Assessing the clinical utility of Wnt pathway markers in colorectal cancer

PURPOSE

β-catenin and AXIN2 play an important role in the Wnt signaling pathway. The aim of this study was to investigate β-catenin and AXIN2 expression in colorectal cancer (CRC) and relate these findings with patients' clinicopathological features and prognosis.

METHODS

57 consecutive patients with surgically treated CRC were included in this study. Quantitative PCR and immunohistochemistry (IHC) analyses were performed to characterize the expression of the aforementioned markers in CRC tissues.

RESULTS

β-catenin overexpression in the nucleus was associated with advanced N stage CRCs (p=0.04). Multivariate Cox regression analysis showed that β-catenin overexpression is an independent prognostic factor for overall survival (OS). A positive correlation between β-catenin location and AXIN2 mRNA was observed.

CONCLUSIONS

Nuclear β-catenin is a valuable prognostic factor. AXIN2 is a component of the "Destruction Complex" and also a Wnt target gene. However, the clinical importance of AXIN2 expression in CRC remains unclear.

Homocysteine as a risk factor of restenosis after carotid endarterectomy

AIM

Homocysteine (Hcy) has been identified as a potential risk factor for vascular disease. This study investigates the role of serum Hcy as clinical risk factor for restenosis after carotid endarterectomy (CEA).

METHODS

In a prospective design, we studied patients who underwent carotid endarterectomy with venous patch closure technique with respect to alterations of Hcy levels pre and postoperatively. The patients studied were subjected to reevaluation for possible restenosis at time-points 3, 6, 9, 12, 18 and 24 months postoperatively.

RESULTS

Fifty-three symptomatic and 37 asymptomatic patients with stenosis of internal carotid artery >70% were studied. Restenosis appeared in 7.25% of the patients within 24 months postoperatively. Hcy was the only parameter that correlated significantly with the presence of restenosis (P=0.010) and the presence of type VI (complicated) atheromatous plaque (P=0.005) within 24 months postoperatively.

CONCLUSION

Hcy levels were found to be statistically significantly correlated with both the presence of complicated atheromatous plaque and the degree of internal carotid artery restenosis after CEA.

Statin treatment is associated with reduced toll-like receptor 4 immunohistochemical expression on carotid atherosclerotic plaques: a novel effect of statins

Toll-like receptor 4 (TLR4) has been recently implicated in inflammatory pathways involved in carotid plaque destabilization. Given that statins have plaque stabilization and inflammation reduction effects, we investigated whether TLR4 expression on carotid atherosclerotic plaques correlates with statin intake. Carotid atherosclerotic plaques were obtained on 140 patients (preoperative statin intake, n = 70). TLR4 immunohistochemical expression was investigated in endothelial cells (ECs), macrophages (MACs) and smooth muscle cells (SMCs) of carotid atheroma. TLR4 positivity, over-expression and intensity of immunostaining were compared in statin versus no-statin users. The results of this study showed that statin users had a significantly lower expression of TLR4 in ECs (P = 0.02, 0.001, 0.006 for TLR4 positivity, increased intensity and over-expression, respectively). Similarly, TLR4 positivity was less pronounced in carotid plaque MACs of statin users (P = 0.03). No carotid specimen with increased EC TLR4 intensity or over-expression was observed among statin users. The prevalence of any cerebrovascular accident was 61.4% in the 'no statin' versus 18.6% in the 'statin' group (odds ratio for statin use: 0.14, 95% CI: 0.07-0.31, P < 0.001). In conclusion, statin treatment is associated with attenuated TLR4 expression on human carotid atherosclerotic plaques and a reduced risk of carotid-related cerebrovascular events. TLR4 may potentially mediate statins' plaque stabilization effects. Further investigation is necessary.

Elective bypass surgery for chronic mesenteric ischemic disease: report of 3 cases and review of the literature

Chronic mesenteric ischemic disease is an unusual cause of chronic abdominal pain. We present our experience from open surgical treatment of patients with this rare disease followed by a short review of the literature. During the period 2006-2008, three patients were referred to our department with clinical and radiological findings of chronic mesenteric ischemic disease. In all patients, at least 2 out of 3 splachnic vessels (celiac artery, superior and inferior mesenteric artery) were occluded, with severe stenosis of the third. Open surgical revasculation was performed in all patients, using autologous or synthetic (Dacron) bypass grafts. Graft patency was examined with triplex ultrasound studies at 3, 6 and 12 months postoperatively and/or follow up CT angiography. All patients had patent grafts during the follow up period and have regained their normal body weight. Immediate and late results, technical details and controversies in open surgical revasculation for chronic mesenteric ischemic disease are reviewed. In conclusion open surgical revasculation for chronic mesenteric ischemic disease is a technically challenging procedure with good results in patients younger than 70 years old , with long occlusions of the splachnic vessels and severe calcification of the vessel wall.

Macrophage infiltration and smooth muscle cells content associated with haptoglobin genotype in human atherosclerotic carotid plaques

We assessed the association between the haptoglobin (Hp) genotype and 2 common indicators of atherosclerotic plaque instability: macrophage infiltration and the smooth muscle cell (SMC) content. A total of 70 consecutive patients who underwent carotid endarterectomy were included in the study. For immunohistochemical study the anti-CD68 and anti-a-actin antibodies were used on adjacent serial sections; 36 plaques from patients with the Hp 1-1 or 2-1 genotype and 34 plaques from patients with the Hp 2-2 genotype were analyzed. The macrophage content (CD68+) was significantly higher in the Hp 2-2 group compared with that in the Hp 1-1 or 2-1 group (P < .001). In plaques from patients with diabetes, the SMC content was significantly lower in the Hp 2-2 group (P = .034). Carotid plaques from diabetic patients with Hp 2-2 genotype had higher macrophage infiltration and lower SMC content. Both parameters are indicators of atherosclerotic plaque instability.

Oxidative stress during abdominal aortic aneurysm repair--biomarkers and antioxidant's protective effect: a review

BACKGROUND AND OBJECTIVES

Oxidative stress during abdominal aortic aneurysm (AAA) repair is likely to result as a response to an ischemia-reperfusion injury (IRI) to the lower limbs and gastrointestinal tract. This paper reviews the oxidative stress during AAA repair, with specific reference to biological markers and the potential antioxidant's protective effect.

EVIDENCE AND INFORMATION SOURCES

The current literature (1966 to July 2010) was reviewed specifically for all articles describing human studies relevant with the particular subject: oxidative stress in patients with AAA repair. Key-words used as single or combined searches included "abdominal aortic aneurysm", "open repair", "EVAR", "oxidative stress", "oxidation" and "antioxidant".

