Vascular Surgery

Amanda Rezende is a vascular resident with an interest in arterial pathologies and surgery. But her main goal is to bring an up to date treatment to her clients. She has built this model after years of experience in research, evaluation, and student orientation in Ipiranga Hospital (Brazil). Her Alma mater is an internationally known university (State University of Campinas - UNICAMP) which introduced her to research. Email: amandancar@gmail.com

Extracranial carotid artery aneurysms (ECCAs) are rare, with an estimated incidence of less than 1% . [1,6,8,9,11,12,17] They can have different etiologies: atherosclerotic (main etiology), dysplastic, infectious, inflammatory and post-traumatic. [1,4,9,12] The diagnosis can be made by CT-Angiogram, but the gold-standard is digital subtraction angiography. [4] Their treatment, not yet been well stablished, [6,11] can be open repair, which is a safe surgical option with low prevalence of complications [3,7,12] (mostly cerebral ischemia [6,9]) endovascular repair, or conservative. [5] Most open repairs require submandibular subluxation, because of the site of the aneurysm. [13,14,15,16] We describe the case of a 61-year-old white women with a cervical bulging (Figure 1), pulsatile at the physical exam, and occipital headache. CT angiogram (Figure 2) showed: signs of dissection of right vertebral artery and a fusiform aneurysm dilatation of the left internal carotid artery. Since patient had two different type of lesions in two different artery sites, the possibility of fibromuscular dysplasia was considered as a differential diagnosis. Since the kinking made endovascular repair unfavorable to be done, open repair was opted and an aneurysm resection was carried out (Figures 3 to 5), with primary end-to-end anastomosis of the internal carotid artery with the internal carotid artery. During the surgical procedure, it was noticed that, because of the location and kinking of the aneurysm, the mandibular subluxation wasn’t necessary (an uncommon feature for this type of surgery). The products of the biopsy s p e c i m e n w e r e c u l t u r e d a n d a n a l y z e d h i s t o a n d anatomopathologycally which subsequently excluded the possibility of FMD.

Dr Andrzej Polanczyk is a researcher and a team leader at the Lodz University of Technology (Poland). He earned a PhD in medical engineering in 2013. He participated in scientific grants in which he build the installation to simulate the blood flow through the abdominal section of the aorta. Recently he received a grant funded by The National Centre for Research and Development. His research areas comprise biomedical, chemical and, environmental engineering

Introduction: A dedicated ex vivo computer controlled circulatory bioengineering reactor was designed and constructed to monitor the real time vascular tissue response under various physiological conditions. Methods: We designed and build dedicated Artificial Circulatory Model (ACM) for computational projection of vessel structure under different flow conditions. Next, we analyzed flow through iliac arteries and silicon tubes supplied with the homemade fluid that mimic blood. Using ACM we analyzed mechanical behavior of vessels such as change of diameter and wall displacement. Accuracy of data collected with ACM was verified with medical data gathered from patients before an operation and reconstructed with 2D-speckle-tracking-technique (2DSTT). Results: The analysis of spatial configuration for silicon tubes indicated approximately 57% lower change of diameter compared to the iliac arteries. Meanwhile we observed approximately 2.3-fold decrease in wall displacement for the silicon tubes compared to the iliac arteries. Moreover, no significant changes between experimental results and medical data. Conclusions: The approach presented in the manuscript may become a useful tool to introduce different types and spatial configurations of vessels for different hemodynamic conditions. By utilizing an ex vivo perfusion system in which ejection volume and frequency of pulsation can be varied independently, we have shown different mechanical response of tissue vascular grafts and silicon tubes.

Dmitry Scheglov has extensive experience in endovascular treatment of cerebral vascular pathology, in particular, aneurysms and malformations. Personal experience is more than 3000 operated patients with arterial aneurysms, arteriovenous malformations of the brain and spinal cord, carotid-cavernous fistulas, stenotic lesions of the head and neck arteries. In 2009 he defended his dissertation for the PhD in Medical Sciences - "Endovascular treatment of intracranial aneurysm in early hemorrhage periods complicated with angiospasm." In 2014 - defended his thesis for the degree of Doctor of Medicine - “Diagnostics and endovascular treatment of intracranial arterial aneurysms.". He is the author of more than 200 published scientific works. His scientific activities linked to the development of endovascular neuroradiology in Ukraine. D. Scheglov was the first in Ukraine, who used stents and coils for cerebral aneurysm occlusion (2002) and first, who included liquid assets (including ONYX et al.) in treatment process of other cerebral vascular pathology (AVM).

