Significant Atherosclerotic Changes Research Articles

Stroke before a haematopoietic stem cell transplantation is a potential risk factor for poor response to therapy in patients with blood cancer

Introduction. More than 50,000 haematopoietic stem cell transplantations (HSCTs) are performed worldwide each year to treat malignant blood cancers, solid tumours, bone marrow aplasia, primary immunodeficiency conditions, autoimmune disorders, and storage disorders. The success of HSCTs depends on many factors, including patient's past medical history.
 Purpose. To assess the effect of an acute cerebrovascular accident (CVA) that occurred before the HSCT on the transplantation outcome in patients with blood cancer.
 Materials and methods. We examined the results of 899 transplantations conducted between 2016 and 2018 at the R.M. Gorbacheva Research Institute for Pediatric Oncology, Haematology and Transplantation of the Pavlov First Saint Petersburg State Medical University. We analysed transplantation parameters, as well as donor and recipient characteristics. Apart from intergroup comparisons, pseudo-randomization was performed using the Propensity Score Matching method. The survival rate analysis was conducted using the KaplanMeier estimate and the log rank test.
 Results. Sixteen patients (1.8%) had cerebrovascular events in their past history before the HSCT: ischaemic stroke in 0.4% of cases and haemorrhagic stroke or intracerebral haemorrhage in 1.4% of cases. Patients with a history of cerebrovascular events included more people with leukaemia (p = 0.02), had more often received an allogenic transplant (р = 0.01), the donors more often had a partial rather than a full HLA match with the recipient (р = 0.06), had a lower body mass index (р = 0.02), and a lower Karnofsky/Lansky score (р = 0.01) than patients in the control group. The presence of a cardiovascular event had a statistically significant association with reduced overall survival rate of HSCT recipients (р = 0.0012).
 Conclusion. Patients with blood cancer and stroke preceding the transplantation do not typically have any 'classical' risk factors (diabetes mellitus, venous system disorders, decreased cardiac output, significant atherosclerotic changes in precerebral arteries), therefore, secondary prevention guidelines for CVA during treatment of the main disease may not be effective and cannot be relied on. This article discusses the most likely causes of CVA in patients with blood cancer. A history of CVA before HSCT may have a significant effect on the transplantation outcome, but is not a contraindication for this treatment method. Recipient selection is a very important stage in HSCT planning. A multidisciplinary team should find a balance between the indications and contraindications for performing HSCT from an unrelated donor.

Outcome of distal lower leg reconstruction with the propeller perforator flap in diabetic patients

In diabetic foot patients, wound coverage options are quite limited due to vascular abnormalities. However, even though significant atherosclerotic changes are found in major vessels of the lower leg in diabetic foot patients, perforating vessels, which are used as the vascular pedicle of propeller perforator flaps, are often spared from atherosclerosis. Therefore, the propeller perforator flap could be an alternative option for diabetic foot patients. The purpose of this study was to compare the outcome of the propeller perforator flap between diabetic and nondiabetic patients in reconstruction of the distal lower leg. We retrospectively included all patients who underwent reconstruction of the distal lower leg with a propeller flap between 2014 and 2018. Thirty-five propeller perforator flaps in 20 diabetic patients and 15 nondiabetic patients were included. Of the 35 patients, 21 showed complete healing, and 14 showed flap complications. The rate of complications in diabetic patients was approximately 85.7%. Sex (p = .002), diabetes (p = .007), chronic renal failure (p < .001), and diabetic neuropathy (p = .011) were associated with flap complications. Crude regression analysis showed that the female sex (p = .002), diabetes (p = .01), and diabetic neuropathy (p = .012) were significant risk factors for the occurrence of any complications, but the significance of diabetes and diabetic neuropathy was not maintained in the adjusted models. Therefore, the propeller perforator flap might not be effective for reconstructing diabetic foot ulcers.

Acute coronary syndromes and atherosclerotic plaque burden distribution in coronary arteries among patients with valvular heart disease (BIA-WAD registry).

