Background: Carbon dioxide (CO2) exists in nature around us. In the middle of the 20th century, the intraluminal injection of CO2 demonstrated similar results to those of Digital Subtraction Angiography (DSA) with an iodinated contrast agent (ICA). Since then, the technology behind CO2 DSA has developed significantly. Objective: The aim of this study is to inform physicians about the unique properties of CO2 and its physiology after intraluminal injection. Methods: An extensive search for English literature on the properties of CO2 and the physiology of intraluminal administration was conducted using Pubmed. Results: There is sufficient literature on the properties of CO2 and the physiology of CO2 DSA. A review of this literature explains what happens to the human organism after the injection of CO2. Conclusion: There is enough evidence that CO2 DSA is both effective, diagnostic and safe, but the properties of CO2 should be taken under consideration as complications occur, although rarely.

Introduction - During the last decade, there has been a dramatic improvement in the medical treatment of patients with vascular disease. However, there is a paucity of contemporary long-term data for restenosis after carotid endarterectomy (1-3). Restenosis occurs in bimodal distribution, generally attributed to neointimal hyperplasia when occurring within the first 2 years or to recurrence of underlying atherosclerotic disease thereafter (4). Several studies have shown a potential relationship between various clinical factors (e.g. homocysteine, lipoprotein a) and myointimal hyperplasia and endothelial dysfunction (5-6) . Apolipoprotein J (Apo J) is a new predictive factor of restenosis, which remains until today less investigated with conflicting results (7-8). The aim of this study is to elucidate the role and evaluate the association of Apo J and other conventional risk factors, with early restenosis following carotid endarterectomy. Methods - This is a retrospective analysis of prospectively collected data, regarding patients that underwent carotid endarterectomy in our department between November 1st 2013 and November 1st 2015. Our study examined the serum ApoJ of 100 cases. From these cases, 44 were healthy individuals which formed the Control Group of the study; the remaining 56 cases were patients which underwent carotid endarterectomy and formed the Vascular Group. Control Group patients were examined only one time during the study. On the other hand, The Vascular Patients Group were evaluated pre-operatively, the first post-operative day (POD1), the first post-operative month (POM1), the sixth- and the twelfth- post-operative months; (POM6) and (POM12) respectively. On these times serum Apo J was laboratory examined. Duplex scanning was postoperatively performed in all groups of patients at specified intervals; 6 and 12 months after the vascular procedure. These results were evaluated by two independent investigators. The Vascular Groups were sub-divided in two sub-groups: 1) Patients with no restenosis of the carotid anastomosis, 2) Patients with restenosis of the carotid anastomosis. All data for statistical analysis are reported as mean ± standard deviation (SD). P values of less than 0.05 (p<0.05) were considered as statistically significant. Results - Comparison of the serum Apo J between the Control and VascularGroupswas statistically important in the pre-operative period (p<0.05). During the follow up period of the Vascular Group, serum Apo J varied and showed an abatement, although remained with higher values than pre-operative period values of the Control Group. Pre-operative serum mean ApoJ value proved to be a significant prognostic factor regarding to the mean %Restenosis for the Vascular Group, as it was statistically important higher for the patients with restenosis comparing to these without (p<0.05). Conclusion - ApoJ is a predictive factor for patients with peripherar vascular disease as it is statistically important differnt (p<0.05) comparing to healthy population. Furthermore, serum values of ApoJ pre-operatively shows increased values within the patients with restenosis after carotid endarterectomy and these without. Clinical trials and further studies are needed to better elucidate our preliminary results. References1.Schillinger M, Minar E. Restenosis after percutaneous angioplasty: the role of vascular inflammation. Vasc Health Risk Manag. 2005; 1(1):73-8.2.Naylor R, Hayes PD, Payne DA, Allroggen H, Steel S, Thomson MM, et al. Randomized trial of vein versus Dacron patching during carotid endarterectomy: long term results. J Vasc Surg 2004;39:985-93.3.Arquizan C, Trinquart L, Touboul PJ, Long A, Feasson S, Terriat B, et al. Restenosis is more frequent after carotid stenting than after endarterectomy: the EVA-3S study. Stroke 2011;42:1015-20.4.Goel SA, Guo LW, Liu B, Kent KC. Mechanisms of post-intervention arterial remodelling. Cardiovasc Res. 2012 Dec 1; 96(3):363-71.5.Bakoyiannis C, Karaolanis G, Moris D, Palla V, Skrapari I, Bastounis E, Georgopoulos S. Homocysteine as a risk factor of restenosis after carotid endarterectomy. Int Angiol. 2015 Apr;34(2):166-71. Epub 2014 Nov 14.6.Miner SE, Hegele RA, Sparkes J, Teitel JM, Bowman KA, Connelly PW, et al. Homocysteine, lipoprotein(a), and restenosis after percutaneous transluminal coronary angioplasty: a prospective study. Am Heart J. 2000;140(2):272-8.7.Park S, Mathis KW, Lee IK. The physiological roles of apolipoprotein J/clusterin in metabolic and cardiovascular diseases. Rev Endocr Metab Disord. 2014 Mar;15(1):45-53.8.Trougakos IP. The molecular chaperone apolipoprotein J/clusterin as a sensor of oxidative stress: implications in therapeutic approaches - a mini-review. Gerontology. 2013; 59(6):514-23.