Arteriovenous malformations (AVM) are frequently associated with cerebral aneurysms (AA), which increase the hemorrhage rate and associated with more unfavorable outcomes. In 91 (21.6%) patients from 421 cases of AVMs, we observed 67 (59,8 %) intranidal AA, 25 (22,3 %) flow-related AA of vessels supplying AVMs, 17 (15,2 %) AA of the circle of Willis origin of an artery supplying to AVM and 3 (2,7 %) AA of remote artery, that wasn’t involved to AVM supply. Endovascular treatment with coils, n-butylcyanoacrylate (NBCA), Onyx and Embolin was performed. 112 AA in 91 patients with AVMs were studied. Hemorrhage was happened in 63 patients (69,2 %), seizures in 24 (26,3 %), 4 (4,5 %) patients had other symptoms. 43 (68,2 %) hemorrhages were caused by AVM rupture with intranidal AA, 12 (19,1 %) – by rupture of AA of vessels supplying the AVMs, 7 (11,2 %) – AA of the circle of Willis origin of an artery supplying to the AVM, 1 (1,5 %) – remote AA that was not involved in the AVM supply. AAs were treated during AVM endovascular treatment. 21 AA were coiled and 82 flow-related and intranidal AA were embolized. 8 patients with AVM and 9 associated AA didn’t receive any treatment for AA, 2 of them with 3 AA died due to terminal coma after hemorrhage. 3 patients had fusiform AA (were left for observation), 1 patient had proximal flow-related Anterior Communicating Artery microaneurysm with complicated afferent vessels anatomy that was hard to occlude but it regressed after subtotal AVM treatment, 2 patients reject any surgery. All 91 patients had clinical follow-up from 1 month to 12 years. One (0,89 %) hemodynamically related AA regressed during follow-up, and none residual AA rupture during the follow-up. 5 patients with flow-related AA had AA de-novo. The main policy is to treat the symptomatic lesion firstly. AA researching during AVM evaluation should turn it in the therapeutic focus. The method of choice is the simultaneous AA and AVM occlusion. Occlusion of associated AA is critical.

Sanjay Singh has expertise and passion in vascular and endovascular surgery. He has done complex aortic endovascular fellowship and is a vascular consultant working in United Kingdom. His open and contextual surgical techniques are based on researched and practiced models which help create new pathways for innovation. He has achieved this aptitude after years of experience in research and teaching in University hospitals and institutions. The ever-responsive and adapting field of endovascular surgery has improved the survival rates of high risk patients.

Background: Carotid artery stenosis accounts for approximately 10% of all ischemic strokes, causing significant morbidity and mortality. The use of local anaesthesia rather than general anaesthesia might lower the risk of a stroke during or after surgery. We investigated peri-operative outcomes of carotid endarterectomy (CEA) done under local anaesthesia at our unit. Methods: Consecutive patients from a single vascular unit with symptomatic carotid stenosis undergoing CEA under local anaesthesia between January 2016 and October 2017 identified from a prospective maintained vascular database were included in the study. Results: Seventy - nine patients who had CEA between Jan 2016 and October 2017, were included in the study. Amaurosis fugax was the index event in 10% of patients (n = 8), TIA in 46% (n = 36), minor stroke in 39% (n = 31), other symptoms in 4.0% (n = 3) and asymptomatic in 1.0% (n = 1). There were 65% (n = 51) male and 35% (n = 28) female patients with a mean age of 74 years. Pre-operative risk factors were age more than 80 years old (26.5%), arterial hypertension (51.8%), hypercholesterolemia (83.5%), current smoking (20%), ex smoking (55%), stenosis ≥ 90% (31.6%). Majority of the patients were referred by stroke physicians (91%). Operative procedure suture with prosthesis patch 96.3%, direct suture 2.5% and eversion 1.2%. Readmission within 30 days of procedure was 3 (3.7%) patients. Repeat TIA were seen in 4 (5%) patients which recovered and no major stroke seen. There was no cranial nerve injury and mortality in our study. Conclusion: Our evidence suggests that carotid endarterectomy can be safely performed under local anaesthesia and can be an effective alternative to general anaesthesia for carotid stenosis.

