vol. 3, n. 4 - edlearning

vol. 3, n. 4.2012

ISSN

203

9-46

32

an International Journal of Medical Sciences

ISSN 2039-4632

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©2012 by MEDIMOND s.r.l. III

Index

Front page .......................................................................................................................... I

Angiology and Vascular Surgery

Thrombophilia and Vascular Disease: Indication to Treatment of Asymptomatic PatientsAluigi L. ............................................................................................................................... 289

Technical considerations of open TAAA repair in a transition country Davidovic L., Ilic N., Dragas M., Koncar I., Banzic I. ............................................................ 297

Changing concept on the chronic lymphedema: it is no longer lymphatic disease!Lee B.B., Laredo J. .............................................................................................................. 305

Carotid endarterectomy under cervical plexus block: a single center experienceMarkovic M., Davidovic L., Sindelic R., Pejkic S., Koncar I., Ilic N., Dragaš M. ....................... 311

Management of patients with polyvascular diseasePoredos P., Jezovnik M.K. ................................................................................................... 317

Peripheral Artery Disease - indicator of systemic atherosclerosisPoredos P. ........................................................................................................................... 321

Asymptomatic Carotid artery stenosis. CEA or CAS? Work in progressLa Barbera G., Vallone M., Ferro G., Valentino F., Parsaei D.M., Cassaro L., Filippone G., Talarico F. ............................................................................................................................ 325

Venous Valve Repair by OSES technique: results on 39 cases at 4 years f-uCamilli D., Camilli S. ............................................................................................................ 331

Miscellaneous

Matrix Metalloproteinase-9 (MMP-9) is a high sensitive marker for monitoring joint disease remissionKarakin E., Müller-Zahm K., Neumann M., Wilke I. ............................................................. 337

IV ScienceMED, vol. 3, 4.2012, Bologna

Quality of life in various types of schizophreniaMariana Adelina M., Claudiu Dacian R., Delia Marina P. ..................................................... 343

Co(II) and Mn(II) binding to a multihistidinic peptidePeana M., Medici S., Zoroddu M.A. ..................................................................................... 349

Author Index ....................................................................................................................... 355

©2012 by MEDIMOND s.r.l. 289PX11R9001

ScienceMED, vol. 3, 4.2012, 289-296, Bologna

Thrombophilia and Vascular Disease: Indication to Treatment of Asymptomatic Patients Aluigi L.

Centre and School of Ultrasound Applications - Dept of Internal Medicine - Major Hospital - Bologna - Italy - [email protected], [email protected]

Abstract Venous thromboembolism (VTE) is a common source of morbidity and mortality in

Western countries. The term thrombophilia describes a tendency to develop thrombosis on the basis of inherited or aquired disorders of blood coagulation or fibrinolyisis leading to a prothrombotic state. Heritable risk factors for VTE can be identified in 30–50% of affected patients: among these Factor V Leiden, prothrombin 20210G>A, and deficiencies of antithrombin, protein C and protein S more frequently increase the risk of a first VTE. Non-modifiable risk factors such as advancing age and family history also increase thrombotic risk as like as many other acquired risk factors. Thus venous thromboembolic disease is now viewed as a multicausal model, the thrombotic event being the result of gene-gene and gene-environment interactions (for instance dietary habits, travel or circumstantial risk factors such as surgery, trauma, pregnancy and puerperium and oral contraceptive intake). An evidence-based risk factor evaluation is an essential step in VTE prevention and for management of asymptomatic subjects

Keywords: venous thromboembolism, thrombophilia, factor V Leiden, manage-ment, prevention.

IntroductionThrombophilic states are congenital or acquired haemostasis disorders with patho-

physiological and statistical association to increased risk of thrombosis. [1] [2] VTE most commonly manifests as deep vein thrombosis (DVT) in the leg but may progress to pulmonary embolism if the clot dislodges and travels to the lung. Approximately one third of individuals with VTE and more than 50% of patients with unprovoked thrombosis have one of the known thrombophilias. Patients with congenital thrombo-philias have, in comparison to those without thrombophilia, increased risk of the first

mailto:[email protected]


290 Aluigi L.

thromboembolic event, while the impact of genetically defined thrombophilic states on recurrence is less evident.[3] Primary prevention of venous thromboembolism requires good knowledge of general precipitating factors as well as the specific risks in each patient and thus also means an early investigation of thrombophilic states in patients who will benefit from their identification and in whom there is at least medium probability of their identification. Even if no evidence has been found that identification of thrombophilia in asymptomatic family members reduces risk of VTE, genetic testing for thrombophilia in probands and their family members is common despite the unproven clinical utility.[4][5][6] When an inherited thrombophilia is identified in an asymptomatic family member the problem arises if, how and when to perform primary prophylaxis to reduce the risk of VTE referring to the genetic condition and to the presence of concomitant acquired conditions. Women with throm-bophilic disorders have an increased risk of thromboembolic event if using hormonal contraception, during pregnancy and hormon replacement therapy (HRT). Universal long-term prevention in so far asymptomatic carriers of congenital thrombophilias is not indicated considering the potential complications of anticoagulant treatment too. Interactions between acquired risk factors for VTE and inherited thrombophilias must be considered to give to the asymptomatic subjects the best management re-commendations to reduce VTE risk.

Inherited Thrombophilia

Table 1 summarize prevalence data and associated risks of VTE derived from different population studies. Inherited thrombophilias include antithrombin, Protein C and Protein S deficiency and specific mutations in the genes for Factor V Leiden and Factor II or Prothrombin 201210G>A both in homozigosis or heterozigosis . Factor V Leiden (heterozygosis) represents the most common inherited thrombophilia (about 5 %) followed by Protrombin 20210G>A (about 2%, heterozigosis). Inherited deficien-cies of antithrombin, protein C and protein S have a combined population prevalence of less than 1%.The annual risk of VTE is low for all the categories, ranging from 0.37% up to 1.30 %.

