New possibility of AAA treatment with E-vita abdominal device

The most dramatic shift in the management of abdominal aortic aneurysms (AAAs) occurred in 1991, when the first endovascular AAA repair was reported. Endovascular aneurysm repair has revolutionized the treatment of infrarenal AAAs. In the last few years, the companies have developed renewed models of grafts and have modified delivery systems tending to make them more atraumatic and flexible in order to deal with difficult anatomies and severely atheromatous and tortuous vessels. The aim of the present paper was to analyze the technical characteristics and properties of the new stent-graft system E-vita abdominal XT and to review the current literature. The E-vita abdominal XT stent-graft seems to be safe and reliable; however, long-term results are needed.

The anti-inflammatory effects of exercise training promote atherosclerotic plaque stabilization in apolipoprotein E knockout mice with diabetic atherosclerosis

Physical exercise is the cornerstone of cardiovascular disease treatment. The present study investigated whether exercise training affects atherosclerotic plaque composition through the modification of inflammatoryrelated pathways in apolipoprotein E knockout (apoE^−/−) mice with diabetic atherosclerosis. Forty-five male apoE^−/− mice were randomized into three equivalent (n=15) groups: control (CO), sedentary (SED), and exercise (EX). Diabetes was induced by streptozotocin administration. High-fat diet was administered to all groups for 12 weeks. Afterwards, CO mice were euthanatized, while the sedentary and exercise groups continued high-fat diet for 6 additional weeks. Exercising mice followed an exercise program on motorizedtreadmill (5 times/week, 60 min/session). Then, blood samples and atherosclerotic plaques in the aortic root were examined. A considerable (P<0.001) regression of the atherosclerotic lesions was observed in the exercise group (180.339±75.613×10³µm²) compared to the control (325.485±72.302×10³ µm²) and sedentary (340.188±159.108×10³µm²) groups. We found decreased macrophages, matrix metalloproteinase-2 (MMP-2), MMP-3, MMP-8 and interleukin-6 (IL-6) concentrations (P<0.05) in the atherosclerotic plaques of the exercise group. Compared to both control and sedentary groups, exercise training significantly increased collagen (P<0.05), elastin (P<0.001), and tissue inhibitor of matrix metalloproteinase-2 (TIMP-2) (P<0.001) content in the atherosclerotic plaques. Those effects paralleled with increased fibrous cap thickness and less internal elastic lamina ruptures after exercise training (P<0.05), while body-weight and lipid parameters did not significantly change. Plasma MMP-2 and MMP-3 concentrations in atherosclerotic tissues followed a similar trend. From our study we can conclude that exercise training reduces and stabilizes atherosclerotic lesions in apoE^−/− mice with diabetic atherosclerosis. A favorable modification of the inflammatory regulators seems to explain those beneficial effects.

The differential anti-inflammatory effects of exercise modalities and their association with early carotid atherosclerosis progression in patients with type 2 diabetes

OBJECTIVE

Adipokines, visfatin, apelin, vaspin and ghrelin have emerged as novel cardiovascular risk factors. We aimed to evaluate the effects of different exercise modalities on the aforementioned novel adipokines and carotid intima-media thickness in patients with Type 2 diabetes mellitus.

METHODS

One hundred patients with Type 2 diabetes were equivalently (n = 25) randomized into four groups: (1) a control group with patients encouraged to perform self-controlled exercise; (2) a supervised aerobic exercise group (exercise four times/week, 60 min/session, 60-75% of maximum heart rate); (3) a resistance training group (60-80% baseline maximum load achieved in one repetition); and (4) a combined aerobic exercise plus resistance training group, as in groups 2 and 3. All participants had HbA(1c) levels ≥ 48 mmol/mol (≥ 6.5%), without overt diabetic vascular complications. Blood samples, clinical characteristics, peak oxygen uptake and carotid intima-media thickness measurements were obtained at baseline and at the end of the study, after 6 months.

RESULTS

At baseline, there were non-significant differences between groups. All active groups significantly ameliorated glycaemic profile, insulin sensitivity and triglycerides levels compared with the control group (P < 0.05). Aerobic training further improved lipids, systolic blood pressure and exercise capacity compared with the resistance training and the control groups (P < 0.05). Moreover, high-sensitivity C-reactive protein and visfatin decreased, while vaspin and apelin circulating levels increased within the aerobic exercise group and the aerobic exercise plus resistance training group, and compared with the other groups (P < 0.05). Within- and between-group comparisons showed negligible alterations in ghrelin serum levels and body weight after all exercise modalities. Finally, aerobic training attenuated the carotid intima-media thickness progression (0.017 ± 0.006 mm) compared with the control subjects (0.129 ± 0.042 mm, P < 0.001). That effect was independently associated with visfatin and amelioration of peak oxygen uptake.

CONCLUSIONS

In subjects with Type 2 diabetes, all exercise training modalities improved metabolic profile. Importantly, aerobic training predominantly ameliorated adipokines concentrations and carotid intima-media thickness progression.

