Introduction: Recent developments in aortic stent-graft technology have led to an increase in the use of wholly percutaneous endovascular aneurysm repair (P-EVAR). The literature was systematically reviewed to analyse the results of P-EVAR.

Background: Aortic arch disease has conventionally been the domain of open surgical repair. Hybrid open and endovascular repair has evolved as an alternative, less invasive, treatment option with promising results. A systematic literature review and analysis of the reported outcomes was undertaken.

Objectives: To analyse early and midterm results of thoracic aortic endografting (TEVAR) in the aortic arch. Methods: Between January 1997 and February 2009 178 patients received TEVAR in the aortic arch at our institution. This population was subdivided into four groups according to the proximal landing zone (LZ) classification in the aortic arch by Ishimaru et al. and a retrospective analysis regarding perioperative mortality, morbidity and endoleak formation was performed.

Objectives: To explore what kind of information surgeons communicate with patients diagnosed with an abdominal aortic aneurysm, and if the information provided regarding the disorder and treatment options available complies with legal requirements.

Objectives: This article describes the long-term outcome of surgical treatment in children with renovascular hypertension (RVH) over a 40-year period. Design: Retrospective study.

Background: Patency and limb salvage after synthetic bypass to the arteries below-knee are inferior to that which can be achieved with autologous vein. Use of a vein collar at the distal anastomosis has been suggested to improve patency and limb salvage, a problem that is analysed in this randomised clinical study.

Endovascular management of critical limb ischemia has advanced significantly in the recent past, especially the ability to treat tibial artery lesions with reasonable results. The indications, results, and technical aspects or endovascular management of CLI is reviewed herein. An algorithm for clinical management of CLI in patients with tibial occlusive disease is also presented.

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Objective: Ischemic strokes represent more than 80% of total strokes in Western countries. The influence of dietary factors on ischemic stroke risk is debated mainly because available data are limited. Our objective was to compare the dietary pattern of symptomatic ischemic stroke patients under 65 years old with control subjects using a validated 14-item food frequency questionnaire (FFQ). We also compared symptomatic ischemic stroke patients with carotid atherosclerosis with those without according to the presence or the absence of carotid plaque defined by duplex scanning.Methods: This was a case-control multi-center study that took place in one University hospital and two general hospitals in France. One hundred twenty-four symptomatic ischemic stroke patients (confirmation by a neurologist and imaging; 66% smokers) and 50 controls (34% smokers) without any known cardiovascular disease or previous nutritional advice were included. The main outcome measure(s) were intake scores for saturated (SFA), monounsaturated (MUFA), Ω-3 polyunsaturated (Ω-3 PUFA), and Ω-6 polyunsaturated fatty acids (Ω-6PUFA). Fruit and vegetables and an overall cardiovascular dietary score were evaluated with the FFQ. The overall cardiovascular score is calculated as (MUFA + Ω-3 PUFA + fruits and vegetables) – (SFA) scores.Results: Compared with controls, ischemic stroke patients had a higher SFA score (6.6 ± 3.0 vs 4.9 ± 2.7; P < .001), lower scores of MUFA (0.8 ± 0.9 vs 1.5 ± 1.2; P < .001), Ω-3 PUFA (1.7 ± 1.6 vs 2.2 ± 1.5; P = .013), Ω-6PUFA (2.6 ± 2.5 vs 3.9 ± 2.7; P = .002), fruit and vegetables (2.9 ± 1.7 vs 3.8 ± 1.6; P = .005), and a lower overall dietary score (−1.2 ± 5.0 vs 2.5 ± 4.4; P < .001). These results remained statistically significant after adjustment for age, gender, and smoking status. Ischemic stroke patients with carotid atherosclerosis (n = 54) had a worse overall cardiovascular dietary score than those without (n = 68): −2.2 ± 4.4 vs −0.2 ± 5.2; P = .024.Conclusion: Compared with controls, ischemic stroke patients, especially those with carotid atherosclerosis, have an unfavorable dietary pattern (high SFA, low fruit and vegetables, and Ω-3 PUFA consumptions) that may have been a facilitating condition of the ischemic stroke. Dietary recommendations of a healthy diet should be useful in ischemic stroke prevention, especially in patients with cardiovascular risk factors.

