Serum lipid and metabolic parameters were measured at baseline and at 6 and 12 weeks of treatment. Homocysteine correlated positively with serum creatinine and uric acid levels and inversely with serum folic acid levels. All treatment modalities reduced total, low‐density lipoprotein (LDL) cholesterol, and triglyceride concentrations. High‐density lipoprotein (HDL) cholesterol levels significantly increased only in the fenofibrate‐treated patients (47.9 ± 12.5 vs. 50.7 ± 12.6 vs. 51.2 ± 12.8 mg/dL, p 0.01). Atorvastatin and fenofibrate treatment resulted in a significant reduction of serum uric acid levels (5.3 ± 1.6 vs. 4.9 ± 1.4 vs. 4.8 ± 1.4 mg/dL, p < 0.0001 for atorvastatin; 5.6 ± 1.6 vs. 4.3 ± 1.4 vs. 4.4 ± 1.4 mg/dL, p < 0.0001 for fenofibrate). Homocysteine levels were significantly increased only by fenofibrate (10.3 ± 3.3 vs. 14.1 ± 3.8 vs. 14.2 ± 3.6 μU/L, p < 0.001) but did not change from baseline following statin treatment. Neither statins nor fenofibrate had any effect on serum vitamin B12 and folic acid levels. In contrast to fenofibrate, therapeutic dosages of atorvastatin and simvastatin have a neutral effect on serum homocysteine levels, which is in favor of their “cardioprotective” properties.

Statins and homocysteine

To the Editor: Hyperhomocysteinemia confers an independent risk factor for atherosclerosis besides the well-established risk factors, such as hypercholesterolaemia, hypertension, diabetes mellitus, smoking habit and family history [1 /3]. However, the effect of statins (especially the most potent drugs of this class) on homocysteine (Hcy) plasma levels is not yet well established. Five recently published studies examined the effect of statins (simvastatin and atorvastatin) on Hcy plasma levels [4 /8] (Table 1). Dieter Luftjohann et al. reported a significant decrease in Hcy plasma levels after high doses of simvastatin (80 mg daily) for 24 weeks, suggesting a possible contribution to the reduction in cardiovascular events seen with high doses of simvastatin. On the contrary, the other studies (Table 1) failed to detect any changes in Hcy after statin therapy. Since the number of patients participating in the above studies was limited, we examined the effect of atorvastatin (40 mg daily) on Hcy plasma levels in 61 patients with hyperlipidaemia attending our lipid clinic. As shown in Table 2, the administration of atorvastatin (40 mg daily) for 10 weeks did not affect the Hcy plasma levels (10.49/3.6 mmol/l before vs. 10.19/3.4 mmol/l after atorvastatin administration). We suggest that the antiatherogenic properties of statins, other than their cholesterol lowering effect, are not through any change in Hcy plasma levels. References

Endovascular Stent-Graft Repair as a Late Secondary Procedure After Previous Aortic Grafts

Thoracic and abdominal aortic endovascular procedures as alternatives to aortic reoperations were studied in three different cases. An anastomotic aneurysm after previous thoracic aortic graft for coarctation, a second-stage elephant trunk repair (descending thoracic aortic aneurysm), and a secondary aneurysm proximal to a previous abdominal aortic graft were successfully treated with endovascular stent-grafts. During the follow-up period no lethal events or major aortic or graft-related complications were observed, except a type II endoleak in the anastomotic aortic aneurysm case. An endovascular stent-graft can be safely deployed into a previously implanted vascular graft, avoiding repeat surgery.

Abdominal aortic endograft proximal collapse: Successful repair by endovascular means.

Infolding of an aortic endograft, usually characterized as endograft collapse, is a quite rare complication reported to occur mainly in thoracic aortic grafts. This report presents a case of an early proximal collapse of an endoprosthesis in an abdominal aortic aneurysm. The complication was diagnosed during the first month of follow-up and was not associated with any endoleak. It was treated with the deployment of a proximal endograft cuff with suprarenal fixation. Endograft collapse may complicate endovascular repair of the abdominal aorta in rare situations. Upon diagnosis of the problem, endovascular repair of graft collapse seems to be feasible.

Stenting of the descending thoracic aorta: a six-year single-center experience

OBJECTIVES The aim of this study was to review the six-year results of the endovascular repair of descending thoracic aortic pathologies, reporting the early perioperative outcomes as well as the mid-term follow-up of the treated patients. METHODS Fifty-five consecutive patients who underwent endovascular repair for thoracic aortic pathology (32 aneurysms, 17 acute thoracic aortic syndromes, and six traumatic aortic ruptures) during a six-year period were retrospectively reviewed. From these patients, 30 (54.5%) were treated electively and 25 (45.5%) on an emergency basis. In eight cases (14.5%) there was a need for left subclavian artery orifice overstenting. In seven patients (12.7%) an abdominal aortic lesion was simultaneously treated, while three more patients (5.5%) had previously had their abdominal aortic aneurysm repaired. RESULTS The primary technical success was 92.7%. Seven patients (12.7%) underwent some operation related complication, while postoperative complications occurred in five patients (9.1%), namely four myocardial infarctions, one acute respiratory distress syndrome and two delayed parapareses resulting in an overall incidence of neurological complications of 3.6%. The combined 30-day and in-hospital mortality was 9.1%, exclusively related to patients treated emergently (P = 0.01). In a mean follow-up period of 34 months there were six deaths, and the overall cumulative survival at four years was estimated at 72.6%. Only one type II endoleak was observed one month after the procedure and it spontaneously disappeared 18 months later. CONCLUSIONS The endovascular repair of descending thoracic aortic pathologies seems to be a well-established method, with favorable morbidity and mortality rates, at least for 30 days and in the mid-term. Taking into account the potential of a wide application of the endovascular technique in many vascular centers, stenting of the thoracic aorta might offer an overall better solution for patients suffering from these devastating pathologies.

