Sotiris Georgopoulos

Surgery for Renal Artery Aneurysms: A Combined Series of Two Large Centers

Objective: To review the clinical features and results of surgical treatment of renal artery aneurysms from two large centers. Patients and Methods: A retrospective analysis of 21 hypertensive patients with renal artery aneurysms operated in two centers during a 24-year period was performed. Results: The presenting symptom was subcostal or flank pain in 8 (38%) and hematuria in 5 (24%) cases. A ring-like calcification was seen on plain X-ray in 6 (29%) cases. All patients were evaluated with renal angiography showing a saccular aneurysm in 13 cases (62%), fusiform in 5 (24%) and dissecting in 3 (14%) cases. All saccular aneurysms were treated with resection followed by reconstruction with vein patch in 10 cases, and with and end-to-end anastomosis in 3 cases. All fusiform and dissecting aneurysms were managed with resection and reconstruction using aortorenal bypass. There was no hospital mortality or significant morbidity. During a follow-up ranging from 6 months to 23 years, there was definite cure of hypertension in 14 (67%) patients and improvement of blood pressure levels in 4 (19%) patients. Three patients continued to be hypertensive. Conclusion: Surgery for renal artery aneurysms can be accomplished with good results and should be considered for patients with aneurysms greater than 2 cm, for aneurysms causing renovascular hypertension, significant stenosis, flank pain, or hematuria, for dissecting, expanding and thrombotic aneurysms, and in women with a potential for pregnancy. However, all aneurysms cannot and should not be treated surgically.

Vascular Endothelial Growth Factor and Matrix Metalloproteinase 9 Expression in Human Carotid Atherosclerotic Plaques: Relationship with Plaque Destabilization via Neovascularization

Background: The aim of this study was to evaluate the potential impact of vascular endothelial growth factor (VEGF) on carotid plaque destabilization in association with matrix metalloproteinase 9 (MMP-9) production. Methods: Expression of VEGF and MMP-9 were determined immunohistochemically in 53 human endarterectomized atherosclerotic carotid plaques. The relationship to carotid plaque characteristics, clinical data and histological morphology was investigated. Results: VEGF and MMP-9 had parallel overexpression in the inflammatory cells, especially in the neovascularized plaque lesions and around the cholesterol crystals. Strong expression of VEGF was evident in symptomatic patients (p < 0.057), in high-degree stenosis (p = 0.005), and in patients with ischemic infarct in brain scan (p = 0.021). No relation was proved between molecule expression and plaque ultrasonic characteristics. Conclusions: An intense expression of VEGF and MMP-9 in carotid plaques is related to plaque instability, high degree of stenosis and presence of symptomatic carotid occlusive disease.

Malondialdehyde as an indicator of oxidative stress during abdominal aortic aneurysm repair.

Ischemia-reperfusion injury significantly contributes to abdominal aortic aneurysm (AAA)— related mortality and morbidity; therefore, we measured oxidative stress during open AAA repair and investigated any potential associations with intraoperative or perioperative events (aortic clamping time, blood loss, and the need to transfer to the intensive care unit). Blood samples were collected at specific time points from 53 patients undergoing open AAA repair: (1) before induction of anesthesia; (2) 15, 30, 60, and 120 minutes after aortic clamping; (3) 15 and 60 minutes after clamp removal; and (4) 24 hours postoperatively. Malondialdehyde (MDA) levels were measured by a spectrophotometric method. Baseline MDA values in patients with AAA were significantly higher than in controls (P < .0001). A positive correlation was found between preoperative MDA levels and the size of AAAs (Pearson correlation = 0.578, P < .001). No difference was observed in MDA levels between ruptured and nonruptured AAAs; however, when all symptomatic patients (ruptured and elective symptomatic AAAs, n = 18) were considered, there was a significant elevation in MDA levels (P < .001). There was also a significant increase in MDA values in patients transferred postoperatively to the intensive care unit (P < .001). Finally, a positive association was found between the duration of aortic clamping with MDA values at 15 and 60 minutes after declamping, but not after 24 hours (Pearson correlation = 0.467, P < .001). MDA levels may predict the postoperative course of elective and ruptured AAAs.

Lower Extremity Bypass Procedures in Diabetic Patients with End-Stage Renal Disease: Is It Worthwhile?