Current knowledge on EVAR with the ultra-low profile Ovation Abdominal Stent-graft System

Endovascular aneurysm repair (EVAR) has revolutionized the treatment of infrarenal abdominal aortic aneurysms (AAAs). The continuous collaboration of surgeons and bioengineers in the improvement of the devices the last two decades, lead to a continuous redesigning and improvement of the various endografts. In the last few years, the majority of companies have developed renewed models of grafts and have modified delivery systems tending to lower profile in order to deal with difficult anatomies. The ultra low profile 14F OD Ovation (Trivascular) Abdominal Stent-graft System with innovative sealing technology achieved through inflatable sealing rings, allows treatment of AAAs with small in diameter access vessels that might be unsuitable for EVAR with other currently available stent-grafts. The aim of the present paper was to analyze the technical characteristics and properties of this endograft and to review the current literature.

The critical role of the external carotid artery in cerebral perfusion of patients with total occlusion of the internal carotid artery

AIM

The ipsilateral external carotid artery (ECA) can potentially provide an important collateral pathway for cerebral blood flow in the presence of occlusion or severe stenosis of the internal carotid artery (ICA), recovering up to 15% of the middle cerebral arterial flow. The aim of the study is to elucidate the role of ECA in cerebral flow of patients with total ICA occlusion.

METHODS

Retrospective study of prospectively collected data of 139 patients with total ICA occlusions. The patients were divided to symptomatic and asymptomatic and were categorized in four subgroups according to the stenosis rates: A) ipsilateral ECA<70% and contralateral internal carotid artery stenosis <70%; B) ipsilateral ECA stenosis <70% and contralateral internal carotid artery stenosis ≥70%; C) ipsilateral ECA stenosis ≥70% and contralateral ICA stenosis <70%; D) ipsilateral ECA stenosis ≥70% and contralateral ICA stenosis ≥75%.

RESULTS

Fifty eight (41.7%) patients were asymptomatic. The highest rate (48.2%) of asymptomatic patients was in Group A. Among patients with strokes, the highest rate belonged in groups C and D (44.4% and 50% respectively) where ipsilateral ECA stenosis was ≥70% irrespectively of the contralateral ICA patency. Ipsilateral external carotid artery stenosis ≥70% proved to be and independent risk factor for symptom presentation (P=0.013).

CONCLUSION

The study reveals the significant role of ECA patency in cerebral flow in patients with ICA occlusion.

Heparin-induced thrombocytopenia: what a vascular surgeon needs to know

The use of unfranctioned heparin and low molecular weigh heparins is very common in general medical practice and moreover in angiology and vascular surgery. Heparin-induced thrombocytopenia is a rare, yet catastrophic complication, with an incidence of 1-5% of patients receiving heparin therapy. Clinical presentation may include deep vein thrombosis, pulmonary embolism, arterial thrombosis, and skin lesions. Hemorrhage may also be present as a result of thrombocytopenia. Current diagnostic criteria include clinical scoring systems as well as laboratory tests for the identification of the specific antibodies. Efficient new alternative anticoagulant agents have been developed and are currently indicated for the treatment of such patients. The syndrome curies up to 53% thrombosis risk in untreated patients, and 28% mortality risk in patients complicated with thrombosis. This article aims in a comprehensive review of the literature for newly emerged data in the pathogenesis, diagnosis and management of heparin-induced thrombocytopenia.

Vascular surgery training and its relationship to other surgical specialties

During the last 50 years vascular surgery has met an enormous evolution, paving the way for the development of modern vascular and endovascular surgery. Although, vascular surgery (VS) has emerged from general (GS) and cardiothoracic surgery (CTS), the need for specialized training has been recognized and gradually practice patterns are shifting towards vascular independence, but yet not in all countries. In these countries VS training is either permitted only after prerequisite GS certification, or as a non accredited surgical specialty, VS might be included in GS or CTS training and certification. Such a policy raises two main issues: the efficiency of vascular training within the GS or CTS curricula and the performance of vascular interventions by general or cardiothoracic surgeons. Meanwhile, the explosion of endovascular procedures has brought new disciplines into play, each one wanting to maintain its stake in the future. Interventional radiologists and a significant number of cardiologists become increasingly involved in the treatment of vascular diseases. The question of which specialist among those qualified should carry out medical treatment, open, and endovascular procedures is still suspended. Under this prism, vascular training issues arise as an important component of the future of vascular surgeons.

Effects of rosiglitazone/metformin fixed-dose combination therapy and metformin monotherapy on serum vaspin, adiponectin and IL-6 levels in drug-naïve patients with type 2 diabetes

OBJECTIVE

Vaspin, adiponectin and interleukin-6 (IL-6) constitute novel adipose-tissue derivatives, known as adipokines, which mediate insulin resistance. The aim of the present study was to evaluate the effects of metformin and rosiglitazone on serum levels of those novel adipokines in drug-naïve patients with type 2 diabetes mellitus (T2DM).