Objectives: The aim was to determine the diagnostic value of a juxtaluminal black (hypoechoic) area without a visible echogenic cap (JBA) in ultrasonic images of internal carotid artery plaques.Methods: Ultrasonic images of plaques from 324 patients with asymptomatic (n = 139) and symptomatic (n = 185) internal carotid 50% to 99% stenosis in relation to the bulb (European Carotid Surgery Trial) referred for duplex scanning were studied. The JBA in mm2 and the gray-scale median (GSM) were obtained after image normalization. Cut-off points for GSM and JBA (combined highest sensitivity with highest specificity) were determined from receiver operator characteristic (ROC) curves.Results: JBA ≥ 8 mm2 was associated with a high prevalence of symptomatic plaques in all grades of stenosis. In a multiple logistic regression model, increasing stenosis (mild, moderate, severe), GSM ≤ 15 and JBA ≥ 8 mm2 were independent predictors of the presence of hemispheric symptoms. This model could identify a high-risk group of 188 plaques that contained 142 (77%) of the 185 symptomatic plaques (odds ratio [OR], 6.7; 95% confidence interval [CI], 4.08-10.91), (P < .001), (sensitivity: 77%; specificity 66%; positive predictive value 75%; negative predictive value 68%).Conclusions: The results of this study indicate the diagnostic value and for the first time suggest a cut-off point of 8 mm2 for JBA. This cut-off point needs to be validated in other groups and then applied to prospective studies of asymptomatic patients.

Objective: Vascular smooth muscle cells (SMCs) are exposed to fluid shear stress (FSS) after interventional procedures such as balloon-angioplasty. Whereas the effects of hemodynamic forces on endothelial cells are explored in detail, the influence of FSS on smooth muscle cell function is poorly characterized. Here, we investigated the effect of FSS on SMC gene expression and function.Methods: Laminar FSS of arterial level (14 dynes/cm2) was applied to SMC cultures for 24 hours in a parallel-plate flow chamber. The effect of FSS on gene expression was first screened with microarray technology, and results further verified by real time polymerase chain reaction (RT-PCR) and immunoblotting. Tissue factor pathway inhibitor-2 (TFPI-2) and caspase-3 protein expression was studied in the rat carotid artery after balloon-injury, and the effect of TFPI-2 on SMC DNA synthesis and apoptosis was examined in vitro.Results: Microarrays identified TFPI-2 as one of the most differentially expressed gene by FSS in cultured SMCs (P < .001). Gene set enrichment analysis revealed significant regulation of genes linked to proliferation, apoptosis, and cell cycle regulation. TFPI-2 induction was confirmed by RT-PCR and immunoblotting demonstrating a more than 400-fold (P < .001) increase in TFPI-2 mRNA in SMCs exposed to FSS compared with static controls, and a consistent protein upregulation. Functionally, SMC proliferation was decreased by FSS (P < .001), and recombinant TFPI-2 was found to inhibit SMC proliferation (P < .001) and induce SMC apoptosis as indicated by activation of caspase-3 (P < .01). In vivo, TFPI-2 expression was found to be upregulated 5, 10, and 20 hours (P < .01) after rat carotid balloon injury, and immunohistochemistry demonstrated TFPI-2 protein in FSS-exposed luminal SMCs, co-localized with caspase-3 in the rat carotid neointima.Conclusion: FSS influenced gene expression associated with cell growth and apoptosis in cultured SMCs and strongly induced expression of TFPI-2 mRNA and protein. TFPI-2 was expressed in luminal, FSS-exposed SMCs together with caspase-3 in the rat carotid neointima after balloon injury. Functionally, TFPI-2 may play a role in vessel wall repair by regulating SMC proliferation and survival. Further studies are needed to elucidate the mechanisms by which TFPI-2 controls SMC function.Clinical Relevance: In the arterial wall, endothelial cells are exposed to fluid shear stress imposed by the flowing blood. However, after vascular interventions, where the endothelial layer is denuded and in intimal hyperplasia that develops, luminal smooth muscle cells are exposed to shear stress. We show that TFPI-2 expression is strongly augmented in smooth muscle cells exposed to shear stress and that TFPI-2 co-localizes with caspase-3 in vivo. In addition, TFPI-2 inhibits smooth muscle cell proliferation and induces apoptosis in vitro. The adaption of smooth muscle cells to shear stress is of interest in understanding the pathophysiology behind intimal hyperplasia and restenosis.

