Michael J. Costanza

Basic Science Review Section: Statin Therapy—Part II: Clinical Considerations for Cardiovascular Disease

3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, commonly known as statins, are the medical treatment of choice for hypercholesterolemia. In addition to achieving a therapeutic decrease in serum cholesterol levels, statin therapy appears to promote pleiotropic effects that are independent of changes in serum cholesterol. These cholesterol lowering and pleiotropic effects are beneficial not only for the coronary circulation, but for the myocardium and peripheral arterial system as well. Patients receiving statin therapy must be carefully monitored, however, as statins potentially have harmful side effects and drug interactions. This article is part II of a 2-part review, and it focuses on the clinical aspects of statin therapy in cardiovascular disease.

External Compression of the Superior Mesenteric Artery by the Median Arcuate Ligament

The median arcuate ligament can compress the proximal portion of the celiac artery causing symptoms of chronic mesenteric ischemia. This rare condition typically affects young women and often poses a diagnostic challenge. Compression of the superior mesenteric artery (SMA) in addition to the celiac artery represents an unusual variant of median arcuate ligament syndrome (MALS). We present a case of MALS resulting predominantly from external compression of the SMA. Diagnostic and therapeutic options are discussed.

Transabdominal Duplex Ultrasonography for Bedside Inferior Vena Cava Filter Placement: Examples, Technique, and Review

Pulmonary embolism remains an endemic challenge for public health care. The first line of treatment for venous thromboembolic disorder has been anticoagulation; however, in the absence of appropriate pharmacologic treatment, because of failure or contraindication, caval filter placement has been widely performed in the prevention of pulmonary embolism. Initially an open surgical procedure, technological advancements have allowed filter placement to be done percutaneously. Bedside filter placement in the intensive care unit with ultrasonographic imaging has been reported to be safe, effective, and reliable. In this report, we present an example, discuss our technique, and review the literature.

Combined endovascular and surgical repair of a large traumatic pseudoaneurysm of the thigh. A case report

Thigh pseudoaneurysms are rare compared to pseudoaneurysms of the groin, and usually result from direct injury to an arterial branch. Direct open repair can be associated with a large volume blood loss. The authors describe a combined endovascular and surgical approach to a large, traumatic, pseudoaneurysm of the thigh. The patient was a 49-year-old man with a history of left femur fracture treated by open reduction and internal fixation, who presented with a painfully swollen left thigh. Duplex ultrasound and computed tomography (CT) scan suggested a large (7.7 x 5.0 x 6.3 cm) pseudoaneurysm that appeared to be associated with a branch of the deep femoral artery. In the operating room, angiography was used to identify and selectively access the feeding artery. This artery was then successfully coil embolized, allowing surgical decompression of the thigh with minimal effort and blood loss. Endovascular and surgical therapy were complementary in successfully treating a large traumatic pseudoaneurysm of the thigh.

Ultrasound accelerated catheter directed thrombolysis for pulmonary embolus and right heart thrombus secondary to transvenous pacing wires.

Acute pulmonary embolism is associated with a significant number of deaths each year, which are commonly attributed to deep venous thrombosis of the lower extremity. Pulmonary embolism due to right-sided cardiac thrombus associated with transvenous wires is a rare occurrence. Treatment considerations have been systemic anticoagulation with heparin or systemic thrombolytic therapy. A unique case of a patient with symptomatic PE and extensive atrial and ventricle thrombus formation associated with transvenous pacing wires treated with ultrasound accelerated catheter directed thrombolysis is presented.

Local tissue coverage for the management of exposed endografts.

This case report describes the use of local tissue coverage for the treatment of surgically exposed endografts. In two cases, an endograft used for the treatment of a pseuodaneurysm was visualized through the arterial defect during open surgical evacuation of an abscess in one case and a sterile hematoma in the second case. Obtaining arterial control to remove the endograft was prohibitive owing to the anatomic location and extensive scarring and inflammation. The endografts were preserved and hemostasis was maintained by using a vein patch in one case and a local muscle flap in both cases. Both cases have had satisfactory short-term follow-up (4–12 months). An exposed endograft represents a rare and challenging problem. Local tissue coverage offers a feasible strategy for maintaining hemostasis and avoiding a potentially morbid surgical dissection. Although the short-term results of this approach have been encouraging, the long-term consequences remain unknown.

Percutaneous Recanalization of the Occluded Iliac Artery: Examples, Techniques, and Complications:

Recanalization of an occluded iliac artery represents a technically challenging endovascular technique. Prior to attempting recanalization, the operator must have an approach in mind and understand the risks and complications associated with this endeavor. In this article, the authors provide 2 cases and review the techniques and complications associated with iliac artery recanalization.

Bilateral lower extremity acute thromboembolism as first presentation for cancer in a child: An interesting report

Although it rarely occurs in children, acute arterial thromboembolism can cause significant morbidity and mortality. Rapid diagnosis and prompt treatment can increase the chances of survival with a functional limb. We describe the case of a 10-year-old boy with acute bilateral lower extremity ischemia due to arterial thromboemboli originating from a rare cancer. We discuss diagnosis of and treatment strategies for acute arterial thromboembolism in the pediatric population, as well as the rare cancer the patient was diagnosed with.

Treatment of Bleeding Varicose Veins of the Scrotum With Percutaneous Coil Embolization of the Left Spermatic Vein: A Case Report

Percutaneous coil embolization of the spermatic vein offers a minimally invasive method for treating symptomatic varicose veins of the scrotum. We describe the case of a 63-year-old man with multiple comorbidities and persistent bleeding from scrotal varicosities. Venography revealed significant left spermatic vein reflux and a large left varicocele. Percutaneous coil embolization of the left spermatic vein completely resolved the bleeding from the left side of the patient’s scrotum. Although many vascular specialists possess the technical skills to perform this procedure, they may not be familiar with its use in the treatment of scrotal varicosities and varicoceles.

Sustained Elevation in MonocyteLevels in Diabetic Patients after Infra-Inguinal Revascularization

Context: Diabetes and atherosclerosis are both pro-inflammatory states that may lead to elevations in monocyte levels. It was previously demonstrated that there is a reduction in monocyte levels after infra-inguinal bypass in patients with critical limb ischemia (CLI). We hypothesized that patients with diabetes would not realize the same reduction in monocyte levels post-bypass as patients without diabetes. Objective: To determine whether patients with diabetes would have a sustained sub-clinical inflammation after resolution of CLI with infra-inguinal bypass, as marked by a persistent elevation of monocyte levels. Design: Patients undergoing lower extremity vascular bypass surgery between 2003 and 2013 at the Syracuse VA Medical Center were retrospectively reviewed. Pre- and post-operative leukocyte count with differential were recorded for each patient and stratified according to the presence of diabetes. Results: Patients with CLI and no bypass failure (n=43) were included for analysis of the primary outcome, change in monocyte level. Diabetic (DM+) patients (n=27) and non-diabetic (DM-) patients (n=16) had similar pre-operative leukocyte counts and differential (p>0.05). In DM-, there was a 5.6% decrease in monocyte count post-operatively, whereas there was an elevation in monocytes in DM+ (+20.8%; p<0.05). The overall rate of complications was significantly greater and the time to develop complications significantly less in DM+ (p<0.05). Conclusion: Diabetic patients have a persistent elevation in monocyte levels even after infra-inguinal vascular bypass as compared with non-diabetic patients. This suggests diabetic patients have persistent sub-clinical inflammation even upon resolution of critical limb ischemia.