Table 1. Inherited thrombophilia: prevalence and relative risks a (adapted from Vargas EA and Kujovich JL) [10]

Prevalence : gene ral Prevalence : Ind ividual s R elati ve VTE Ann ual risk of Thrombo philia pop ulati on (%) W/ V TE (% ) Ri sk (OR) V TE (%/year) An tithromb in def iciency 0.02 -0.17 0.5 -0.49 10 -20 0.8 -1.5 Protein C def iciency 0.14 -0.50 3-9 7-10 0.4 -1.0 Protein S D eficiency 0.10 -1 1-3 5-10 0.28 -0.4 Fa ctor V Leiden (he terozygo us)b 3-5 12 -20 3-8 0.41 -0.58 Fa ctor V Leiden (H omozygo us) 0.004.0.065 0.01 9-80 1.30 Prothromb in 20 210G> A (he terozyg ou s)b 1-3 6-8 2-3 0.37 Prothromb in 20 210G> A (ho mozy gous) 0.001 -0.012 0.2 -4 NA 1.10 Fa ctor V Leiden /prothromb in 20 210G> A 0.1 -00.22 2 -4.5 9-20 0.4 -0.57 (do uble he terozy gotes)

NA, not available; OR, odds ratio; VTE, venous thromboembolism.a References [1],[3],[6],[7],[8],[9]b Prevalence vary with the population studied

291Thrombophilia and Vascular Disease: Indication to Treatment of Asymptomatic Patients

Homozygotes tend to develop thrombosis more frequently and at a younger age but the clinical course of an acute episode is not more severe or resistant to antico-agulation than in heterozygotes.[3] Individuals with multiple thrombophilic disorders have a higher risk of first and recurrent thrombosis and develop VTE at a younger age. The combination of factor V Leiden heterozygosity and most thrombophilias has a supra-additive effect on overall thrombotic risk.[11] MTHFR polymorphism responsible of mild elevation of homocysteine plasma levels (hyperhomocysteine-mia) is very common in the general population and confer a two- to three increased risk of VTE [3]. Polymorphisms in plasminogen activator inhibitor 1 (PAI-1 ) and other fibrinolytic pathway proteins, the protein C promoter region, and tissue factor pathway inhibitor gene, may increase the risk of VTE, although the evidence is inconclusive. Recent genome-wide association studies identified several potentially prothrombotic polymorphisms that are common in the general population. Individually, these polymorphisms have at most a weak effect on thrombotic risk and testing is not recommended.[12]

Acquired risk factors and interaction with inherited Thrombophilia

At least 50% of VTE events in individuals with inherited thrombophilia are provoked by one or more predisposing factors [1],[10],[13]. Table 2 summarize the principal risk factors which may interact with inherited thrombophilia in provoking VTE.

Table 2. Acquired risk factors for VTE

Non modifiable risk factors : Family History of VTE, Age, APLA 1 Situational risk factors : Immobility, Hospitalization, Surgery, Trauma, Cancer, CVC 2 Modifiable risk factors : Oral contraception, HRT 3 SERMS 4, Obesity, Travel 1 Antiphospholipid Antibodies, 2 Central Venous Catheter, 3 Hormone Replacement Therapy, 4 Selective Re-

ceptor Estrogen Modulators

Non modifiable risk factors

For all inherited thrombophilias, the thrombotic risk is higher in individuals with a strong family history; higher VTE risk is realized when multiple family members are affected and when VTE occurs <50 years. Advancing age is an unavoidable and potent risk factor for VTE: the risk of VTE increases nearly twofold for each decade after 55 years of age. [10],[14] Persistent APLA increase the risk of arterial and venous thrombosis, pregnancy loss and possibly other obstetric complications. The risk of VTE in individuals with inherited thrombophilia and persistent APLA has not been adequately studied. It is unclear to what extent APLA affect the thrombotic risk of inherited thrombophilia but the Overall VTE risk probably is to be considered higher with persistent coexisting APLA .[15]

Situational risk factors

Every type of immobility increases the risk of VTE and contributes to a significant proportionof VTE in individuals with thrombophilia. The magnitude of risk depends

292 Aluigi L.

on the type and duration of immobility and other predisposing factors.[16][17] The high thrombotic risk during hospitalization is due to both relative immobility and the prothrombotic effects of acute illness even if the risk of VTE in hospitalized individuals with inherited thrombophilia is not well defined. All types of surgery increase the risk of VTE, but those with the highest risk include neurosurgery, ma-jor orthopedic surgery and abdominal and pelvic surgery for malignancy. Surgery patients are stratified into thrombotic risk categories based on the type of surgery and individual risk factors. It is unclear if thrombophilia increases the risk of VTE associated with surgery, but any excess thrombotic risk conferred by thrombophiliais probably small in comparison with the risk of surgery. The trauma related risk on VTE is increased nearly 13-fold after major trauma and the risk increases with the severity of the injuries and when multiple limb or pelvic fractures and major head or spinal cord injury with paralysis occurs.[17] The effects of inherited thrombophi-lias on thrombotic risk after major trauma are not defined. If it is well known that malignancy increases six- to sevenfold the risk of VTE varying with the cancer type and resulting increased during tratement, it is unclear to what extent thrombophilia increases the risk of VTE in neoplastic patients. Central venous catheters often used in cancer patients represent the strongest risk factor for upper extremity thrombosis, but limited data suggest an increased risk in presence of thrombophilia; moreover consensus guidelines do not recommend routine prophylaxis to prevent CVC-related thrombosis in individuals with cancer and/or thrombophilia [18].