Objectives: To evaluate whether either angiotensin converting enzyme (ACE) inhibitors or other classes of antihypertensive drug attenuate or increase growth rates of small infrarenal abdominal aortic aneurysms.Methods: Prospective cohort study of 1701 patients enrolled in the UK Small Aneurysm Trial or associated study at 93 hospitals between 1991 and 1995 and who had at least two ultrasound measurements of aneurysm diameter and baseline drug prescription data recorded. Abdominal aortic aneurysm diameter was measured in the anterior-posterior plane using ultrasound. The mean growth rate was estimated through a mixed-effects linear growth model.Results: Mean aneurysm growth rate in 169 patients taking ACE inhibitors at baseline was 3.33 mm/y vs 2.77 mm/y in the remaining 1532 patients, P = .009. The significance of this finding did not alter after adjustment for known confounders. The prescription of any antihypertensive agent and other specific classes of antihypertensive drugs were not found to be associated with aneurysm growth rate.Conclusion: These results show that patients taking ACE inhibitors have faster aneurysm growth and are in conflict with the observation from a large Canadian data-base that aneurysm patients taking ACE inhibitors are less likely to present with aneurysm rupture. There is an urgent need for a randomized trial to assess whether ACE inhibitors are beneficial or harmful to patients with aneurysms below the threshold size for surgical intervention.

Objectives: To investigate changes in aortic diameter in hemodynamically unstable trauma patients and the implications for sizing of thoracic endovascular aortic repair (TEVAR) in patients with traumatic thoracic aortic injury (TTAI).Methods: We retrospectively evaluated all trauma patients that were admitted with hemodynamic instability (mean arterial pressure <95 mm Hg and a pulse ≥100 beats/min) and underwent computed tomography (CT) of the thorax and abdomen both at admission and at another moment (control CT scan), at the Yale New Haven Hospital between 2002 and 2009. The CT examinations were reviewed in a blinded fashion and the aortic diameter was measured at six different levels by a cardiovascular radiologist. Differences in aortic diameter between the initial CTs obtained in the trauma bay and the control CTs were compared using the paired Student t test.Results: Forty-three patients were identified, including 32 males. Mean age was 37 ± 16 years, mean injury severity score was 26 ± 15, the mean pulse and blood pressure were 122 beats/min and 103/63 mm Hg, respectively. Overall, the mean aortic diameter was significantly larger at the control CT examinations compared with the initial CT examinations while hemodynamically unstable, at all evaluated levels. Among patients with a pulse ≥130/min, the mean increase in aortic diameter was most consistent at the level of the mid descending thoracic aorta (DTA, +12.6%, P = .003) and at the level of the infrarenal aorta (+12.6%, P = .004).Conclusions: The aortic diameter decreases dramatically in trauma patients with hemodynamic instability. This decrease in aortic diameter could theoretically lead to inaccurate aortic measurements and undersizing of the endograft in hemodynamically unstable TTAI patients requiring TEVAR. Further research is needed to better predict the actual aortic diameters in individual hemodynamically unstable patients requiring endovascular aortic repair.

Endofibrosis of the external iliac artery is an uncommon disease affecting primarily young, otherwise healthy, endurance athletes. Thigh pain during maximal exercise with quick resolution postexercise is characteristic of the so-called cyclist's iliac syndrome. We report an unusual case in which the typical endofibrotic plaque was accompanied by dissection of the external iliac artery. The patient was treated surgically with excision of the affected artery segment and placement of an interposition graft. This case highlights an unusual finding in association with external iliac artery endofibrosis and provides an opportunity to briefly review the literature on the subject.