Moshe Halak

Leptin Locally Synthesized in Carotid Atherosclerotic Plaques Could Be Associated With Lesion Instability and Cerebral Emboli

Background Unstable carotid plaques cause cerebral emboli. Leptin promotes atherosclerosis and vessel wall remodeling. We hypothesized that carotid atherosclerotic lesion instability is associated with local leptin synthesis. Methods and Results Carotid endarterectomy plaques from symptomatic (n=40) and asymptomatic patients with progressive stenosis (n=38) were analyzed for local expression of leptin, tumor necrosis factor (TNF)-α, and plasminogen activator inhibitor type 1. All lesions exhibited advanced atherosclerosis inclusive of thick- and thin-cap fibroatheromas or lesion rupture. Symptomatic lesions exhibited more plaque ruptures and macrophage infiltration (P=0.001 and P=0.05, respectively). Symptomatic plaques showed preferential leptin, TNF-α, and plasminogen activator inhibitor type 1 transcript (P=0.03, P=0.04, and P=0.05, respectively). Leptin mRNA and antigen in macrophages and smooth muscle cells were confirmed by in situ hybridization and immunohistochemistry. Plasma leptin levels were not significantly different between groups (P=1.0), whereas TNF-α was significantly increased in symptomatic patients (P=0.006). Human aortic smooth muscle cell culture stimulated by TNF-α, lipopolysaccharide, or lipoteichoic acid revealed 6-, 6.7-, and 6-fold increased secreted leptin antigen, respectively, at 72 hours (P<0.05). Conclusions Neurologically symptomatic patients overexpress leptin mRNA and synthesize leptin protein in carotid plaque macrophages and smooth muscle cells. Local leptin induction, presumably by TNF-α, could exert paracrine or autocrine effects, thereby contributing to the pathogenesis of lesion instability. Clinical Trial Registration URL: www.Clinicaltrials.gov. Unique identifier: NCT00449306.

Endovascular Management of Mycotic Aortic Aneurysms

Purpose: We report a single-center experience with the endovascular management of mycotic aortic aneurysms. Case reports: Four cases of mycotic aortic aneurysms are described; all treated with endovascular stent graft with variable configurations. All patients underwent successful placement of stent grafts for their aneurysms. No 30-day perioperative mortality was observed. One patient died during the follow-up period from a cause unrelated to the aneurysm. Conclusion: Repair of mycotic aneurysms can be accomplished with endovascular repair. This may be a valid alternative to open repair particularly in patients who are not candidates for conventional open repair.

Clostridium septicum post-endovascular aneurysm repair stent-graft infection.

Endovascular aortic aneurysm repair (EVAR) is establishing its role as a valid alternative for the treatment of abdominal aortic aneurysm. Post-EVAR graft infection is a rare and devastating complication. The incidence of post-EVAR graft infection is yet to be defined, and available data at this stage consist of case reports and small series. Possible etiologies for aortic stent-graft infection include perioperative contamination and hematogenous seeding. To the best of our knowledge, this is the first report of post-EVAR stent graft infection with Clostridium septicum. The possible mechanisms of this unusual hematogenous seeding have been discussed.

Acute limb ischemia in cancer patients: Aggressive treatment is justified

Background The outcome of cancer patients with acute limb ischemia (ALI) is not well defined. The purpose of this study is to report our experience treating patients with active malignancy who developed ALI and compare their outcome with non-cancer patients. Methods A retrospective review of patients treated for ALI between 2009 and 2012 with ALI. We identified those patients who suffered from ALI and compared the outcome of those with active malignancy to those without malignancy. Results Of 147 patients treated for ALI (122 lower extremity, 25 upper extremity), 24 (16%) were cancer patients. Mean follow-up was 9.8 months for the malignancy group and 13.4 months for the control. Perioperative mortality rates were similar among cancer and non-cancer patients (20% vs. 16%, respectively, NS). Freedom from major amputation at 30 months was similar (95% vs. 89%, NS). Long-term survival rates of cancer patients were significantly lower compared to non-cancer patients (45% vs. 77% respectively, P < 0.05). Conclusions Treatment of ALI among cancer patients can be achieved with perioperative mortality and limb salvage rates comparable to non-cancer patients. Aggressive treatment is justified when treating cancer patients with ALI.