Modifiable risk factors

Oral contraceptive use substantially increases the risk of VTE in women with inherited thrombophilia even if the absolute thrombotic risk of oral contraceptives may still be low because of the low baseline risk in young healthy women. Of course the risk becomes higher when homozygous and/or combined thrombophilia are present.[10] Clinical consensus guidelines recommend against estrogen-containing contraception for thrombophilic women; moreover, asymptomatic thrombophilic women should be informed about the thrombotic risks of different contraceptives. [18] Women with thrombophilia are advised to avoid hormone replacement because of the HRT associated a two- to fourfold increased relative risk of VTE in healthy post-menopausal women: when necessary because of severe menopausal symptoms transdermal preparation must be preferred thanks to the lowest verified thrombotic risk.[19] Currently, there are insufficient data to draw conclusions about the use of SERMS in thrombophilic women even if their use is estimated with a two- to threefold increased risk of VTE. Obesity increases the risk of VTE associated with thrombophilia and have a seven- to eightfold higher risk of VTE than those without either risk factor.[22] In the absence of other risk factors, the absolute incidence of VTE is low for long-distance travel, independently if by car, train or plane but may range 14-to 16-fold increased risk in presence of thrombofilia. Usually for long di-stances it’s enough to avoid constrictive clothing and maintain mobility to prevent venous thrombosis, but the risk of VTE should be assessed on an individual basis: for high-risk patients elastic stockings and prophylactic dose of LWMH (low weight molecular heparin) may be recommended. [23],[24 The risk for VTE is five-to six fold higher during pregnancy than in non-pregnant women of similar age. Pregnant asymptomatic women with thrombophilia require an individualized risk assessment,


taking into account the particular thrombophilic defects and additional risk factors: for ‘low-risk’ thrombophilia (heterozygous factor V Leiden or prothrombin 20210G>A, protein C or protein S deficiency) and no history of VTE consensus guidelines do not routinely recommend prophylactic anticoagulation; prophylactic anticoagulation during pregnancy and postpartum may be suggested for asymptomatic women with multiple inherited thrombophilia, especially if homozigotes and/or in presence of other circumstantial risk factors [25].

Table 3 synthesizes the management of thrombophilic patients when the above mentioned acquired risk factors interaction may occur giving some indications for prophylaxis when necessary and right messages to the patients to be well informed.

Table 3. Interaction of acquired risk factors and thrombophilia: Implicaion for counselihg and management (adapted from Vargas EA and Kujovich JL) [10]

Fa mily history of VTE The f amily history is impo rta nt for ind ividuali zed risk assessmen t. The age and number of affec ted family membe rs sho uld be cons ide red

Age Age -spec ific relati ve and abso lut e risk info rmati on sho uld be presen ted

APL A ( 1) Ind ividual s with AP LA sho uld be aware of inc reased risk for VTE, art er ial thrombos is (stroke) and obs tetric comp licati ons . Immob ilit y Prophy lactic anticoagulati on and p hys ic prophyla xis ar e recommen ded depend ing on the type and durati on of imm obilit y Hosp itali zati on Prophy lactic anticoagulati on is recom mend ed for mos t hosp ital pati en ts conf ined to bed Sur ge ry Prophy lactic anticoagulati on is recomme nded follow ing major orthop edic, ur olog ic, gyneco logic or bariatri c sur ge ry, irr espec tive of thromb oph ilia statu s Trau ma Prophy lactic anticoagulati on recom mend ed for major trau ma pati en ts in the absence of a strong con trai nd icati on regardless of thromb ophilia statu s Ca nce r Ca nce r pati en ts requiri ng sur ge ry, hosp itali zati on or immob ilizati on requir e prophy lactic anticoagulati on regardless of thrombo philia statu s CVC (2) Prophy lactic anticoagulati on is no t routi ne ly recommen ded to prevent CVC-relat ed thrombos is in ind ividual s with thromboph ilia Con tra cep tion Estrogen -con tai ning contra cep tion not recomm ended for asymptom ati c women with thromboph ilia. Barri er me thods ar e the safes t op tions . HR T (3 ) Women with thromboph ilia shoul d be adv ised to avo id Hormone Rep lacemen t T he rap y Sho rt-term use of a low -dose tra nsde rmal preparation has the lowes t thrombo tic risk SE RMS (4) Thromboph ilic women shoul d be aware of the increased VTE risk assoc iat ed with SE RM S Obes ity Thromboph ilic ind ividual s sho uld be enc oura ged to maintai n a healt hy we igh t Trave l Long -distance tra ve lers sho uld av oid cons trictive clothing and maintai n mob ilit y. Gra duat ed comp ress ion stockings o r a sing le prophy lactic dose of low -mo lecular we igh t hep ari n ar e rese rved for high -risk tra ve lers

Pregn ancy Prophy lactic anticoagulati on duri ng pregn ancy not routi ne ly recomme nded for low -risk thromboph ilic women . Poten tial thrombo tic complicati ons and risks vs benef its of a sho rt cour se of pos tpartu m anticoagulatio n sho uld be discussed

Ri sk factors Imp licati ons for counse ling and managem ent

1 APLA, antiphospholipid antibodies; 2 CVC, central venous catheters; 3 HRT, hormone replacement therapy 4 SERMS, selective estrogen receptor modulators; VTE, venous thromboembolism. References cited in the text