METHODS

140 patients with T2DM, already treated with diet, but without adequate glycemic control (HbA1c > 7%), were randomly assigned to: RSG+MET group, (n = 70): Combination therapy with fixed dose of 4 mg rosiglitazone plus 500 mg metformin. MET group, (n = 70): Half-maximum dose of metformin monotherapy (1 700 mg/day). Before and after 6-month treatment, body-mass index (BMI), blood pressure (BP), fat-mass, fasting plasma glucose (FPG), HbA1c, insulin resistance indexes (HOMA-IR, insulin), lipids, high-sensitivity CRP (hsCRP), vaspin, adiponectin, and interleukin-6 (IL-6) were measured.

RESULTS

Glucose regulation and insulin resistance were equivalently improved from baseline within both groups (p < 0.05). There was a considerable amelioration of hsCRP, WBC, adiponectin, IL-6, systolic and diastolic BP with rosiglitazone/metformin combined treatment as compared to baseline (p < 0.05) and MET group (p < 0.05). In contrast, metformin monotherapy significantly reduced BMI (p < 0.001), total-cholesterol (p = 0.012) and LDL (p = 0.020) levels compared to RSG+MET group. Importantly, serum vaspin concentration was equivalently decreased from baseline in both RSG+MET (-0.96 ± 0.75 ng/ml, p < 0.001) and MET (-0.92 ± 0.57 ng/ml, p=0.001) group. The aforementioned vaspin changes correlated with changes in WHR, HbA1c, FPG, HOMA-IR, insulin, IL-6 (only in the RSG+MET group) and fat-mass. In standard multiple regression analysis, FPG, HbA1c, HOMA-IR and insulin remained independent determinants of serum vaspin levels changes (R² = 0.836, p = 0.004).

CONCLUSIONS

Both rosiglitazone/metformin combination therapy and metformin monotherapy decreased serum vaspin levels through glucose and insulin sensitivity regulation, while they exerted differential effects on adiponectin, IL-6 and other cardiovascular risk factors in drug-naïve patients with T2DM.

Current knowledge on E-vita abdominal endograft

The field of endovascular abdominal aortic repair has changed remarkably compared to what it was prior to 1993, the year of the first commercial endograft deployment in the United States. Over the years of endovascular aneurysm repair experience, various companies have attempted to construct an ideal stent-graft for exclusion of an abdominal aortic aneurysm (AAA). However, it has become evident that not all abdominal aortic anatomies are amenable to endovascular treatment and that the rationale "one device fits all AAAs" can lead to disastrous results. Different endografts have dissimilar properties and characteristics. Type of graft material, configuration and type of stent structural support, modularity, type of transrenal fixation, are potentially influential factors of endograft behavior. The self-expanding E-vita abdominal stent-graft (JOTEC, Hechingen, Germany) is a relatively new infrarenal, modular stent-graft with suprarenal fixation designed for AAA reconstruction. The present paper analyzes the technical characteristics and properties of this device. We also analyze our experience with the endoprosthesis and review the current literature.

An update of the role of endovascular repair in blunt carotid artery trauma

Blunt carotid injury (BCAI) is an increasingly recognised entity in trauma patients. Without a prompt diagnosis and a proper treatment, they can result in devastating consequences with cerebral ischaemia rate of 40-80% and mortality rate of 25-60%. Several applied screening protocols and continuously improving diagnostic modalities have been developed to identify patients with BCAI. The appropriate treatment of BCAI still remains controversial and strictly individualised. Besides anti-thrombotic/anticoagulation therapy and surgical intervention, continuously evolving endovascular techniques emerge as an additional treatment option for patients with BCAI. We provide an update on blunt carotid trauma, emphasising the role of endovascular approaches.

Urgent CAS for patients in high neurologic risk

Patients with residual carotid stenosis discovered following an acute ischemic insult represent a new subset of patients eligible for early carotid intervention that may decrease the risk of recurrent stroke by new emboli and improve cerebral blood flow. Short-term clinical outcomes of patients undergoing urgent CAS appear favorable, indicating that endovascular management may be a reasonable treatment option, particularly when combined with endovascular interventions for intracranial lesions. Data on indication and complication profiles are still limited. This review focuses on current knowledge, advantages and pitfalls of urgent and/or early (up to 2 weeks) carotid stenting in those presenting with an acute neurologic event or recently symptomatic carotid stenosis.

Visfatin (nampt) and ghrelin as novel markers of carotid atherosclerosis in patients with type 2 diabetes

OBJECTIVE

Visfatin (nampt) and ghrelin are the most recently identified adipocytokines, but their role in atherosclerosis is poorly clarified. In our study we investigated their association with advanced carotid atherosclerosis and carotid intima-media thickness (CIMT) in patients with type 2 diabetes mellitus (T2DM).

METHODS

122 patients (50 males) with T2DM, aged 55-70 were enrolled. Sixty-four age- and sex-matched healthy individuals served as controls (group A). CIMT was assayed in all participants by ultrasound. Among diabetic patients, 47 appeared with carotid plaques (group B), while 75 without plaques (group C). Anthropometric parameters, blood pressure, glycemic and lipid profile, high-sensitivity CRP (hsCRP), insulin resistance (HOMA-IR), fibrinogen, nampt and ghrelin were measured.