IntroductionValvular heart diseases (VHD) are a significant problem in the Polish population. Coexistence of coronary artery disease (CAD) in patients with VHD increases the risk of death and affects the further therapeutic strategy.AimAnalysis of atherosclerotic plaque burden distribution in coronary arteries and long-term prognosis among patients with VHD.Material and methodsInclusion criteria were met by 1025 patients with moderate and severe VHD. Mean observation time was 2528 ±1454 days.ResultsSevere aortic valve stenosis (AVS) occurred in 28.2%, severe mitral valve insufficiency (MVI) in 20%. CAD with severe angiographic stenoses was noted in 42.3% (n = 434). Among patients with severe MVI, CAD was noted in 47.1% of cases, and prior acute coronary syndromes (ACS) in 27.1% of patients (n = 58). In severe AVS patients, significant angiographic atherosclerotic changes were observed in 29.6% (n = 86), and prior ACS in 7.6% (n = 22) of patients. During the observation 52.7% of patients died, including 62.9% of patients with severe MVI and 51.6% of those with severe AVS. Age (OR = 1.038; 95% CI: 1.005–1.072; p = 0.022) and coexisting aortic valve insufficiency (AVI) (OR = 2.39, 95% CI: 5.370–11.065, p = 0.035) increased the mortality rate.ConclusionsSevere AVS is starting to be the most prevalent VHD. CAD is one of the most significant factors deteriorating prognosis of patients with VHD. AVI and age were significant risk factors for mortality. The worst prognosis was observed in severe MVI, which may result from more frequent occurrence of CAD in this group. A lesser burden of CAD and ACS in the group of patients with severe AVS did not affect survival.

Ochronne właściwości cholesterolu HDL i zwapnień w blaszce miażdżycowej w zaawansowanej miażdżycy u pacjentów z udarem niedokrwiennym mózgu

STRESZCZENIEWstęp: Zmiany miażdżycowe w tętnicach szyjnych odgrywająistotną rolę w patogenezie udaru niedokrwiennego mózgu.W znacznym procencie przypadków stwierdza się wyraźną asymetrięw rozwoju tych zmian, które zajmują tylko jedną tętnicę.Celem pracy było ustalenie wpływu sercowo‑naczyniowychczynników ryzyka na obecność istotnych hemodynamiczniezmian miażdżycowych lub niedrożności tylko w jednej tętnicyszyjnej w porównaniu do obustronnego ich zajęcia u pacjentówz udarem niedokrwiennym mózgu.Materiały i metody: Pacjenci z rozpoznaniem udaru niedokrwiennegomózgu poddani zostali retrospektywnej oceniew kierunku zwężenia ≥70% lub niedrożności, co najmniej w jednejtętnicy szyjnej wewnętrznej lub wspólnej. Do badania zostałowłączonych 104 pacjentów. Grupę I stanowili chorzy z istotnymhemodynamicznie zwężeniem (≥70%) lub niedrożnością jednejtętnicy (n = 48). Grupę II stanowiły osoby z obustronnymistotnym hemodynamicznie zwężeniem (≥70%) lub niedrożnościątętnic szyjnych (n = 56).Wyniki: Nie stwierdzono różnic w częstości występowanianiemodyfikowalnych czynników ryzyka pomiędzy grupami.W grupie I stwierdzono istotnie wyższy poziom cholesteroluHDL (45,7 vs 38,9 mg/dL, p = 0,038) i istotnie częściej obecnośćzwapnień w blaszkach miażdżycowych tętnic szyjnych(p = 0,03). Nie stwierdzono różnic w częstości występowaniainnych badanych czynników pomiędzy grupami.Wnioski: Ochronne właściwości cholesterolu HDL i wolniejszadynamika powstawania bardziej stabilnych, uwapnionych blaszekmiażdżycowych odgrywają istotną rolę w rozwoju tylkojednostronnych, zaawansowanych zmian miażdżycowych w tętnicachszyjnych. Rola HDL w patomechanizmie powstawaniaudaru mózgu wymaga dalszych badań.

Immune cells and vasa vasorum in the tunica media of atherosclerotic coronary arteries.