294 Aluigi L.

ConclusionsApproximately one third of individuals and more than 50% of individual with

familial VTE have an identifiable inherited predisponsition (thrombophilia). But throm-bofilia is not a disease: it is just a condition which predisposes the subject affected to a greater risk to have thrombosis than the “normal” population. Thrombophilia is not to be properly considered a disease, mostly if compared with other conditions (e.g. Carotid plaque, Hypertension, Gastric ulcer ) that require therapy, even if asymptomatic, because of the real evidence of illness and of their related high risk of complications. Venous thromboembolism (VTE) is a multicausal disease that results from the interac-tion between genetic, acquired and circumstantial predisposing factors: mainly family history of VTE, age, antiphospholipid antibodies, cancer, central venous catheters, immobility and hospitalisation, truma, surgery, hormonal contraception, hormonal replacement therapy, selective estrogen receptor modulators (SERMS), pregnancy, obesity, long distance travel or flights. When the multicausal don’t interact together we don’t have thrombosis; it’s rear that thrombosis occurs in presence of only one predisposing factor. Thrombophilia needs acquired and/or circumstantial interaction to realise venous thrombosis. The 3- to 20-fold increased relative risk of VTE conferred by inherited thrombophilias Asymptomatic individuals with inherited thrombophilia often generates questions about the need for primary prophylaxis in affected indi-viduals with no prior thrombotic history. There is no evidence that antiaggregation or antithrombotic therapies reduce or avoid the risk of undergoing thrombosis; on the other hand prophylactic therapy may result dangerous for side effects. Nevertheless preventive strategies are required and mostly include avoidance of circumstantial risk factors and prophylactic treatment during unavoidable high risk periods: prophylactic anticoagulation during high risk circumstances has the potential to prevent a lot of thrombotic episodes. The real problem is in giving correct informations about their “condition” and about the addictional risk related to acquired predisposing factors. Patients and their family members require counseling on avoidable circumstantial risk factors (e.g. contraceptives, hormone replacement,and travel), and the impact of lifestyle factors (e.g. obesity, immobility) on risk. A correct understanding of ac-quired factor predisposing to VTE is required for individualized risk assessment and counseling. In the absence of other predisposing factors, the absolute risk of VTE in asymptomatic subject is low and it is very important to avoid in such a patient an overestimation of thrombotic risk or a misperception of the personal risk which could result in increased, unmotivated worry and, indeed, in a worsened quality life.. An awareness of risk and an understanding of triggering events of thrombosis will enable asymptomatic individuals with thrombophilia to make well-informed decision about avoidable risk factors. Patient education and family counselling may be con-sidered the best treatment of asymptomatic thrombophilia.

REFERENCES 1. Rosendaal FR. (2005) Venous thrombosis: the role of genes, environment, and behavior.

Hematology Am Soc Hematol Educ Program: 1–12. Epub 24 November 2. Brouwer JL, Veeger NJ, Kluin-Nelemans HC, van der Meer J.(2006) The pathogenesis of

venous thromboembolism: evidence for multiple interrelated causes. Ann Intern Med: 145 (11):807–815.


3. Foy P, Moll S. (2009) Thrombophilia: 2009 update. Curr Treat Options Cardiovasc Med: 11(2): 114–128.

4. Varga E (2007) Inherited thrombophilia: key points for genetic counseling. J Genet Couns: 16(3): 261–277.

5. Baglin T, Gray E, Greaves M et al. (2010) Clinical guidelines for testing for heritable thrombophilia. Br J Haematol: 149(2): 209–220

6. EGAPP Working Group. (2011) Recommendations from the EGAPP Working Group: routine testing for Factor V Leiden (R506Q) and prothrombin (20210G>A) mutations in adults with a history of idiopathic venous thromboembolism and their adult family members. Genet Med : 13(1): 67–76.

7. Simioni P, Sanso BJ, Prandoni P et al (1999) Incidence of venous thromboembolism in families with inherited thrombophilia. Thromb Haemost: 81(2): 198-202

8. Kujovich JL. (2011). Factor V Leiden thrombophilia. Genet Med :13(1): 1-16 9. Lijfering WM,Brouwer JL, Veeger NJ (2009) Selective testing for thrombophilia in pa-

tients with first venous thrombosis: results from a retrospective family cohort study on absolute thrombotic risk for currently known thrombophilic defects in 2479 relatives . Blood: 113(21): 5314-5322

10. Varga EA, Kujovich JL. (2012) Management of inherited thrombophilia: guide for genetics professionals. Clin Genet: 81;7-17

11. Brouwer JL, Veeger NJ, Kluin-Nelemans HC, van der Meer J. (2006) The pathogenesis of venous thromboembolism: evidence for multiple interrelated causes. Ann Intern Med: 145 (11): 807–815.

12. Morange PE, Bezemer I, Saut N et al (2010). A follow-up study of a genome-wide asso-ciation scan identifies a susceptibility locus for venous thrombosis on chromosome 6p24.1. Am J Hum Genet: 86 (4): 592–595.

13. Langlois N, Wells P. (2003) Risk of venous thromboembolism in relatives of symptomatic probands with thrombophilia: a systematic review. Thromb Haemost: 90 (1): 17–26.

14. Bezemer ID, van der Meer FJ, Eikenboom JC, Rosendaal FR, Doggen CJ. (2009) The value of family history as a risk indicator for venous thrombosis. Arch Intern Med: 169 (6): 610–615.Epub 25 March 2009

15. Lim W, Crowther MA, Eikelboom JW. (2006) Management of antiphospholipid antibody syndrome: a systematic review.JAMA: 295 (9): 1050–1057.