RESULTS

Diabetic patients had a higher mean-CIMT, increased body-mass index, worse lipid profile, elevated blood pressure and higher levels of white blood cells count, nampt and hsCRP with respect to controls (p<0.01). Among diabetic patients, groups B and C were comparable in anthropometric, glycemic and lipid parameters. Serum nampt was significantly higher in group B rather than in groups A and C (p<0.05). On the other hand, ghrelin levels were considerably lower only in diabetic patients with carotid atherosclerosis compared with healthy individuals. In univariate analysis, mean-CIMT correlated with age (r=0.312; p=0.003), nampt (r=0.341; p<0.001) and ghrelin (r=-0.421; p=0.002) and the latter associations remained significant in multiple regression analysis.

CONCLUSIONS

High nampt and low ghrelin serum levels are significantly associated with advanced carotid atherosclerosis in patients with T2DM. Moreover these adipocytokines are independently associated with CIMT, implicating their role as novel atherosclerotic biomarkers and providing another important link between adiposity and atherosclerosis.

Self-assessment of technical skill in surgery: the need for expert feedback

INTRODUCTION

Technical skill has been formally assessed in the Fellow of the European Board of Vascular Surgery Examinations (FEBVS) since 2002. The aim of this study was to examine the relationship between expert assessment and trainee self-assessment.

MATERIALS AND METHODS

Forty-two examination candidates performed a saphenofemoral junction (SFJ) ligation and an anterior tibial anastomosis on a synthetic simulation. Each candidate was rated by two examiners using a validated rating scale for their generic surgical skill for both procedures. Candidates then anonymously rated their own performance using the same scale. Parametric tests were used in the statistical analysis; a P-value < 0.05 was considered significant.

RESULTS

The maximum mark in each assessment was 40; 24 was considered a competent score. The interobserver correlation for examiners marks were high (SFJ ligation, alpha = 0.68; distal anastomosis, alpha = 0.76). Examiners' marks were averaged. The mean examiner score for the SFJ ligation station was 27.8 (SD = 4.1) with 36 candidates (85.8%) attaining a competent score. The mean self-assessment score for this station was 30.7 (SD = 4.66). The mean examiners' marks for the distal anastomosis station was 29.2 (SD = 4.2); 39 candidates (92.8%) attained a competent score. The mean self-assessment score was 32.1 (SD = 4.0). There was no correlation between examiner and self-assessment scores in either station (Pearson's correlation coefficient: SFJ, r = 0.045, P = NS); distal anastomosis, r = 0.089, P = NS). Bland and Altman plots assessed the agreement between examiner and self-assessment. These showed candidates marked themselves higher than examiners with a mean difference of 2.9 marks in each station.

CONCLUSIONS

Candidates' self-assessment and expert independent assessment correlate poorly. Trainees overestimate their ability according to independent assessment; regular technical feedback during training is, therefore, essential.

Beneficial effects of rosiglitazone on novel cardiovascular risk factors in patients with Type 2 diabetes mellitus

AIM

Impaired exercise capacity, adiponectin, MMPs and TIMPs have all been implicated in the development of cardiovascular disease. The aim of our study was to determine the effects of rosiglitazone on these factors in diabetic patients.

METHODS

Seventy individuals with Type 2 diabetes were assigned randomly to either a rosiglitazone group (8 mg/day, RG) or a control group (CG) for 6 months. All participants took gliclazide 160 mg plus metformin 1700 mg in stable dose. None of the individuals had diabetic complications or had previously participated in an exercise programme. Anthropometric parameters, VO2 peak, oxygen pulse, glycaemic indices, lipid profile, adiponectin, insulin resistance, blood pressure and serum MMP-9, TIMP-1, TIMP-2 levels were assessed at baseline and at the end of the study. After Bonferroni adjustment, a P-value < 0.017 was assumed to be statistically significant.

RESULTS

Rosiglitazone treatment significantly increased VO2 peak (P < 0.0001), the duration of the exercise test (P < 0.0001), oxygen pulse (P = 0.010) and TIMP-2 levels (P = 0.008) in comparison with CG. Insulin resistance, hyperglycaemia, diastolic blood pressure and MMP-9 levels were also reduced (P < 0.017). Fat mass, lipid profile, TIMP-1 levels and MMP9 : TIMP-1 ratio were unaltered after rosiglitazone treatment. There were no significant changes in these parameters in control subjects. In univariate analysis, the rosiglitazone-induced increment of VO2 peak was associated with alterations in plasma adiponectin (r = 0.691), HOMA-IR (r = -0.782) and HbA(1c) (r = -0.676) (P < 0.017). These relationships retained significance after multiple regression analysis (P = 0.005).

CONCLUSIONS

Rosiglitazone treatment increases cardiorespiratory fitness and modulates favourably serum adiponectin, MMP-9 and TIMP-2 levels. Whether these effects produce cardiovascular benefits in the long term requires further investigation.