In coronary artery disease (CAD), the disruption of the tunica media immune privilege manifests as increased leukocyte infiltration and the formation of vasa vasorum. We aimed to characterize the immune privilege status of the tunica media in human coronary arteries (CAs) with atherosclerotic plaques, by comparing the abundance and composition of immune-cell infiltrates within the individual arterial-wall layers, and by evaluating vasa vasorum neovascularization of the tunica media. The tissue samples were obtained from 36 symptomatic patients with diffuse CAD (aged 60-72 years) who underwent coronary endarterectomy. T and B cells, macrophages and endothelial cells in the CAs were detected by immunohistochemistry. Morphological analysis of CAs showed significant atherosclerotic changes in all specimens. In the media, we observed damage and loss of smooth muscle cells, destruction of the extracellular matrix architecture, and fibrosis. There were 43.3% of immune cells in the intima, 50% in the adventitia, and 6.7% in the media. In the media, 51.1% of the immune cells were T cells (p ˂ 0.001 compared to B cells and macrophages; ANOVA, Scheffe post hoc analysis), 23.5% were B cells, and 25.4% were macrophages. The number of vasa vasorum in the media was 1 in 38.9% of CAs, 2-3 in 36.1%, and ≥4 in 25% of CAs. Our results indicate that, in atherosclerotic CAs, the immune privilege of the media is disrupted by the infiltration of T and B cells, macrophages, and the presence of vasa vasorum.

RENAL HEMODYNAMICS EVALUATION IN PATIENTS SUFFERING FROM RHEUMATOID ARTHRITIS WITH AND WITHOUT COMORBID HYPERTENSION

Aim. To study the features of renal arterial blood flow in patients suffering from rheumatoid arthritis, its interaction with visual markers of atherosclerosis in the presence of comorbid hypertension. Materials and methods. 113 patients with rheumatoid arthritis (RA) were enrolled into this study. Depending on the comorbidity of hypertension the patients were divided into two groups: without (n=53) and with hypertension (n=60). The comparison group consisted of 41 patients with arterial hypertension without RA. Clinical characteristics and blood biochemistry of all the patients were measured. Renal arterial resistance index (RI), presence of atherosclerotic plaques (ASP) in the carotid arteries were assessed by ultrasound scan. Results. In this investigation we report the correlation of the of renal resistive index (RI) and ultrasound signs of carotid atherosclerosis with hypertension in patients with RA. It was found out that there is the increase of RI in RA associated with the age of patients, the onset of the disease at a later age, the presence of atherosclerotic plaques in the carotid arteries and hypertension. In addition, patients with RA had a high frequency of bilateral RI increase by more than 0.7 (64%). Patients with bilateral high RI had a two-fold increase in the registration rate of atherosclerotic plaques in both group of patients with RA. Conclusion. Increased renal arteries RI in patients with RA is a factor associated with the comorbid hypertension and accompanied by more significant atherosclerotic changes in the carotid arteries in the form of an increased incidence of atherosclerotic plaques.

Comprehensive Ultrasound Assessment of the Craniocervical Circulation in Transient Global Amnesia.

Structural changes and metabolic stress have been reported on diffusion-weighted magnetic resonance imaging in the cornu ammonis 1 area of the hippocampus in patients with transient global amnesia (TGA), but a consensus on pathogenesis is still lacking. The aim of our study was to perform a comprehensive ultrasound analysis of the cerebrovascular circulation in our population of patients with TGA. One hundred patients with TGA and 50 age- and sex-matched control participants underwent ultrasound examinations of the cervicocranial circulation. The most significant risk factor for TGA was arterial hypertension (P < .01). There were no significant atherosclerotic lesions on the large arteries of the neck (mean internal carotid artery stenosis ± SD, 28.7% ± 11.7%) or on the large intracerebral arteries (good structural and hemodynamic status; P > .05). Rarely detected microembolic signals or a right-left cardiopulmonary shunt excluded an emboligenic mechanism of TGA (P > .05). The internal jugular vein valves were incompetent in 54% of patients with TGA, and this condition was associated with an increased risk of TGA (odds ratio, 4.16; 95% confidence interval, 1.91-9.04). The mean values of the breath holding index and pulsatility index, as parameters of small-vessel function, were within normal ranges and without differences between the TGA and control groups (P > .05). Our ultrasound examination did not detect significant structural atherosclerotic changes of cervicocranial arteries, and an emboligenic mechanism was excluded. Only a significant rise of blood pressure in TGA and significant valvular insufficiency of the internal jugular vein were established. New research should clarify whether these simultaneous functional circulatory changes have relevance for metabolic stress in the cornu ammonis of the hippocampus.