RESULTS

A total of 14 relevant human studies were identified. In the majority of studies all samples (blood samples or/and muscle biopsies) were obtained from the patients using regional sampling techniques before or after anaesthesia, during aortic clamping or balloon occlusion (ischemic time) and after aortic clamp removal (reperfusion time) in different time intervals up to 24 or 48 hours. The oxidative status during AAA repair operation was evaluated by measuring quantitative changes of different substances including mainly vascular endothelial adhesion molecules, lipid peroxidation by-products or reactive oxygen species (ROS) and their metabolites. Two studies compared two groups of patients with AAA treated either by open or endovascular repair (EVAR), while four studies used different types of antioxidant supplementation in order to correlate it with a reduction in oxidative stress and damage in the antioxidant group of patients.

PERSPECTIVES AND CONCLUSIONS

Current evidence suggests that there is a high-grade oxidative stress during AAA repair operation. This was higher in cases of open repair beside EVAR and in cases with ruptured AAAs beside elective cases. The beneficial effect of an antioxidant supplementation in reducing the oxidative stress during AAA repair was also demonstrated. The use of a biological marker as a predictor of the development of systemic complications could also give a therapeutic advantage.

ICU transfer after elective abdominal aortic aneurysm repair can be succesfully reduced with a modified protocol. A fourteen year experience from a University Hospital

AIM

To compare different selective criteria for Internal Care Unit (ICU) admission in two different timeframes, after abdominal aortic aneurysm (AAA) repair. A retrospective audit of acquired data was performed.

METHODS

During a period of fourteen years (1994-2008), 1152 patients underwent an elective open operation for infrarenal abdominal aortic aneurysm, in our department. Six hundred and two patients (Group A) were treated in the period January 1994-January 2003, and 550 patients (Group B) between January 2003 and August 2008. Postoperatively, all patients were transferred to postanesthesia unit (PAU). After a 2 hours period of close observation, they were transferred either to the ICU or to the surgical ward, according to certain selective criteria (SC). In group A we used SC-A, for admission to an ICU, and in group B we used new, stricter, criteria (SC-B). Thirty-day mortality and morbidity, elective admissions to ICU, rate of subsequent ICU admission, from ward to ICU, and the mean hospital and ICU length of stay, were compared between the two groups.

RESULTS

The use of SC-B resulted in a significant reduction of elective admissions to ICU (3.1% vs 8.5%, P<0.001). Nevertheless, the portion of patients, which were transferred with a severe postoperative complication from the ward to ICU, remained similar between the two groups (1.1% vs 0,9%, in group A and B, respectively). All other endpoints were similar in both groups.

CONCLUSION

Modifying the protocol of ICU transfer, after elective abdominal aortic aneurysm repair, we can reduce the number of patients requiring ICU, without compromising patients' safety.

Retroperitoneal tumor invasion of the inferior vena cava. A single-centre experience in tumor thrombectomy

BACKGROUND AND AIM

Radical surgical treatment improves survival in patients suffering from retroperitoneal tumors with co- existing inferior vena cava thrombus. The extraction excision can be performed through many techniques such as liver mobilization which is performed in liver transplantation procedures.

METHODS

During 2000-2007, 11 patients with retroperitoneal tumors and inferior vena cava thrombus were surgically treated in our department. Classification of the thrombus was defined as suggested by Neves and Zinke. All patients were categorized as level I or level II. In all cases a transabdominal approach, liver mobilization and extraction of the thrombus by milking down or Fogarty catheter were used.

RESULTS

No peri-operative mortality was observed. One case of pulmonary embolisation was conservatively treated. One patient presented recurrence 6 months after the procedure.

CONCLUSIONS

The use of liver transplantation techniques in the surgical management of retroperitoneal tumors with inferior vena cava thrombus, is a safe procedure that improves the survival of these patients.

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.

Carotid endarterectomy versus carotid angioplasty with or without stenting for treatment of carotid artery stenosis: an updated meta-analysis of randomized controlled trials

Carotid angioplasty with or without stent placement (CAS) has been proposed as an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis. We performed a systematic review and meta-analysis of randomized controlled trials to compare the safety and efficacy of endovascular techniques with surgery for carotid stenosis. We searched MEDLINE, PubMed and Cochrane databases to identify randomized controlled trials comparing CAS with CEA. Both random and fixed effects models were used to calculate the pooled odds ratios (OR) and their confidence intervals, with values lower than one indicating a benefit from the endovascular approach. Continuity correction was used for studies with zero events in one arm. We identified 11 trials randomizing a total of 3 258 patients; 1 623 to CEA and 1 635 to CAS. By random effects model, there was no significant difference between the treatments for any stroke (OR, 1.28; 95% CI, 0.82-2.02), or death or any stroke at 30-day (OR, 1.30; 95% CI, 0.92-1.84) and death or any stroke at 6 months (OR, 1.34; 95% CI, 0.86-2.09) or 1 year (OR, 1.41; 95% CI, 0.24-8.27). However there was a significantly higher risk of 30-day death or any stroke (OR, 1.33; 95% CI, 1.01-1.75) after CAS by fixed effects model. Endovascular treatment significantly reduced the risk of 30-day cranial nerve injury (OR, 0.13; 95% CI, 0.04-0.44). In conclusion treating carotid artery stenosis with CAS offers lower rates of cranial nerve injury compared with CEA. CAS could not be proved to be as safe as CEA in treating carotid artery stenosis. The results of ongoing randomized trials comparing CAS with CEA are easily awaited because they may provide sufficient evidence for a change in clinical practice.

Distribution of traction forces associated with shape changes during amoeboid cell migration

Amoeboid motility results from the cyclic repetition of shape changes leading to periodic oscillations of the cell length (motility cycle). We analyze the dominant modes of shape change and their association to the traction forces exerted on the substrate using Principal Component Analysis (PCA) of time-lapse measurements of cell shape and traction forces in migrating Dictyostelium cells. Using wild-type cells (wt) as reference, we investigated Myosin II activity by studying Myosin II heavy chain null cells (mhcA-) and Myosin II essential light chain null cells (mlcE-). We found that wt, mlcE-and mhcA- cells utilize similar modes of shape changes during their motility cycle, although these shape changes are implemented at a slower pace in Myosin II null mutants. The number of dominant modes of shape changes is surprisingly few with only four modes accounting for 75% of the variance in all cases. The three principal shape modes are dilation/elongation, bending, and bulging of the front/back. The second mode, resulting from sideways protrusion/retraction, is associated to lateral asymmetries in the cell traction forces, and is significantly less important in mhcA- cells. These results indicate that the mechanical cycle of traction stresses and cell shape changes remains remarkably similar for all cell lines but is slowed down when myosin function is lost, probably due to a reduced control on the spatial organization of the traction stresses.

