Zoltán Szeberin

Variations in Abdominal Aortic Aneurysm Care: A Report from the International Consortium of Vascular Registries

Background: This project by the ICVR (International Consortium of Vascular Registries), a collaboration of 11 vascular surgical quality registries, was designed to evaluate international variation in the contemporary management of abdominal aortic aneurysm (AAA) with relation to recommended treatment guidelines from the Society for Vascular Surgery and the European Society for Vascular Surgery. Methods: Registry data for open and endovascular AAA repair (EVAR) during 2010 to 2013 were collected from 11 countries. Variations in patient selection and treatment were compared across countries and across centers within countries. Results: Among 51 153 patients, 86% were treated for intact AAA (iAAA) and 14% for ruptured AAA. Women constituted 18% of the entire cohort (range, 12% in Switzerland–21% in the United States; P<0.01). Intact AAAs were repaired at diameters smaller than recommended by guidelines in 31% of men (<5.5 cm; range, 6% in Iceland–41% in Germany; P<0.01) and 12% of women with iAAA (<5 cm; range, 0% in Iceland–16% in the United States; P<0.01). Overall, use of EVAR for iAAA varied from 28% in Hungary to 79% in the United States (P<0.01) and for ruptured AAA from 5% in Denmark to 52% in the United States (P<0.01). In addition to the between-country variations, significant variations were present between centers in each country in terms of EVAR use and rate of small AAA repair. Countries that more frequently treated small AAAs tended to use EVAR more frequently (trend: correlation coefficient, 0.51; P=0.14). Octogenarians made up 23% of all patients, ranging from 12% in Hungary to 29% in Australia (P<0.01). In countries with a fee-for-service reimbursement system (Australia, Germany, Switzerland, and the United States), the proportions of small AAA (33%) and octogenarians undergoing iAAA repair (25%) were higher compared with countries with a population-based reimbursement model (small AAA repair, 16%; octogenarians, 18%; P<0.01). In general, center-level variation within countries in the management of AAA was as important as variation between countries. Conclusions: Despite homogeneous guidelines from professional societies, significant variation exists in the management of AAA, most notably for iAAA diameter at repair, use of EVAR, and the treatment of elderly patients. ICVR provides an opportunity to study treatment variation across countries and to encourage optimal practice by sharing these results.

Serum level of soluble Hsp70 is associated with vascular calcification

It has been previously reported that serum levels of 70-kDa heat shock protein (Hsp70) are elevated in peripheral artery disease. The aim of the present study was to examine whether increased serum Hsp70 levels are related to the extent of arterial calcification and standard laboratory parameters of patients with peripheral artery disease, as well as to markers of inflammation (C-reactive protein), atherosclerosis (homocysteine), and calcification (fetuin-a). One hundred eighty chronic atherosclerotic patients with significant carotid stenosis and/or lower extremity vascular disease were enrolled in this cross-sectional study. Systemic atherosclerosis and calcification was assessed by ultrasound (carotid intima–media thickness (IMT), presence of calcification at the abdominal aorta, carotid and femoral bifurcations, and aortic and mitral cardiac valves). Standard serum markers of inflammation, diabetes, renal function, ankle-brachial indexes, and traditional risk factors for atherosclerosis were noted. Serum Hsp70 levels were measured with enzyme-linked immunosorbent assay. Standard laboratory parameters (clinical chemistry), C-reactive protein (CRP), and homocysteine levels were determined by an autoanalyzer using the manufacturer’s kits. Fetuin-a levels were measured by radial immunodiffusion. Patients’ median age was 64 (57–71) years, 69% were men, and 34.5% had diabetes. Serum heat shock protein 70 levels were significantly higher in patients with more severe arterial calcification (p < 0.02) and showed significant positive correlations with serum bilirubin (r = 0.23, p = 0.002) and homocysteine levels (r = 0.18, p = 0.02). Serum Hsp70 did not correlate with body mass index, IMT, CRP, or fetuin-a levels in this cohort. Logistic regression analysis confirmed the association between sHsp70 and calcification score (OR, 2.189; CI, 1.156–4.144, p = 0.016) and this correlation remained significant (OR, 2.264; CI, 1.021–5.020, p = 0.044) after the adjustment for age, sex, eGFR, smoking, CRP, and homocysteine levels. Our data show that serum Hsp70 levels correlate with the severity of atherosclerosis in patients with carotid artery disease and chronic lower limb ischemia. These data support a putative role for plasma Hsp70 in the development of arterial calcification. Nevertheless, further studies are required to investigate the usefulness of circulating Hsp70 level as a marker of atherosclerotic calcification.