Molecular imaging in cardiovascular diseases.

Cardiovascular diseases remain the leading cause of morbidity and mortality in industrialized and developing countries. In clinical practice, the in-vivo identification of atherosclerotic lesions, which can lead to complications such as heart attack or stroke, remains difficult. Imaging techniques provide the reference standard for the detection of clinically significant atherosclerotic changes in the coronary and carotid arteries. The assessment of the luminal narrowing is feasible, while the differentiation of stable and potentially unstable or vulnerable atherosclerotic plaques is currently not possible using non-invasive imaging. With high spatial resolution and high soft tissue contrast, magnetic resonance imaging (MRI) is a suitable method for the evaluation of the thin arterial wall. In clinical practice, native MRI of the vessel wall already allows the differentiation and characterization of components of atherosclerotic plaques in the carotid arteries and the aorta. Additional diagnostic information can be gained by the use of non-specific MRI contrast agents. With the development of targeted molecular probes, that highlight specific molecules or cells, pathological processes can be visualized at a molecular level with high spatial resolution. In this review article, the development of pathophysiological changes leading to the development of the arterial wall are introduced and discussed. Additionally, principles of contrast enhanced imaging with non-specific contrast agents and molecular probes will be discussed and latest developments in the field of molecular imaging of the vascular wall will be introduced. Molecular magnetic resonance imaging has great potential to improve the in vivo characterization of atherosclerotic plaques. Based on the molecular information is feasible to enable a better differentiation of stable and unstable (vulnerable) atherosclerotic plaques.

Is Prostatic Artery Embolization Similar to Uterine Artery Embolization?

Recently, arterial embolization has been proposed as a safe and effective treatment for benign prostatic hyperplasia (BPH) [1]. Nonetheless, prostatic arterial embolization (PAE) is not a new procedure; it has been used for almost 40 years to control prostatic bleeding [2]. In 2000, De Merritt et al. [3] reported a case of embolization to treat hematuria after prostate biopsy in a patient with BPH. Interestingly, embolization not only stopped the bleeding, but also reduced the size of the gland and led to improvement in lower urinary tract symptoms. This observation sparked interest in a potential new application for embolotherapy. Early proponents of this new application noticed some similarities between prostatic artery embolization (PAE) and the well-established uterine artery embolization (UAE) procedure. UAE for treatment of symptomatic fibroids is now considered an excellent alternative to hysterectomy based on level I scientific evidence [4]. But what is the relationship between embolization for uterine fibroids and BPH? There are indeed some similarities. Both diseases are the most common benign tumors of the female and male pelvis, respectively. Both diseases have a tissue structure characterized by the presence of stromal and smooth muscle components, which are intrinsically hormone-dependent for their development and growth—estrogen and testosterone, respectively. Although considered benign tumors, both illnesses cause symptoms that produce a deep impact on quality of life, and usually are treated with conventional medical and surgical therapies, intrinsically associated with risks and morbidity, including sexual dysfunction. In contrast, embolization is a minimally invasive alternative that delivers embolic agents with the aim of causing targeted and controlled tissue ischemia and necrosis of the offending tumors. However, aside from these similarities, there are also many differences, which should be kept in mind for those who have experience in UFE and intend to explore the PAE field. Uterine fibroids affect premenopausal, therefore young, women up to the fifth decade of life, whereas BPH affects men starting from the fifth decade of life, with most symptomatic patients requiring treatment when they are even older. As a consequence, many BPH patients have significant atherosclerotic changes in their vessels, which make endovascular procedures more difficult and challenging. Uterine arteries in women with fibroids have a fairly constant anatomic location, distribution, and course, and their diameter grows proportionally to the size of the leiomyomatous uterus. In contrast, prostatic arteries are subject to numerous anatomic variations in terms of their origin and distribution, while remaining quite small in diameter, even when the prostate reaches fairly large volumes. It is also not uncommon to find more than one prostatic artery on each side [5]. In an anatomic description published recently, two main arterial pedicles to the prostate have been identified: the superior and inferior prostatic pedicles [5]. The former provides the main arterial supply of the prostate, in addition to both the inferior bladder and N. Kisilevzky (&) Interventional Radiologist at Endovascular Center, Rua Guararapes 682, City Lapa, SP CEP 05077051, Brazil e-mail: dr.nestor@embolution.com.br