Anesthesia for carotid endarterectomy (CEA), general or locoregional, has been an issue of debate in literature ever since the first Cochrane review in 1991. The largest available study on the subject, the GALA trial, has not shown any difference in patient's outcome – incidence of stroke and 30-day-mortality postsurgery. However, increasing evidence favors regional anesthesia as an independent factor of reduced morbidity after CEA. The advantages and disadvantages of general versus regional anesthesia for CEA have been well established. Cervical plexus blocks (CPBs) are safe and effective anesthetic techniques, but they may also present adverse effects that we must be aware of. Optimal cerebral function monitoring remains a problem to be solved. Cerebral oximetry may prove to be a reliable tool in predicting neurological impairment. This narrative review intends to highlight the latest implemented anesthetic modalities for CEA, including CPB under ultrasound guidance, and to outline the main limitations of general versus regional anesthesia. Following the appropriate anesthetic, modality necessitates a thorough preoperative consultation among the patient, the surgeon, and the anesthetist. The anesthetic plan should be made on an individual basis, taking into consideration patient's comorbidities and wish.

Background: Aneurysms of the subclavian artery are usually the result of trauma, atherosclerosis, or thoracic outlet syndrome. Until the 90s, open surgical repair was considered the only therapeutic choice, exhibiting high complication rates. Since the first report of endovascular repair of subclavian aneurysms in 1991, promising results have been published. The aim of this review was to summarize all available data on subclavian artery (SA) true and false aneurysm stenting to reach conclusions regarding morbidity, mortality, and other procedure-related characteristics. Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. Eligible studies were sought in the Medline (PubMed), ClinicalTrials. gov, and Cochrane libraryeCochrane Central Register of Controlled Trials (CENTRAL) databases through February 2017 using the following MeSH terms: "endovascular'', "hybrid'', "aneurysm'',"pseudo-aneurysm'', "pseudo-aneurysm'', "false aneurysm'', "arterial injury'', "subclavian artery'', "axillo-subclavian,'' and "axillosubclavian artery''. The reference lists of eligible articles and pertinent reviews were screened for potential relevant studies. Results: Seventy-three studies encompassing data on 142 patients who underwent endovascular or hybrid SA aneurysm repair were deemed eligible. One hundred forty-seven stents and stent grafts were used. Median age of all patients was 56 years, and males comprised 46% of the study sample. Trauma was the most common mechanism of injury. Pulsatile mass or hematoma was the most frequent presenting sign. Pseudoaneurysms were the most frequent type of aneurysms, followed by true aneurysms. Most authors used selfexpanding polytetrafluoroethylene-covered stents. Access was obtained by either brachial, femoral, or both arteries. Through-and-through technique was also used in angulated vessels. All-cause mortality was 10.6%, slightly higher to that already reported in literature and lower to the respective rate of the open repair. Reintervention rate was 8.5% despite the high 15.5% complication rate. Conclusions: Endovascular SA aneurysm repair is a technically feasible technique, useful in both elective and emergency cases. Although preliminary results quote its safety and efficacy, larger cohort studies are warranted to elucidate its benefit in treating SA aneurysms.

Carotid endarterectomy (CEA) is an effective surgical option for stroke prophylaxis in most patients. Restenosis after CEA can lead to re-intervention and adverse events, but the factors predicting restenosis are poorly understood. Apolipoprotein J (ApoJ) is considered to be a novel predictive factor of vascular restenosis and is associated with a large number of processes related to atherosclerosis and cell-cycle phases. The aim of this study was to elucidate the predictive value of Apo J in internal carotid artery (ICA) restenosis following CEA. This retrospective study examined all prospectively collected data for patients who underwent CEA at our surgical department over a 2-year period. The serum ApoJ levels of 100 patients were examined; 56 patients who underwent CEA comprised the vascular group (VG), and 44 patients who underwent minor surgery comprised the control group (CG). ApoJ samples were obtained preoperatively, 24 h after the surgical procedure and at 1, 6 and 12 months thereafter during the follow-up. The preoperative difference in ApoJ levels between the CG and VG was statistically signifcant; the mean values were 39.11±14.16 and 83.03±35.35 μg/mL, respectively. In the VG, the serum ApoJ levels were 112.09±54.40, 71.20±23.70, 69.92±25.76 and 62.25±19.17 μg/mL at postoperative day 1 and at 1, 6 and 12 months post-operatively, respectively, while the ApoJ concentrations of patients in the CG remained unchanged. Further subdivision of the VG into patients with or without restenosis revealed that restenosis patients presented signifcantly higher mean ApoJ values than non-restenosis VG patients. In summary, ApoJ seems to be an important predictor for carotid restenosis at 6 and 12 months postoperatively.

Warfarin-induced skin necrosis is an infrequent and well-recognized complication of warfarin treatment. The incidence was estimated between 0.01% and 0.1% whereas a paradoxal prothrombotic state that arises from warfarin therapy seems to be responsible for this life-threatening disease. To the best of our knowledge we present the first case of an old woman diagnosed with warfarin-induced skin necrosis, in whom novel oral anticoagulants and extensive surgical debridement were combined safely with excellent results.