Enhanced TLR4 endothelial cell immunohistochemical expression in symptomatic carotid atherosclerotic plaques

BACKGROUND AND PURPOSE

Toll-like receptor-4 (TLR4) has been linked to the pathogenesis of atherosclerosis. Carotid atheroma endothelial cells (ECs) express TLR4, nevertheless correlations with cerebrovascular symptomatology, epidemiological and clinical variables remain unresolved.

METHODS

Carotid atherosclerotic plaques were obtained by standard carotid endarterectomy from 157 patients with carotid artery disease (84 asymptomatic - Group A, 73 symptomatic - Group B). TLR4 expression was detected by immunohistochemistry and TLR4 positivity, overexpression and intensity of immunostaining in ECs were correlated with cerebrovascular symptomatology, epidemiological and clinical variables.

RESULTS

A significant association was found between TLR4 positivity in ECs and the occurrence of any cerebrovascular event (overall response (OR): 2.85, 95% CI 1.33 - 6.11, p = 0.009). TLR4 overexpression and staining intensity in ECs were both significantly enhanced in symptomatic patients (p < 0.0001 and p = 0.003, respectively). These associations were stronger for the occurrence of a major cerebrovascular accident (CVA) compared with a transient ischemic attack (TIA) or amaurosis fugax. TLR4 expression in ECs was less prominent in statin users (OR: 0.25, 95%CI 0.1 - 0.58, p = 0.001], while it was enhanced in restenotic plaques compared with primary atherosclerotic lesions (p = 0.012).

CONCLUSIONS

TLR4 expression in ECs of carotid atheroma was enhanced in symptomatic patients with most commonly 'unstable' - 'more prone to rupture' carotid plaques.

Transradial access for carotid artery stenting: a single-center experience

AIM

The aim of this study was to report our initial experience using the radial artery as access for carotid artery stenting (CAS) and review the existing literature.

METHODS

From January to June 2008, nine high-risk consecutive patients were treated with carotid stents by using the radial artery as an access point. Major complications (perioperative myocardial infarction, stroke, transient ischemic attack [TIAs] and death) and minor complications (radial artery occlusion or hematomas) were evaluated during this procedure.

RESULTS

Seven of these patients had a right (77.8%) and two had a left (22.2%) sided carotid artery stenosis. Patients were symptomatic (TIAs or strokes or both) and had a >60% stenosis of the internal carotid artery. The technical success rate was 100% and all patients mobilized two hours after the procedure and were discharged home on the first postoperative day. No major or minor complications were reported.

CONCLUSION

Patients with vessel pathology or unfavorable anatomy in the iliofemoral arteries or/and the aorta, can be candidates for CAS through the radial artery. Refinement of the technique and improvement in endovascular devices may lead to the replacement of the conventional femoral access by the transradial route in the near future.

Coverage strategies in exposed implants

Implants are widely used and are not without complications. The most serious complication is infection with consequent exposure of the implant and is characterized by increased morbidity and mortality. Until recently, infected implants were removed and replaced with another one. These operations are accompanied by increased morbidity and might result in permanent disability. Coverage of the implant with a flap is an alternative solution. The objective of this article is to study the effectiveness of muscle or myocutaneous flaps in covering infected and exposed implants. A series of 17 patients with infected implants, which were treated with coverage of the implant with muscle or myocutaneous flap, is presented. Eight patients had an orthopedic implant, seven a vascular implant, and two had a pacemaker. The flaps ensured immediate coverage of the implant and the biologic ability of eliminating the infectious process with the increased concentration of antibiotics resulting from increased blood flow of the muscle. In all the patients, the implants were preserved and the infectious process was eliminated. The use of muscle and myocutaneous flaps in the treatment of infected implants is therefore effective and in some cases it is superior to other methods because of lower morbidity and cost.

Coverage Strategies in Exposed Implants

Implants are widely used and are not without complications. The most serious complication is infection with consequent exposure of the implant and is characterized by increased morbidity and mortality. Until recently, infected implants were removed and replaced with another one. These operations are accompanied by increased morbidity and might result in permanent disability. Coverage of the implant with a flap is an alternative solution. The objective of this article is to study the effectiveness of muscle or myocutaneous flaps in covering infected and exposed implants. A series of 17 patients with infected implants, which were treated with coverage of the implant with muscle or myocutaneous flap, is presented. Eight patients had an orthopedic implant, seven a vascular implant, and two had a pacemaker. The flaps ensured immediate coverage of the implant and the biologic ability of eliminating the infectious process with the increased concentration of antibiotics resulting from increased blood flow of the muscle. In all the patients, the implants were preserved and the infectious process was eliminated. The use of muscle and myocutaneous flaps in the treatment of infected implants is therefore effective and in some cases it is superior to other methods because of lower morbidity and cost.

Serum leptin levels in patients undergoing carotid endarterectomy: a pilot study

INTRODUCTION

Elevated serum leptin levels are associated with cardiovascular events. We investigated the role of serum leptin in patients undergoing carotid endarterectomy (CEA).

METHODS

A total of 74 patients (55 men; 38 symptomatic and 36 asymptomatic; mean age 66.9 +/- 8.2 years) undergoing CEA for >70% carotid artery stenosis were enrolled.

RESULTS

Serum leptin levels were lower in symptomatic compared with asymptomatic patients (7.1 +/- 1.3 vs 14.4 +/- 4.7 ng/dL; P < .001). Interleukin-6 (IL-6) levels were higher in symptomatic compared with asymptomatic patients (4.3 +/- 1.7 vs 3.3 +/- 1.1 pg/dL; P = .017). Symptomatic patients had more intense macrophage accumulation (0.7% +/- 0.1% vs 0.3% +/- 0.1%; P < .001). Serum leptin and serum IL-6 levels were independently associated with the presence of symptoms in multivariate analysis.

CONCLUSION

Serum leptin levels were decreased in symptomatic carotid artery disease. This finding requires further investigation in larger studies.

Guided remote endarterectomy for superficial femoral artery occlusions: a technical note

The aim of this paper was to describe a new modification of the remote endarterectomy for the treatment of long superficial femoral artery (SFA) occlusions and to present our preliminary results. Through a subinguinal incision and arteriotomy over the SFA origin, a hydrophilic guidewire was introduced into the subintimal plane of the SFA and advanced distally until reentry into the distal patent popliteal artery. The hydrophilic guidewire is exchanged for an Ablatz wire to provide support for the advancement of the single endarterectomy ring. The MollRing Cutter was introduced in the SFA after the removal of the single endarterectomy ring and it was advanced until the re-entry point. The atherosclerotic core was removed and a nitinol self-expanding stent was placed at the peripheral end of the endarterectomy. Arteriotomy was closed with a patch. Guided subintimally-assisted remote endarterectomy seems to be a successful and safe modification of the traditional technique in the treatment of SFA occlusion, in patients with critical limb ischemia.

