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Membranoproliferative GN (MPGN) was recently reclassified as alternative pathway complement–mediated C3 glomerulopathy (C3G) and immune complex–mediated membranoproliferative GN (IC-MPGN). However, genetic and acquired alternative pathway abnormalities are also observed in IC-MPGN. Here, we explored the presence of distinct disease entities characterized by specific pathophysiologic mechanisms. We performed unsupervised hierarchical clustering, a data-driven statistical approach, on histologic, genetic, and clinical data and data regarding serum/plasma complement parameters from 173 patients with C3G/IC-MPGN. This approach divided patients into four clusters, indicating the existence of four different pathogenetic patterns. Specifically, this analysis separated patients with fluid-phase complement activation (clusters 1–3) who had low serum C3 levels and a high prevalence of genetic and acquired alternative pathway abnormalities from patients with solid-phase complement activation (cluster 4) who had normal or mildly altered serum C3, late disease onset, and poor renal survival. In patients with fluid-phase complement activation, those in clusters 1 and 2 had massive activation of the alternative pathway, including activation of the terminal pathway, and the highest prevalence of subendothelial deposits, but those in cluster 2 had additional activation of the classic pathway and the highest prevalence of nephrotic syndrome at disease onset. Patients in cluster 3 had prevalent activation of C3 convertase and highly electron-dense intramembranous deposits. In addition, we provide a simple algorithm to assign patients with C3G/IC-MPGN to specific clusters. These distinct clusters may facilitate clarification of disease etiology, improve risk assessment for ESRD, and pave the way for personalized treatment.

Introduction: Anastomotic pseudoaneurysm following renal transplantation is uncommon. Indications for repair, treatment options and outcomes remain controversial. Report: We present 6 renal transplant recipients with large anastomotic pseudoaneurysms. Five of the patients underwent open repair while one had a stent-grafting and delayed transplant nephrectomy for a ruptured pseudoaneurysm. A transplant nephrectomy was needed in all cases but one. Arterial reconstruction enabled limb salvage in all cases. One patient died of sepsis postoperatively. No patient presented late infection, failure of vascular reconstruction, nor pseudoaneurysm recurrence. Conclusions: Surgical excision of anastomotic pseudoaneurysms results in high rates of allograft loss. Less invasive techniques have a place in selected cases. © 2009 European Society for Vascular Surgery.

Background The management of patients with abdominal aortic aneurysm (AAA) and concurrent malignancy is controversial. This study retrospectively assessed the outcome of endovascular repair (EVAR) and open repair (OR) for the treatment of AAA in patients undergoing curative treatment for concomitant malignancies. Methods All patients who underwent surgery for a nonruptured infrarenal AAA of ≥5.5 cm and concomitant malignancy between 1997 and 2005 were retrospectively reviewed. Results Identified were 25 patients (22 men; mean age, 70.3 years) with nonruptured infrarenal AAA of ≥5.5 cm (mean size, 6.4 cm) and concomitant malignancy amenable for curative treatment. EVAR was used to treat 11 patients, and 14 underwent OR. The EVAR patients had a smaller mean aneurysm size (5.9 cm vs 6.8 cm; P = .006) than the OR patients. The mean cumulative length of stay for all patients who received treatment for both AAA and cancer was 12.8 days (range, 4 to 26) for EVAR and 18.2 days (range, 9 to 42 days) for OR. In the EVAR group, no patients died perioperatively; in the OR group, three patients died perioperatively (21.4%; P=NS). Postoperative complications occurred in one patient in the EVAR group and in seven in the OR group for a morbidity rate, respectively, of 9.1% and 50% ( P = .04). One late complication (9.1%) occurred in the EVAR group. The mean follow-up was 37.7 months (range, 16 to 60 months) in the EVAR group and 29.6 months (range, 11 to 55 months) in the OR group. At 1 and 2 years, survival rates were 100% and 90.9% in the EVAR group and 71.4% and 49% in the OR group (log-rank P = .103) Conclusions With low morbidity and mortality, EVAR is a safe technique for the treatment of AAA in patients with concomitant malignancy and could be considered as an alternative to OR.

May-Thurner syndrome (MTS) is an anatomically variable condition resulting in compression of the left common iliac vein between the right common iliac artery and the underlying spine with subsequent development of a left deep vein thrombosis (DVT). Although this syndrome is rare, its true prevalence is likely underestimated. Mainly, clinical symptoms and signs include, but are not limited to, pain, swelling, venous stasis ulcers, skin pigmentation changes and post-thrombotic syndrome. Correct treatment is not well established and is based on clinical presentation. Staged thrombolysis with/without prophylactic retrievable inferior vena cava filter placement followed by angioplasty/stenting of the left iliac vein appears to be the best option in MTS patients with extensive DVT. The aim of this review is to present in a simple and didactic form all variable clinical presentations of MTS and to outline possible management within the current guidelines.