European continuing medical education in vascular surgery: 5-year results of congresses approved by the Union Européenne des Médecins Spécialistes Section of Vascular Surgery

AIM

Continuing medical education (CME) can be defined as ''educational activities that serve to maintain, develop, or increase the knowledge, skills and professional performance of a physician to provide services for patients, the public, or the profession''. CME is a major professional responsibility. The European Board of Vascular Surgery of the Union Européenne des Médecins Spécialistes (UEMS) Section of Vascular Surgery has, through its European Vascular CME (EVCME) Committee, accredited 74 congresses during the 5-year period from 2000-2004.

METHODS

Official evaluation forms were completed by the congress participants for a personal appraisal of the quality of the activities. The data in this manuscript focused on questions that were the most relevant and of the greatest interest to the participants. A statistical analysis of the results was performed utilizing ANOVA and Robust tests of equality of means as well as a posthoc analysis for further investigation, and non parametric Wilcoxon signed ranks test.

RESULTS

The educational needs of participants regarding new diagnostic and therapeutic modes were stated as ''important'' and ''extremely important'' in the responses at over 80% in total. Over 75% of the participants answered ''extremely important'' and ''important'' to the question ''how important is evidence-based practice to your practice''.

CONCLUSION

This survey indicates that the EVCME approved congresses had a positive impact for the vascular surgeon by updating overall knowledge on vascular surgery; the majority of comments by the participants also indicates that EVCME is fulfilling its aim to bring as much evidence-based practice as possible into the daily work schedule of the surgeon by turning knowledge acquired by CME into performance of the participants.

Lipid Management and Peripheral Arterial Disease

Peripheral arterial disease (PAD) is a common disorder usually associated with silent or symptomatic arterial disease elsewhere in the circulation and a "cluster" of cardiovascular risk factors (e.g. smoking, dyslipidemia, hypertension, and insulin resistance/diabetes mellitus). The medical management of PAD should focus on both the relief of symptoms and prevention of secondary cardiovascular complications. This approach must include smoking cessation, optimal cholesterol levels, blood pressure and glycemic control as well as prescribing antiplatelet therapy. This review focuses on the evidence supporting the use of lipid-lowering drugs in PAD. Several trials indicate that getting low density lipoprotein-cholesterol levels to target (<2.6 mmol/l; 100 mg/dl), or even lower, is associated with improvement of symptoms and a reduction in vascular events in patients with PAD.

Can Statins Reduce Perioperative Morbidity and Mortality in Patients Undergoing Non-Cardiac Vascular Surgery?

AIMS

To determine whether statins can reduce perioperative morbidity and mortality in patients undergoing non-cardiac vascular surgery.

METHODS

A search using Pubmed was performed to identify reports in English. The search terms were: "statins", "perioperative morbidity", "perioperative mortality" and "vascular surgery". We excluded studies dealing with the effect of statins in cardiac surgery. Retrieved articles were manually searched.

RESULTS

Current evidence shows that statins decrease perioperative morbidity and mortality in patients undergoing non-cardiac vascular surgery. Any benefit probably occurs soon (within a month) after initiating treatment.

CONCLUSIONS

Appropriately designed trials need to confirm the beneficial effect of perioperative statin therapy in various patient categories. The optimal duration and dose of perioperative statin therapy should be defined.

The examination assessment of technical competence in vascular surgery

Background

The European Board of Surgery Qualification in Vascular Surgery is a pan-European examination for vascular surgeons who have attained a national certificate of completion of specialist training. A 2-year study was conducted before the introduction of a technical skills assessment in the examination.

Methods

The study included 30 surgeons: 22 candidates and eight examiners. They were tested on dissection (on a synthetic saphenofemoral junction model), anastomosis (on to anterior tibial artery of a synthetic leg model) and dexterity (a knot-tying simulator with electromagnetic motion analysis). Validated rating scales were used by two independent examiners. Composite knot-tying scores were calculated for the computerized station. The stations were weighted 35, 45 and 20 per cent, respectively.

Results

Examiners performed better than candidates in the dissection (P &lt; 0·001), anastomosis (P = 0·002) and dexterity (P = 0·005) stations. Participants performed consistently in the examination (dissection versus anastomosis: r = 0·79, P &lt; 0·001; dexterity versus total operative score: r = −0·73, P &lt; 0·001). Interobserver reliability was high (α = 0·91). No correlation was seen between a candidate's technical skill and oral examination performance or logbook-accredited scores.

Conclusion

Current surgical examinations do not address technical competence. This model appears to be a valid assessment of technical skills in an examination setting. The standards are set at a level appropriate for a specialist vascular surgeon.

Inflammation and Chlamydia pneumoniae Infection Correlate with the Severity of Peripheral Arterial Disease

BACKGROUND

Our aim was to investigate the association of inflammation and Chlamydia pneumoniae infection with the presence and severity of peripheral arterial disease.