Transfemoral endovascular treatment of proximal common carotid artery lesions: A single-center experience on 153 lesions

PURPOSE To assess primary success and safety of percutaneous transluminal angioplasty (PTA) and/or stenting of ostial/proximal common carotid artery lesions (pCCA) and to compare its 30-day stroke/mortality level with the literature data for surgical options. METHODS A total of 147 patients (153 stenoses, 6 recurrent) (71 female; 121 left) with significant diameter stenosis (>70% in symptomatic, n = 46; >85% in asymptomatic, n = 101 patients) of pCCA treated between 1994 and 2006 were retrospectively reviewed. With the exception of one, all procedures were performed using a transfemoral approach. A stent was implanted in 108 (70.5%) of cases. Stents were not available in the early years of our experience, but gradually became a routine practice. Embolic protection devices were used in 16 cases. Follow-up included neurological examination, carotid duplex scan, and office/telephone interview. RESULTS Primary technical success was 98.7% (151/153 stenoses). There were no deaths. Periprocedural (<48 hours) neurological complications included 3/153 (2.0%) ipsilateral major strokes and 4/153 (2.6%) TIAs (including one contralateral TIA). There were 8/153 (5.2%) access site hematomas, 1/153 (0.7%) bradycardia, and 1/153 (0.7%) acute left ventricular failure with respiratory distress. Follow-up was achieved in 115/147 patients (78.2%) undergoing 120 procedures for a mean of 24.7 months and revealed one additional contralateral TIA and one additional minor stroke in an asymptomatic patient. In patients with follow-up, the 30-day procedural death/all-stroke rate was 3/120 (2.5%) The cumulative primary patency rate in the 115 patients with follow-up was 97.9% +/- 2.1% at 1 year, 82.0% +/- 7.1% at 4-years, and 73.5% +/- 12.7% at 7 years. The cumulative secondary patency rate was 100% at 1 year, 88.0% +/- 7.0% at 4 years, and 88.0% +/- 11% at 7 years. Log-rank test showed no statistical difference (P = .82) in primary cumulative patency between PTA alone (n = 34) or PTA/stent (n = 86). CONCLUSION Transfemoral PTA/stenting appears to be appropriate treatment option for ostial/proximal common carotid artery significant stenoses. This study should also draw attention to the lack of data on natural history or effect of best medical treatment alone for these lesions, making evidence-based decision currently impossible for treatment of symptomatic or asymptomatic ostial and proximal common carotid artery significant stenoses.

Plasma nociceptin/orphanin FQ levels are lower in patients with chronic ischemic cardiovascular diseases--A pilot study.

BACKGROUND Clinical studies are limited regarding the role of human nociceptin/orphanin FQ (N/OFQ) in ischemic cardiovascular diseases, which are still the number one cause of death in the developed world. The aim of our study was to measure the plasma levels of N/OFQ in patients with chronic ischemic cardiovascular diseases in a pilot study. METHODS AND RESULTS Our study population consisted of 22 patients presenting symptoms of stable angina pectoris (SAP): 12 severe Canadian Cardiovascular Society (CCS) III-IV functional class, and 10 with milder SAP (CCS II-III). 12 patients were also enrolled with chronic peripheral artery disease (9 with intermittent claudication; 3 with rest pain and gangrene). Patients were asked to avoid any exertion or given analgetics for their rest pain. Patients had no episodes of chest or limb pain in 1week before their fasting blood samples were taken and N/OFQ plasma levels were measured by radioimmunoassay. 14 healthy subjects without any cardiac risk factors served as a control group. CONCLUSIONS N/OFQ levels were significantly lower in patient groups with severe vs. milder chronic angina (p<0.05) and vs. control subjects (p<0.01). Patients suffering from peripheral artery disease had also a lower plasma N/OFQ levels than in healthy controls (p<0.01). Our findings show that chronic ischemic conditions of atherosclerotic origin are associated with significantly lower plasma N/OFQ levels.

