Nikola Aleksic

Percutaneous angioplasty of internal jugular and azygous veins in patients with chronic cerebrospinal venous insufficiency and multiple sclerosis: early and mid-term results

Purpose: To assess the safety of endovascular treatment of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS). Materials and Methods: A total of 72 patients with CCSVI and MS (44 with relapsing remitting – RR, 4 with primary progressive, 20 with secondary progressive and 4 with benign MS) underwent percutaneous angioplasty. Outcome measures were colour Doppler ultrasonography parameters, gradient pressure at the vein abnormality level, postoperative complications, re-stenosis, disease severity scored by means of Expanded Disability Status Scale (EDSS) and patients’ assumption of disease status. Controls were done after one month on 72 patients, six months on 69 patients and one year on 61 patients, respectively (the average follow-up was 11 months). Results: There were no postoperative complications. Colour Doppler ultrasonography showed significant improvement in cross-sectional area parameters (P < 0.05) and significant decrease in confluence velocity values (P < 0.05). Postoperative gradient pressure decreased, in internal jugular vein (IJV) significantly (P < 0.05). Re-stenosis appeared in 5.3% of patients. EDSS score was significantly improved (P < 0.01) and about half of patients reported significant or mild improvement in disease status and none of them worsening of symptoms. Conclusion: Endovascular treatment of the IJV and azygous veins in patients with CCSVI and MS is a safe procedure with no post-procedural complications followed by significant improvement of IJV flow haemodynamic parameters and decrease in the EDSS score. Whether CCSVI percutaneous treatment might affect clinical improvement in patients suffering from MS is yet to be seen after completion of major multicentric clinical trials, still it seems like that this procedure is not negligible.

Compressive syndrome of internal jugular veins in multiple sclerosis: does it matter?

Objectives Condition known as chronic cerebrospinal venous insufficiency (CCSVI) is characterized by insufficient cerebral vein drainage in patients with multiple sclerosis (MS) and internal jugular vein (IJV), vertebral and/or azygos veins stenoses. However, external compression on the IJV was not clearly described as a potential cause of CCSVI. We aim to present a case of CCSVI in a patient with MS caused by bilateral IJV inverted valves combined with IJV external compression by carotid bulb. Methods A 31-year-old female patient was admitted to our institute for IJV and vertebral veins morphological and haemodynamical assessment after being treated for MS for the last 14 years. Colour Doppler ultrasonography showed right IJV prestenotic dilation and inverted valves in both IJV. Computerized tomography angiography showed bilateral IJV compression by carotid bulb. Haemodynamical Doppler parameters showed that external IJV compression significantly contributed to CCSVI occurrence. Results Bilateral IJV confluence percutaneous angioplasty (PTA) was done, and the patient was discharged for further neurological examination. Partial carbon dioxide pressure was significantly lower in the distal part of both IJV following PTA and oxygen saturation increased. Conclusion In the case presented, PTA of the IJV confluence resulted in haemodynamic improvement despite the presence of IJV external compression.

Color Doppler sonographic evaluation of flow volume of the internal carotid and vertebral arteries after carotid endarterectomy

To measure by Doppler sonography the blood flow volume (BFV) of the ipsilateral and contralateral extracranial internal carotid arteries (ICAs) and both vertebral arteries (VAs) before and after a carotid endarterectomy (CEA) of the ICA. We correlated the result with the degree of stenosis of the ICA.

Color duplex sonography in the detection of internal carotid artery restenosis after carotid endarterectomy: comparison with computed tomographic angiography.

Internal carotid artery restenosis after carotid endarterectomy is a major postoperative event, but the clinically best suited means for diagnosis of restenosis are still debated. The objective of this study was to evaluate the sensitivity and specificity of color duplex sonography for detection of substantial internal carotid artery restenosis, verified by computed tomographic (CT) angiography.

Preoperative Insight Into the Quality of Radial Artery Grafts.

We investigated the impact of preoperative ultrasonography of the forearm circulation on radial artery conduit selection. Preoperative ultrasound of the forearm circulation was performed routinely in 536 patients planned for radial artery harvesting. The safety assessment of the harvest included the following algorithm of tests: the ultrasound, the Allen test, and pulse oximetry. The quality criteria that were used to exclude a radial artery from harvesting were small size of the artery, diffuse atherosclerosis, calcifications, and severe neointimal hyperplasia. The overall rejection rate due to safety reasons was 16.4%. Seventy-one (13.2%) radial arteries did not fulfill the conduit quality criteria and consequently these arteries were not harvested. In 13.4% of radial arteries, localized arterial wall disease was found in the distal third of the artery. The distal part of the artery was discarded and the rest was used as a conduit. Our results indicate that the ultrasound provides an accurate preoperative insight into the radial artery morphology, enabling selection of the arteries with favorable morphological features.

Scoring system to predict early carotid restenosis after eversion endarterectomy by analysis of inflammatory markers

