An aneurysm of the superior mesenteric artery (SMA) with a diameter of 2.2 cm was found incidentally on an ultrasound (US) examination in a 26-year-old woman. The only known risk factor was an ...intracranial aneurysm that was found on her grandmother's autopsy. Based on pregnancy planning and the current literature, endovascular management with a covered stent was proposed.
Self-expandable, covered stent (Bard, Fluency
) was implanted using a single transfemoral approach. A stiff guidewire and a large sheath distorted the anatomy, which resulted in an incomplete aneurysmal neck covering. In the absence of additional covered stents, the procedure was terminated. Two weeks later, computed tomographic angiography (CTA) confirmed persistent aneurysmal perfusion due to the incomplete neck coverage. A multidisciplinary board opted for a second endovascular attempt, this time with a longer covered stent via the transaxillary approach in order to reduce anatomical distortion. Balloon, expandable, cobalt-chrome covered stent (Jotec, E-ventus BX
) was implanted in the SMA, covering the aneurysmal neck and overlapping the previously implanted covered stent. Angiography confirmed a complete exclusion of the aneurysm. A control US performed three weeks later confirmed a patent covered stent and complete aneurysmal exclusion. There was a mild median nerve damage periprocedurally that resolved in three months. The most recent US control examination, performed eleven months after the procedure, showed an excluded aneurysm and a patent covered stent. There were no clinical signs of bowel ischaemia during the follow-up period.
Endovascular management of SMAA proved to be safe and efficient. The "access from above" is probably safer and should be considered in the majority of cases with acceptable sizes of access vessels. Mid-term results in our patient are good and life-long follow-up is planned to prevent late complications.
Aneurizma abdominalne aorte (AAA) čest je problem u starije populacije, a rizik rupture korelira s promjerom aneurizme. Tradicionalno su se bolesnici s aneurizmom abdominalne aorte većeg promjera ...liječili otvorenim kirurškim tehnikama, dok u posljednjih 20 godina pratimo porast korištenja tehnike endovaskularnog popravka aneurizme aorte (EVAR-a), koja uključuje postavljanje prostetskog nepropusnog grafta unutar lumena abdominalne aorte s ciljem isključenja aneurizme iz protoka i sprječavanja rupture. Sigurnosni profil i dugoročni podatci metode EVAR rezultirali su značajnim porastom korištenja EVAR-a, unatoč studijama koje dugoročnim praćenjem nisu pokazale bolje preživljavanje ili kvalitetu života. Zbog porasta broja bolesnika liječenih EVAR-om, očekujemo porast broja komplikacija i potrebu za sekundarnim intervencijama. U najčešće komplikacije nakon EVAR-a ubrajamo endoleak , migraciju stent-grafta, kinking-proteze, trombozu te infekciju grafta. Sekundarne komplikacije prvenstveno treba zbrinjavati endovaskularno, no kasne komplikacije koje zahtijevaju otvorenu kiruršku operaciju možemo očekivati u do 9 % bolesnika kojima je učinjen EVAR. Operacije aneurizme abdominalne aorte nakon nezadovoljavajućeg rezultata EVAR-a prati veći broj komplikacija, zbog atrofije zida aorte, periaortalne upale i fibroze te otežanog postizanja proksimalne i distalne vaskularne kontrole zbog pozicije stent-grafta, što često zahtijeva suprarenalno klemanje. Otvorena kirurgija gotovo je uvijek potrebna kod sekundarne rupture AAA, ako endovaskularne opcije odmah nisu dostupne ili tehnički moguće, kao i kod infekcije grafta, gdje je poželjna potpuna ekstrakcija protetskog materijala. Ključno je praćenje bolesnika nakon EVAR-a te pravovremeno i elektivno zbrinjavanje komplikacija.