PANCREATIC INJURY AFTER THORACOABDOMINAL AORTIC OCCLUSION IN A PORCINE MODEL

Background:  The aim of this study was to investigate pancreatic injury after 45 min of thoracoabdominal aortic occlusion in a porcine model.

Endovascular Treatment of Chronic Total Occlusions of the Iliac Arteries: Early and Midterm Results

BACKGROUND To examine the effects of endovascular therapy on the treatment of chronic total occlusions (CTOs) of the iliac arteries. METHODS We analyzed a cohort of 48 patients (56 limbs) who were treated by endovascular means for iliac artery CTOs during a period of 4 years in 2 vascular surgery centers in Greece. The data were collected retrospectively and were statistically analyzed to report on technical success, morbidity, mortality, primary and secondary patency, and limb salvage through different patient and/or lesion stratifications. RESULTS Recanalization was accomplished without assisting devices, and primary stenting was always performed. The technical success of the endovascular treatment reached 91%. Patients experienced 4.2% major morbidity and 2.1% mortality rate. Mean ankle-brachial pressure index increased from 0.43 ± 0.12 preoperatively to 0.89 ± 0.11 postoperatively. A median improvement by 3 Rutherford clinical categories was recorded at the first-month follow-up. The estimated limb salvage rate for patients suffering from critical limb ischemia (CLI) was 90.9% at 36 months. Kaplan-Meier analysis estimation for overall primary and secondary patency rate of the treated lesions was 91.4% and 95.3%, respectively at 36 months. There were no statistically significant differences in primary and secondary patency rate between patients in different clinical stages (CLI versus intermittent claudication), as well as between CTO lesions of different Trans-Atlantic Inter-Society Consensus (TASC) categories (TASC B versus TASC C versus TASC D). There was not statistical significant difference between the technical success of TASC B, C, and D lesion groups. CONCLUSIONS The endovascular treatment of iliac CTOs seems to be safe and feasible. The technical success of the procedure could be high, whereas primary and secondary patency rates seem to be optimal, with remarkable limb salvage rate and overall clinical improvement. A potential shift to an endovascular-first approach for such lesions might be currently justified.

Contained rupture of a celiac artery aneurysm treated with aortic endograft deployment and assisting percutaneous coil and thrombin infusion

In this report we present a case of a ruptured celiac artery aneurysm (CAA) with a thrombosed distal neck, which was treated as an emergently with a deployment of a tube thoracic endograft to the descending thoracic and upper abdominal aorta. The initial treatment was assisted with a second stage percutaneous, transhepatic, ultrasound guided needle infusion of coil and thrombin to the aneurysmal sac due to type Ib endoleak, with immediate thrombosis of the aneurysm. This technique, although not standard, could also be considered as a useful choice for the treatment of CAAs with wide proximal and patent distal neck.

Modified staged surgical approach to coexisting severe coronary artery disease and large abdominal aortic aneurysm.

Abstract  Surgical management of coexisting severe coronary artery disease and large or symptomatic abdominal aortic aneurysm may be required in patients who are unsuitable candidates for minimally invasive interventions. Although several options have been proposed, the optimal timing to deal with both entities, in order to achieve the best outcome, is still debatable. This report presents a modified approach based on a two‐stage treatment in a single anesthetic session.

Endovascular repair for thoracic aortic disease : Tertiary single-center experience in northwestern greece

The purpose of this article is to report the initial experience with endovascular repair of thoracic aortic disease in a single tertiary vascular unit in northwestern Greece. Between 2003 and 2005, 16 patients were treated with endovascular techniques for various pathologies of the descending thoracic aorta. Twelve patients were treated electively and four emergently. Operative and follow-up data for a mean time of 18.4 months were retrospectively collected and analyzed. Primary technical success was obtained in 14 (87.5%) cases. No early or late deaths occurred, and there was no major operation-related complication. No paraplegia was observed in our patients. Stent graft–related complications occurred in 18.75% (one type 2 and two type 3 endoleaks), but they all had a favorable outcome. No further problems have been reported in any of our patients. Endovascular stent graft repair for diseases of the thoracic aorta seems to be a promising alternative to open surgery, especially for high-risk patients. Long-term results are needed to confirm the early benefit of this treatment option with regard to morbidity and mortality rates. The potential of this technique to be applicable even in relatively small, tertiary vascular centers might be of great benefit to patients.