16. Tsai AW, Cushman M, Rosamond WD, Heckbert SR, Polak JF, Folsom AR. (2002) Cardio-vascular risk factors and venous thromboembolism incidence: the longitudinal investigation of thromboembolism etiology. Arch Intern Med : 162 (10):1182–1189

17. Samama MM. (2000) An epidemiologic study of risk factors for deep vein thrombosis in medical outpatients: the Sirius study. Arch Intern Med: 160 (22): 3415–3420.

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19. Renoux C, Dell’Aniello S, Suissa S. (2010) Hormone replacement therapy and the risk of venous thromboembolism: a populationbased study. J Thromb Haemost: 8 (5): 979–986.

20. Duggan C, Marriott K, Edwards R, Cuzick J. (2003) Inherited and acquired risk factors for venous thromboembolic disease among women taking tamoxifen to prevent breast cancer. J Clin Oncol: 21 (19): 3588–3593. Epub 27 September 2003

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Technical considerations of open TAAA repair in a transition country Davidovic L., Ilic N., Dragas M., Koncar I., Banzic I.

Clinic for Vascular and Endovascular Surgery.Clinical Center of Serbia. Faculty of Medicine, University of Belgrade, Belgrade, Serbia

SummaryMajor problems during repair of thoracoabdominal aortic aneurysms (TAAA) are

renal and spinal cord ischemia. The most recently published analyses indicate the presence of acute renal failure (ARF) in less than 6% of cases after this procedure. The incidence of paraplegia during TAAA repair decreased in the first decade of the new century, to 3% only. Our Clinic started with routine repair of TAAA at the time of Yugoslav civil conflict. An embargo, sanctions and crisis completely interrupted the development of vascular medicine in Serbia and our preliminary results after this procedure were alarming. At that time we treated only patients with ruptured and symptomatic TAAA. In the last 30 months we have performed 30 thoracoabdominal aortic reconstructions. The ARF rate was 10.0% paraplegia rate 6.7%, while mortality rate was 16.7%. At the moment fenestrated and branched stent grafts are too expen-sive for Serbian health care system. On the other hand, hybrid procedures routinely performed in Serbia require suitable anatomy. Having in mind all previous reasons majority of patients with TAAA in Serbia, especially people without significant risk factors, have one chance only-complete open surgery.

Keywords: thoraco-abdominal aneurysms, repair, transition countries

IntroductionThe aim of this paper is to explain how the doctors and institutions in transition

countries such as Serbia, without the most sophisticated equipment and cutting-edge technology, deal with renal and spinal cord ischemia during surgery on thoraco-abdo-minal aorta. We repair types I, II, III and V of thoraco-abdominal aortic aneurysms (TAAA) under the distal aortic retrograde perfusion with the partial femoral-femoral cardiopulmonary bypass using moderate hypothermia. However, this standard well known procedure sometimes may occur to be insufficient.

298 Davidovic L., Ilic N., Dragas M., Koncar I., Banzic I.

Renal failureAccording to well-known articles from the 90-es, the acute renal failure (ARF)

incidence, after these procedures, was 16%, while the mortality rate related to this complication, was over 30%1-4. In the meantime, this problem is mostly solved. This retrospective analysis performed by Cosseli and co with over 2000 treated TAAA, indicated the presence of ARF in less than 6% of cases5.ARF related to open repair of these aneurysms is caused by acute ischemic and toxic injury of the kidneys6. Predictors of ischemic renal injury include preoperative renal insufficiency with in-creased creatinine level, as well as prolonged aortic cross-clamping6-8. Furthermore, complex and time-consuming procedures on renal arteries additionally prolong renal ischemia. What can we do in such cases?

During the creation of proximal anastomosis, as well as during the intercostal arteries re-attachment, kidneys are protected by retrograde perfusion. A practical solution for visceral artery perfusion could be multiple perfusion catheters a technique that saves ischemic period making surgeon more relaxed during visceral artery reattachment. Unfortunately, until recently we didn’t use this technique. Instead, we performed a separate three-minute anterograde blood perfusion of each significant renal artery. The procedure is repeated each 20 minutes, when necessary 13. (Fig. 1). Critical ischemic period could be shortened by simultaneously re-attachment celiac, superior mesenteric and right renal artery with a common Carrel patch. However, left and all significant accessory renal arteries should be re-vascularized separately.

Figure 1. *A separate revascularization of the left renal artery with tube graft.

**Direct reattachment of the accessory left renal artery.

A separate revascularization of all visceral arteries are indicated in cases with aortic dissection, Marfan syndrome and very sic aorta, situations which additionally prolong kidney’s ischemia period9,10. It can be shortened using branched graft which is adjusted manually prior to termination of retrograde perfusion11. (Fig. 2).The better solution is a so called, Coselli graft12. However, it is not enough. Furthermore, during the throaco-abdominal aortic surgery, toxic kidney lesion is caused by myoglobinuria which is a consequence of prolonged leg muscle ischemia. We found as many pre-vious authors, that the side arm technique of canulation of the left femoral artery is a successful prevention8.

299Technical considerations of open TAAA repair in a transition country

Figure 2 A and B.The usage of homemade brunched graft shorts ischemic period during separate revascularization of all visceral arteries.

Spinal cord ischemiaThe incidence of paraplegia during the repair of TAAA decreased from 16% at

the beginning of the ‘90s2,14, , to 3% only5,15,16 in the first decade of the new century. We use so-called “combined method”, for the spinal cord protection. It includes ce-rebrospinal fluid (CSF), distal aortic retrograde perfusion with sequential-segmental


clamping and de-clamping of the thoraco-abdominal aorta, as well as reattachment of critical intercostal feeders of the artery of Adamkiewicz.2,5,6.17The target CSF pressure during aortic cross clamping and in next three postoperative days should be less than 10mm Hg18.