A 69-year-old man with a history of hypertension and severe pulmonary disease had asymptomatic bilateral common iliac and popliteal artery aneurysms. A bifurcated Talent and two Wallgraft stent-grafts were deployed via open femoral arteriotomies to exclude the aneurysms, respectively. The patient had an uncomplicated recovery, with no transfusion need; the hospital stay was 4 days. After a 5-year follow-up, no complication or endoleak has been detected, with patency of endografts and a mean decrease of 15% in aneurysm transverse diameters. Simultaneous endovascular repair should be considered in the treatment of multiple peripheral aneurysms, to avoid sequential conventional or endovascular procedures.

AIM: Pseudoaneurysm (PA) at the anastomosis site in kidney transplantation is a rare but serious complication that usually requires graft nephrectomy. Literature reports are sporadic and usually focused on limb rather than graft salvage. In this paper we focus on this last point. MATERIAL OF STUDY: 6 patients presenting large PA at the anastomosis between iliac and graft artery were identified in our series. The diagnosis was performed with US, AngioTC scan and angiography. Blood cultures and labeled leukocyte scintigraphy were also performed. All patients underwent open surgery. RESULTS: Transplant nephrectomy was needed in all cases except one, in which it was possible to perform a graft replanting on hypogastric artery. Our perioperative mortality and morbidity rate was recorded. DISCUSSION: Etiology of PA is multifactorial, however an association with chronic rejection or infection must be also considered. Our mortality and morbidity rates are in accordance to literature. In our experience we observed only large PA so to require an open surgery but this approach has allowed the rescue of graft functioning just in a single case. Endovascular procedures are linked to higher rate of graft salvage than surgery but they can be used just in selected cases. CONCLUSIONS: Our experience and literature review led us to believe that the rate of graft salvage in patients with large PA at anastomosis site could be improved only by a planned therapeutic program that includes surgical and endovascular approach, taking the advantages of both technique and overcoming their limits.

The nitinol TrapEase inferior vena cava filter is a new device for pulmonary embolism prophylaxis. No cases of filter migration or filter-related complications with this type of device have so far been described. We report a case of intracardiac migration of this filter in a patient with a patent foramen ovale, resulting in severe cardiogenic shock, cerebral and right arm paradoxical embolism. Surgical treatment, results, causes of these complications are discussed.

Objective Inflammation is a pivotal process in atherosclerosis development and progression, but the underlying molecular mechanisms remain largely obscure. We have conducted an extensive expression study of atherosclerotic plaques to identify the inflammatory pathways involved in atherosclerosis. Methods We studied 11 human carotid plaques, their respective adjacent regions and 7 control arteries from different subjects. Expression of 92 genes was studied by TaqMan low-density array human inflammation panel. Human aortic endothelial and smooth muscle cells were used for in vitro experiments. Results The mRNA levels of 44/92 genes (48%) differed significantly between the tissues examined (13 up-regulated and 31 down-regulated). Dysregulated genes encode molecules belonging to different functional classes although most of them encode enzymes involved in the eicosanoid synthesis pathway. The expression of PTGIS and PTGIR genes was decreased in human aortic endothelial and smooth muscle cells stimulated with oxLDL and TNF-α. Conclusions This study not only reveals several dysregulated genes in human lesions but also focuses the role played by the genes involved in the eicosanoid synthesis pathway during atherosclerotic development. The decrease of PTGIS and PTGIR expression after oxLDL treatment mirrors the decreased mRNA levels in atherosclerotic lesions versus control arteries, which suggests that oxidation is important for PTGIS and PTGIR regulation in human vessel cells during atherosclerosis development.

Background A 74-year-old male patient complaining of crescendo TIAs, hypertension and hyperlipidaemia. Investigation Duplex ultrasound scan MR angiography. Diagnosis Pseudoaneurysm stemming from the ICA. Treatment An open or endovascular procedure for the right pECCA repair, or a left CEA or CAS.