The differential effect of estrogen, estrogen–progestin and tibolone on coagulation inhibitors in postmenopausal women

OBJECTIVES

Hormone therapy increases the risk of venous thromboembolism, possibly through a negative effect on coagulation inhibitors. The aim of the study was to assess the effect of conjugated equine estrogens alone or in combination with medroxyprogesterone acetate, low-dose 17beta-estradiol combined with norethisterone acetate and tibolone on inhibitors of coagulation.

METHODS

Two hundred and sixteen postmenopausal women received orally either conjugated equine estrogens 0.625 mg (CEE, n=24) or tibolone 2.5 mg (n=24) or CEE+medroxyprogesterone acetate 5 mg (CEE/MPA, n=34) or 17beta-estradiol 1 mg+norethisterone acetate 0.5 mg (E2/NETA, n=66) or no therapy (control, n=68) for 12 months. Plasma antithrombin, protein C and total protein S were measured at baseline and at 12 months.

RESULTS

CEE, CEE/MPA and E2/NETA treatment were associated with a significant decrease in antithrombin levels (CEE: baseline 235.6+/-47.6 mg/l, follow-up 221.3+/-48.3 mg/l, p=0.0001; CEE/MPA: baseline 251.1+/-38.6 mg/l, follow-up 225.0+/-42.6 mg/l, p=0.009; E2/NETA: baseline 257.1+/-59.4 mg/l, follow-up 227.1+/-50.4 mg/l, p=0.007; tibolone: baseline 252.6+/-62.4 mg/l, follow-up 261.9+/-59.1 mg/l, p=0.39). Protein C decreased significantly in the CEE and CEE/MPA groups (CEE: baseline 3.64+/-1.17 mg/l, follow-up 2.48+/-1.47 mg/l, p=0.004; CEE/MPA: baseline 3.24+/-1.23 mg/l, follow-up 2.61+/-1.38 mg/l, p=0.001; E2/NETA: baseline 3.24+/-1.10 mg/l, follow-up, 3.15+/-1.11 mg/l, p=0.08; tibolone: baseline 3.26+/-1.25 mg/l, follow-up 3.09+/-1.32 mg/l, p=0.37). Protein S decreased significantly only in the CEE/MPA group (CEE: baseline 19.4+/-2.76 mg/l, follow-up 18.0+/-2.45 mg/l, p=0.56; CEE/MPA: baseline 18.4+/-3.42 mg/l, follow-up 14.5+/-3.43 mg/l, p=0.005; E2/NETA: baseline 19.0+/-3.11 mg/l, follow-up 19.5+/-3.43 mg/l, p=0.18; tibolone: baseline 18.5+/-3.09 mg/l, follow-up 18.0+/-4.09 mg/l, p=0.32).

CONCLUSIONS

Estrogen and estrogen-progestin therapy are associated with a reduction in coagulation inhibitors, the extent of which depends on the regimen administered. Tibolone appears to have no effect on inhibitors of coagulation.

The effects of endogenous and exogenous androgens on cardiovascular disease risk factors and progression

Cardiovascular disease incidence rates have long been known to significantly differ between the two sexes. Estrogens alone fail to explain this phenomenon, bringing an increasing amount of attention to the role of androgens. Contrary to what was initially hypothesized, androgens seem to have an overall cardioprotective effect, especially in men. Recent studies and published data continue to support this notion displaying a consistent inverse correlation with atherosclerosis progression and cardiovascular disease both in regressive and prospective study models. Clinical studies have also revealed what seems to be a differential androgenic effect on various cardiovascular risk factors between men and women. Further insight indicates that in order to avoid confusion it may be also preferable to separately examine the effects of endogenous androgen levels from exogenous testosterone administration, as well as discern the differential results of low to normal and supraphysiological administration doses. This review summarizes old and recent data according to the above distinctions, in an attempt to further our understanding of the role of androgens in cardiovascular disease.

Toll-like receptor modulation: a novel therapeutic strategy in cardiovascular disease?

BACKGROUND

Toll-like receptors (TLRs) have been recently recognised as primary receptors in the innate immune system. Apart from initiating a prompt immune response against invading pathogens, TLRs are also considered to be an important link between innate immunity, inflammation and a variety of clinical disorders, including cardiovascular diseases. TLR signalling manipulation with novel drugs could offer important opportunities for cardiovascular disease modification.

OBJECTIVE

To present the latest knowledge supporting the involvement of TLRs in the pathogenesis and progress of cardiovascular diseases and explore the role of TLRs as potential targets for therapeutic intervention in cardiovascular territory.

METHODS

A review of the literature documenting implication of TLR signalling in cardiovascular disorders. Current progress in TLR-targeting drug development and the potential role of such a treatment strategy in cardiovascular disorders are discussed.

CONCLUSIONS

A growing body of evidence supports a role for TLRs in cardiovascular disease initiation and progression. Altering TLR signalling with novel drugs could be a beneficial therapeutic strategy for patients with cardiovascular disorders.

Mortality in diabetic and nondiabetic patients after amputations performed from 1996 to 2005 in a tertiary hospital population: a 3-year follow-up study

AIMS

Diabetes is the leading cause of lower-extremity amputations worldwide. The objective of this study was to look at the survival after first amputation between subjects with and without diabetes in a sample of Greek population.

METHOD

We performed a retrospective study of all nontrauma, nonneoplasm-related amputations performed in a tertiary centre during the years 1996-2005 in diabetic (n=183) and nondiabetic patients (n=75). Survival status was assessed from the first amputation until December 31, 2005.

RESULTS

A total of 54.6% of amputees with diabetes and 51.6% of those without diabetes died in a mean [95% confidence interval (CI)] time of 4.3 (3.5-5.1) and 6.6 (4.6-8.6) years after the first amputation, respectively (P=.65). Diabetic patients underwent a second amputation (P=.003) and contralateral amputations (P=.02) more often in comparison with nondiabetic subjects. Predictors of all-cause mortality in the diabetic group, after adjustment for sex, were age [hazard ratio (HR) (95% CI), 1.04 (1.02-1.06); P<.001] and the level of amputation (major vs. minor) [HR, 1.55 (1.00-2.40), P=.05]. The respective values in the nondiabetic patients were HR of 1.06 (1.03-1.08; P<.001) and HR of 3.12 (1.27-7.64; P=.01). Median length of hospital stay was comparable between the two groups.

CONCLUSION

Mortality rates after amputation were high in both patients with and without diabetes. Older age and a higher level of amputation were associated with poorer survival. Diabetic patients more often underwent a second amputation to the same and the contralateral limb. Additionally, mortality rates, length of hospital stay, and perioperative mortality were not different between patients with and without diabetes.

