Raffaella Mauro

Impact of postoperative transient ischemic attack on survival after carotid revascularization.

OBJECTIVE Major postoperative complications such as stroke and myocardial infarction are usually carefully evaluated in the analysis of carotid revascularization performance. Although transient ischemic attacks (TIAs) are often left unreported, they also may influence long-term outcome. The aim of our study was to evaluate the influence of postoperative TIA in the long-term survival of patients submitted to carotid revascularization. METHODS All consecutive patients submitted to either carotid artery stenting or carotid endarterectomy for symptomatic or asymptomatic carotid stenosis from 2005 to 2012 were retrospectively analyzed. Patients were stratified according to their postoperative (30-day) neurologic course (no symptoms, TIA, or stroke). Kaplan-Maier with log-rank analysis was performed to compare the 5-year survival of patients with postoperative TIA, stroke, or neither; factors affecting the 5-year mortality were evaluated by multivariable Cox proportional hazards models. RESULTS Over a total of 1390 carotid revascularizations (carotid endarterectomy, n = 868 [62.4%]; carotid artery stenting, n = 522 [37.6%]), neurological perioperative complications occurred in 67 (4.7%) cases (38, 2.7% TIA; 29, 2.0% stroke). At 5-year follow-up, overall survival was significantly lower in patients with postoperative TIA (78.4 ± 8.0% vs 97.4 ± 0.6%; P < .001) and postoperative stroke (68.2 ± 14.4% vs 97.4 ± 0.6%; P = .03) compared with patients without neurological complications. By means of multivariate Cox analysis, postoperative TIA and stroke were independent predictors of decreased survival (hazard ratio [HR], 3.10; 95% confidence interval [CI], 1.01-9.72; P = .04, and HR, 3.87; 95% CI, 1.13-13.19; P = .03, respectively), other than age >80 years, postoperative myocardial infarction, and chronic renal failure (HR, 2.07; 95% CI, 1.41-4.90; P = .01; HR, 4.33; 95% CI, 2.74-23.79; P = .04; HR, 2.54; 95% CI, 1.04-6.19; P = .04, respectively). CONCLUSIONS TIAs are significant events, possibly determined by a wider extent of atherosclerotic disease, with important effects on long-term mortality similar to that in strokes. Different from most trials evaluating the outcomes of revascularization techniques, the incidence of perioperative TIA should be accurately considered in the analysis.

Contralateral carotid occlusion in endovascular and surgical carotid revascularization: a single centre experience with literature review and meta-analysis.

OBJECTIVE/BACKGROUND The influence of contralateral carotid occlusion (CCO) on the outcome of carotid endarterectomy (CEA) and stenting (CAS) is debated. This study aims to evaluate CEA and CAS results in patients with CCO. METHODS All carotid revascularizations from 2005 to 2011 were analyzed, focusing on the role of CCO on 30-day cerebral events and death (CED). A meta-analysis was performed to evaluate the results of the literature by random effect. RESULTS Of the 1,218 carotid revascularizations performed in our institution, 706 (57.9%) were CEA and 512 (42.1%) were CAS. CED occurred in 3.6% of the CEAs and 8.2% of the CASs (p = .001). CCO was present in 37 (5.2%) CEAs and 38 (7.4%) CASs. In CEA, CCO patients had a higher CED compared with the non-CCO patients (16.2% vs. 2.9%, p = .001), as confirmed by multiple regression analysis (OR [odds ratio]: 5.1[1.7-14.5]). In CAS, CED was not significantly different in the CCO and non-CCO patients (2.6% vs. 8.7%, p = 0.23). The comparative analysis of the CCO patients showed a higher CED in CEA compared with that in CAS (16.2% vs. 2.6%, p = 0.04). Meta-analysis of 33 papers (27 on CEA and 6 on CAS) revealed that CCO was associated with a higher CED in CEA, but not in CAS (OR: 1.82 [1.57-2.11]; OR: 1.22 [0.60-2.49], respectively). CONCLUSION CCO can be considered as a risk factor for CED in CEA, but not in CAS. CAS appears to be associated with lower CED than CEA in CCO patients.

Nestin and WT1 expression in atheromathous plaque neovessels: association with vulnerability.