Coronary subclavian steal syndrome: an extracoronary cause of acute coronary syndrome

Significant atherosclerotic changes of the coronary arteries are the common cause of cardiac chest pain. We report the case of an 80-year-old woman suffering from unstable angina caused by extracoronary atherosclerosis. The patient had an extensive medical history with severe coronary heart disease and cardiac bypass surgery (LIMA to LAD, two venous bypass grafts). An urgent coronary angiography was performed. The angiogram displayed the already known three-vessel disease, the bypass grafts were in a good functional condition. Subsequently, a stenosis of the proximal segment of the left subclavian artery was detected. Measurement of the pullback pressure gradient confirmed the significance of the stenosis. We suspected a "steal phenomenon" concerning the bypass graft LIMA to LAD. An ad hoc PTA with consecutive stenting (self-expandable stent) enabled a successful revascularization of the left subclavian artery without any adverse effects to the vertebral arteries. Cardiac chest pain did not occur any more. Coronary Subclavian Steal Syndrome should be considered a rare but important differential diagnosis in acute coronary syndrome after bypass surgery.

Assessment of Vascular Reactivity in the Peripheral and Coronary Arteries by Cine 3T-Magnetic Resonance Imaging in Young Normotensive Adults after Surgery for Coarctation of the Aorta

This study aimed to investigate whether coarctation of the aorta in infancy indicates an altered vascular reactivity in the peripheral and coronary arteries apart from the secondary effect of hypertension or other complications of the disease. Patients with repaired coarctation of the aorta have a high prevalence of premature cardiovascular complications. The etiology still is not fully understood, and the cause is most likely multifactorial. Endothelial function was assessed by peripheral flow mediated dilation (FMD) and coronary flow reserve (CFR) in a study of 10 control subjects and 10 patients with a successfully repaired coarctation of the aorta (mean age, 20.9 years; 20.5 years after repair). No one had re- or rest-coarctation of the aorta, hypertension, pathologic blood pressure response during exercise, or associated cardiac malformations such as bicuspid aortic valve. CFR was achieved by phase-contrast velocity encoding cine magnetic resonance imaging in the coronary sinus before and during infusion with adenosine (0.14mg/kg/min). FMD was measured in the brachial artery before and after 5min of arterial occlusion. A normal CFR and FMD was found in both groups. Most studies have been conducted with large, unselected groups. The current study group represented the best outcome of the coarctation spectrum (i.e., patients with no evidence of a residual gradient across the coarctation site or systemic hypertension). The findings reassuringly suggest that significant endothelial dysfunction and atherosclerotic changes were not present in this selected cohort.

