Raffaele Dito

Hypothermia during Carotid Endarterectomy: A Safety Study

Background CEA is associated with peri-operative risk of brain ischemia, due both to emboli production caused by manipulation of the plaque and to potentially noxious reduction of cerebral blood flow by carotid clamping. Mild hypothermia (34–35°C) is probably the most effective approach to protect brain from ischemic insult. It is therefore a substantial hypothesis that hypothermia lowers the risk of ischemic brain damage potentially associated with CEA. Purpose of the study is to test whether systemic endovascular cooling to a target of 34.5–35°C, initiated before and maintained during CEA, is feasible and safe. Methods The study was carried out in 7 consecutive patients referred to the Vascular Surgery Unit and judged eligible for CEA. Cooling was initiated 60–90 min before CEA, by endovascular approach (Zoll system). The target temperature was maintained during CEA, followed by passive, controlled rewarming (0.4°C/h). The whole procedure was carried out under anesthesia. Results All the patients enrolled had no adverse events. Two patients exhibited a transient bradycardia (heart rate 30 beats/min). There were no significant differences in the clinical status, laboratory and physiological data measured before and after CEA. Conclusions Systemic cooling to 34.5–35.0°C, initiated before and maintained during carotid clamping, is feasible and safe. Trial Registration ClinicalTrials.gov NCT02629653

Regulatory T CD4 + CD25+ lymphocytes increase in symptomatic carotid artery stenosis

Abstract Background: Atherosclerosis is a multifactorial disease characterized by an immune-inflammatory remodeling of the arterial wall. Treg and Th17 subpopulations are detectable inside atherosclerotic plaque; however, their behavior in symptomatic carotid artery stenosis (CAS) is not fully elucidated. The aim of this study was to evaluate Th17 and Treg subsets and their ratio in patients affected by symptomatic and asymptomatic CAS. Methods: 14 patients with symptomatic CAS (CAS-S group), 41 patients with asymptomatic CAS (CAS-A group), 32 subjects with traditional cardiovascular risk factors (RF group), and 10 healthy subjects (HS group) were enrolled. Th17 and Treg frequency was determined by flow cytometry and by histology and immunohistochemistry. Interleukin (IL)-10, IL-17, and metalloproteinase (MMP)-12 levels were measured by ELISA. Results: Th17 were significantly increased in CAS-A versus RF and versus HS. Tregs were significantly increased in CAS-S versus CAS-A. Tregs/Th17 ratio was significantly reduced in CAS-A versus RF and versus HS, whereas it was significantly increased in CAS-S versus CAS-A. Conclusions: The results of this study suggest that Th17 are related to the late stages of CAS but not to plaque instability. Moreover, Treg expansion seems to represent a specific cellular pattern displayed by patients with symptomatic CAS and associated with brain injury. KEY MESSAGES Tregs expansion seems to represent a specific cellular pattern displayed by patients with symptomatic CAS and associated with CD4+ effector depletion and brain ischemic injury. Th17 lymphocytes are related to the late stages of CAS but not to plaque instability.

Hemodynamic changes in chevalier eversion versus conventional carotid endarterectomy

OBJECTIVES The eversion carotid endartectomy (E-CEA), mainly performed by means of Vanmaele technique, has been associated with loss of the baroreceptor reflex and postoperative hypertension. The purpose of this paper is to determine whether the eversion endarterectomy performed by means of Chevalier technique (C-CEA) modifies the function and the efficiency of baroreceptors, leading to lower postoperative hemodynamic change. METHODS A retrospective review of 380 patients who underwent carotid endarterectomy (120 Chevalier-CEA; 260 Standard-CEA) from December 2002 to November 2012 has been performed. The changes of blood pressure baseline during the postoperative course in C-CEA and S-CEA group were analysed and compared. Postoperative hypertension was defined as an elevation of systolic pressure >180 mm Hg or >40% rise above baseline. RESULTS The patients with Chevalier eversion technique did not develop a significantly higher blood pressure in the postoperative course compared to those operated with the standard technique. In the recovery room, the mean systolic blood pressure was 134 ± 21.9 mm Hg in C-CEA group versus 132 ± 24.6 mm Hg in S-CEA group. In the first postoperative day it was 132 ± 17.2 mm Hg in C-CEA versus 133 ± 17.4 mm Hg in S-CEA group. During the first six hours in the recovery room, the need for intravenous antihypertensive drugs was similar in the two groups. Fourteen patients in C-CEA group (11%) and thirty patients (11.5%) in the S-CEA group required vasodilators, without any significant difference (p = 1). The dosage of current preoperative antihypertensive therapy was increased in six patients (4.9%) of C-CEA group and in twelve patients (4.9%) of S-CEA group, without significant difference (p = 1). CONCLUSIONS C-CEA has the same rate of postoperative hypertension of standard-CEA, which is probably related to the sparing of baroreceptor apparatus, compared to standard E-CEA. The Chevalier procedure could represent an E-CEA technique with its inherent advantages, without penalties related to postoperative hypertension, commonly observed after E-CEA.