Endovascular repair of a right-sided descending thoracic aortic aneurysm associated with a right aortic arch and a left subclavian artery arising from a Kommerell's diverticulum

This case report describes the endovascular repair of a right-sided descending thoracic aortic aneurysm associated with a right aortic arch and an aberrant left subclavian artery. A 76-year-old male with multiple comorbidities was incidentally found to have a right-sided descending thoracic aortic aneurysm with a maximum diameter of 6.2 cm. Additionally, there was a right aortic arch with a retroesophageal segment and separate arch branches arising in the following order: left common carotid artery, right common carotid artery, right subclavian artery, and left subclavian artery that was aberrant, arising from a Kommerrell's diverticulum. The aneurysm was successfully excluded by deployment of a Zenith TX1 36 x 32 x 20-mm stent-graft using wire traction technique via the left femoral and right brachial arteries in order to deal with two severe aortic angulations. At 18-month follow-up the patient was doing well, with aneurysm sac shrinkage to 5.9 cm and no signs of endoleak or migration. Endovascular repair of right-sided descending thoracic aortic aneurysms with a right arch and aberrant left subclavian artery is feasible, safe, and effective. In such rare configurations, which demand considerably increased technical dexterity and center experience, endovascular repair emerges as an attractive therapeutic option.

Alterations of hemostasis after laparoscopic and open surgery

BACKGROUND

After tissue injury caused by trauma or surgery, alterations of hemostasis are observed and there is a risk for postoperative thromboembolic complications. Laparoscopic surgery, by causing limited tissue injury, appears to be associated with a lower risk for thromboembolism than open surgery. We conducted a prospective randomized study in order to detect potentially existing differences in activation of coagulation and fibrinolytic pathways between open and laparoscopic surgery.

METHODS

Forty patients suffering from chronic cholelithiasis were randomly assigned to undergo open (group A n = 20) or laparoscopic cholecystectomy (group B n = 20) by the same surgical and anesthesiology team. Demographic data were comparable. Blood samples were taken (a) preoperatively, (b) at the end of the procedure, (c) 24 h postoperatively and (d) 72 h postoperatively. The following parameters were measured and compared within each group and between groups: platelets (PLT), soluble fibrin monomer complexes (SFMC), fibrin degradation products (FDP), D-dimers (D-D), fibrinogen (FIB), activated partial thromboplastin time (APTT), prothrombin time (PT). Thrombin-antithrombin III complexes (TAT) were measured at 24 and 72 h postoperatively. Prothrombin fragment 1 + 2 (F1 + 2) was measured at 24 and 72 h postoperatively in 11 patients of group A and 13 patients of group B, respectively.

RESULTS

Demographics were comparable between groups. Immediately postoperatively, TAT and F1 + 2 were significantly higher in group A as compared to group B (p < 0.05). They also increased significantly postoperatively as compared to preoperative levels within each group (p < 0.05). D-dimers were significantly higher in group A as compared to group B (p < 0.01) immediately postoperatively. D-dimers also increased significantly postoperatively in group B as compared to preoperative levels (p < 0.001). FIB decreased slightly in both groups at 24 h postoperatively but there was a significant increase in group A as compared to group B (p < 0.01). SFMC were detected twice in group A and only once group B. FDP levels over 5 mug/ml were detected more often in group A than in group B (p < 0.05). No patient from either group suffered thromboembolism or abnormal bleeding as a postoperative complication.

CONCLUSIONS

Open surgery as compared to laparoscopic procedures leads to activation of the clotting system of a higher degree. Although of a lower degree, hypercoagulability is still observed in patients undergoing laparoscopic surgery and, therefore, routine thromboembolic prophylaxis should be considered.

The relationship of endothelin-1 and inducible nitric oxide synthase at several stages of the anastomotic healing process

AIM

The aim of this study was to investigate the interaction between the endothelin-1 (ET-1) and inducible NO synthase (iNOS) in anastomotic healing.

METHODS

The expression of ET-1 and iNOS were investigated by immunohistochemistry in a rat end-to-end arterial anastomotic model. The aorta of 50 male Wistar rats was exposed, then transversely divided and re-anastomosed. The animals were sacrificed immediately after the operation (group A, control group), after 24 h (group B), on 7th postoperative day (group C), on 30th day (group D) and at 6 months (group E). Intima and media thickness and their ratio of the anastomotic segments in each group were calculated from computer digitized images of the individual sections. ET-1 and iNOS expression were measured on a semiquantitative scale ranging from 0 to 3.

RESULTS

ET-1 was expressed from endothelial and smooth muscle cells (SMCs), while iNOs was expressed from SMCs and inflammatory cells. An intense expression of ET-1 was demonstrated mainly at 1 week and to a lesser degree at 1 month. Yet, at 6 months this expression was significantly weakened (P<0.001). In contrast, an intense iNOS expression was identified at 24 h, substantially regressing at statistical significant lower levels after 1 week (P<0.001). Bivariate correlation test showed a positive correlation between ET-1 and iNOS expression.

CONCLUSION

ET-1 appears to play an important role in intimal thickening during anastomotic healing, especially in the late period of the process. Although there is a positive correlation between ET-1 and iNOS production, the activity of the latter is relatively limited after the first postanastomosis week.

Reliability of panoramic radiograph for carotid atheroma detection: a study in patients who fulfill the criteria for carotid endarterectomy

OBJECTIVES

To evaluate the reliability of panoramic radiograph (PR) for carotid artery atheroma detection, by comparing its results with the carotid-vertebral digital subtraction angiography (DSA) findings, as well as with the detected calcium deposition in the carotid plaques, which were surgically resected, using direct radiographs.

STUDY DESIGN

Forty consecutive patients suffering from carotid artery atherosclerotic occlusive disease confirmed by preoperative DSA, fulfilling the criteria for carotid endarterectomy, were operated on. Preoperatively, all of the patients had undergone PR, while postoperatively all of the surgically resected carotid plaques were radiographed using radiographic films and submitted to histologic examination. Compared with the DSA and the radiographic film findings, the PR results were classified as: 1) true-positive; 2) true-negative; 3) false-positive; or 4) false-negative.

RESULTS

Panoramic radiograph has low sensitivity and specificity compared with the DSA findings and the direct radiographs results. However, a positive predictive value (PPV) of 100% per patient as well as for luminal stenosis >80% was documented.

CONCLUSION

Even in the subgroup of patients who fulfill the criteria for carotid endarterectomy, PR has a low sensitivity and specificity; therefore, it cannot be considered to be a useful screening tool for atheroma detection in the general dental population. However, the 100% PPV per patient and for luminal stenosis >80%, indicates that positive calcification PR findings at the C(3)-C(4) region are highly suggestive for carotid artery atherosclerotic occlusive disease. Therefore, especially asymptomatic patients should be referred for further examination.