METHODS

Twenty-eight patients whose initial claudication distance (ICD) in the traditional constant-load treadmill test was <200 m, underwent femoral endarterectomy as part of their interventional treatment (group A). Group B consisted of 23 patients whose ICD was >200 m and were put on medication and a daily exercise program. The control group consisted of 30 non-vascular patients of the Ophthalmology Department (group C). We measured the levels of C-reactive protein, fibrinogen, vascular cell adhesion molecule-1 and tumor necrosis factor-alpha, and the titers of IgA and IgG antibodies against C. pneumoniae in the serum of all the patients. Finally, the atheromas and vein segments of group A patients, were immunohistochemically (IHC) examined for the presence of C. pneumoniae.

RESULTS

Peripheral arterial disease (PAD) patients, had significantly higher CRP (p=0.026) and anti-Cp IgA levels (p=0.001) when compared to control subjects, after a multiple linear regression analysis. The odds ratio for the prevalence of femoral atherosclerosis was 3.16 for IgA seropositive patients (CI 1.15-8.67). When comparing group A and group B patients, CRP (p=0.003) and IgA (p=0.011), were significantly correlated with severe PAD. Group A patients with positive immunohistochemical examination of the plaque, had higher anti-Cp IgA levels (p=0.023) and TNF-alpha values (p=0.031), compared to the IHC negative patients. C. pneumoniae was detected in 50% of the femoral atheromas, but in only 3.6% of the veins.

CONCLUSION

This study supports the hypothesis that inflammation (CRP) and chronic C. pneumoniae infection (IgA seropositivity), have an important role in lower limb atherosclerosis and correlate with the severity of the disease.

Inflammation and Atherosclerosis

PURPOSE

The aim of this article is to discuss the role of inflammation in atherosclerosis.

SUMMARY

An initial chemical, mechanical or immunological insult induces endothelial dysfunction. This triggers a cascade of inflammatory reactions, in which monocytes, macrophages, T lymphocytes and vascular smooth muscle cells participate. Leukocyte adhesion molecules, cytokines, growth factors and metalloproteinases participate in all stages of atherogenesis. Almost all of the traditional risk factors for atherosclerosis are associated with and participate in the inflammatory process. Many infectious agents, mainly Chlamydia pneumoniae, have been proposed as potential triggers of the cascade. The immune system has been implicated in plaque formation, through the activation of cellular and humoral immunity against innate or microbial heat shock protein 60. Methods of detection of systemic or local plaque inflammation have been developed and research is being conducted on the potential use of anti-inflammatory and antibiotic drugs in atherosclerosis.

The deceptive clinical picture of primary saphenofemoral junction aneurysms

Venous aneurysms may remain undetected for years due to their obscure and non-specific clinical picture. Two cases of primary saphenofemoral junction aneurysm are described, and their vague clinical picture is highlighted. The importance of increased alertness and suspicion is noted, because of the gravity of the possible complications of an undetected venous aneurysm, namely rupture of the aneurysm and/or recurrent pulmonary embolism.

Carotid body paraganglioma and SDHD mutation in a Greek family

BACKGROUND

Carotid body (CB) is a highly specialized paraganglion originating from the neural crest ectoderm. CB paraganglion can be caused either by a genetic predisposition (hereditary paraganglia) or by chronic hypoxic stimulation. Germline mutations in any of the following genes: SDHD, SDHC, SDHB, PGL2 or other unknown genes, can cause paragangliomas (PGLs).

MATERIALS AND METHODS

We studied a Greek family in which the two daughters had carotid body paraganglioma, whereas both parents did not. RNA extraction, reverse transcriptase polymerase chain reaction and direct DNA sequencing were performed, in order to identify SDHD mutations in all four exons.

RESULTS

Our results revealed the existence of the missense mutation Y114C, in exon-4 of the SDHD gene, in the unaffected father and both affected sisters.

CONCLUSION

DNA testing was performed, for the first time in Greece, on patients with carotid body tumor. This marks a new geographical location, in the literature, for this mutation.

Long-term treatment of deep venous thrombosis with a low molecular weight heparin (tinzaparin): a prospective randomized trial

OBJECTIVES

Evaluation of the effectiveness and safety of the low molecular weight heparin (LMWH) tinzaparin versus unfractionated heparin (UFH) followed by acenocoumarol in proximal deep venous thrombosis (DVT).

DESIGN

Prospective, randomized clinical trial.

MATERIAL AND METHODS

Consecutive patients (n=108) with acute leg DVT, confirmed by duplex, were randomized to either tinzaparin alone or UFH and acenocoumarol for 6 months. Patients were evaluated ultrasonographically at entry, 1, 3, 6 and 12 months. Thrombus regression, reflux distribution and the incidence of complications were studied. A cost-analysis, comparing the two treatments, was performed.