Objective: Popliteal artery aneurysms (PAA) are most frequent among peripheral aneurysms. The most commonly performed surgical repair is proximal and distal ligation with a saphenous vein bypass. We aim to report the early and mid-term outcome of surgical repair of popliteal artery aneurysms via a posterior approach. Methods: A retrospective review of consecutive patients who underwent surgical PAA repair in two vascular surgery units between 1998 and 2009 was performed. Within this group, the posterior approach was used in 28 repairs in 26 patients (25 men). All patients had an ultrasound examination. Eighteen patients underwent conventional angiography while CT angiography with 3-D reconstruction was used from 2003 to evaluate an endovascular option. Primary and secondary graft patency, limb salvage and patient survival rates were determined using Kaplan–Meier methods. Results: All aneurysms did not involve the superficial femoral artery and the popliteal trifurcation. Interposition grafting was performed with a great saphenous vein in 19 repairs while a 6.0-mm–8.0-mm PTFE graft in the remaining nine. The 30-day primary patency rate was 100%. The average popliteal aneurysm diameter was 3.8 cm (range, 2.1–6.4). Three aneurysms were thrombosed at the time of surgery, and two of these presented as acute limb ischemia. Eight patients had chronic symptoms, claudication was present in five and ischemic rest pain in three. The remaining patients were asymptomatic or with mild discomfort. An S-shaped curvilinear incision was preferred in all repairs and no problems with postoperative healing or wound infection were observed. The average length of stay was 4.6 days. Four patients were lost to follow-up. One-year primary graft patency, secondary graft patency, limb salvage and patient survival rates were 92.8%, 96.4%, 96.4% and 100%, respectively. Conclusions: These data demonstrate that surgical PAA repair through a posterior approach is associated with excellent mid-term durability. Moreover, the posterior approach facilitates the resection of aneurysm, avoids continued aneurysm expansion from communicating branches and reduces wound complications frequently seen after femoro-popliteal bypass.

Aim. The aim of this study was to evaluate the impact of intraoperative cell salvage (ICS) on the early outcome after open repair (OR) of ruptured abdominal aortic aneurysm (rAAA). Methods. This is a retrospective review of 73 consecutive patients who underwent emergency OR of infiarenal rAAA with ICS between 2005 and 2008 (Group tr), compared to 5l repairs from 21lll2-2ll1l4 with no ICS (Group II). In addition, a transfusion protocol of platelets and tiesh frozen plasma (FFP) administration on admission and during surgerv was adopted in patients in Group I to maintain coagulation conrpetence. Results. ICS reduced bank blood demand by 63.6Vc (from I I to 4 units, P

Objective— Many gene products involved in oxidation and inflammation are implicated in the pathogenesis of atherosclerosis. We investigated paraoxonase 2 (PON2), 5-lipoxygenase (5-LO), and 5-LO activating protein (FLAP) expression and malondialdehyde (MDA) levels in carotid lesions to assess their involvement in plaque formation. Methods and Results— We measured gene expression and MDA levels in atherosclerotic plaques from 59 patients undergoing carotid endarterectomy, and in plaque-adjacent tissue from 41/59 patients. Twenty-three fetal carotids and 6 mammary arteries were also investigated. Real-time polymerase chain reaction and immunohistochemistry revealed decreased PON2 expression in plaques versus adjacent regions ( P P P P P P P Conclusions— We demonstrate that PON2 mRNA and protein are decreased in plaques versus plaque-adjacent tissue, mammary arteries, and fetal carotids. Our data indicate that the protective effect of PON2 could fail during atherosclerosis exacerbation; this was confirmed by the increase of MDA levels. The increase of 5-LO and FLAP mRNA expression confirms their role as inflammatory markers associated to atherosclerosis.

Objective: To assess the feasibility and mid-term outcome of combined subintimal recanalization and stenting for the treatment of long superficialFebruary, and then Protégé® EverFlexTM) were placed in the whole subintimal space. The number and the length of stents was dictated from the length of the intentional subintimal dissection. The site of re-entry was chosen without compromise the feasibilty of a future bypass grafting. When completion arteriogram revealed residual stenosis, a post-dilatation was performed. Results: Twenty-eight patients (90.3%) underwent successful procedures, whereas two attempts failed because of inability to pass the guidewire through SFA occlusion and one because of arterial perforation. Two of the patients with unsuccessful SFA subintimal recanalization underwent successful leg bypass and one required an above-knee amputation. Arterial stenoses proximal or distal to the recanalized segment were treated with concomitant balloon angioplasties in five (16.2%) cases. The mean ABI increased to 0.87 (range 0.62-1.0) after the procedures. All the patients with successful SFA subintimal recanalization and stenting had resolution of symptoms and healing of ischemic lesions. Twenty-three of the 28 patients (82.1%) who had successful SFA procedures were patent at a mean follow-up of 21±6 months (range 2-57 months), and overall survival was 80.7%. Conclusions: Subintimal recanalization and routine stent placement allows high technical success rates and mid-term patency rates in the management of long SFA occlusions, with no significant procedure-related complications. femoral artery (SFA) occlusions. Methods: From 2002 to 2006, 31 consecutive patients (22 male, 9 female) with severe chronic ischemia were intended to be submitted to subintimal wire placement and routine stenting of SFA. The mean age of the patients was 67.3 years (range 61-79 years). Risk factors included diabetes mellitus (n=9, 29%) and end-stage renal failure (n=4, 12.9%). Thirteen patients (41.9%) were treated for disabling intermittent claudication, seven (22.6%) were treated for rest pain and 11 (35.5%) for ischemic ulcers or gangrene. The mean ankle-brachial index (ABI) was 0.51 (range 0.28-0.72). The procedures were performed under local anesthesia and using fluoroscopic guidance for entering subintimal space with an angled 0.035’ hydrophilic guidewire (Radifocus; Terumo, Japan); in 14 (45.1%) cases of flush occlusion of SFA, the procedures were made with associated duplex guidance to direct the devices into the SFA ostium. After advancement over the wire of a 5 Fr vertebral catheter (Terumo, Japan) and re-entry into the true lumen at the distal end of the lesion, self-expandable nitinol stents (Bard® LuminexxTM until 2006