Background: Inflammation is one of the mechanisms that leads to carotid restenosis (CR). The aim of this study was to examine the influence of increased values of inflammation markers (high‐sensitivity C‐reactive protein [hs‐CRP], C3 complement, and fibrinogen) on CR development after eversion carotid endarterectomy (CEA). Methods: A consecutive 300 patients were included in the study, in which eversion CEA was performed between March 1 and August 1, 2010. Demographic data, atherosclerosis risk factors, comorbidities, and ultrasound plaque characteristics were listed in relation to potential risk factors for CR. Serum concentrations of hs‐CRP, fibrinogen, and C3 complement were taken just before surgery (6 hours); 48 hours after CEA; and during regular checkups at 1 month, 6 months, 1 year, and 2 years. An “inflammatory score” was also created, which consisted of six predictive values of inflammatory markers (hs‐CRP just before and just after CEA, fibrinogen just before and just after CEA, and C3 complement just before and just after CEA) with a maximum score of 6 and a minimum score of 0. At every follow‐up visit to the outpatient clinic, ultrasound assessment of the carotid artery for restenosis was done. Results: Our results showed an increased risk of early CR within 1 year in patients with increased hs‐CRP before CEA (6 hours) and increased fibrinogen 48 hours after surgery and in patients not taking aspirin after CEA. Sex was determined to be an independent predictor of CR, with female patients having a higher risk (P = .002). Male patients taking aspirin with an inflammatory score >2 had an increased risk for restenosis compared with male patients with inflammatory score <2. Not taking aspirin after CEA and fibrinogen (48 hours) were the strongest predictors, and the Fisher equation incorporating these predictors was used to predict CR. A computer program was created to calculate whether the patient was at high or low risk for CR by selecting whether the patient was taking aspirin (yes or no) and whether fibrinogen was increased 48 hours after CEA (yes or no) and to display the recommended therapeutic algorithm consisting of aspirin, clopidogrel, cilostazol, and statins. Conclusions: Increased hs‐CRP before CEA, increased fibrinogen 48 hours after CEA, and not taking aspirin were the main predictors of early CR. With the clinical implementation of the Fisher equation, it is possible to identify patients at high risk for early CR and to apply an aggressive therapeutic algorithm, finally leading to a decreased CR rate.

Correlation Between Pulpal and Carotid Arteries Blood Flow in Two Age Groups

Abstract Introduction Vascular network of dental pulp is supplied through common and external carotid artery and terminal dental branches that supply each pulp tissue. Age related changes of pulp tissue influence pulpal vascularization as well. The aim of this study was to compare and correlate pulpal and common and external carotid artery blood flow in young and middle age individuals of general population. Material and Methods Two groups of 10 participants were included in the study, young (20-25 years) and middle age (50-55 years) group. Pulpal blood flow (PBF) measurements on intact right and left upper central incisors were performed using laser Doppler flowmetry (LDF) method. Carotid arteries blood flow was assessed using carotid ultrasonography. Results PBF levels were significantly higher in young (3.11±0.67 and 3.46±1.11, right and left upper central incisors, respectively) compared to middle age (1.93±0.47 and 2.30±0.64, right and left upper central incisors, respectively) participants (independent sample t test; p<0.05). There was no correlation between common and external carotid artery blood flow and upper central incisors PBF in young as well as middle age participants, for right or left side. Conclusion Absence of correlation between carotid arteries blood flow and PBF suggests that reduced PBF in middle age participants was probably not due to reduced blood supply from carotid arteries but it was result of age related changes at the level of pulpal blood vessels.

Surgical treatment of internal carotid artery restenosis following eversion endarterectomy

INTRODUCTION Carotid angioplasty and internal carotid artery stenting is the therapeutic method of choice in the treatment of carotid restenosis, but when it is not technically feasible (expressed tortuosity of supraaortic branches, calcifications, presence of pathological elongation of very long lesions) a redo surgery is indicated. OBJECTIVE The aim of our study was to examine the benefits and risks of redo surgery in patients with symptomatic and asymptomatic significant internal carotid artery restenosis and its impact on early and late morbidity and mortality. METHODS The study included 45 patients who were surgically treated for a hemodynamically significant internal carotid artery restenosis from January 2000 to December 2009. Surgical techniques included redo endarterectomy with direct suture, redo anderectomy with a patch plastic and resection with Dacron tubular graft interposition. The patients were followed for postoperative neurological ischemic events (transient ischemic attack (TIA), stroke), local surgical complications and lethal outcome after one month, six months, one year and after two years). RESULTS In the early postoperative period (up to 30 days) there were no lethal outcomes. TIA was diagnosed in four patients (8.8%), minor stroke in one patient (2.2%) and one patient (2.2%) also had cranial nerve injury. After two years two patients died (4.4%) due to fatal myocardial infarction, three patients (6.5%) had ipsilateral stroke and one patient developed graft occlusion (2%). CONCLUSION In the case of symptomatic and asymptomatic carotid restenosis that cannot be treated by carotid percutaneous angioplasty, redo surgical treatment is therapeutic option with an acceptable rate of early and late postoperative complications.

Angiofollicular Lymphoid Hyperplasia—An Unusual Cause of Axillary Artery Pseudoaneurysm

BACKGROUND Angiofollicular lymphoid hyperplasia (Castlemans disease) is a rare inflammatory condition. Its cause is unknown and it can be both localized and general. Eighty-six percent of lesions are found in the mediastinum or hilum, and 91% are of the hyaline vascular type. Although Castlemans disease is primarily involving the chest and retroperitoneum, it may also involve neck and axilla in 2-4% of cases. In this article, we present a very rare case of Castlemans disease causing axillary artery pseudoaneurysm. METHODS AND RESULTS A 30-year-old woman patient presented with pulsating tumefaction of the left arm which was 3.5 x 10 cm in size, and became evident 15 days before admission. History revealed that she suffered trauma of the left upper arm in childhood; therefore, it was suspected that tumefaction may be due to a post-traumatic aneurysm. Duplex scan and multislice computed tomography examinations were performed and an axillary artery pseudoaneurysm was diagnosed. Since intraoperatively the tumefaction resembled the tumorous formation but not the aneurysmal wall, specimens were sent for pathohistological analysis. Arterial reconstruction was performed using autologous vein graft. Pathohistological findings showed vascular type of angiofollicular lymphoid hyperplasia. CONCLUSION Although angiofollicular lymphoid hyperplasia is rarely localized in the axillary area, this disease should also be considered when axillary artery pseudoaneurysm is diagnosed.