RESULTS

The overall incidence of major events (mortality, DVT recurrence, pulmonary embolism, major bleeding, heparin-induced thrombocytopenia) was significantly different (p=0.035) in favor of tinzaparin (7 versus 17 events). The ultrasonographic clot volume score (an index of recanalization) decreased significantly in both treatment groups. However, tinzaparin produced significantly more extended overall recanalization from 3 months onwards (p<0.02). Thrombus regression was equivalent or in favor of tinzaparin in the different DVT subgroups and venous segments, but the statistical significance varied. Reflux showed non-significant differences overall or in subgroups. A cost-analysis resulted in favor of LMWH.

CONCLUSIONS

A fixed daily dose of tinzaparin for 6 months was at least as effective and safe as UFH and acenocoumarol. Regarding major events and recanalization, there was a significant benefit in favor of tinzaparin. Long-term DVT treatment with tinzaparin could represent an alternative to conventional treatment.

Vascular surgery training in Greece

The aim of the study was to describe current training in vascular surgery in Greece. The method used was the presentation of data obtained by direct contact with the units. Vascular surgery has been a mono-specialty in Greece since 1989. The duration of training is 7 years (3 years common trunk in general surgery, 3 years in vascular surgery and 1 year in cardiothoracic surgery). However, its duration often exceeds 11 years due to lost time in waiting to start training. The latter happens because there has been a tremendous increase of the number of medical graduates during the last decade and thus the number of trainees has increased disproportionately to the demand for vascular surgeons nationwide. Greece has the second higher ratio of vascular trainees per million population in EU (3.6 trainees/million population). There are 14 accredited centres for training in vascular surgery, the majority of them being in Athens (9/14). In these centres there are a total of 52 trainers and 38 trainees (ratio 1.4/1). An average of 380 operations are performed per centre/year and 140 operations/trainee/year. In conclusion, there is a need for re-defining the training programme in vascular surgery in Greece. The main concern is the tremendous increase in medical graduates leading to a discrepancy between accredited training posts and fellows waiting to fill them.

Venöse Anomalien in Zusammenhang mit Rekonstruktion von abdominellen Aortenaneurysmen

The coexistence of abdominal aortic aneurysm (AAA) and venous abnormalities is unusual. In this article two cases of AAA with concomitant anomalities of a retroaortic left renal vein and left-sided inferior vena cava are presented.

An appraisal of different cardiac risk reduction strategies in vascular surgery patients

OBJECTIVES

to summarize existing evidence regarding the benefits and the risks of all available interventional and medical means aimed at cardiac risk reduction in patients undergoing vascular surgery.

DESIGN

review of the literature.

MATERIALS AND METHODS

a critical review of all studies examining the impact of various prophylactic cardiac maneuvers on perioperative outcome following vascular surgery was performed. Overall mortality, cardiac mortality and myocardial infarction rate were used as the outcome measures.

RESULTS

coronary artery bypass grafting is associated with a 60% decrease in perioperative mortality in patients undergoing vascular surgery, but in most of the cases this decrease does not outweigh the combined risk of the cardiac and the subsequent noncardiac vascular procedure. Data supporting the cardioprotective effect of percutaneous transluminal angioplasty in the perioperative setting are insufficient. beta-blockade has been shown to decrease perioperative mortality and cardiac morbidity in both high-risk (strong evidence) and low-risk (weak evidence) patients.

CONCLUSIONS

coronary revascularization is rarely indicated to simply get the patient through vascular surgery and should be reserved for patients who would need it irrespective of the scheduled vascular procedure. Among all available pharmacological agents, including beta-blockers, alpha-agonists, calcium channel blockers and nitrates, only beta-blockers have been proven to reduce the cardiac risk of vascular surgery.

The impact of the carotid plaque type on restenosis and future cardiovascular events: a 12-year prospective study

OBJECTIVES

to evaluate the impact of the carotid plaque type on recurrent carotid stenosis, future cardiovascular events and patients' survival.

DESIGN

open prospective study.

PATIENTS AND METHODS

three hundred and eight patients who underwent a total of 338 carotid endarterectomies were included in the study. All of the patients were evaluated postoperatively with clinical examination and colour duplex 1 month after the operation and every 6 months thereafter. Mean duration of follow-up was 63 months (range: 12-144). Eight patients (3%) were lost to follow-up. Restenoses, cardiovascular events and deaths were recorded and analysed with regard to the traditional risk factors and the ultrasonographic characteristics of the plaques. Statistical analysis was performed using the Kaplan-Meier method, the log rank test and Cox regression analysis.

RESULTS

cumulative restenosis rate at 10 years of follow-up was 21% and was associated with coronary artery disease (p=0.01) and echolucent plaques (p=0.02). Life-table analysis showed a 10-year survival rate of 64% and a 10-year rate of cardiovascular events of 41%. Hypertension (p=0.003), coronary artery disease (p=0.002) and echolucent plaques (p=0.01) were associated with a higher incidence of cardiovascular events.