AIM: The aim of this study was to determine the clinical outcome of carotid endarterectomy in heart transplant recipients and morphologic features of atherosclerotic plaques removed during operation. METHODS: Between April 1993 and October 2001 5 heart transplant patients with symptomatic carotid stenosis >70% underwent carotid endarterectomy with regional anesthesia, including a staged bilateral procedure in one patient. Cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol were evaluated in each patient. The plaques ( n=6) underwent histologic analysis after carotid endarterectomy. Carotid artery duplex imaging was added to the routine postoperative evaluation. RESULTS: Carotid plaques resulted to be echolucent on B-mode ultrasound examination. Cholesterol, triglycerides and LDL-cholesterol levels were found to be increased, while HDL-cholesterol were decreased. All patients underwent successful carotid endarterectomy; there were no perioperative deaths, major neurologic or cardiac events. The mean length of stay was 2.2 days. The mean follow-up was 44 months. In 1 case, an asymptomatic restenosis >50% occurred 9 months later and, in 2 other cases, a contralateral mild stenosis was found 12 and 36 months later. One patient had a progressive contralateral stenosis, requiring operation 18 months later. High lipid content and heterogeneous cellular infiltration were observed, including macrophages, T-lymphocytes, neutrophils, and also eosinophils in the rapidly progressing plaque. CONCLUSIONS: Heart transplant patients receiving immunosuppression may successfully undergo carotid endarterectomy, without increased risk, but progression of atherosclerotic disease in the carotid arteries seems to continue, despite lipid-lowering regimen and antiplatelet therapy.

Aim. To eval¬u¬ate the effi¬ca¬cy of ¬intra-arte¬ri¬al throm¬bol¬y¬sis and adjunc¬tive endo¬vas¬cu¬lar pro¬ce¬dures for infra¬in¬gui¬nal ¬native ¬artery chron¬ic occlu¬sions, ¬that ¬result in a ¬recent wors¬en¬ing of symp¬toms ¬because of throm¬bo¬sis super¬im¬posed on under¬ly¬ing path¬o¬log¬ic ¬lesions. Methods. Intra-arte¬ri¬al cath¬e¬ter-direct¬ed throm¬bol¬y¬sis ¬with urok¬i¬nase 300000 IU ¬bolus fol¬lowed by 70000 IU /h for 24-48 ¬hours was admin¬is¬tered to 54 ¬patients affect¬ed ¬with low¬er ¬limb ische¬mia. Twenty-¬three ¬patients (25 ¬limbs) pre¬sent¬ed ¬severe clau¬di¬ca¬tio and 31 -patients (34 ¬limbs) crit¬i¬cal leg ische¬mia; sub¬acute (14 ¬days-3 ¬months) symp¬toms ¬were ¬present in 60.9% and 77.4% , respec¬tive¬ly. After suc¬cess¬ful throm¬bol¬y¬sis, endo¬vas¬cu¬lar pro¬ce¬dures (i.e., angio¬plas¬ty, endo¬lu¬mi¬nal stent¬ing, endo¬pros¬the¬sis place¬ment) ¬were per¬formed in 72% and 67.6%, respec¬tive¬ly. In addi¬tion, infra¬in¬gui¬nal autog¬e¬nous ¬vein recon¬struc¬tion was per¬formed in 5 ¬patients ¬with crit¬i¬cal leg ische¬mia. Results. Initial clin¬i¬cal improve¬ment was ¬seen in 76% of 25 extrem¬ities in ¬group I, ¬with a 30-day pri¬mary paten¬cy and ¬relief of clau¬di¬ca¬tio in 68%. Arterial rec¬a¬nal¬iza¬tion was ¬achieved in 23 (67.6%) and res¬to¬ra¬tion of ¬flow in tar¬get ves¬sels for sub¬se¬quent ¬bypass in 5 (14.7%) of 34 extrem¬ities in ¬group II. The 30-day ¬limb-sal¬vage was 73.5%; ¬limb ¬loss includ¬ed 2 ampu¬ta¬tions (5.9%) as a ¬result of infec¬tion and/or necro¬sis in dia¬bet¬ic ¬patients, ¬despite ana¬tom¬ic paten¬cy at the endo¬vas¬cu¬lar pro¬ce¬dure ¬site. Relief of ische¬mia was ¬achieved in 56% of clau¬di¬cants (¬mean fol¬low-up, 42 ¬months) and ¬limb sal¬vage in 52.9% of ¬patients ¬with crit¬i¬cal ische¬mia (¬mean fol¬low-up, 36 ¬months). Conclusion. Thrombolysis and adjunc¬tive endo¬vas¬cu¬lar pro¬ce¬dures are an accept¬able ther¬a¬peu¬tic ¬option for the treat¬ment of wors¬en¬ing man¬i¬fes¬ta¬tions of chron¬ic occlu¬sive dis¬ease of the femor¬o¬pop¬li¬teal arte¬ri¬al seg¬ment.