INTRODUCTION Neoangiogenesis is crucial for the progression and vulnerability of atheromasic lesions. Since adult vasa vasorum, which represent the neoangiogenetic burden of healthy arteries, constitutively express Nestin and Wilms Tumor (WT1), the aims of the present study are: i) to describe and quantify Nestin and WT1 in plaque neovessels; ii) to investigate the relationship between neovessel phenotype and plaque instability. METHODS We prospectively evaluated 49 consecutive carotid endarterectomy specimens. Histopathological characteristics were separately collected, particularly the intraplaque histological complications. Immunohistochemistry was carried out for CD34, Nestin and WT1; the density of positivity was evaluated for each marker. RT-PCR was performed to assess Nestin and WT1 mRNA levels on the first 10 plaques and on 10 control arteries. RESULTS Six (12.2%) plaques showed no neoangiogenesis. In the others, the mean immunohistochemical densities of CD34, Nestin, and WT1-positive structures were 41.88, 28.84 and 17.68/mm2. Among the CD34+ neovessels, 68% and 42% expressed Nestin and WT1 respectively, i.e., nearly 36% of the neovessels resulted to be Nestin+/WT1-. Furthermore, complicated plaques (n=30) showed significantly more CD34 and Nestin-positive vessels than uncomplicated plaques (n=13; P=0.045 and P=0.009), while WT1 was not increased (P=0.139). RT-PCR confirmed that WT1 gene expression was 3-fold lower than Nestin gene in plaques (p=0.001). CONCLUSIONS Plaque neoangiogenesis shows both a Nestin+/WT1- and a Nestin+/WT1+ phenotype. The Nestin+/WT1- neovessels are significantly more abundant in complicated (vulnerable) plaques. The identification of new transcription factors in plaque neoangiogenesis, and their possible regulation, can open new perspectives in the therapy of vulnerable plaques.

Inflammatory Mediators and Cerebral Embolism in Carotid Stenting: New Markers of Risk

Purpose To investigate serological predictors of risk for cerebral embolism after carotid artery stenting (CAS). Methods Twenty consecutive symptomatic and asymptomatic patients (13 men; mean age 74 years) with carotid artery stenosis undergoing standardized filter-protected CAS (Wallstent) were preoperatively evaluated to identify unstable plaque (duplex ultrasound), complicated aortic plaque (transesophageal echocardiography), and inflammatory status [high-sensitivity C-reactive protein (hs-CRP) and serum amyloid-A protein (SAA) serum levels]. Aortic arch type, carotid tortuosity, and complexity of the procedure were considered. Cerebral embolism was evaluated by comparing the number, volume, and side (ipsilateral and non-ipsilateral) of preoperative and postoperative cerebral lesions detected on diffusion-weighted resonance magnetic imaging (DW-MRI) and through light and scanning electron microscopy analysis of cerebral protection filters obtained from CAS. Results All CAS procedures were completed with no complications. All patients had a negative preoperative DW-MRI, but at least 1 asymptomatic cerebral lesion appeared on DW-MRI after the procedure in 18 (90%) patients. Female gender was associated with a higher number of cerebral lesions (18.2±10.9 vs. 8.3±8.8 for men, p=0.03). Carotid plaque morphology, supra-aortic vessel anatomy, and procedure complexity did not correlate with number or volume of new cerebral lesions. Complicated aortic plaque was associated with a higher volume of non-ipsilateral cerebral lesions than uncomplicated plaque (235.0±259.3 vs. 63.6±63.2 mm3, respectively; p=0.02). Hs-CRP ≥5 mg/L and SAA ≥10 mg/L were significantly associated with a higher number of new cerebral lesions [16.2±10.7 vs. 4.3±3.4 for hs-CRP <5 mg/L (p=0.02) and 14.8±10.3 vs. 2.8±3.4 for SAA <10 mg/L (p=0.006), respectively]. Hs-CRP ≥5 mg/L and SAA ≥10 mg/L also correlated with greater surface involvement by embolic materials in the protection filters at microscopic analysis [37.0% (5.1%) vs. 26.9% (2.5%) for hs-CRP <5 mg/L, p=0.004; 35.9% (13.5%) vs. 22.2% (6.9%) for SAA <10 mg/L, p=0.02]. Conclusion In addition to female gender and the presence of complicated aortic plaque, inflammatory status can be a predictor of cerebral embolism in CAS.

