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.

Background: Matrix metalloproteinase-9 protein (MMP-9) and cyclooxygenase-2 (COX -2) proteins may have a role in remodelling of atherosclerotic plaques. We analysed and compared the radiological, histological and immunohistochemical characteristics of carotid atherosclerotic plaques between symptomatic and asymptomatic patients who underwent carotid endarterectomy (CEA). Methods: This prospective single-blinded study included 31 patients (70 [64-75] years, 58% males, 42% symptomatic) who under-went CEA and a total of 155 carotid plaque sections that were analysed. Preoperative assessment and multimodality diagnostic imaging with magnetic resonance imaging (MRI) or computed tomography angiography (CTA), histological and immunohisto-chemical analyses of carotid plaques including the expression of MMP-9 and COX-2 proteins were performed. Results: Symptomatic and asymptomatic patients did not sig-nificantly differ in respect to preoperative characteristics. Unstable plaques were detected in 12/13 (92.3%, p = 0.020) symptomatic patients using MRI or CTA. There was no perioperative mortality and perioperative outcomes were comparable in both groups. A significantly higher expression of MMP-9 in macrophages was observed among symptomatic patients (p = 0.020). ROC curve analysis showed statistically sig-nificant associations of both the higher intensity of COX-2 staining in CD68 PG-M1 positive macrophages (area under the curve [AUC]=0.701, p = 0.014) and higher MVD (AUC=0.821, p < 0.001) within the plaque with cerebrovascular symptoms. The expres-sion of COX-2 and the intensity of COX-2 staining in macrophages within the unstable carotid plaques detected by preoperative MRI or CTA were significantly higher (76.1% vs. 40.0%, p = 0.038; 76.2% vs. 30.0%, p = 0.01, respectively). Conclusions: Advanced non-invasive multimodality diagnostic imaging including MRI or CTA is reliable in differentiating unstable from stable carotid plaques. High expression of MMP-9 and COX-2 in macrophages within the symptomatic plaque is associated with increased risk of cerebrovascular complications. Trial Registration: This study has been registered at the ISRCTN registry (ID ISRCTN46536832), isrctn.org Identifier: https://www. isrctn.com/ISRCTN46536832

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%, p = 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, p = 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 (p = 0.064 and p = 0.132, p = 0.360 and p = 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.

European Journal of ImmunologyVolume 49, Issue S4 p. 1-75 Abstracts of MESIA 2019Free Access 4th Meeting of Middle European Societies for Immunology and Allergology, 28–30 November 2019, Samorin, Slovakia First published: 21 November 2019 https://doi.org/10.1002/eji.201970500AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume49, IssueS4Special Issue: 4th Meeting of Middle European Societies for Immunology and Allergology, 28–30 November 2019, Samorin, SlovakiaNovember 2019Pages 1-75 RelatedInformation

Background: 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.Case Report: Self-expandable, covered stent (Bard, Fluency (R)) 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 (R)) 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.Conclusions: 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.

Sažetak.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 2,8/100.000ljudi 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

Changes in immune and inflammatory responses may play a crucial role in the development and progression of atherosclerosis, as an autoimmune, chronic and progressive inflammatory disease. Immunological activity and vascular inflammation during atherosclerosis can be modulated by autoimmune responses against self-antigens, according to changeable risk factors (cholesterol, oxidized low-density lipoprotein (ox-LDL) in the vascular wall, fatty acids, etc.), and accompanied by accumulation of leucocytes and proinflammatory cytokines, which stimulate the transcription of matrix metalloproteinases (MMPs), whose concentration are increased in foam cell-rich regions. Regulatory T cells (Tregs) represent a unique subpopulation of T cells specialized in the regulation of immune response and in the suppression of proatherogenic T cells. The aim of our study was to examine the interactions between the concentration of enzyme matrix metalloproteinases 2 and 9 (MMP-2 and 9) in urine and the percentage of Tregs in peripheral blood of two groups of patients: with carotid artery stenosis (CAS), undergoing surgery and with mild atherosclerosis (A) from general practice. The method of enzyme immunoassay (ELISA) was used to determine enzyme MMP expression, and Tregs was examined by flow cytometric analysis. Our data have showed a large increase in the enzyme MMP-2 and 9 in the urine of CAS and A patients in comparison with healthy controls and indicated this method as an easy marker for the monitoring of the development of atherosclerosis. Simultaneously, the diminished number of Tregs in the same patients pointed the importance of these regulatory mechanisms in the etiopathogenesis of atherosclerosis and possible Tregs-mediated therapy.

Stenoza unutarnje karotidne arterije povecava rizik od moždanog udara. Velike randomizirane studije pokazale su da karotidna endarterektomija (engl.

U Klinickom bolnickom centru Rijeka je u razdoblju od 2014. do 2016. godine ucinjeno ukupno 49 endovaskularnih zahvata (TEVAR 20, EVAR 29). U 14 bolesnika (28, 6%) zahvat je hitno izveden zbog AAS. Vecina procedura ucinjena je perkutano (30 bolesnika, 61%). Periproceduralna smrtnost iznosi 2% (1 bolesnik), unutar 30 dana umrlo je 4 bolesnika (8, 1%). Daljnji razvoj pretpostavlja stabilno financiranje te dodatnu integraciju i edukaciju multidisciplinarnog endovaskularnog tima sastavljenog od vaskularnih kirurga, intervencijskih radiologa i kardiologa.

We report a successful treatment of unusual case of a 48 year old male patient with acute aortic dissection type Stanford A that expanded into left common and external iliac artery diagnosed by MSCT angiography, presenting as a single leg paresis, without symptoms of a chest or back pain. Patient was operated with conventional ascending aortic replacement. Patient had no known prior medical condition. He has been treated for acute thrombosis of the left popliteal artery developing one day after ascending aortic replacement surgery, embolectomy was performed. Critical limb ischemia developed due to preocclusive stenosis of the left common and left external iliac artery and was treated by endovascular procedure of iliac artery stenting performed on the fifth postoperative day. After 17 days patient was discharged form hospital, showing no neurological or vascular deficit. For successful treatment of acute aortic dissection type Stanford A complicated with limb ischemia, rapid and accurate diagnosis is essential, together with close cooperation of cardio surgeons, vascular surgeons and invasive radiologists and individual approach to these demanding patients.

Introduction: Early screening of patients with carotid artery stenosis as well as postoperative ultrasound follow up of thrombendarterectomy (CEA) treatment is paramount in primary and secondary prevention of stroke.