Konstantinos Filis

How Many Patients with Infrarenal Aneurysms are Candidates for Endovascular Repair? The Northern California Experience

PURPOSE To determine how many patients with abdominal aortic aneurysms (AAA) meet the anatomical selection criteria for AneuRx stent-graft repair in community hospitals of Northern California. METHODS The records were reviewed of 220 AAA patients (171 men, 49 women) who were considered for endovascular repair by the treating vascular surgeon at 28 community hospitals in Northern California between January and October 2001. Contrast computed tomographic angiography (CTA) and selective arteriography were performed at each institution and reviewed by a centralized, independent image-reading center. Selection criteria determined by the manufacturer and published in the indications for use were applied to each set of imaging studies. The number of patients who met inclusion criteria were recorded, as were the anatomical characteristics of each aneurysm. RESULTS The mean aneurysm size in the 220 patients was 55.3 +/- 0.7 mm. Among these patients, 122 (55%) were judged to be candidates for endovascular repair and 98 (45%) were considered ineligible. The primary anatomical reason for ineligibility was a short infrarenal neck in 43 (44%) patients, followed by a large proximal neck diameter (25, 25%), iliac aneurysms (10, 10%), extremely tortuous or calcified neck (7, 7%), iliac occlusion (6, 6%), and small distal aortic bifurcation and accessory renal arteries (5, 5%). Four (4%) patients were classified as non-candidates due to poor quality imaging. There was no difference in aneurysm diameter (54.0 +/- 0.8 versus 57.1 +/- 1.2 mm, p=NS) or age (72.2 +/- 1.2 versus 74.6 +/- 2.2 years, p=NS) between candidates and non-candidates. However, proportionally more men (60%) than women (39%) were eligible for endovascular repair with the AneuRx stent-graft (p<0.05). All 122 patients who were considered candidates for endovascular repair were treated, with successful stent-graft placement achieved in 121 (99%). CONCLUSIONS Fifty-five percent of patients considered for endovascular AAA repair in community hospitals in Northern California met the anatomical selection criteria for the AneuRx stent-graft. Men appeared to be twice as likely to meet the eligibility requirements as women. Unfavorable infrarenal neck anatomy was the primary exclusion criterion for endovascular repair in this community setting.

Melatonin attenuates high fat diet-induced fatty liver disease in rats

AIM To investigate melatonins preventive action in oxidative stress in a rat model with high fat diet-induced non-alcoholic fatty liver disease (NAFLD). METHODS NAFLD was induced by high fat diet (HFD) in adult, male, Wistar rats, weighing 180-230 g. After acclimatization for one week, they were randomly assigned to 6 experimental groups that comprised animals on regular diet plus 5 or 10 mg/kg melatonin, for 4 or 8 wk; animals on HFD, with or without 5 or 10 mg/kg melatonin, for 4 or 8 wk; and animals on HFD for 8 or 12 wk, with melatonin 10 mg/kg for the last 4 wk. Liver damage was assessed biochemically by the serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and histologically. Lipid peroxidation and oxidative stress were assessed by malondialdehyde and glutathione levels in liver tissue. Lipidemic indices and portal vein pressure were also measured. RESULTS Compared to rats not receiving melatonin, rats on 5 or 10 mg/kg of melatonin had lower mean liver weight (-5.0 g and -4.9 g) (P < 0.001) and lower liver weight to body weight ratio (-1.0%) (P < 0.001), for the two doses, respectively. All rats fed HFD without melatonin developed severe, grade III, steatosis. Rats on HFD with concurrent use of melatonin showed significantly less steatosis, with grade III steatosis observed in 1 of 29 (3.4%) rats on 10 mg/kg melatonin and in 3 of 27 (11.1%) rats on 5 mg/kg melatonin. Melatonin was ineffective in reversing established steatosis. Melatonin also had no effect on any of the common lipidemic serum markers, the levels of which did not differ significantly among the rats on HFD, irrespective of the use or not of melatonin. Liver cell necrosis was significantly less in rats on HFD receiving melatonin than in those not on melatonin, with the AST levels declining by a mean of 170 U/L (P = 0.01) and 224 U/L (P = 0.001), and the ALT levels declining by a mean of 62.9 U/L (P = 0.01) and 93.4 U/L (P < 0.001), for the 5 and 10 mg/kg melatonin dose, respectively. Melatonin mitigated liver damage due to peroxidation and oxidative stress in liver tissue as indicated by a significant decline in MDA production by 12.7 (P < 0.001) and 12.2 (P < 0.001) μmol/L /mg protein /mg tissue, and a significant increase in glutathione by 20.1 (P = 0.004) and 29.2 (P < 0.001) μmol/L /mg protein /mg tissue, for the 5 and 10 mg/kg melatonin dose, respectively. CONCLUSION Melatonin can attenuate oxidative stress, lessen liver damage, and improve liver histology in rats with high fat diet-induced NAFLD, when given concurrently with the diet.