Abdominal aortic aneurysm (AAA) is more common in the elderly population, and the risk of rupture correlates with the diameter of the aneurysm. Traditionally, patients with larger AAA were treated with open surgical techniques, but over the last 20 years, there has been an increase in the use of the endovascular aneurysm repair technique (EVAR), which involves placing a prosthetic impermeable graft within the lumen of the abdominal aorta to exclude the aneurysm from circulation and prevent rupture. The safety profile and long-term data of the EVAR method have resulted in a significant increase in the use of EVAR, despite studies that have not shown better survival or quality of life with long-term follow-up. Due to the increasing number of patients treated with EVAR, we expect an increase in the number of complications and the need for secondary interventions. The most common complications after EVAR include endoleak, stent graft migration, kinking of the prosthesis, thrombosis, and graft infection. Complications secondary to EVAR should primarily be managed endovascularly, but late complications requiring open surgery can be expected in up to 9% of patients who have undergone EVAR. Surgeries of the abdominal aorta secondary to failed EVAR are accompanied by a greater number of complications than the primary open procedures. Open surgery is almost always necessary for secondary rupture of AAA if endovascular options are not immediately available or technically feasible, as well as for graft infection, where complete extraction of the prosthetic material is desirable. The monitoring of patients after EVAR and the timely and elective management of complications are crucial.
The purpose of the study was to histologically analyse transition from pulpitis to periapical periodontitis on dog's teeth. Pulps of mandibular premolars (37 roots) were exposed using a low‐speed ...handpiece. Teeth were left open to the oral environment for 20, 35, 50 and 65 days. After the experimental period animals were sacrificed. Undemineralised teeth with surrounding bone, embedded in methylmetacrylate, were prepared for standard histological analysis. All teeth with pulpitis (five roots), regardless of the experimental period, had acute serose periapical periodontitis. All teeth (15 roots) with partial pulp necrosis had subacute periapical periodontitis. Teeth with complete pulp necrosis (19 roots) had chronic periapical periodontitis and in one case suppurative apical periodontitis. The condition of the pulp correlates with the histopathological findings of periapical tissue in the open types of pulp infection. Acute periapical periodontitis begins during pulpitis and can occur before 20 days of pulp exposure in the dog.
Aim: The aim of this study was to ascertain the percentage of apoptotic myocites in patients who underwent coronary artery bypass surgery. Apoptotic index (AI) obtained with in situ terminal ...deoxynucleotidyl transferase‐labeled dUTP nick end labeling (TUNEL) method and Bak protein expression were compared. Patients and Methods: Twenty consecutive patients who underwent coronary artery bypass surgery, myocardial samples from the right atrium were taken in three stages: before cannulation (the first sample group), after declamping (the second sample group), and 20 minutes after reperfusion (the third sample group). The percentage of apoptotic cells was determined by TUNEL method. Expression of Bak protein was immunohistochemically analyzed. Intermittent ischemia and moderate hypothermia were used as methods of myocardial management during surgery. A statistical analysis was performed by using the Friedman ANOVA analysis of variances, the Kendall coefficient of concordance and the Wilcoxon matched pair test. Results: In the first sample group mean value of Bak expression was 2.61 ± 2.18, compared with AI 5.38 ± 3.58, after declamping (the second sample group) the mean value of Bak expression was 4.31 ± 2.68 while AI was 7.63 ± 4.38 and after 20 minutes of reperfusion in the third sample group mean value of Bak expression was 8.89 ± 4.45, while AI was 15.6 ± 8.45. When compared by using Wilcoxon matched pair test two methods significantly correlated, p > 0.0001. Conclusion: The positive correlation between AI obtained by TUNEL method and expression of Bak protein may suggest that apoptosis is activated mainly through mitochondrial activation pathway in ischemic reperfusion injury. The results suggest that ischemic reperfusion injury increases the AI in the right atrial tissue. If so, immunohistochemical expression of Bak protein could be used as a marker of myocardial ischemia induced injury.
Components of carotid atherosclerotic plaque can be analysed preoperatively by non-invasive advanced imaging modalities such as magnetic resonance imaging (MRI). The expression of matrix ...metalloproteinase-9 protein (MMP-9), which has a potential role in remodelling of atherosclerotic plaques, can be analysed immunohistochemically. The aim of the present prospective pilot study is to analyse histological characteristics and expression of MMP-9 in carotid plaques of patients undergoing carotid endarterectomy (CEA) and to investigate the correlation with preoperative clinical symptoms and MRI features. Preoperative clinical assessment, MRI imaging, postoperative histological and immunohistochemical analyses were performed. Fifteen patients with symptomatic (7/15; 47%) and asymptomatic carotid artery stenosis undergoing CEA were included. Among symptomatic patients, 5 (71%) had recent stroke and 2 (29%) had recent transient ischaemic attack with a median timing of 6 weeks (IQR: 1, 18) before the surgery. Both groups did not significantly differ in respect to preoperative characteristics. Prevalence of unstable plaque was higher in symptomatic than asymptomatic patients, although it was not significant (63% vs. 37%,
= 0.077). The expression of MMP-9 in CD68 cells within the plaque by semiquantitative analysis was found to be significantly higher in symptomatic as compared to asymptomatic patients (86% vs. 25% with the highest expression,
= 0.014). The average microvascular density was found to be higher and lipid core area larger among both symptomatic patients and unstable carotid plaque specimens, although this did not reach statistical significance (
= 0.064 and
= 0.132,
= 0.360 and
= 0.569, respectively). Our results demonstrate that MRI is reliable in classifying carotid lesions and differentiating unstable from stable plaques. We have also shown that the expression of MMP-9 is significantly higher among symptomatic patients undergoing CEA.