Purpose:To describe a unique case of misdiagnosed leiomyosarcoma of the common femoral artery presenting with signs and symptoms of high-grade stenosis, which was treated with stent placement.Case Report:A 31-year-old woman with a history of diabetes and hyperlipidemia had recurrent claudication and showed significant in-stent restenosis of the common femoral artery in a postoperative angiogram at 5 months. The patient's clinical stage remained unchanged after repeat percutaneous intervention, and leiomyosarcoma was diagnosed from surgical specimens. The patient underwent resection and repair of the involved artery. She has survived 30 months with no further evidence of local recurrence or systemic metastatic disease.Conclusions:Endovascular repair may cause a long delay in the diagnosis of an arterial leiomyosarcoma mimicking peripheral occlusive disease.

A spontaneous rupture of the external iliac vein revealed as a phlegmasia cerulea dolens with acute lower limb ischemia: Case report and review of the literature.

BACKGROUND: Treatment of lymphoceles complicating vascular procedures is controversial. The purpose of this study was to evaluate the practicability, effectiveness and safety of conservative management on an outpatient basis. METHODS: Medical records were reviewed for 23 postoperative lymphoceles (in 18 patients) seen at our institution between 1986 and 1999. Diagnosis was made by physical examination and needle aspiration of fluid collection; bacterial cultures were obtained in all. Ultrasonography was performed in all patients, lymphoscintigraphy (99mTc HSA) in 11, angio-TC in 2 cases, MRI in 3 large lymphoceles. RESULTS: Twenty-one lymphoceles developed in the groin, 2 in the thigh and were mostly (72.2%) diagnosed after hospital discharge. Imaging techniques detected subcutaneous wound collection; in addition, lymphoscintigraphy showed lymphatic interruption and collateral pathways in patients with limb swelling. Outpatient management consisted of limited ambulation, limb elevation and pressure dressings; no serial aspirations were made. Resolution was obtained in all patients over a mean period of 21 days (range, 12 to 35). No patient required re-hospitalization or developed wound and/or graft infection. No recurrence was noted after a follow-up of all patients for 1 year. CONCLUSIONS: Outpatient treatment of lymphoceles following arterial reconstructive procedures can be performed safely. Significant advantages of this pathway include no re-hospitalization and cost reduction.

Objective: The prognostic factors and treatment options for thoracic aortic intramural hematoma are controversial. The purpose of this study was to determine the most suitable treatment of this condition in very elderly patients. Methods: In a review of the world literature, eight octogenarians with thoracic aortic intramural hematoma were found; to these the three cases reported here must be added. The descending thoracic aorta was involved in eight cases and the ascending/arch in three. Results: In spite of patients' poor general conditions, the medical treatment group showed survival rates of 85.7% (descending) and 66.6% (ascending/arch), respectively. Conclusion: Extensive atherosclerotic changes of the aortic wall in the elderly, combined with control of hypertension, may probably prevent thoracic aortic intramural hematoma from progressing to dissection, with a favourable outcome. An earlier and more accurate preoperative diagnosis by modern diagnostic techniques, including spiral computed tomography (CT), as were performed in our own patients, will allow optimal treatment and increased patient survival.