Aortic arch surgery with a mild-to-moderate circulatory arrest: the significance of aortic arch pathology

We read with great interest the article by Urbanski et al. [1] about aortic arch surgery using a mild-to-moderate hypothermic circulatory arrest. They evaluated a large series of patients who underwent aortic arch surgery in an elective setting. The mean temperature at circulatory arrest was 29.9°C and the mean duration of circulatory arrest was only 18 min. Surgical results were remarkable. Thirty-day mortality was only 0.9%, permanent neurological deficits and temporary neurological deficits were both also 0.9%, respectively, and there was no paraplegia. They showed quite a low incidence of postoperative acute renal failure and respiratory failure. In this series, an acute aortic dissection was excluded and most of the patients’ indication for surgery was degenerative or atherosclerotic disease. Interestingly, 299 (86%) patients had aortic valve disease and 312 (90%) patients underwent concomitant aortic valve surgery, although the reports of other large series showed that only 8% of patients had an aortic root replacement and 3.8% of patients had an aortic valve replacement [2]. Probably, in these authors’ report, many patients had aortic valve stenosis and/or regurgitation with an ascending aortic aneurysm. For this pathology, it is often an aneurysm which extends to the proximal aortic arch; therefore, sometimes a proximal arch replacement is required in addition to aortic valve or root surgery. In this setting, open distal anastomosis is an appropriate procedure to repair the proximal aortic arch. However, compared to a distal aortic arch aneurysm, the atherosclerotic change in the anastomosis site would be mild and the anastomsis technique would not be as complex and time-consuming. For repairing the distal aortic arch aneurysm, the distal anastomosis site could be deep inside the chest cavity and the aortic arch usually has significant atherosclerotic changes. Therefore, selective cerebral perfusion time and circulatory arrest time could be longer than the proximal arch repair and the risk of permanent neurological deficit could be higher. We believe that it is difficult to generalize the authors’ technique and strategy to all kinds of patient pathologies, because patient characteristics are extraordinary in this report.

Left ventricular morphology and function in diabetic and nondiabetic hemodialyzed patients

Morbidity in end-stage renal disease (ESRD) diabetic patients is worse than in patients without diabetes mellitus (DM). This study aims to compare clinical, laboratory, and echocardiographic features between the ESRD patients with and without DM. Fifty-eight ESRD patients on dialysis were prospectively divided into two groups according to the presence of DM. Demographic, clinical, laboratory, and echocardiographic features (ejection fraction and wall motion score index) were compared between the two groups. Overall, 20 out of 58 patients (37.8%) with ESRD had DM. There were no significant differences between the patients with DM and those without DM when it comes to age (60.6 ± 10.6 vs. 59.0 ± 10.6 years, P = 0.665), ejection fraction (52.6% ± 12.8% vs. 54.2% ± 12.8%, P = 0.59), and wall motion score index (1.21 ± 0.3 vs.1.15 ± 0.3, P = 0.37). In multivariant analysis of the interventricular septum, posterior wall thickness and left atrium size correlated positively with DM. There was also no statistical difference in myocardial perfusion disturbances on real-time contrast echocardiography between the groups with and without DM (12 (60%) patients vs. 14 patients (36.8%), P = 0.079). Among diabetics 77.8% had significant atherosclerotic changes, while in the group without DM, only 38.1%, P = 0.01. From the laboratory parameters ferritin and high-sensitivity C-reactive protein levels were significantly higher in the group with DM, P = 0.014 and P = 0.026, respectively. Patients with ESRD and DM have significantly bigger left atrial size, thicker left ventricular walls, and higher serum ferritin and high-sensitivity C-reactive protein levels than the patients without DM. The aforementioned features may be possible risk factors for the development of adverse cardiac events in patients on hemodialysis.

ST-elevation myocardial infarction caused by thromboembolism from the left atrial appendage

A 64-year-old gentleman was admitted for primary percutaneous coronary intervention (PCI) after he experienced chest pain while drinking alcohol in a pub. The electrocardiograms demonstrated atrial fibrillation (AF) with a rapid ventricular response rate and transient ST-segment elevation with loss of R waves in the anterior leads (Figure 1). Coronary angiography revealed a thrombotic occlusion of the distal segment of the left anterior descending artery (Figure 2). The proximal left anterior descending, circumflex and right coronary arteries were angiographically free from significant atherosclerotic changes. …

Spontaneous rupture of a giant coronary artery aneurysm causing cardiac tamponade: A case report