Aneurizma poplitealne arterije lokalizirano je proširenje lumena poplitealne arterije koje najčešće nastaje kao posljedica ateroskleroze. Epidemiološka istraživanja pokazuju da su ovo najčešće ...aneurizme perifernih arterija s incidencijom od 0,1 do 2,8/100.000 ljudi koje uglavnom zahvaćaju mušku populaciju. U približno 50 % pacijenata aneurizme se nalaze bilateralno, a u 78 % slučajeva pacijenti ih imaju i na drugim arterijama, posebno na abdominalnoj aorti i ilijačnim krvnim žilama (64 %). U samom početku bolest je asimptomatska, a kasnije se može prezentirati bolovima, kompresijom, rijetko rupturom. Ako dođe do embolizacije tromba, koji potom distalno uzrokuje akutnu ishemiju ekstremiteta, očituje se plavim nožnim prstima, bljedilom, ulceracijama, gangrenom te u najgorem slučaju završava amputacijom uda. Osnova dijagnostike je višeslojna kompjutorska tomografija (MSCT) angiografija koja predstavlja zlatni standard, a ponekad je dovoljna i palpacija poplitealne jame iza koljenog zgloba. Temelj liječenja je operativni zahvat koji se sastoji od podvezivanja i isključivanja aneurizme iz krvotoka te formiranja i zaobilaženja aneurizme premosnicom. Druga opcija je endovaskularno liječenje, pri čemu se ugrađuje stent unutar aneurizme kako bi se ona isključila iz krvotoka. Prednosti ovog tipa zahvata su brz oporavak i kratko vrijeme hospitalizacije, a pogodna je u pacijenata s visokim operativnim rizikom. Ipak, veliki nedostaci su veća učestalost rane tromboze i začepljenja te veći broj komplikacija u odnosu na operativnu metodu. Operacija medijalnim pristupom najčešća je operativna metoda današnjice u liječenju aneurizmi poplitealnih arterija. Najbitnije prednosti su njeni odlični dugoročni rezultati, odsutnost komplikacija, jednostavnost i kratko trajanje zahvata, zbog čega predstavlja standard i prvu opciju kod liječenja aneurizmi poplitealnih arterija.
The aim of this study was to assess the functional outcome of a population of lower limb amputees supplied with prosthesis. The research was conducted from June to September of 2010 at the Center for ...Physical and Rehabilitation Medicine, of the Clinical Hospital Center Rijeka, Croatia. The study included 50 adult subjects of both genders with a unilateral transtibial or transfemoral lower limb amputations. The 2-minute walk test (2MWT) was used to assess the functional outcome of these individuals. Data were statistically analyzed. Subjects were divided into groups according to age. The best results were obtained by subjects between the age of 45 and 59 years. The difference between groups was statistically significant (p < 0.001). Taking into account the cause of amputation, there was a statistically significant difference in the results of the 2 MWT between subjects in whom the cause of amputation was circulatory and those where the cause of the amputation was not due to circulatory problems. The best results were obtained in subjects in whom the cause of amputation was not circulatory (p = 0.009). Considering the level of amputation there was a statistically significant difference in the results of the 2MWT between subjects with transtibial and those with transfemoral amputations. Better results were obtained in transtibial amputees (p = 0.039). Considering the first prosthetic supply, better results were obtained in subjects using prosthetic devices over 9 years (p = 0.031). Our research confirmed that age, gender, level and cause of amputation, including the time from the first prosthetic supply have an effect on the 2MWT results.
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