Why laparoscopic cholecystectomy today

Traditional open cholecystectomy became the “gold standard” of surgical treatment for symptomatic gallstone disease during the last century. In spite of its good results, clinicians have been trying to establish effective nonsurgical methods of eliminating gallstones. Although oral, percutaneous, or retrograde litholysis can be used effectively for cholesterol stones, these represent only 10% of all gallstones. Moreover, intracorporeal lithotripsy is an invasive method, and while extracorporeal shock wave lithotripsy is a promising procedure, even after careful selection, only 70%–80% of the patients become stone-free within 1 year. In fact, none of the methods which leave the gallbladder intact are free of complications, and they are followed by 50% stone recurrence within 5 years. Since 1987, laparoscopic cholecystectomy has become the procedure of choice as it is safe and only minimally invasive. We believe that the laparoscopic technique is a promising way to the surgery of the future.

Quality Improvement in Vascular Surgery: The Role of Comparative Audit and Vascunet

Most nations with developed healthcare systems have a strong interest in audit, both for financial and clinical quality control. Whereas financial control has been a key political requirement for managing healthcare, the use of clinical outcome data has, until recently, taken more of a back seat. Clinical audit has a long history of describing outcomes and challenging established attitudes or practice. Responses to published audits vary. Some clinicians voice criticism of bias as a result of selective reporting, either from a few units, or because of incomplete datasets. Attitudes have gradually changed with improved understanding of the role of audit as a tool to examine and refine standards of practice. This has been accompanied by a growth in clinical audit across all branches of medicine. The turn of the century marked a shift towards more widespread clinical audit, with development of political interest in using quality to justify or contain costs. The advent of organisations such as the National Institute for Clinical Excellence (NICE) in the UK saw a growth in the use of research and audit to set standards both for outcomes and processes of care. A good example of this in vascular surgery is the NICE clinical guideline 68, which sets out clear standards for assessment, referral, and treatment of patients with TIA and minor stroke. These standards are incorporated into national audits in Europe and reporting now encompasses both outcomes and performance indicators such as timeliness of surgery and cranial nerve injury. Such reporting has driven improvement in quality of services by focussing clinicians on key components of highquality pathways of care. Vascunet was formed in 1997 as a collaboration of national registries in Europe, New Zealand, and the state of Victoria in Australia, with its first report produced in 2007. Since then, the Vascunet group have published comparative data on carotid surgery, abdominal aortic aneurysm, lower limb bypass, and popliteal artery aneurysm. One of the key features of these publications has been to describe the variation in clinical practice across neighbouring countries, notable examples being rates of surgery for asymptomatic stenosis and rates of lower limb bypass for intermittent claudication. Variation in outcomes is also reported at a national level. The value of such reporting was demonstrated by the 2008 Vascunet report. This demonstrated outlying mortality

Decreased plasma nociceptin/orphanin FQ levels after acute coronary syndromes

Foregoing researches made on the N/OFQ system brought up a possible role for this system in cardiovascular regulation. In this study we examined how N/OFQ levels of the blood plasma changed in acute cardiovascular diseases. Three cardiac patient groups were created: enzyme positive acute coronary syndrome (EPACS, n = 10), enzyme negative ACS (ENACS, n = 7) and ischemic heart disease (IHD, n = 11). We compared the patients to healthy control subjects (n = 31). We found significantly lower N/OFQ levels in the EPACS [6.86 (6.21-7.38) pg/ml], ENACS [6.97 (6.87-7.01) pg/ml and IHD groups [7.58 (7.23-8.20) pg/ml] compared to the control group [8.86 (7.27-9.83) pg/ml]. A significant correlation was detected between N/OFQ and white blood cell count (WBC), platelet count (PLT), creatine kinase (CK), glutamate oxaloacetate transaminase (GOT) and cholesterol levels in the EPACS group.Decreased plasma N/OFQ is closely associated with the presence of acute cardiovascular disease, and the severity of symptoms has a significant negative correlation with the N/OFQ levels. We believe that the rate of N/OFQ depression is in association with the level of ischemic stress and the following inflammatory response. Further investigations are needed to clarify the relevance and elucidate the exact effects of the ischemic stress on the N/OFQ system.