Backgroud/Aims: Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging therapeutic problem. Furthermore, diabetes mellitus is frequently associated with ischemic gangrene, persistent infection and impaired wound healing. The present study was undertaken to examine graft patency, limb salvage and survival in patients with ESRD and diabetes following bypass grafting to treat lower limb critical ischemia. Methods: A retrospective analysis of 56 arterial reconstructions performed in 39 patients with diabetes mellitus and ESRD during a period of 8 years. The indications for bypass grafting were: ischemic rest pain (n = 13), non-healing ulcer (n = 18) or foot gangrene (n = 25). Risk factors in association with surgical morbidity and mortality, limb loss and graft patency were evaluated. Results: Thirty-four patients were on hemodialysis and 5 on peritoneal dialysis. Forty-nine infrainguinal reconstructions were performed; the site of distal anastomosis was the below knee popliteal artery (n = 22), the anterior tibial artery (n = 12), the posterior tibial artery (n = 8), and the peroneal artery (n = 7). Seven axillofemoral reconstructions were also performed; the site of distal anastomosis was the common femoral artery (n = 5) and the above knee popliteal artery (n = 2). The 30-day operative mortality rate was 18% (7 patients). The mean follow-up was 11.5 (range 1–93) months. Patient survival rate at 1 and 2 years was 63 and 45%, respectively. Primary patency rate was 64% at 1 year and 58% at 2 years. The limb salvage rate was 65% in the first year. Conclusion: Limb salvage rate in patients with ESRD and diabetes justifies an aggressive policy of revascularization, despite decreased survival of this population.

THE VALIDITY OF CURRENT VASCULAR IMAGING METHODS IN THE EVALUATION OF AORTIC ANASTOMOTIC ANEURYSMS DEVELOPING AFTER ABDOMINAL AORTIC ANEURYSM REPAIR

The aim of this cross-sectional study was to evaluate the validity of current imaging methods for diagnosing anastomotic false aneurysms (AFA) of the aorta. One hundred four patients who had undergone elective abdominal aortic aneurysm repair between January 1, 1985, and May 31, 1991, were studied. All of them were investigated for potential development of an aortic anastomotic aneurysm by B-mode ultrasonography, CT scanning, digital subtraction arteriography, and MRI. These findings were compared with results of color-coded Doppler imaging, which is considered the “gold standard,” and were subsequently classified as true positive or true negative. The accuracy of color Doppler ultrasound was independently evaluated by clinical examination of the patients, which was carried out for a mean period of 77.5 months during follow-up. On the basis of the data obtained and observations made during follow-up (mean 36.4 months), the sensitivity and specificity of the preceding imaging methods were estimated. Aortic anastomotic aneurysms were detected in two patients (1.9%). The sensitivity of all methods was 100% and specificity was as follows: 74.2% for ultrasound, 59.8% for nonenhanced CT scans, 85.4% for enhanced CT scans, and 99% for digital subtraction arteriograms. Color Doppler and MRI were 100% specific for ruling out aortic anastomotic aneurysms. In a comparison of the accuracy, estimated cost, safety, and the availability of each method, color Doppler appeared to be the diagnostic method of choice for identifying aortic anastomotic aneurysms after abdominal aortic aneurysm repair.

Iatrogenic Injury of Profunda Femoris Artery Branches after Intertrochanteric Hip Screw Fixation for Intertrochanteric Femoral Fracture: A Case Report and Literature Review

A case of arterial rupture of the profunda femoris arterial branches, following dynamic hip screw (DHS) fixation for an intertrochanteric femoral fracture, is presented. Bleeding is controlled by coil embolization, but, later on, the patient underwent orthopedic material removal due to an infection of a large femoral hematoma.

Vascular endothelial cadherin expression in human carotid atherosclerotic plaque and its relationship with plaque morphology and clinical data.

OBJECTIVES To determine the relationship between Vascular Endothelial (VE)-cadherin expression in carotid plaques, carotid plaque morphology and clinical findings of carotid disease. MATERIALS AND METHODS Fifty-three formalin-fixed, paraffin embedded specimens of human carotid atherosclerotic plaque obtained by endarterectomy and 20 normal postmortem arteries (control group) were studied. Thirty patients were symptomatic and 23 asymptomatic. The expression of VE-cadherin was examined by an avidin-biotin immunoperoxidase technique using specific monoclonal antibodies against this molecule. We used a scale for the estimation of the expression of the VE-cadherin, in which negative expression was indicated by 0, weak expression by 1, and strong expression by 2. In serial sections we also determined the cellular phenotype of atherosclerotic plaques: i.e. the endothelial cells (F8), macrophage (CD68) and smooth muscle cells. Possible relations between variables in statistical analysis were examined by the chi-square test or Fishers exact test. RESULTS Expression of VE-cadherin was observed in small newly established vessels, particularly in areas with intense inflammatory infiltrations by macrophages and leucocytes. A strong expression of VE-cadherin was evident particularly in symptomatic instead in asymptomatic patients (43% vs. 13%, p=0.057), in high degree stenosis group (81% vs. 0%, p=0.005), and in patients with ischaemic infarct in brain scan (71% vs. 23%, p=0.021). On the other hand, there was no relation between molecule expression and plaque ultrasonic characteristics (echogenic or echolucent, p=0.499). Finally, there was a significant statistical correlation in the expression of VE-cadherin and the histological type of the plaque, namely fibrotic and complicated plaques. Strong VE-cadherin expression was observed in 64% of complicated plaques instead of 6.5% in fibrotic plaques (p=0.001). CONCLUSION An intense expression of VE-cadherin in carotid plaques is linked with plaque instability, high degree of stenosis and clinical events. This molecule seems to be a marker of progression of the atherosclerotic plaque.