Can the diameter of endoluminal shunt influence the risk of hyperperfusion syndrome after carotid endarterectomy?

AIM

The aim of this study was to evaluate if there is a possible relation between the size of endoluminal shunt, in carotid endarterectomy (CEA), and the risk of postoperative hyperperfusion syndrome.

METHODS

We retrospectively studied prospectively collected data from 156 patients, who were subjected to CEA using shunting and vein patch angioplasty. One hundred and thirty-eight of the patients had bilateral, high grade (> or = 90%) internal carotid lesions and the remaining 18 had a high-grade stenosis (> or = 90%) and a contralateral internal carotid artery (ICA) occlusion. In 81 patients varying diameters of shunts were used (8-14 Fr) according to the diameter of ICA (group A) and in the other 75 patients (group B) only the smallest shunt was used (8 Fr). Development of hyperperfusion syndrome was evaluated both clinically and radiologically with magnetic resonance imaging.

RESULTS

Fifteen patients developed hyperperfusion syndrome (9.6%), between 0 to 6 days postoperatively. Thirteen belonged to group A (86.6%), and 2 (13.3%) belonged to group B (P<0.05). One had an intracerebral hemorrhage (0.6% of the study group) the 3rd postsurgical day.

CONCLUSIONS

During CEA in patients with high-grade bilateral lesions, we recommend the use of a shunt with small diameter: this aims at reducing the risk of hyperperfusion syndrome.

High-Sensitivity CRP Is Correlated With Neurologic Symptoms and Plaque Instability in Patients With Severe Stenosis of the Carotid Bifurcation

The aim of this study is to investigate the correlation of high-sensitivity C-reactive protein and E-selectin with clinical manifestations and plaque characteristics in 88 patients (69 with and 19 without neurological symptoms) with high-grade stenosis of the carotid bifurcation who underwent endarterectomy. The grade of stenosis was quantified by duplex ultrasonography and digital subtraction angiography. Preoperatively, serum high-sensitivity C-reactive protein and E-selectin were measured. Postoperatively, carotid plaque morphology was established according to the American Heart Association classification. High-sensitivity C-reactive protein levels were significantly ( P < .001) higher in symptomatic than in asymptomatic patients, as well as in patients with unstable compared with those with stable plaques ( P < .001). Serum high-sensitivity C-reactive protein levels correlated significantly ( P < .05) with macrophage count on the plaque. In conclusion, serum high-sensitivity C-reactive protein levels are associated with presence of neurological symptoms and plaque instability in patients with high-grade stenosis of the carotid bifurcation.

Pressure dressing in breast surgery: is this the solution for seroma formation?

PURPOSE

Pressure dressing (PD) after modified radical mastectomy (MRM) for breast cancer is investigated here as an easy-to-apply method to reduce seroma formation and subsequent need for clinical care.

PATIENTS AND METHODS

Two hundred mastectomized patients who were treated with PD on the skin flaps and the axilla immediately postoperatively (group A) were compared with a similar non-PD group (B). Surgical technique and perioperative care were the same. Drains were removed when drain output was reduced to 30 ml per day, or on postoperative day 8 regardless of output.

RESULTS

Mean time with drains kept in situ was 4.9 and 5.5 days in group A and B, respectively. Five (2.5%) patients in group A and 16 (8%) in group B developed seromas after the removal of the drains. In total, 9 seroma needle aspirations were performed in group A and 26 in group B. Differences were statistically significant.

CONCLUSION

Our findings are supportive of PD as an effective, cheap and easy-to-apply method for the reduction (a) of the time with drains in situ after MRM, (b) of the number of patients developing seromas and (c) of the seroma aspirations. This can potentially reduce further complications, needed medical care and cut expenditure.

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.

The use of Speckle Reduction Imaging (SRI) Ultrasound in the characterization of carotid artery plaques

BACKGROUND AND PURPOSE

Speckle Reduction Imaging is a new algorithm that improves the image quality of B-mode scanning by reducing the reverberation artifacts. In the present study the value of this method for the characterization of atherosclerotic plaques in the internal carotid artery was investigated.

METHODS

Two hundred and twenty two patients (161 men, 61 women; mean age 73 years) referred for carotid ultrasound evaluation were included in the study. Patients with plaques of the internal carotid artery as identified by conventional B-mode scanning were investigated also with the addition of Speckle Reduction Imaging (SRI) with the use of a 4-11-MHz wide band linear transducer. Plaque morphology was rated according to a standardized protocol by two independent observers.

RESULTS

For the determination of plaque echogenicity, the reproducibility of SRI (kappa=0.83) was higher than that of conventional B-mode ultrasound (kappa=0.68). The interobserver agreement for plaque surface characterization was also higher for SRI (kappa=0.8) than for conventional B-mode (kappa=0.61). At the evaluation of the image quality through a semiquantitative analysis, SRI was rated superior in the plaque texture resolution, plaque borders determination, vessel wall demarcation and fibrous cap depiction. In addition, the level of "speckle" was reduced with the use of SRI.

CONCLUSIONS

SRI is a technique that shows good general agreement with high-resolution B-mode and can be used for the characterization of atherosclerotic plaques in the carotid artery. Furthermore, because this advanced technique allows reduction of ultrasound artifacts, it improves the image quality allowing more precise visualization of plaque morphological details.

Endovascular repair of late abdominal aortic aneurysm rupture owing to mixed-type endoleak following endovascular abdominal aortic aneurysm repair

We report the successful endovascular repair of a ruptured abdominal aortic aneurysm (AAA) in a multimorbid patient 8 months after endovascular abdominal aortic aneurysm repair (EVAR). A 74-year-old man with a history of EVAR 8 months earlier presented with hypotension, severe back pain, and tenderness on abdominal palpation. A contrast-enhanced computed tomographic scan showed a large retroperitoneal hematoma and confirmed the diagnosis of secondary abdominal aortic rupture. Because the patient had severe comorbidities, the endovascular method was chosen for further management. Two stent grafts were placed appropriately to eliminate a type 1a and a type 3 endoleak owing to modular separation of the left iliac graft limb from the main body stent graft. An additional self-expanding stent was deployed in the solitary right renal artery to open its origin, which was partially overlapped by the proximal cuff. The patient was discharged on the tenth postoperative day and is alive and well 1 year postoperatively. This case indicates that endovascular repair is feasible not only in cases of primarily ruptured AAAs but also in secondarily ruptured AAAs after failure of EVAR.

A Short Incision for Carotid Endarterectomy Results in Decreased Morbidity

OBJECTIVES

To investigate the effect of a short incision (<5 cm) on the complication rate of the carotid endarterectomy (CEA).

DESIGN

A retrospective cohort study.