Endovascular treatment of late coronary-subclavian steal syndrome

OBJECTIVE Coronary-subclavian steal syndrome (CSSS) is a rare cause of myocardial ischemia subsequent to stenosis or occlusion of the subclavian artery (SA) proximal to internal thoracic artery (ITA) coronary bypass. Only single cases have been reported in published studies to date. We report a significant series of patients with late CSSS treated through an endovascular approach. METHODS We reviewed a series of consecutive patients treated for CSSS. The clinical, anatomic, and technical characteristics of the procedures were considered. Follow-up was performed through clinical and laboratory (electrocardiography, echocardiography, duplex ultrasonography) evaluations. RESULTS From January 2005 to March 2013, 10 patients with CSSS were treated; 7 had stable and 3 unstable angina. Of the 10 patients, 8 had left SA stenosis (6 ostial to the origin and 2 in the middle segment), 1 had proximal occlusion of the left SA, and 1 had stenosis in the innominate artery (proximally to a right internal thoracic artery). Arterial access was at the brachial artery through surgical exposure (n=6), or radial artery percutaneously (n=3). In 1 case of proximal occlusion of the left SA, simultaneous femoral and percutaneous radial access was necessary. Predilatation of the stenotic lesion was performed in 6. Balloon expandable stents were used in 7 patients with proximal ostial stenosis or occlusion and self-expandable stents in 2 with nonostial lesions. In 1 other patient with proximal heavy calcified stenosis, cutting-balloon predilatation was performed, resulting in dissection of the SA and occlusion of the ITA graft; blood flow was restored in the left upper arm and myocardium by adjunctive dilatation of the SA and endovascular coronary revascularization. No patients developed angina during the follow-up period (15±7 months). CONCLUSIONS A tailored endovascular approach can be used to treat CSSS. However, the occurrence of potentially lethal complications is possible and needs prompt correction.

Chronic oral anticoagulant therapy in carotid artery stenting: The un-necessity of perioperative bridging heparin therapy

INTRODUCTION Chronic oral anticoagulant therapy (OAT) is of widespread use, and usually its management in patients undergoing carotid artery stenting (CAS) is through perioperative bridging heparin therapy. Aim of the present study is to analyze a single center experience of CAS in patients maintaining OAT without perioperative bridging heparin therapy. MATERIALS AND METHODS A retrospective evaluation of consecutive patients submitted to CAS was performed. Clinical anatomical characteristics and chronic OAT were evaluated to find a correlation with stroke, death, myocardial infarction and bleeding from the access site by Chi-square, Fishers tests and regression analysis. RESULTS 502 CAS were performed in a 5-year period. Twelve (2.4%) strokes, 1 (0.2%) death, no myocardial infarctions and 4 (0.8%) access site bleeding occurred in the perioperative period. In the overall population the presence of type 3 or bovine aortic arch was associated with stroke (5.5% vs. 1.5% p=0.02), and preoperative neurological ischemic symptoms were correlated with higher incidence of the composite event of stroke/death (4.8% vs. 1.4%, p=0.05). Twenty patients (4.0%) under chronic OAT were submitted to CAS without perioperative bridging heparin therapy with no complications. Overall, patients under OAT had no significantly different outcome compared with patients without OAT. CONCLUSIONS OAT without perioperative bridging heparin therapy is safe and effective. This data could be useful in the management of patients with chronic OAT submitted to CAS.

A Comparison of Two Surgical Techniques for the Second Stage of Brachiobasilic Arteriovenous Fistula Creation

Two-stage transposed brachiobasilic arteriovenous fistula is a common procedure after brachiobasilic fistula (BBF) creation. Different techniques can be used for basilic vein transposition but few comparative literature reports are available. The aim of our study was to compare two different techniques for basilic vein transposition. The first maintains the BBF anastomosis and the basilic vein is placed in a subcutaneous pocket (BBAVF). The second transects the basilic vein at the BBF anastomosis and tunnels it superficially, with a new BBF in the brachial artery (BBAVFTn). From 2009 to 2014, all patients who underwent basilic vein superficialization were treated by one of the two techniques, recorded in a dedicated database and retrospectively reviewed. The surgeon chose the technique on the basis of personal preference. The two techniques were compared in terms of perioperative complications, length of hospital stay, time of cannulation, ease of cannulation, and long-term patency. Eighty patients were included in the study: 40 (50%) BBAVF and 40 (50%) BBAVFTn. Length of hospital stay was similar in the two groups (median [interquartile range-IQR] 3(2) [BBAVF] vs. 2(1) [BBAVFTn], P = 0.52, respectively). BBAVFTn was associated with a lower hematoma incidence (1/40 [2.5%] vs. 15/40 [37.5%], P = 0.01), shorter first cannulation time (median IQR: 11(10) vs. 23(8) days, P = 0.01) and easier cannulation compared with BBAVF (32/40 [80%] vs. 15/40 [37.5%], P < 0.001). Median (IQR) follow-up was 16(7) months. No statistical differences in terms of primary and assisted primary patency were found in BBAVFTn vs. BBAVF (at 24 months 91(5) vs. 71(7), P = 0.21 and 93(6) vs. 78(8), P = 0.33, respectively). Patients who underwent BBAVFTn surgery showed fewer surgical complications, better dialytic performance, and easier cannulation compared with those submitted to BBAVF.

Diffuse calcifications protect carotid plaques regardless of the amount of neoangiogenesis and related histological complications.