Toll-Like Receptor 4 Immunohistochemical Expression Is Enhanced in Macrophages of Symptomatic Carotid Atherosclerotic Plaques

Background: A growing body of evidence supports a role for Toll-like receptor 4 (TLR4), a primary receptor of the innate immune system, in atherosclerosis initiation and progression. Carotid atheroma macrophages (MACs) and smooth muscle cells (SMCs) express TLR4; nevertheless, correlations with epidemiological and clinical variables and especially cerebrovascular symptomatology remain unsettled. Methods: Carotid atherosclerotic plaques were obtained by standard carotid endarterectomy on 157 patients with carotid artery disease (84 asymptomatic – 73 symptomatic). TLR4 expression in MACs and SMCs of carotid atheroma was detected by immunohistochemistry techniques. TLR4 positivity, overexpression and intensity of immunostaining in MACs and SMCs were correlated with cerebrovascular symptomatology, epidemiological and clinical variables. Results: MAC TLR4 positivity was noted in 129 (82.2%) patients. Patients receiving statins had significantly lower TLR4 expression. Rates of MAC TLR4 positivity were higher among symptomatic patients (odds ratio, OR = 5.1; 95% confidence interval, CI = 1.8–14.3; p < 0.001); the association was stronger for transient ischemic attacks. TLR4 overexpression was also significantly enhanced among symptomatic patients (OR = 2.3; 95% CI = 1.02–5.03; p < 0.05). No correlations were detected between SMC TLR4 expression and cerebrovascular symptoms. In multivariate models adjusting for age, gender, body mass index, hyperlipidemia and smoking, MAC TLR4 positivity was associated with a cerebrovascular event during the last 6 months (OR = 4; 95% CI = 1.2–13.3; p = 0.02). Conclusions: Symptomatic carotid artery plaques are characterized by increased expression of TLR4 in macrophages supporting a potential role for TLR4 in the pathophysiology and clinical presentation of cerebrovascular disease. Further investigation is warranted.

Endovascular vs. Open Repair for Ruptured Abdominal Aortic Aneurysm

Background Patients presenting with ruptured abdominal aortic aneurysms are most often treated with open repair despite the fact that endovascular aneurysm repair is a less invasive and widely accepted method with clear benefits for elective aortic aneurysm patients. A debate exists regarding the definitive benefit in endovascular repair for patients with a ruptured abdominal aortic aneurysm. The aim of this literature review was to determine if any trends exist in favor of either open or endovascular repair. Material/Methods A literature search was performed using PUBMED, OVID, and Google Scholar databases. The search yielded 64 publications. Results Out of 64 publications, 25 were retrospective studies, 12 were population-based, 21 were prospective, 5 were the results of RCTs, and 1 was a case-series. Sixty-one studies reported on early mortality and provided data comparing endovascular repair (rEVAR) and open repair (rOR) for ruptured abdominal aneurysm groups. Twenty-nine of these studies reported that rEVAR has a lower early mortality rate. Late mortality after rEVAR compared to that of rOR was reported in 21 studies for a period of 3 to 60 months. Results of 61.9% of the studies found no difference in late mortality rates between these 2 groups. Thirty-nine publications reported on the incidence of complications. Approximately half of these publications support that the rEVAR group has a lower complication rate and the other half found no difference between the groups. Length of hospital stay has been reported to be shorter for rEVAR in most studies. Blood loss and need for transfusion of either red cells or fresh frozen plasma was consistently lower in the rEVAR group. Conclusions Differences between the included publications affect the outcomes. Randomized control trials have not been able to provide clear conclusions. rEVAR can now be considered a safe method of treating rAAA, and is at least equal to the well-established rOR method.

Combined abdominal aortic aneurysmectomy and other abdominal operations

Background and Aim: Co-existence of intra-abdominal non-vascular disease with an abdominal aortic aneurysm (AAA) poses a difficult surgical challenge. Material and Methods: Review of hospital records of 602 patients undergoing elective surgery for AAA during a 9-year period identified 61 (10.3 %) patients with a co-existent intra-abdominal non-vascular disease requiring surgery. Results: The concomitant operations were 26 cholecystectomies, 11 inguinal hernia repairs, 2 small bowel resections, 5 left and 5 right hemicolectomies and 1 low anterior resection for colorectal carcinoma, 1 gastrectomy for gastric carcinoma, 5 nephrectomies, one salvage cystectomy for renal carcinoma and 1 left liver lobectomy for hepatrocellular carcinoma. Additional procedures for benign diseases prolonged the operative time by a mean of 35 (range 20–105) minutes and the major operations for malignancy by 120 (range 60–225) minutes. The overall hospital mortality and morbidity rates in the whole series of AAA (n = 602) remained as low as 0.66 % and 13.6 % respectively. There was no mortality and only two complications occurred in patients undergoing the combined procedure (n = 61). During a follow up period of 4–70 months, no graft infections were detected. Conclusion: In selected patients, the one stage approach is safe and effective. Attention should be given to the technical details and the rules of antisepsis. In elderly patients with AAA, a co-existent malignancy should be actively excluded.