Modified Radical Mastectomy With Axillary Dissection Using the Electrothermal Bipolar Vessel Sealing System

HYPOTHESIS The use of the electrothermal bipolar vessel sealing system is feasible, safe, and effective in modified radical mastectomy with axillary dissection in terms of lymph vessel sealing, hemostasis, and perioperative complications. DESIGN Prospective study. SETTING University surgical department. PATIENTS Between January 1, 2003, and December 31, 2003, 60 patients with locally advanced breast cancer (T2 or T3) admitted for modified radical mastectomy with axillary dissection were included in this study. The entire procedure was performed by the same surgical team using the electrothermal bipolar vessel sealing system. MAIN OUTCOME MEASURES Final outcome, operative time, hospitalization stay duration, intraoperative blood loss, postoperative mastectomy and axillary drainage volume and duration, and postoperative complications (seroma, bleeding, skin burn, hematoma, lymphedema, pneumothorax, and wound infection or necrosis). RESULTS The mean (SD) intraoperative blood loss was 45 (12) mL, and the mean (SD) operative time was 105 (7) minutes. No postoperative bleeding, seroma, hematoma, lymphedema, or other complications occurred. The mean (SD) mastectomy and axillary drainage volumes were 20 (8) and 155 (35) mL, respectively, and the mean (SD) drainage durations were 1.3 (0.2) and 2.7 (0.5) days, respectively. The mean (SD) hospital stay was 3.7 (0.6) days. CONCLUSIONS In this first report (to our knowledge) of modified radical mastectomy with axillary dissection using the electrothermal bipolar vessel sealing system, the technique was feasible, safe, and effective. The device simplified the surgical procedure, while achieving efficient lymph vessel sealing and hemostasis. Compared with historical data regarding the conventional or harmonic scalpel, this technique seems to result in reduced operative time, perioperative blood loss, drainage volume and duration, and incidence of seroma or lymphedema. Prospective randomized controlled studies are necessary to evaluate the effect of this technique on perioperative complications.

Three-dimensional CT evaluation for endovascular abdominal aortic aneurysm repair. Quantitative assessment of the infrarenal aortic neck.

Abstract Endovascular grafting of abdominal aortic aneurysms should be offered only to those patients with suitable anatomy. This is especially true at the level of the proximal aortic neck in order to secure long-term proximal fixation. Aortoiliac anatomy is easy to understand conceptually, however, it is difficult to define and measure quantitatively. In this article, we discuss the use of three dimensional computed tomographic angiography to determine aneurysm morphology and select patients for endovascular repair. Specifically, we apply our methods to define and measure angulation of the aorta and iliac arteries. The anatomic definition of the angulation of the proximal aortic neck is emphasized.

Treatment of Axillosubclavian Vein Thrombosis: A Novel Technique for Rapid Removal of Clot Using Low-Dose Thrombolysis

PURPOSE To report successful combined percutaneous mechanical thrombectomy and pharmacological lysis for axillosubclavian vein thrombosis, with rapid clot removal at a single setting using low-dose thrombolysis. CASE REPORTS Two consecutive patients presented with arm swelling; the diagnosis of axillosubclavian vein thrombosis was confirmed with duplex ultrasound. Both patients were treated percutaneously with the Solera mechanical thrombectomy device, after which 5 mg of tissue plasminogen activator were delivered within approximately 10 minutes via the Trellis infusion catheter to remove any residual thrombus. Completion venography and serial duplex ultrasound scans in follow-up demonstrated widely patent axillosubclavian veins with no residual thrombus in both cases. CONCLUSIONS Standard treatment of axillosubclavian vein thrombosis may require 12 to 36 hours, with multiple trips to the angiography suite. The novel technique combining mechanical thrombectomy and pharmacological lysis can be performed safely and successfully at a single setting with a small dose of the lytic drug.

Spontaneous Rectus Sheath Hematoma in the Elderly: An Unusual Case and Update on Proper Management

Spontaneous rectus sheath hematoma (SRSH) is an uncommon medical emergency in the elderly. We present a case of SRSH with an atypical clinical presentation and discuss literature regarding diagnosis and proper management. A 75-year-old female patient was transferred to the emergency department due to acute dyspnoea and confusion. Her medical history revealed a viral infection of the upper respiratory tract, and no coughing or use of anticoagulants. The clinical examination showed tenderness of the left lower abdomen, although palpation was misleading due to patients obesity. Laboratory investigations showed light anaemia. Ultrasonography and computed tomography revealed a large rectus sheath hematoma of the left abdominal wall. Despite further deterioration of the patient, conservative management including bed rest, fluid replacement, blood products transfusion, and proper analgesia was successful. No surgical intervention was needed. Prompt diagnosis and management of SRSH plays significant role in the prognosis, especially in elder patients. Independently of size and severity, conservative management remains the first therapeutic choice. Only by failure of supportive management, progressive and large hematoma or uncontrollable hemodynamic patients, interventional management including surgery or less invasive newer techniques is indicated.

Long-term outcomes following 282 consecutive cases of infrapopliteal PTA and association of risk factors with primary patency and limb salvage.