A Double Nellix and Chimney Covered Stents: Challenging Treatment of Pararenal Aortic Aneurysm

A 77-year-old male patient presented with a symptomatic, 66-mm pararenal aortic aneurysm. The patient was classified as unsuitable for open surgery due to significant comorbidities. Fenestrated or branched endografts were contraindicated due to the poor iliac access (6 mm diameter). A double Nellix with chimney endovascular aneurysm sealing (ChEVAS) technique was selected to exclude the pararenal aortic aneurysm and to preserve renal arteries and the superior mesenteric artery. Technical preplanning considered the ideal proximal landing zone to be close to the origin of the almost occluded celiac trunk and the distal common iliac arteries as the ideal distal landing zone. The total length of the aorta to cover was estimated as >180 mm, requiring 2 aortic EVAS systems, bilaterally overlapped. Technical success was achieved, and the patient was discharged on postoperative day 8 in good general condition. Successful aneurysm exclusion and target vessel patency without endoleak or stent-graft kinking or migration were confirmed at angio-computed tomography at 6 months.

Different approaches in popliteal artery aneurysm management

SummaryBackgroundThe purpose of the popliteal aneurysm surgical treatment is the prevention of thromboembolic events or the increase of the aneurysm size. Our prospectively collected data were analyzed with the aim to identify factors that could characterize the immediate and long-term success of the treatment, with particular regards to quality of life in terms of early recovery.Materials and methodsFrom July 2004 to September 2012, 36 patients affected by 39 popliteal aneurysms have been treated. A total of 16 posterior accesses, 5 medial accesses, 12 above and below the knee joint medial accesses, and 6 endovascular accesses have been performed. Functional recovery, quality of life, as well as primary and secondary patency have been compared for different access.ResultsA complete sac excision before the graft repair has been obtained for all patients subjected to posterior or medial access with section of the goose foot tendons. The posterior access functional recovery has been compared with that of the patients subjected to medial access in terms of motility (p = 0.0001). The average follow-up was 27 months; the primary patency was 87 % and the secondary one 96 %. The limb salvage rate was 100 %.ConclusionsThe posterior access offers a better aneurysm exposure and a better functional recovery.

Morphofunctional characterization of a rare extracranial internal carotid artery giant aneurism

Aneurisms of the extracranial tract of the internal carotid artery (EICAA) are extremely rare, accounting for 0,4% to 2% of all carotid procedures (El-Sabrout et al., 2000); in females incidence is 2-11 times lower than in males (Siablis et al., 2004). A giant EICAA (32 x 35 mm) at C3 level was studied in a woman aged 81. Samples were prepared for standard transmission electron microscopy. Semithin sections were stained according to Relucenti et al. (2010). Ultrathin sections were contrasted with uranyl acetate and lead citrate. Images revealed the presence of many microvessels just beneath the tunica intima. They were patent, often showed sprouts and pericytes. Endothelial cells appeared metabolically active, with euchromatin, nucleoli, membrane blebs and junctional complexes. Their basal membrane was thickened and sometimes multilaminated. Leukocytes adhering to the endothelium were observed. The internal elastic lamina was so fragmented that it was very difficult to recognize it. The tunica media showed vascular smooth muscle cells (VSMCs) arranged in bundles encircled by collagen-rich extracellular matrix (EM), as well as scattered in the EM. VSMCs had perinuclear organelles, dense bands and caveolae. Collagen fibrils were arranged in a twisted or coiled fashion. Elongated fibroblasts were scattered among VSMCs. The external elastic lamina was conserved. Literature on EICAA is almost exclusively clinical, so this morphofunctional study elucidates structural and ultrastructural changes in the aneurism wall that can contribute to the knowledge of aneurism etiopathogenesis.