Figure 3. Temporary occlusion of the possible critical intercostal arteries with Fogarty catheters.


Unfortunately, we are still unable to check motor evoked potentials (MEP) during repair of TAAA. So, how do we estimate whether retrograde perfusion is efficient, now? Main prerequisites for an adequate spinal cord perfusion are adequate values of distal aortic pressure (DAP) and spinal collateral network pressure (SCNP). The SCNP is about 75% of mean arterial pressure and could be at the minimum of 20mmHg19. Even the slightest SCNP change can affect the spinal cord. Uncontrolled retrograde bleeding from intercostal arteries lowers this pressure, causing the “steal phenome-non16. That is the reason why even the insignificant intercostal arteries have to be ligated instantly, while the possible critical ones should be temporarily occluded by the Fogarty catheters until their re-implantation is finished. (Fig.3). Other option to maintain the SCNP balanced is an adequate DAP. Its monitoring is especially impor-tant in situations where MEP cannot be estimated (for example, in our situation). In one of our previous studies we have started off with the assumption that DAP can’t be the same for all the patients20. Different patients (for example normotensive and hypertensive persons) have different level of vessels’ auto regulatory mechanisms. Assuming that the lowest spinal collateral network perfusion pressure value could be 20 mmHg, we used the formula for profundo-popliteal collateral index to calculate DAP for each patient preoperatively20.

SCNP = (MAP-DAP)/MAP DAP = MAP – (MAP x SCNP)

Legend: SNMP…spinal collateral network pressure,MAP...mean arterial pressure;DAP...distal aortic pressure

We found that in significant number of cases DAP should be higher than 70 mmHg which is the traditional opinion.

Third prerequisite for prevention of the spinal cord ischemia is a re-implantation of the intercostal feeders of the artery of Adamkiewicz. According to the most recen-tly published articles, in 75% of cases, this artery originates between 9th and 12th thoracic level21. It is rather favorable to determine its origin preoperatively using some of well-known imaging procedures21-23.Usually intercostal arteries reattachment is performed using Carell patch technique2,5,6,17. However in case of very diseased aorta, we perform revascularization using an additional vascular graft a so called Elefteriadis24.or Voo25 technique.

Our Clinic started with repair of TAAA 17 years ago and until now we perfor-med more than 150 procedures26. Our preliminary results were alarming. However, it was a time of Yugoslav civil conflict. Civil conflict, as well as economic crisis, sanctions and embargo which lasted for at least ten years, completely interrupted the development of vascular medicine in our country. At that time we treated only patients with ruptured and symptomatic TAAA with pain despite maximal medical therapy. However, during the ten years that followed, we significantly improved our results using previously mentioned perioperative strategy. In the last 30 months we performed repair at 30 patients with TAAA. The ARF rate was 10.0%, paraplegia rate-6.7%, while mortality rate was 16.7%.

ConclusionWhat is a reality of patients with TAAA in transient countries, such as Serbia?

At the moment with 10% of Gross Domestic Product of an investment in National


Health Care System, Serbia is quite comparable to most developed European countri-es. The problem is that our Gross Domestic Product is significantly lower then in other European countries. That is why fenestrated and brunched stent grafts are too expensive for Serbian health care system. For that reason patients with TAAA in Serbia for a long time period will not have a chance for total endovascular repair, unfortunately. Other options are different hybrid procedures which are routinely per-formed in Serbia27-29. However, these procedures require suitable anatomy. Having in mind all previous reasons, majority of patients with TAAA in transition countries such as Serbia, especially people without significant risk factors, have one chance only-complete open repair.

References1. Crawford ES, DeNatale RW. (1986).Thoracoabdominal aortic aneurysm:observations re-

garding the natural course of the disease. J VascSurg 3, pp. 578–84.2. Swenson LG, Crawford ES, Hess KR, et al (1993). Experience with 1509 patients under-

going thoracoabdominal aortic operations. J VascSurg 17,pp. 357–70.3. Godet G, Fleron M-H, Vicaut E, Zubicki A. (1997). Risk factors for acute postoperative

renal failure in thoracic or thoracoabdominal aortic surgery: A prospective study. Anes-thAnalg 85, pp. 1227–1232.

4. Safi HJ, Harlin SA, Miller CC, et al. (1996). Predictive factors for acute renal failure in thoracic and thoracoabdominal aorticaneurysm surgery. J Vasc Surg24. Pp. 338–344.

5. Coselli JS, Bozinovski J, LeMaire SA. (2007) Open surgical repair of 2286 thoracoabdo-minal aortic aneurysms. Ann ThoracSurg 83,pp. S862–4; discussion pp. S890–S862.

6. Crawford ES, Crawford JL, Safi HJ, et al. (1986). Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J VascSurg 3, pp. 389–404.

7. Kashyap VS, Cambria RP, Davison JF, L’Italien GJ. (1997). Renal failure after thoraco-abdominal aortic surgery. J VascSurg26, pp. 49–955.

8. C.C. Miller III*, M.A. Villa, J. Sutton, et al. (2009).Serum Myoglobin and Renal Mor-bidity and Mortality following Thoracic and Thoraco-Abdominal Aortic Repair: Does Rhabdomyolysis Play a Role? Eur J Vasc Endovasc Surg37, pp. 388-394

9. Toda K, Taniguchi K, Kainuma S, Yokota T. (2008). Novel technique for reimplantation of intercostal arteries using tailored patch graft. Eur J Cardio-thoracic Surg 34,pp. 458—459

10. Cambria RP, Clouse WD, Davison JK, et al. (2002). Thoracoabdominal aneurysm repair: results with 337 operations performed performed over a 15-year interval. Ann Surg 236, pp. 471-9; discussion pp. 479.