PATIENTS AND METHODS

From January 1994 to December 2005, 874 patients underwent 1048 primary carotid endarterectomy (CEA) procedures. Seven hundred and sixty nine operations were performed through a long neck incision (group A), while 279 were performed through a smaller incision (<5 cm) according to a standard protocol (group B). Preoperative and postoperative cranial nerve assessment was completed on all patients. The main outcome measures were stroke, death, cranial and cervical nerve injuries rates.

RESULTS

The 30-day mortality rate was 0.26% in group A and 0.35% in group B (p=.792). The stroke rate was 0.13% and 0% in group A and B respectively (p=.839). The mean length of stay was 2.59 days in group A and 1.67 days in group B (p<.0001). In group A the overall incidence of motor and sensory nerve deficits was 13.5% (104 CEA, 92 patients) but in group B 2.9% (8 CEA, 7 patients, p<.0001, odds ratio [OR] 0.189, 95% confidence interval [CI] 0.091-0.393).

CONCLUSIONS

Carotid endarterectomy through a small incision is a feasible and safe approach that provides cosmetic results and fewer nerve complications without compromising the safety of the procedure.

Renal artery aneurysm endovascular repair

A 68-year-old woman with a left renal artery aneurysm underwent successful endovascular repair with the use of a commercial type self-expanding stent-graft. Complete aneurysm exclusion was achieved after stent-graft expansion. A side branch vessel was occluded after stent-placement, resulting in a small upper lobe renal perfusion defect. There were no other complications. The aneurysm remained excluded and its greatest diameter has been reduced from 2.6 cm to 1.95 cm, 10 months after treatment. Renal function remained normal.

[Restoration of the continuity of the colon with preservation of an existing colostomy]

A new technique for the restoration of the continuity of the colon with preservation of an existing colostomy is described here. A 75-year-old male with a three-year history of abdominal-perineal resection and a well functioning end colostomy was admitted to our department for a second primary cancer of the descending colon. At operation the colon was divided close to the abdominal wall; the colostomy was left in situ while the descending colon and mesocolon were radically resected. The viability of the colostomy was being continuously inspected. An EEA stapler was then inserted through the colostomy and an anastomosis was created. Shortening the length of the operation and avoiding the possible complications that follow the creation of a new stoma are the major benefits of the technique. Still, the viability of the colostomy after its separation of the rest of the colon and mesocolon has to be ensured before proceeding.

Emergency Stenting of a Ruptured Infected Anastomotic Femoral Pseudoaneurysm

A 74-year-old man presented with a ruptured infected anastomotic femoral pseudoaneurysm. Due to severe medical comorbidities he was considered unsuitable for conventional surgical management and underwent an emergency endovascular repair with a balloon-expandable covered stent. The pseudoaneurysm was excluded successfully and the patient had an uneventful postoperative recovery with long-term suppressive antimicrobials. He remained well for 10 months after the procedure with no signs of recurrent local or systemic infection and finally died from an acute myocardial infarction. To our knowledge, emergency endovascular treatment of a free ruptured bleeding femoral artery pseudoaneurysm has not been documented before in the English literature. This case illustrates that endovascular therapy may be a safe and efficient alternative in the emergent management of ruptured infected anastomotic femoral artery pseudoaneurysms when traditional open surgery is contraindicated.

Endovascular repair of a type III thoracoabdominal aortic aneurysm in a patient with occlusion of visceral arteries

The successful endovascular repair of a type III thoracoabdominal aortic aneurysm (TAAA) with the use of a tube endograft is reported. A 56-year-old male with a 6.4-cm type III TAAA, a 4.2-cm infrarenal abdominal aortic aneurysm, and chronic renal insufficiency presented with flank pain, nausea, acute anuria, and serum creatinine of 6.1 mg/dl. Acute occlusion of the left solitary renal artery was diagnosed and emergent recanalization with percutaneous transluminal angioplasty and stenting was performed successfully, with reversal of the serum creatinine level at 1.6 mg/dl. Further imaging studies for TAAA management revealed ostial occlusion of both the celiac artery (CA) and the superior mesenteric artery (SMA) but a hypertrophic inferior mesenteric artery (IMA) providing retrograde flow to the aforementioned vessels. This rare anatomic serendipity allowed us to repair the TAAA simply by using a two-component tube endograft without fenestrations (Zenith; William Cook, Bjaeverskov, Denmark) that covered the entire length of the aneurysm, including the CA and SMA origins, since a natural arterial bypass from the IMA to the CA and SMA already existed, affording protection from gastrointestinal ischemic complications. The patient had a fast and uneventful recovery and is currently doing well 6 months after the procedure. To our knowledge, this is the first report in the English literature of successful endovascular repair of a TAAA involving visceral arteries with the simple use of a tube endograft.

Liver tissue dissection: ultrasonic or RFA energy?

BACKGROUND

Hepatic resection is the only potential curative treatment for a wide variety of conditions. However, liver surgery is technically demanding and closely associated with a number of serious complications. New devices and techniques are currently being applied in practice, which will improve the surgical outcome.

METHODS

This retrospective study compares two methods of liver parenchymal division: ultrasound energy, a modern but already widely used technique, and radio-frequency ablation (RFA), a completely novel method. The parameters investigated include the amount of blood transfused, the necessity of the Pringle maneuver, the length of time required for parenchymal division, and postoperative morbidity and mortality. The patients were divided into two groups. In one group (Group A), 15 patients underwent 17 ultrasound-assisted liver resections, in which ten metastatic tumors, six hepatomas, and one cholangiocarcinoma were resected. In Group B, 21 patients underwent 22 RFA-assisted hepatectomies in which 11 metastatic tumors, ten hepatomas, and two cholangiocarcinomas were removed.

RESULTS

Thirteen patients (87%) in Group A and 11 (52%) in Group B received a transfusion, with an average of 3.5 and 1.6 units of red blood cells, respectively. The Pringle maneuver was necessary in two cases in Group A but was unnecessary in Group B. The mean length of time required for parenchymal dissection was 124 min in Group A and 93.18 min in Group B. One (6.7%) and four (19%) complications were observed in Group A and B, respectively (statistically not significant). Mortality remained zero in both groups.

CONCLUSIONS

RFA energy provides a novel reliable and safe alternative that can be used exclusively or as a supplement to the older techniques. Both resection time and amount of blood transfusion were reduced in the RFA group.

Infected femoral artery pseudoaneurysm in drug addicts: The beneficial use of the internal iliac artery for arterial reconstruction

BACKGROUND

Infected femoral artery pseudoaneurysm (IFAP) is a severe complication in parenteral drug abusers, with difficult and controversial management. Ligation alone without revascularization is frequently associated with later intermittent claudication and limb amputation. Furthermore, arterial reconstruction with a synthetic or venous conduit is limited because of a contaminated field and, often, unavailability of autologous venous grafts. In this study, we present our experience with the internal iliac artery (IIA) as a graft for arterial reconstruction after IFAP excision in these patients.