Background. Neoangiogenesis is crucial in plaque progression and instability. Previous data from our group showed that Nestin-positive intraplaque neovessels correlated with histological complications. The aim of the present work is to evaluate the relationship between neoangiogenesis, plaque morphology, and clinical instability of the plaque. Materials and Methods. Seventy-three patients (53 males and 20 females, mean age 71 years) were consecutively enrolled. Clinical data and 14 histological variables, including intraplaque hemorrhage and calcifications, were collected. Immunohistochemistry for CD34 and Nestin was performed. RT-PCR was performed to evaluate Nestin mRNA (including 5 healthy arteries as controls). Results. Diffusely calcified plaques (13/73) were found predominantly in females (P = 0.017), with a significantly lower incidence of symptoms (TIA/stroke (P = 0.019) than noncalcified plaques but with the same incidence of histological complications (P = 0.156)). Accordingly, calcified and noncalcified plaques showed similar mean densities of positivity for CD34 and Nestin. Nestin density, but not CD34, correlated with the occurrence of intraplaque hemorrhage. Conclusions. Plaques with massive calcifications show the same incidence of histological complications but without influencing symptomatology, especially in female patients, and regardless of the amount of neoangiogenesis. These results can be applied in a future presurgical identification of patients at major risk of developing symptoms.

Carotid Revascularization in Patients with Ongoing Oral Anticoagulant Therapy: The Advantages of Stent Placement

PURPOSE To assess the influence of oral anticoagulant therapy conversion to heparin (OAT-CH) on carotid endarterectomy (CEA) outcomes and the influence of unmodified oral anticoagulant therapy (OAT) on carotid artery stenting (CAS) and to compare the outcomes of CEA in OAT-CH with CAS in ongoing OAT. MATERIALS AND METHODS The 30-day results from all patients who underwent CEA and CAS in a 6-year period were analyzed for stroke, death, myocardial infarction (MI), and hematoma of the access site requiring surgical evacuation. We evaluated the influence of OAT-CH in CEA and the influence of OAT in CAS and compared CEA and CAS outcomes in patients receiving OAT-CH and OAT. RESULTS Among 1,222 carotid revascularizations, there were 711 CEAs (58.1%) and 511 CAS procedures (41.9%). In the CEA group, 31 (4.4%) patients were treated with OAT-CH, and these patients had a significantly higher complication rate compared with patients not receiving OAT, including death (1 [3.2%] vs 4 [0.6%]; P = .04), stroke (4 [12.9%] vs 10 [1.4%]; P = .001), and hematoma (3 [9.6%] vs 11 [1.6%]; P = .02). In CAS, the results were similar in patients receiving OAT (30 [5.8%]) and patients not receiving OAT. Patients receiving OAT who underwent CAS had better outcomes than patients receiving OAT-CH who underwent CEA, including stroke, death, MI, and hematoma combined (0 [0.0%] vs 7 [22.5%]; P =.01). CONCLUSIONS OAT management significantly influences the results of carotid revascularization. Because CAS with unmodified OAT had a significantly better outcome than CEA with OAT-CH, carotid revascularization strategies should favor CAS rather than CEA in this setting.

Plication for the treatment of a radio-cephalic fistula with ulnar artery steal

Purpose Generally the steal syndrome occurs in proximal arterial-venous fistulas and only exceptionally with distal vascular access because of the high number of arteries supplying the hand. We describe a rare case of steal syndrome of a proximalized distal radio-cephalic fistula stealing from both the radial and ulnar artery through the palmar arch. Methods An 86 year old man was admitted because of a cyanotic, swollen left hand with trophic lesions at the third finger. He had a latero-terminal radio-cephalic fistula performed in 2006 with subsequent proximalization performed four years later after failure of the first one. Duplex ultrasound examination showed a high flow within the fistula (2080 mL/min) and a retrograde perfusion of the radial artery from the ulnar artery through the palmar arch and an angiography excluded stenosis along the radial artery. Results We treated the steal syndrome through a plication technique that was performed with careful flow variations measurement, under duplex evaluation, during the surgical procedure. That procedure was effective to maintain the fistula flow and obtain the symptoms relief. The patient was evaluated the day after the intervention and after 10 weeks. The clinical examination highlighted the resolution of hand ischemia. The Duplex Ultrasound examination showed a lower flow within the fistula (1060 mL/min) and a retrograde perfusion of the radial artery from the ulnar artery through the palmar arch with a three-phase flow. Dialysis access from the fistula was never interrupted from immediately after surgery to the present date. Conclusions Plication is an effective technique for treatment of steal syndrome requiring a short operative time and it is related to satisfying post-operative results