11. De Rongo P, Estrera A.L, Miller C III, et al (2011). Operative outcomes using a side-branched thoracoabdominal aortic graft (STAG) for thoracoabdominal aortic repair. Eur J VascEndovascSurg 41,pp. 41-47.

12. Coselli graft13. Deriu GP, Grego, F, Lepidi S et al (2001). Short-term arterial blood flow reperfusion of

normothermic kidney in renal artery and abdominal aorta reconstructive surgery. Eur J VascEndovascSurg 21, pp. 314-9.

14. Schepens M, Boezeman E, Hamerlijnk R, et al (1994). Somatosensory evoked potentials during exclusion and reperfusion of critical aortic segments in thoracoabdominal aortic aneurysm surgery. J Card Surg 9, pp. 692–702.

15. Hollier LH, Money SR, Naslund TC, et al. (1992). Risk of spinal cord dysfunction in patients undergoing thoracoabdominal aorticreplacement. Am J Surg164, pp. 210–3.


16. Jacobs MJ, de Mol AB, Elenbaas T, et al. (2002). Spinal cord blood supply in patients with thoracoabdominal aortic aneurysms. J VascSurg35, pp. 30–7

17. Safi HJ, Hess KR, Randel M, et al. (1996). Cerebrospinal fluid drainage and distal aor-tic perfusion: Reducing neurologic complications in repair of thoracoabdominal aortic aneurysms types II and I. J VascSurg 23, pp. 223–229.

18. Coselli JS, Lemaire SA, Koksoy C, et al. (2002). Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J VascSurg 35(4), pp. 631–639.

19. Griepp RB, Griepp EB. (2007). Spinal cord perfusion and protection during descending thoracic and thoracoabdominal aortic surgery: the collateral network concept. Ann Tho-racSurg 83, pp. 865-9.

20. Ilic N, Davidovic L, Koncar I, et al. (2010). Delayed paraplegia in transition countries: are we missing something? JThorCardiovascSurg 140(3). Pp. 729-30, author reply pp. 730-1.

21. Mellisiano, G, Chiesa R. (2009). Advances in imaging of the spinal cord vascular supply and its relationship with paraplegia after aortic interventions. A Review.Eur J VascEndo-vascSurg 38,pp. 567-577.

22. Yoshioka K, Niinuma H, Ohira A, et al. (2003). MR angiography and CT angiography of the artery of Adamkiewicz: noninvasive preoperative assessment of thoracoabdominal aortic aneurysm. Radiographics 23, pp. 1215-25.

23. Kieffer E, Richard T, Chiras J, et al. (1989). Preoperative spinal cord arteriography in aneurysmal disease of the descending thoracic and thoracoabdominal aorta: preliminary results in 45 patients. Ann VascSurg 3, pp. 34–46.

24. Elefteriades JA, Coady MA, Nikas DJ, et al. (2000). “Cobra head” Graft for Intercostal Artery Implantation during Descending Aortic Replacement. Ann ThoracSurg 69, pp. 1282– 4.

25. Woo YE, McGreevy M, Jackson BM, et al. (2007). Spinal cord ischemia may be reduced via a novel technique of intercostal artery revascularization during open thoracoabdominal aneurysm repair. J VascSurg 46, pp. 421–6

26. Davidovic L, Ilic N, Koncar I, et al. (2011). Some technical considerations of open tho-racoabdominal aortic aneurysm repair in a transition country. Vascular 19(6), pp. 333-7.

27. Davidovic LB., Radak D., Koncar I., et al. (2011). Endovascular aortic repair: initial experience in the Serbian bi-centric study. Eur Surg 43(5), pp. 302-308.

28. Ilic N, Davidovic L, Koncar I, et al. (2010). Penetratingaorticulcerassociatedwithjuxtare-nalaorticocclusion. Am Surg 76(8), pp. 909-11.

29. Koncar I, Colic M, Vjestica M, et al. (2009). Tratamiento hibrido de aneurisma aortico tortacoabdominal. Presentacion de un caso clinico. Tecnicas Endovasculares 12, p. 2983-6.



Changing concept on the chronic lymphedema: it is no longer lymphatic disease!Lee B.B., Laredo J.

Department of Surgery, George Washington University, Washington DC, USA

Chronic lymphedema starts as a simple clinical condition of lymph stasis to cause a diffuse swelling of affected limb/region due to the mechanical failure to transport protein-rich interstitial fluid by the blockage of lymph-transporting/collecting system.

But such simple ‘reversible’ fluid retention as edema in early stage soon takes a chronic degenerative and inflammatory process, and the impact of lymphatic fluid accumulation, initially limited to the lymphatics and lymph nodes, would soon spread to entire surrounding soft tissue and skin resulting in ‘irreversible’ damage (1-4).

Therefore, lymphedema is no longer considered as a simple ‘static’ clinical ma-nifestation of mechanical failure of lymphatic system but considered as a “chronic degenerative and inflammatory disease” of skin and soft tissue beyond the lymphatics and lymph nodes.

It often invites bacterial and fungal infection to accelerate chronic inflammation and

subsequent dermato-lipo-fibrosis along the entire affected limb to become a disabling and distressing condition. The recurrent dermato-lymphatico-adenitis forms a vicious cycle between recurrent sepsis. It further progresses to cause immunodeficiency and wasting phenomenon not a rare phenomena/complication and its end stage has been known for the risk of new malignancy (e.g. Kaposi sarcoma; lymphangiosarcoma)

Therefore, chronic lymphedema should be no longer considered a simple ‘static’ condition of lymph stasis (old concept) but should be recognized as a complicated degenerative and inflammatory process beyond the lymphatics and lymph nodes in-volving entire soft tissue/skin with steady fibrotic change through repeated episodes of dermato-lymphoadenitis (new concept) (5-8).