METHODS

Data of 14 consecutive patients who presented with IFAP secondary to parenteral drug abuse from 2001 to 2005 were analyzed. Twelve patients (85.7%) were male. The median age was 27 years (range, 19-42 years). In 13 cases, the IFAP involved the common femoral artery, and in 1 case it involved the profunda femoris artery (PFA). In nine patients, we used the IIA for arterial reconstruction (five as a patch and four as an interposition graft), whereas in two patients the arterial deficit was repaired with a great saphenous vein patch. In two cases, an extra-anatomic bypass with a synthetic polytetrafluoroethylene graft was performed. In one patient, the pseudoaneurysm involved the PFA and was treated with excision and ligation of the PFA.

RESULTS

All nine patients who underwent revascularization with the use of IIA were free of claudication symptoms. None of them experienced any perioperative complications, had signs of reinfection, or required limb amputation during the follow-up period (median, 19 months; range, 4-52 months). Regarding the remaining five patients, one died 25 days after surgery because of multiorgan failure, and one underwent reoperation because of proximal anastomotic rupture of a synthetic graft. The latter patient finally underwent a transmetatarsal amputation.

CONCLUSIONS

The use of IIA for arterial reconstruction after IFAP excision in drug abusers is safe and effective. These preliminary results indicate that the implementation of this technique offers many advantages compared with traditional treatment options.

Changing patterns in the etiology of acute lower limb ischemia

AIM

The aim of this study was to examine the causes of acute lower limb ischemia (ALLI) in a major referral center in Greece.

METHODS

Hospital records of patients that were admitted with ALLI between January 1, 2000 and December 31, 2004, were retrospectively reviewed for this purpose. A total of 440 cases of ALLI in 351 patients were identified.

RESULTS

In 174 (39.54%) cases, the ischemia was attributed to embolism; in 221 (50.23%) to thrombosis and in the remaining 45 (10.23%) to less common causes of ALLI (trauma [iatrogenic and non], vasculitis, dissection). Of 174 cases of embolism, 136 (78.16%) were of cardiac origin, 22 (12.64%) were due to non-cardiac emboli, while in the remaining 16 cases (9.2%) no specific origin of embolism was found. Of 221 cases of thrombosis 66 (29.86%) concerned native arterial thrombosis, while 155 (70.14%) concerned postinterventional thrombosis, including 144 (65.16%) cases of bypass graft thrombosis and 11 (4.98%) cases of iliac or femoral stent thrombosis. Sixty patients were admitted more than once with ALLI, most commonly due to repeated bypass graft thrombosis (85%). The latter was diagnosed in 32.73% of all ALLI cases and presented more often than native arterial thrombosis by a ratio of approximately 2.2:1.

CONCLUSION

This study indicates that currently the leading cause for hospital admissions in patients with ALLI is thrombosis which most commonly occurs in bypass grafts rather than in native arteries.

Laparoscopic esophagomyotomy for achalasia without a complementary antireflux procedure

BACKGROUND

Achalasia is a progressive motility disorder of the esophagus, without a definitive cure. The principal method of palliation is myotomy of the distal esophagus. We analyzed the 5-year experience at our institution with laparoscopic Heller myotomy without an antireflux procedure to determine its results, particularly regarding postoperative gastroesophageal reflux.

MATERIALS AND METHODS

Thirty-three patients, mean age 43 years (range, 29-62 years) with clinical, manometric, x-ray, and endoscopic proof of achalasia were operated on and followed up for 24 months. Prior to being referred to surgery they had all undergone at least one pneumatic balloon dilation. The operative technique was a 7-cm myotomy that included the lower esophageal sphincter but did not exceed 5 mm of the gastric cardia. Follow-up consisted of clinical observation, cineesophagography, and 24-hour pHmetry.

RESULTS

All patients reported satisfactory to excellent results regarding dysphagia and no heartburn two years after the operation. The 24-hour pHmetry and the radiographic investigation showed no evidence of gastroesophageal reflux.

CONCLUSION

It seems that the risk of gastroesophageal reflux is very low when the cardiomyotomy does not exceed the length of 5 mm. Our results are in accordance with other observational studies as well as larger cohort and meta-analysis studies. Prospective randomized studies are needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.

Comparison of monopolar electrocoagulation, bipolar electrocoagulation, Ultracision, and Ligasure

PURPOSE

Hemostasis is a fundamental principle of surgery. We compared the safety and efficacy of monopolar electrocoagulation (ME), bipolar electrocoagulation (BE), Ligasure (LS), a modern bipolar vessel sealing system, and Ultracision (UC), a system of ultrasound energy based shears. We also studied the healing process after their use.

METHODS

We used each of the above methods to coagulate and divide the short gastric vessels of 16 white male New Zealand rabbits. The animals were killed after 3, 7, 14, or 21 days, and the coagulation sites and the adjacent gastric wall were examined histologically.

RESULTS

LS and UC achieved complete hemostasis without any complications. Conversely, ME and BE often resulted in failed coagulation and perforation of the neighboring gastric wall from a side thermal injury. Histologically, LS demonstrated the mildest side thermal injury and the fastest healing process. We noted greater thermal injury and inflammatory response after UC than after LS on days 7 and 14; however, ME and BE caused the most severe lesions.

CONCLUSIONS

LS and UC are clearly the safest and most efficient methods of coagulation, whereas ME and BE could cause serious clinical and histological complications. We found histological evidence that UC causes a slightly greater inflammatory response than LS, and the clinical implications of this warrant further investigation.

The effect of an estrone D-lactam steroid ester derivative on breast cancer cells and its predicted binding interactions with the ligand binding domain of estrogen receptor-alpha

In order to further improve the toxicity profile and the anticancer effect of chlorambucil (CBL), we have synthesized a new estrone D-lactam steroidal ester of CBL (ESBL). The aim of this study was to investigate the in vitro activity of ESBL against primary breast carcinoma (BC) cells of operable tumors in comparison with CBL. Cells derived from fresh tumor sections that were obtained from 28 postmenopausal women with ductal BC were treated with CBL and ESBL. Apoptotic cells were distinguished from viable ones with flow cytometric methods. ESBL generated a significantly higher rate of cell apoptosis and cytotoxicity than CBL. ESBL cytotoxic effect demonstrated a significant positive weak to moderate dose-dependent correlation with the ER expression. ESBL produced antineoplastic activity superior to CBL on primary BC tumors in vitro. Moreover, a docking study on the binding interactions of ESBL with the ligand binding domain (LBD) of estrogen receptor-alpha (ERalpha) was investigated. ESBL was found to be positioned inside the binding cavity with its steroidal moiety, whereas the alkylating moiety protruded out of receptor's pocket.