A 62-year-old woman with a history of dyslipidemia and hypothyroidism was referred to our institution with syncope. Cardiac tamponade due to spontaneous rupture of a 50-mm aneurysm of the coronary artery was diagnosed by transthoracic echocardiography, enhanced computed tomography, and coronary angiography. Emergency surgery was performed, and despite developing postoperative complications such as acute renal insufficiency, the patient was discharged from hospital without sequelae 89 days later. Histological findings revealed cystic media degeneration, but neither significant atherosclerotic changes nor inflammatory cell infiltration. Although coronary artery aneurysms are comparatively rare and generally asymptomatic, those over 30mm in diameter are considered to be at increased risk of rupture. A coronary artery aneurysm of about 50mm ruptured in our patient, supporting this view.

Impact of Diabetes Mellitus on Survival in Patients with End-Stage Renal Disease: A Three-Year Follow-Up

Background/Aims: To assess the impact of diabetes mellitus (DM) on clinical outcome in patients with end-stage renal disease (ESRD) on a 3-year follow-up. Methods: 58 ESRD patients were divided into 2 groups according to the presence of DM. We analyzed following end points: death, cardiac arrest, myocardial infarction, stroke, hospitalizations due to cardiovascular causes, revascularization, and combined end point. Results: Among diabetics, 14 (77.8%) had significant atherosclerotic changes, in the group without DM only 8 (38.1%), p = 0.01. In the group without DM, 14 (46.7%) patients reached combined end point, while in the group with DM 16 (53.3%) patients, p = 0.0013. There were no statistical differences in mortality (p = 0.423). Conclusion: Survival of hemodialyzed diabetic patients is not inferior to nondiabetics; however, morbidity is significantly higher due to adverse cardiac events.

Oligosymptomatic and giant basilar artery dolichoectasia discovered after a stroke: case report

The most frequently diagnosed complication of vertebrobasilar dolichoectasia (VBD) is the compression of structures adjacent to the vertebral and basilar arteries. A giant VBD with only slight compressive symptoms is unusual. In this setting, the diagnosis of VBD may be casually revealed after the occurrence of a posterior circulation stroke, another potential complication. We report a 48-year-old woman who presented a two-month history of continuous buzz and a slight right-sided hearing loss that was followed by a cerebellar ischemic stroke. Brain CT and MRI revealed a marked compression of the brainstem due to an ectatic, tortuous and partially thrombosed basilar artery (BA). The largest cross-sectional diameter of BA was 18 mm. The patient had a good functional recovery within the two-month follow-up after stroke with modified Rankin scale score (mRSS)=2. At the one-year follow-up, patient still kept the complaints of continuous buzz, slight right-sided hearing loss and the mRSS was the same. We call attention for an unusual giant VBD that caused an impressive brainstem compression with displacement of important structures in an oligosymptomatic patient. Diagnosis was made only after the occurrence of a stroke. Despite of the good functional recovery after stroke, the presence of significant atherosclerotic changes and the large BA diameter may indicate a poor outcome. However, after one year, she remains oligosymptomatic.