The deep femoral artery, a readily available inflow vessel for lower limb revascularization: a single-center experience

The deep femoral artery (DFA) offers several advantages as an inflow vessel in lower-extremity bypasses. We report a single-center experience using the DFA as an inflow artery for lower-extremity revascularization. We reviewed all patients who underwent a lower-extremity bypass utilizing the DFA as the inflow vessel. Demographics, indications for surgery, indication for use of the DFA, type of conduits and target vessels were recorded. Follow-up data included resolution of symptoms, bypass graft patency, major amputations and survival. Over 2.5 years, 23 patients were treated with a DFA-inflow bypass. Eighteen (78%) suffered from wounds and five (22%) from rest pain. The proximal, middle and distal DFA was used in 8, 14 and 1 patients, respectively. Indications for using the DFA were limited vein conduit (16) and a hostile groin (5). All patients experienced initial resolution of their ischemic symptoms. The primary patency at two years was 93%. The survival rate was 83%. In conclusion, the DFA is an excellent and underutilized alternative inflow artery in patients requiring lower limb revascularization. It offers excellent patency rates and should be considered in patients with hostile groins or insufficient lengths of a vein conduit.

Endovascular repair of an abdominal aortic aneurysm in the presence of a hydronephrotic horseshoe kidney.

The aim of this paper is to report an unusual case of a patient with an abdominal aortic aneurysm (AAA) and a hydronephrotic horseshoe kidney (HSK) that was repaired by endovascular means. An 81-year-old male patient with a known HSK was found to have hydronephrosis and an AAA. The patients aneurysm was treated with an endovascular stent graft which required the covering of accessory renal arteries. He had an uneventful recovery with complete resolution of the hydronephrosis evident on a computed tomography scan performed seven months after the surgery. In conclusion, endovascular aneurysm repair is a feasible therapeutic option for an AAA coexisting with an HSK and may be considered as a valid alternative to open repair when concomitant hydronephrosis is present.

Open Repair of Hepatic Artery and Celiac Artery Aneurysms in a Patient With Prior Aortic Dissection With an Iliac to Hepatic Artery Bypass

A 67-year-old male with a history of an aortic dissection was found to have a large hepatic and celiac artery aneurysm. Due to the extent of the dissection within the aorta, a bypass was performed from his iliac artery to the hepatic bifurcation, followed by exclusion and ligation of the aneurysms.

Hybrid revascularization of the superior mesenteric artery in a patient with acute mesenteric ischemia and an occluded aorta

A 60-year-old man with a history of chronic mesenteric ischemia and chronic aortic occlusion presented with diffuse abdominal pain. On admission he was hypotensive and acidotic. A computed tomography angiogram revealed occlusion of his entire infrarenal aorta to the femoral arteries, an occluded celiac trunk and inferior mesenteric artery (previously stented), and severe stenosis of his superior mesenteric artery (SMA; A). He underwent explorative laparotomy, during which three segments of gangrenous small bowel were resected. The rest of the small bowel appeared ischemic but viable. Endovascular attempts to recanalize the SMA were unsuccessful. Owing to his hemodynamic instability and metabolic status, we performed a hybrid procedure. Under fluoroscopy, the thrombosed aorta was punctured. A wire and catheter were introduced into the thoracic aorta. After intraluminal position was confirmed, a 14F peel-away sheath was placed. A 6-mm hybrid vascular graft (W. L. Gore and Associates, Flagstaff, Ariz) was introduced (10-cm nitinol reinforced section and a 50-cm nonringed graft). The sheath was removed and the visible end of the nitinol section, which protruded through the aorta, was secured with stitches to the aortic wall. (model, B) An 8-mm ringed polytetrafluoroethylene graft was placed over the 6-mm graft to prevent kinking and the graft was anastomosed to the SMA. The remaining bowel improved immediately. Postoperative computed tomography angiography showed the hybrid graft was patent, with filling of the SMA (C and D/Cover).

The Vanishing Giant Abdominal Aortic Aneurysm

Spontaneous sac size regression of a giant abdominal aortic aneurysm (AAA) is a rare event that has not been previously described. We report a case of an 89-year-old woman with a known 9-cm AAA, which was diagnosed in 2003. The patient had refused any kind of treatment at that time. Recent imaging studies obtained 7 years later revealed an AAA of 4 cm diameter. This is the first recorded case of significant spontaneous AAA sac shrinkage.