Triantafillos G. Giannakopoulos

Current role of biomarkers in carotid disease: a systematic review

Background and purpose Accumulating evidence suggests that carotid plaque vulnerability can be used as a determinant of ischemic stroke risk stratification and carotid intervention. Novel markers of high-risk carotid plaque in patients are needed. Summary of review Advances in cellular and molecular pathophysiology, the demand for accurately predicting carotid risk, and choosing the optimal prevention strategy are stimulating great interest in the development of novel surrogate markers. Biomarkers in cardiovascular disease are expected to predict the natural history, clinical outcomes, and the efficacy of disease-modifying interventions. We aimed to review the literature regarding clinical data on novel serum biomarkers related to ischemic cerebrovascular events associated with carotid artery disease. We provide background information on the biomarkers related to all aspects of carotid disease: natural history, carotid intervention strategies for symptomatic and asymptomatic patients, perioperative risk prediction, and their therapeutic implications. Conclusion At present, heterogeneous data support evidence that biological markers can help existing practices to more accurately assess patients at risk for stroke. Randomized-controlled trials for carotid artery disease and carotid intervention, incorporating biomarkers, are needed.

Predictors affecting in-hospital mortality of ruptured abdominal aortic aneurysms: a Greek multicenter study.

BACKGROUND Endovascular aortic repair (EVAR) is being used with increasing frequency for the treatment of ruptured abdominal aortic aneurysms (rAAAs), although conflicting results have been reported concerning perioperative mortality. The aim of our study was to evaluate potential difference in mortality rates between EVAR and open surgical repair (OSR) and identify independent risk factors for in-hospital mortality in rAAAs. This study also aimed to evaluate the Glasgow Aneurysm Score (GAS) in predicting in-hospital mortality. A time-trend analysis of EVAR for ruptured AAAs was also performed. METHODS Prospectively collected data from 7 public hospitals in Greece concerning rAAA repairs between January 2006 and April 2012 were analyzed. Primary outcome was in-hospital mortality. Multivariate logistic regression analysis was used to identify independent risk factors. The receiver-operator characteristic curve was used to determine the value of the GAS in predicting in-hospital death. Time-trend analysis, depicting annual changes (%), concerning EVAR for ruptured AAAs was also conducted. RESULTS A total of 418 patients (92.3% men, mean age = 74.3 ± 8.8) with rAAAs were recorded during the study period. Among them, 113 patients (27%) underwent EVAR. Overall in-hospital mortality was 45.2%, whereas in-hospital mortality after EVAR and OSR was 20.4% and 54.3%, respectively (P < 0.001). Multivariate analysis evidenced that hemodynamic instability (P < 0.001), OSR (P < 0.001), age ≥80 years (P < 0.001), coronary artery disease (P < 0.001), and renal insufficiency (P = 0.02) independently increased in-hospital mortality. Area under the curve of GAS was 0.80 (95% confidence interval [CI] = 0.75-0.85, P < 0.001) for OSR and 0.64 (95% CI = 0.51-0.77, P = 0.04) for EVAR. Annual increase of proportion (%) of EVAR for rupture was 5% (P = 0.004). CONCLUSIONS EVAR is being used with increasing frequency for the treatment of rAAAs and it appears to be associated with lower in-hospital mortality compared with OSR, after adjustment for hemodynamic instability and known atherosclerotic risk factors. Preoperative predictors of in-hospital mortality such as GAS should be probably modified in these patients.

Endograft Accommodation on the Aortic Bifurcation: An Overview of Anatomical Fixation and Implications for Long-term Stent-Graft Stability

In light of the results of randomized trials, it seems that despite the favorable short and midterm outcomes of standard endografts, concern over endograft migration has escalated, as this event will be responsible for almost all late complications in endovascular aneurysm repair (EVAR). Migration forces, both caudal and sideways, depend heavily on blood pressure, inlet diameter, and angulation of the stent-graft, while the bifurcation generates more force than any other segment of the stent-graft. It thus seems that the position of the endografts flow divider influences force distribution and migration risk. Additionally, due to concomitant ongoing aortic degeneration, postoperative dilatation of the infrarenal aortic neck poses a threat to EVAR patients as soon as the diameter of the infrarenal neck reaches the dimensions of the proximal graft. This review evaluates the significance of endograft accommodation on the aortic bifurcation and cumulative experience of the only endografts utilizing this feature: the Zenith Composite and the Powerlink.

Rupture after endovascular abdominal aortic aneurysm repair: a multicenter study.

A total of 22 patients with ruptured abdominal aortic aneurysms (rAAAs) after previous endovascular aortic repair (EVAR; rAAAevar) were presented to 7 referral hospitals in Greece, between January 2006 and April 2012. Type Ia endoleak and endograft migration were identified in 72.7% and 50%, respectively. Compliance to follow-up protocol prior to rupture was 31.8%. In-hospital mortality was 36.4% (9.1% for those treated with secondary EVAR and 63.6% for those treated with open surgical repair, P = .02). An increase in the proportion of patients with rAAAevar among the total number of patients with rAAAs from 1.3% in 2007 to 18.2% in 2012 (P for trend = .04) was recorded, corresponding to an annual increase of 2.8% (b = 2.84, P = .04). Rupture after EVAR seemed to be a clinical entity encountered with increasing frequency over the past years. Type I endoleak and endograft migration were most frequently observed, whereas compliance to follow-up was low.