We aimed to determine the long-term results after infrapopliteal PTA (primary patency, limb salvage, survival) and examine for association with risk factors (e.g. diabetes, infection, etc). We studied 268 patients with 282 critically ischemic limbs treated with PTA of at least one crural artery during a six-year period. Data included TASC II morphological classification of lesions and risk factors. Technical success rate was 97.2%, and overall mortality 0.7%. Patients with milder TASC lesions preserved primary patency longer than patients with more severe lesions. Similar results were obtained for limb salvage and survival. Fontaine stage, TASC class and postoperative infection of operated limb increased the risk for loss of primary patency and major amputation. Concomitant carotid stenosis was associated with loss of primary patency. Diabetes mellitus, preoperative ulcer or gangrene were associated with need of major amputation. PTA was a safe and effective treatment for CLI due to lesions of infrapopliteal vessels.

Heparin-Induced Thrombocytopenia and Phlegmasia Cerulea Dolens of the Upper Limb Successfully Treated with Fondaparinux

cause of left upper extremity edema. Doppler ultrasound revealed extensive thrombosis of the axillary, cephalic and basilic veins. The diagnosis of phlegmasia cerulea dolens of the upper limb was made, for which intravenous heparinization was initiated. The following day blood sample analyses revealed a marked decrease of platelet counts (50 ! 10 9 /l) thus giving rise to the clinical suspicion of the HIT syndrome. In view of these data heparin was discontinued and 2 ! 2.5 mg/day fondaparinux (Arixtra inj. sol 2.5 mg/0.5 ml, GlaxoSmithKline, Athens, Greece) was subcutaneously administered. A few days later a strongly positive anti-PF4/ polyanion enzyme immunoassay confirmed our diagnosis. The platelet count recovered after 3 days and phlegmasia cerulea dolens gradually improved. HIT is strongly associated with UEDVT in patients with current or recent CVC use [1] . The insertion of a CVC can serve both as a potential source of heparin exposure, through heparin flushes, and as a local prothrombotic factor. Moreover the prothrombotic effect of the CVC appears to persist even after its removal. Our patient developed UEDVT 6 days after the removal of his CVC. Heparin-induced thrombocytopenia (HIT) is a clinicopathologic syndrome that results in acquired hypercoagulability. Upper extremity deep vein thrombosis (UEDVT) is relatively rare and more frequently occurs in HIT patients with central venous catheters (CVC) [1] . Fondaparinux, a selective inhibitor of factor Xa, has shown in recent studies some rather promising results concerning the thromboembolic treatment or prophylaxis of patients with the HIT syndrome [2, 3] . We report on a 55-year-old male who underwent an elective resection of abdominal aortic aneurysm with graft application. Perioperatively a non-heparin-coated, central catheter was inserted in the left jugular vein and was removed on the 5th postoperative day. He had received a single dose of 2,500 IU of unfractionated heparin during the clamping of the aorta. During the postoperative period the patient received low-molecular-weight heparin 0.3 ml every 12 h by subcutaneous injection (Fraxiparine inj. sol 2,850 anti-Xa IU/0.3 ml, GlaxoSmithKline, Athens, Greece) that was discontinued on the 7th day. The patient recovered uneventfully and was discharged on the 8th day. On the 11th postoperative day he was readmitted beAccepted after revision: October 20, 2008 Published online: January 5, 200

Traumatic Carotid Artery Dissection: A Different Entity without Specific Guidelines.

According to literature data, there are no distinct guidelines regarding the proper diagnostic and therapeutic management of traumatic carotid artery dissection (TCAD). Although most of cases evaluated in research studies refer to spontaneous carotid artery dissection, traumatic cases demand special considerations as far as diagnosis and treatment are concerned. Although both types of dissection share some common characteristics, a patient with TCAD usually presents with several concomitant injuries as well as a higher bleeding risk, thus complicating decision making in such patients. Therefore, aim of this review is to present available data regarding epidemiology, clinical presentation, diagnostics and treatment strategy in cases with TCAD in order to produce useful conclusions for everyday clinical practice.

Osteopontin and Osteoprotegerin as Potential Biomarkers in Abdominal Aortic Aneurysm before and after Treatment

Aim. Although osteopontin (OPN) and osteoprotegerin (OPG) have been associated with abdominal aortic aneurysms (AAAs), no association of these two biomarkers with AAA surgical or endovascular treatment has been reported. Material and Methods. Seventy-four AAA patients were prospectively selected for open or endovascular repair. All aneurysms were classified (Types A–E) according to aneurysmal extent in CT imaging (EUROSTAR criteria). All patients had preoperative serum OPN and OPG values measurements and 1 week after the procedure. Preoperative and postoperative values were compared with a control group of twenty patients (inguinal hernia repair). Results. Preoperative OPN values in patients with any type of aneurysm were higher than in the control group, while OPG values showed no difference. Postoperative OPN values in AAA patients were higher than in the control group. OPN values increased after open surgery and after EVAR. OPG values increased after open surgery but not after EVAR. There was no difference in OPN/OPG values between EVAR and open surgery postoperatively. Conclusions. OPN values are associated with aneurysm presence but not with aneurysm extent. OPG values are not associated either with aneurysm presence or with aneurysm extent. OPN values increase after AAA repair, independently of the type of repair.