Unusual Open Surgical Repair of a Type IB Endoleak and a Giant Symptomatic Aortic Aneurysm following Stent Grafting for Type B Aortic Dissection

Treatment of type IB endoleak after thoracic endovascular aortic repair (TEVAR) for post-dissection aortic aneurysm usually includes attempts of endovascular interventions using coils or plugs to occlude the false lumen or placement of a distal fenestrated endograft. Open conversion usually requires deep hypothermia and circulatory arrest with the associated increased mortality and complications. We present a case of a young patient with a 90 mm descending thoracic aneurysm caused by a chronic type B aortic dissection. A type II endoleak after TEVAR was successfully treated with left subclavian artery transposition. The patient had a rapidly increasing aortic aneurysm with a persistent type IB endoleak in spite of placement of an Amplatzer plug into the false lumen of the dissection. He developed progressive acute compression of the main stem bronchi by the aneurysm sac and his dyspnea worsened by an acute pulmonary embolism treated with anticoagulation. Adequate oxygenation could only be achieved with mechanical ventilation using a double-lumen endobronchial tube. A left thoracotomy was performed and the type IB endoleak was treated with bending of the distal aorta around the stent graft with a Dacron graft sleeve. Aortic clamping and circulatory support devices were avoided. The sac of the aneurysm was opened, a giant hematoma was evacuated, and aneurysmorrhaphy was performed to cover the stent graft. There was no residual endoleak and the bronchi were decompressed. The patient recovered after prolonged hospitalization and he was discharged home in good condition 24 days after admission. He returned to his normal activities and is asymptomatic 5 months later. Computed tomographic angiography showed decreased aneurysm sac, no evidence of endoleak, no residual pulmonary embolus, and no bronchial compression.

Fetuin-A serum levels in patients with aortic aneurysms of Marfan syndrome and atherosclerosis.

Eur J Clin Invest 2011; 41 (2): 176–182

Few internal iliac artery aneurysms rupture under 4 cm

Objective: This study investigated the diameter of internal iliac artery (IIA) aneurysms (IIAAs) at the time of rupture to evaluate whether the current threshold diameter for elective repair of 3 cm is reasonable. The prevalence of concomitant aneurysms and results of surgical treatment were also investigated. Methods: This was a retrospective analysis of patients with ruptured IIAA from seven countries. The patients were collected from vascular registries and patient records of 28 vascular centers. Computed tomography images taken at the time of rupture were analyzed, and maximal diameters of the ruptured IIA and other aortoiliac arteries were measured. Data on the type of surgical treatment, mortality at 30 days, and follow‐up were collected. Results: Sixty‐three patients (55 men and 8 women) were identified, operated on from 2002 to 2015. The patients were a mean age of 76.6 years (standard deviation, 9.0; range 48‐93 years). A concomitant common iliac artery aneurysm was present in 65.0%, 41.7% had a concomitant abdominal aortic aneurysm, and 36.7% had both. IIAA was isolated in 30.0%. The mean maximal diameter of the ruptured artery was 68.4 mm (standard deviation, 20.5 mm; median, 67.0 mm; range, 25‐116 mm). One rupture occurred at <3 cm and four at <4 cm (6.3% of all ruptures). All patients were treated, 73.0% by open repair and 27.0% by endovascular repair. The 30‐day mortality was 12.7%. Median follow‐up was 18.3 months (interquartile range, 2.0‐48.3 months). The 1‐year Kaplan‐Meier estimate for survival was 74.5% (standard error, 5.7%). Conclusions: IIAA is an uncommon condition and mostly coexists with other aortoiliac aneurysms. Follow‐up until a diameter of 4 cm seems justified, at least in elderly men, although lack of surveillance data precludes firm conclusions. The mortality was low compared with previously published figures and lower than mortality in patients with ruptured abdominal aortic aneurysm.