Retrograde Transpopliteal Approach of Iliofemoral Lesions

Purpose: Aim of this study is to present our initial experience with the use of the retrograde popliteal artery access in patients with certain anatomic lesions. Methods: Between September 2008 and September 2010, 24 patients underwent a transpopliteal retrograde subintimal recanalization. Instead of its usage when antegrade recanalization failed, the “facedown” technique was preferred as a first choice in patients with common femoral artery stenosis or occlusion, proximal lesions of the superficial femoral artery (SFA) with no stump, severe obesity, tandem iliac, and SFA lesions. Results: Technical success was achieved in 91.7% of patients.The complication rate was 12.5%. The primary patency at 6, 12, and 18 months was 86.4%, 65.8%, and 65.8%, respectively. Conclusions: The retrograde popliteal artery approach can be considered as the primary SFA recanalization strategy in carefully selected patients, with competitive immediate and midterm results.

Extracranial internal carotid artery aneurysm

Extracranial internal carotid artery aneurysms are rare but dangerous, associated with a high risk of neurological thromboembolic events, cranial nerve compression, and, more rarely, rupture. A 74-year-old male was admitted to our hospital because of a pulsatile mass at the left side of the neck, below the angle of the mandible. The patient reported that he had noticed the mass for the first time 5 years before. The mass had been considered to derive from the left submandibular gland, and a fine needle aspiration was performed, which was negative for malignancy. Over the past few months, the size of the mass increased rapidly, and its pulsatile nature became more evident. The patient was submitted to a color Duplex scan, which revealed the presence of an aneurysm of a kinked left internal carotid artery (ICA). A computed tomography angiography followed, verifying the presence of a giant aneurysm of the left ICA, measuring 7 cm in diameter (A/Cover). The ICA was kinked 2 cm distally to the carotid bifurcation, and after 3 more cm, a saccular aneurysm arose with no intraluminal thrombus. The huge aneurysm was displacing the distal ICA laterally, so that the proximal and the distal part of the ICA were almost in contact. The anatomy of the aneurysm made endovascular treatment impossible, due to the kinking of the ICA, but it facilitated open surgical repair, due to the elongation of the ICA and the fact that both the proximal and the distal part of the ICA were displaced laterally and in close proximity with each other. The patient was taken to the operating room and, under general anesthesia, a standard anterior sternocleidomastoid incision was made. The carotid bifurcation, the proximal and the distal part of the ICA were exposed (B), and the aneurysm was ligated proximally and distally. The continuity of the ICA was restored with a beveled end-to-end anastomosis compensating for the significant diameter mismatch between the two parts of the ICA (C). The aneurysm was not resected, but its 40-mL content was evacuated by needle puncture and aspiration with a syringe. The postoperative course was uneventful. Informed consent to the publication of his anonymous data was obtained from the patient.

Contemporary Applications of Ultrasound in Abdominal Aortic Aneurysm Management

Ultrasound (US) is a well-established screening tool for detection of abdominal aortic aneurysms (AAAs) and is currently recommended not only for those with a relevant family history but also for all men and high-risk women older than 65 years of age. The advent of minimally invasive endovascular techniques in the treatment of AAAs [endovascular aneurysm repair (EVAR)] has increased the need for repeat imaging, especially in the postoperative period. Nevertheless, preoperative planning, intraoperative execution, and postoperative surveillance all mandate accurate imaging. While computed tomographic angiography and angiography have dominated the field, repeatedly exposing patients to the deleterious effects of cumulative radiation and intravenous nephrotoxic contrast, US technology has significantly evolved over the past decade. In addition to standard color duplex US, 2D, 3D, or 4D contrast-enhanced US modalities are revolutionizing AAA management and postoperative surveillance. This technology can accurately measure AAA diameter and volume, and most importantly, it can detect endoleaks post-EVAR with high sensitivity and specificity. 4D contrast-enhanced US can even provide hemodynamic information about the branch vessels following fenestrated EVARs. The need for experienced US operators and accredited vascular labs is mandatory to guarantee the reliability of the results. This review article presents a comprehensive overview of the literature on the state-of-art US imaging in AAA management, including post-EVAR follow-up, techniques, and diagnostic accuracy.

Vascular Surgery in Greece in the Wake of Financial Crisis

Vascular surgery in Greece has been thriving over the past 20 years being one of the first European countries that implemented an independent specialty curriculum and got separated from General Surgery in 1989. The endovascular procedures got integrated early on into the vascular training curriculum and vascular surgeons hold the vast majority of aortic and a significant percentage of peripheral endovascular procedures against other specialties. In the midst of a global economic crisis and while Greek governments had been spending for years more than their means, Greece fell into recession in 2009 and the economy entered a deep structural and multi-faceted crisis. This had an immediate impact in the health system structure and health expenditures. While structural reforms were long awaited, side effects including personnel and resource reduction could not be avoided. Health care, health indices, medical research and education have been all affected in the wake of this financial crisis. As contemporary vascular practice has shifted to minimal invasive expensive endovascular technology the ability of a financially-drained health system to sustain such expenditure is currently challenged.

Management of Peripheral and Truncal Venous Injuries

Civilian injuries are increasing according to the World Health Organization, and this is attributed mainly to road traffic accidents and urban interpersonal violence. Vascular injuries are common in these scenarios and are associated with high morbidity and mortality rates. Associated peripheral venous trauma is less likely to lead to death and controversy remains whether ligation or repair should be the primary approach. Conversely, non-compressible truncal venous insult can be lethal due to exsanguination, thus a high index of suspicion is crucial. Operative management is demanding with fair results but recent endovascular adjuncts demonstrate promising results and seem to be the way forward for these serious conditions.