The content of copper and zinc in human ulcerated carotid plaque

Copper and zinc have significant antiatherogenic effect influencing activity of antioxidant enzymes (glutathione-peroxidase and superoxide-dismutase), mechanism of apoptosis and other mechanisms. Few studies showed increased copper and zinc concentration in atherosclerotic plaque in comparison to normal vascular tissue. The aim of the study was to compare copper and zinc concentrations in carotid artery tissue without significant atherosclerotic changes and human ulcered atherosclerotic plaque. Study was conducted on 66 patients. Carotid endarterectomy due to the significant carotid atherosclerotic changes with cerebrovascular disorders was performed in 54 patients (81.8%). Control group consisted of 12 patients (18.2%) without carotid atherosclerotic changes operated due to the symptomatic kinking and coiling of carotid artery. Operated group consisted of 38 men (62.96%) and 16 women (37.04%). Control group had the same number of patients: six men (50%) and six women (50%). Preoperatively, all patients were examined by vascular surgeon, neurologist and cardiologist. Duplex sonography of carotid and vertebral arteries was performed by Aloca DSD 630 ultrasound with mechanical and linear transducer 7.7 MHz. Indication for surgical treatment was obtained according to non-invasive diagnostic protocol and neurological symptoms. Copper and zinc concentration in human ulcered atherosclerotic plaque and carotid artery segment were estimated by spectrophotometry (Varian AA-5). Average age of our patients was 59.8+/-8.1 years. For males average age was 76.1+/-9.8 years. And for females 42.4+/-5.8 years. In group with carotid endarterectomy female patients were significantly younger than male patients (p<0.01). In group with carotid endarterectomy clinically determined neurological disorders were found in 47 patients (87.03%)--35 male (74.47%) and 12 female patients (25.53%). Regarding risk factors for cardiovascular diseases, no significant difference among groups was found for blood pressure and smoking. However, patients with carotid endarterectomy had significantly more diabetes mellitus (p<0.05), obesity (p<0.01) and hypercholesterolemia (p<0.01). Our study showed significantly lower total copper value in the group with human ulcered atherosclerotic plaque in comparison with the control group (p<0.05). We also found significantly lower total zinc value in the group with human ulcered atherosclerotic plaque in comparison with the control group (p<0.05). Our study revealed significant difference in copper and zinc content between human ulcered atherosclerotic plaque and normal carotid tissue. Closer correlation of these oligoelements and endothelial dysfunction will be established in future investigations.

Role of carotid sonography as a first examination in the evaluation of patients with transient ischemic attacks and strokes: benefit in relation to age.

We studied the influence of age on the utility of carotid sonography in patients with transient ischemic attacks and strokes. The results of Doppler ultrasound examinations of the carotid arteries in 613 consecutive patients with transient ischemic attacks (n = 450) or strokes (n = 163) were analyzed for different age groups. For each patient, the grade of stenosis was scored for the ipsilateral internal carotid artery. The results of the ultrasound examinations were correlated with angiographic findings and findings at endarterectomy. The extent of atherosclerosis for each age group was expressed as the ratio between the number of grade II-IV stenoses (> or = 50%) in the carotid arteries and the number of patients in that group ("atherosclerosis ratio"). Under the age of 40 years, high-grade atherosclerotic stenoses were not found. However, 3 relatively young patients had dissections of the internal carotid arteries. The atherosclerosis ratio exceeded 0.5 for age groups 65-69 years through 80+ years. Among the patients with high-grade stenoses, ischemic heart disease prevented endarterectomy in 63% of patients in age group 80+ years, 44% in age group 75-79 years, and 26% in age group 70-74 years. Carotid sonography did not detect any significant atherosclerotic changes in young patients but was useful for diagnosing other etiologies of ischemic cerebral disease, eg, carotid dissection. At the other end of the spectrum, the impact of carotid sonography on patient management appears to be limited in patients over the age of 70 years. Carotid sonography seems to be most useful for patients 40-69 years old.

Severe Congenital Stenosis of the Left Coronary Artery Ostium and Its Possible Pathogenesis According to Current Knowledge on Coronary Artery Development

We report a 72-year-old woman with severe congenital stenosis of the left coronary artery orifice and clinically significant atherosclerotic changes in both the right and left coronary arteries. The stenotic ostium was located at the point at which the left and posterior aortic valve leaflets joined to form the left commissure, just at the distal vertex of the left interleaflet triangle, between the left and posterior aortic sinuses. The right coronary artery was more developed in size than usual, whereas the left coronary artery consisted of a short left main coronary trunk that bifurcated into left anterior descending and left circumflex arteries. The left coronary artery system was filled retrogradely through two vessels proceeding from the right coronary artery, namely, the conal artery and a well-developed branch that ran across the interventricular septum. This abnormal arrangement of the coronary arteries showed striking functional similarities with atresia of the left main coronary artery. Current knowledge on the morphogenesis of the coronary arteries suggests that the present anomalous coronary artery pattern resulted from the penetration of the anticipated left coronary artery system into the aorta at a totally erroneus site. This hindered the normal development of the ostium, which subsisted as a punctiform, practically nonfunctional opening.