Witold Norbert Nowak is a biochemist and molecular biologist. He has expertise in isolation and characterisation of human and mouse progenitor cells. In collaboration with Jagiellonian University Medical College, he showed changes in populations of circulating stem and progenitor cells in patients with type 2 diabetes and its complications or in patients with intermittent claudication subjected to a treadmill training. His recent interests focus on the regulation of cellular metabolism in aging blood vessels and during the atherosclerosis progression.

Circulating proangiogenic cells (PACs), were described as bone marrow-derived cells that can contribute to angiogenesis and even de novo blood vessel formation. Number and function of PACs are impaired in patients with diabetes or cardiovascular diseases. Both diseases can be accompanied by decreased levels of heme oxygenase-1 (HMOX1), cytoprotective, heme-degrading enzyme, which is crucial for PAC function in mouse models. Therefore, our study aimed to check whether pharmacological enhancement of HMOX1 expression in hematopoietic stem/progenitor (HSPC) derived PAC cells would improve their paracrine proangiogenic activity. We used GCSF-mobilized CD34+ cells, FACS-sorted from a healthy donor PBMCs. Sorted cells were CD45dimCD90-CD105-CD181- and predominantly CD133+ and CD11b-. CD34+ cells after 6 days in culture were stimulated with atorvastatin, acetylsalicylic acid, sulforaphane, resveratrol or metformin for 48 h. Conditioned media from such cells were then used to stimulate human aortic endothelial cells (HAoEC) to enhance tube-like structure formation in Matrigel assay. The only stimulant that enhanced PAC paracrine angiogenic activity was atorvastatin. On the other hand, the only one that induced heme oxygenase-1 expression was sulforaphane, a known activator of HMOX1 inducer – NRF2. Moreover, none of the stimulants changed the levels of 30 cytokines and growth factors tested with the multiplex test. Then, we used atorvastatin-stimulated cells or conditioned media from them in the Matrigel plug in vivo angiogenic assay. Neither atorvastatin alone in control media nor conditioned media nor AT-stimulated cells affected numbers of endothelial cells in the plug or plug's vascularisation. Concluding, atorvastatin can enhance the paracrine angiogenic activity of human CD34+ HSPC-derived PAC cells in vitro, but the effect was not observed in vivo. Moreover, the enhancement of HMOX1 expression with sulforaphane does not influence PAC proangiogenic action in vitro.

Cun-Tao Yu is one of the most famous cardiovascular surgeons in China. He is especially good at all kinds of operation of large vessels, and has completed over 1500 operations such as total arch replacement and thoracoabdominal aortic replacement. Jin-Lin Wu is his doctoral candidate

Introduction: Given the high mortality rate in patients with type A aortic dissection, predictive tools to identify patients at increased risk of aortic dissection, when the diameter of ascending aorta is still under the threshold of 55 mm, are needed to assist clinicians for optimal intervention and to help patients raise their alert. Method: We evaluated 528 consecutive patients of acute type A aortic dissection (AAAD) admitted to Fuwai hospital, Beijing, China between 2009 and 2013. Univariate testing followed by multivariate logistic regression analysis was performed to identify independent predictors of AAAD at a diameter less than 55 mm. A simplified scoring system for predicting aortic dissection at a smaller diameter was then established based on the results of the multivariate analysis. Results: Of the 528 AAAD patients, 375 (71%) were with a diameter less than 55mm at the level of ascending aorta. A total of 25 variables as regard with demographic characteristics, clinical features and imaging were investigated. Logistic regression identified the following presenting variables as predictors of AD at a diameter less than 55 mm: age≥50 years (OR, 0.41; 95%CI, 0.26 to 0.65; P<0.01), hypertension (OR, 2.02; 95%CI, 1.20 to 3.40; P=0.01), history of aortic valve replacement (OR, 0.05; 95%CI, 0.01 to 0.42; P=0.01), history of catheterization (OR, 7.45; 95%CI, 1.26 to 44.21; P=0.03), hepatic cyst (OR, 2.69; 95%CI, 1.30 to 5.60; P=0.01), renal cyst (OR, 3.62; 95%CI, 1.85 to 7.08; P<0.01), bovine arch (OR, 6.39; 95%CI, 1.47 to 27.90; P=0.02), BAV (OR, 0.19; 95%CI, 0.04 to 0.95; P=0.04). Area under the receiver operating curve (ROC) was 0.73. Hosmer-Lemeshow statistic, P=0.28. Conclusion: Patients with age < 50 years, hypertension, a history of catheterization, hepatic cyst, renal cyst, or bovine arch were more likely to develop aortic dissection at a smaller diameter.