Low molecular weight heparins in the long-term treatment of venous thromboembolism

Low molecular weight heparins (LMWHs) have extensively replaced unfractionated heparin (UFH) in both thromboprophylaxis and initial treatment of venous thromboembolism (VTE) and their use for such indications is now well established. This paper reviews the role of LMWHs in the long-term treatment of VTE. Venous thrombosis, although a very frequent occurrence in everyday practice, still remains controversial in its treatment. Available literature comparing different LMWHs with UFH and oral anticoagulants (OAs) is presented. Comparison and evaluation of the effectiveness, safety and costs of alternative treatments are also made. The differences of various LMWHs are discussed and the need for separate clinical trials for every single LMWH is highlighted.

Carotid stenosis: factors affecting symptomatology

BACKGROUND AND PURPOSE

The ability to predict future strokes in asymptomatic patients with carotid stenosis is currently limited. The management of symptomatic patients with <50% stenosis is also debatable. In this context, we performed the following open prospective study to identify factors affecting symptomatology in patients with carotid stenosis.

METHODS

During 1988-1997, 442 arteries with various degrees of stenosis were followed with the use of color Duplex ultrasonography every 6 months. The main outcome measures were development of symptoms related to the carotid territory and progression in the degree of stenosis. Results of follow-up were analyzed in relation to the traditional risk factors for atherosclerosis as well as the ultrasonographic characteristics of the plaques. Statistical analysis was performed by multiple linear and Cox regression analysis.

RESULTS

Mean duration of follow-up was 44 months (range, 12 to 120 months). Significant progression of stenosis occurred in 18.5% of the cases and was more frequent in younger patients (P=0.09), in patients with coronary artery disease (P=0.02), and in patients with echolucent plaques (P=0.02). In regard to clinical presentation, men (P=0.07), hypertensives (P=0.07), and patients with echolucent plaques (P=0.09) showed a trend toward higher frequency of stroke in their history. During the follow-up period, neurological events developed in 12.4% of the cases and were associated with the severity of carotid disease (P<0.001), history of neurological events (P=0.02), progression of stenosis (P=0.002), echolucent plaques (P=0.01), and hypertension (P=0.02).

CONCLUSIONS

Factors other than degree of stenosis and history of neurological events are also important in determining high-risk carotid plaque. In our study hypertension, echolucent plaques, and progressive lesions were associated with an increased risk of neurological events. These factors should be taken into consideration in determining treatment strategies for carotid stenosis.

Recurrent carotid artery stenosis: natural history and predisposing factors. A long-term follow-up study

BACKGROUND

The aim of this study was to evaluate the impact of various risk factors, excluding the type of closure of the arteriotomy, on the development of recurrent carotid stenosis after carotid endarterectomy.

TYPE OF STUDY

single-center, open prospective.

METHODS

Three hundred and eight patients, who underwent a total of 338 carotid endarterectomies, were evaluated postoperatively with color duplex 1 month after the operation and every 6 months thereafter, the mean duration of follow-up being 52 months (range: 6-144). Only patients submitted to primary closure of the arteriotomy were included. Statistical analysis was performed using the Kaplan Meier method, the log rank test and Cox regression analysis.

RESULTS

Three patients (0.9%) died during the perioperative period. Three (0.9%) patients had a transient ischemic attack and 7 (2.1%) a nonfatal stroke. Recurrent carotid stenosis of >50% was identified in 11 patients, leading to a 21.6% cumulative restenosis rate at 10 years of follow-up. Only one of the 11 patients with restenosis developed neurological symptoms during the follow-up period. Both univariate and multivariate analyses showed that coronary artery disease was significantly associated with restenosis, while patients with uniformly echogenic plaques as well as those with hypercholesterolemia showed a lower incidence of restenosis.

CONCLUSIONS

The cumulative recurrent stenosis rate following carotid endarterectomy was 21.6% at 10 years of follow-up. Restenosis was symptomatic in 1 patient. Coronary artery disease was associated with an increased risk of restenosis, while uniformly echogenic plaques and hypercholesterolemia were associated with a lower risk.

Role of malignancy and preoperative embolization in the management of carotid body tumors

The purpose of this retrospective study is to present our approach to the management of patients with carotid body tumors (CBTs), emphasizing the role of malignancy and preoperative embolization. Between 1975 and 1998 a series of 18 patients with CBTs were treated, and 16 of them underwent successful excision of the tumor. According to the Shamblin classification, six of the tumors were type I, six type II, and six type III. In three of these patients (two with type II tumors and one with type III) in whom preoperative embolization had been performed, mean intraoperative blood loss was 400 ml, whereas in the remaining 13 cases this loss was 700 ml. Two patients with intracranial tumor spread underwent only radiotherapy. Neither postoperative deaths nor strokes occurred. Temporary cranial nerve injury occurred in four cases (25%). Local lymph node invasion was found in two patients, establishing the diagnosis of malignancy. One of these patients developed distal metastases 3 years after the operation and was treated with radiotherapy and octreotide. Follow-up ranging from 30 months to 23 years (mean 5 years) revealed no local recurrence except for the two patients who were treated with radiotherapy only. In conclusion, surgical excision remains the treatment of choice for CBTs and can be performed without major risks and with low morbidity and mortality. Preoperative embolization is helpful by diminishing intraoperative bleeding, and malignancy, though rare justifies early management.