Lymphedema will therefore, continue to progress with extremely variable severity/extent through various clinical stages, from simple reversible edema in early stage to rubbery firm swelling with extensive skin/soft tissue change (e.g. elephantiasis) reaching to its late stage (9, 10).

306 Lee B.B., Laredo J.

Hence, proper understanding of new concept is warranted for the contemporary strategy to aim to manage this condition as a systemic rather than a local disease and also to reduce, if not prevent, the risk of development at the same time (11-13).

Risk of lymphedema development involving lymph nodes dissection (e.g. breast/ uterine cancer surgery) or radiation should be anticipated as the “iatrogenic” conse-quence of surgical and/or radiation injury to the lymphatic system, and prepared for the aggressive control of these inevitable (?) but iatrogenic consequences even before it becomes clinically detectable.

Infection is another serious condition involved to the progress of the lymphedema because the lymphedema has an extraordinary susceptibility to secondary bacterial infection. Erysipelas secondary to beta-hemolytic streptococcal infection causes re-curring lymphangitis and recurrent cellulitis will result in such devastating sequela of peripheral lymphedema.

Therefore, proper prevention with meticulous personal hygienic measures avoiding skin injury, and aggressive control of infection before spreading are utmost urgent. Hence, continuous surveillance of the patients is warranted through constant education with critical warning for life-time susceptibility to infection to all the lymphedema regardless its severity and clinical stage.

Early recognition of the condition based on appropriate diagnostic evaluation is mandated with full awareness of such serious nature affecting through the rest of the life. Precise diagnosis including its etiology and clinical staging should be extended to appropriate differential diagnosis with various systemic (e.g. cardiac failure) and local/regional (e.g. lipedema, phlebolymphedema) conditions before the formulation of right treatment strategy ( 1, 4, 10, 14).

Following careful history and physical examination (e.g. Stemmer’s sign) to assess the extent/severity of the lymphedema, basic laboratory evaluation should be performed to confirm the clinical impression.

Lymphatic system should be evaluated with• Volume measurement: volumetry • Radionuclide Lymphoscintigraphy - mandatory test• MRI and/or CT scan for the differential diagnosis (e.g. exclude underlying

malignancy • Duplex ultrasonography• Standard (ascending) lymphangiography –optional• Microscopic fluorescent lymphangiography - optional• Percutaneous direct puncture lymphangiography - optional• Ultrasonographic & MR lymphangiography: investigationalAnd also the venous system should be assessed together with• Venous duplex ultrasonography• Air plethysmographyProper combination of various non- to minimally invasive tests (e.g. radionuclide

lymphoscitnigraphy and Duplex ultrasonography) is generally adequate for the dia-gnosis as well as the staging of the lymphedema which is mandated for the proper selection of the therapy.

Ultimate goal of the treatment is the improvement of quality of life through proper social adaptation for socially useful life, functional adaptation for physically normal

307Changing concept on the chronic lymphedema

activity and psychological adaptation for psychologically accept physical deformity.Treatment plan holds three different modalities;• Physical therapy - essential and basic care• Surgical therapy - supplemental therapy to the non- to poor- response group

to physical therapy.• Reconstructive surgery• Physiologic reductive surgery; excisional or liposuctional• Medical therapy - optional if indicatedConservative treatment based on the physical therapy remains a mainstay of the

management of all the chronic lymphedema regardless of its clinical stages. The de-congestive lymphatic therapy (DLT) is now the treatment of choice regardless of the condition/clinical stage; it consists of exercise/movement, manual lymphatic drainage (MLD), and compression (bandaging, garments) therapy in addition to basic skin care, education for risk reduction of infections and trauma (15- 17).

However, DLT is a strategy to control the edema and does not result in “cure”. DLT in general is effective to delay the progress of the condition only during the treatment. To maintain long term control often means continuous commitment and requires a lifetime commitment.

Surgical treatment modalities, either for curative/reconstructive or palliative/exci-sional purposes, have also been known for decades as the most effective methods of controlling chronic lymphedema ( 18, 19). But for the last two decades, DLT-based conservative care was fully accepted to control the lymphedema in its majority as a most effective mean. And the surgical therapy remains an auxiliary role generally till the DLT fails to prevent the progress or the complications should intervene.

Both therapeutic modalities are now fully incorporated to the new concept of total care management through multidisciplinary approach.

Reconstructive surgery ( 20-27) can provide a unique opportunity of providing a “cure”; its goal aims at the repair of damaged lymph-transport system to enhance lymph flow and subsequently restore lymphatic function. Therefore, it is generally accepted when the condition should meet the indication:

1) Failure to respond to proper care at clinical stage I or II for a minimum two years 2) Progress of the disease to advanced stages such as from stage I to stage II or

stage II to III despite proper treatment within a year3) Chylous-reflux combined with extremity lymphedema4) High recurrence of local and systemic infection, and5) Poor tolerance to CDP - based conservative treatmentThere are several methods: Lymphatico-venous or lymphatico-lymphatic bypass,

lymphatico-lymphatic segmental reconstruction, and free lymph node transplantation. The lymphatic reconstruction remains the only treatment modality for a possible

chance of ‘cure’ but only when done in ‘early’ stage lymphedema while the lympha-tic dysfunction is in a reversible stage. Once the function of the initial (lymphatic) capillaries fails and the lymph stasis persists certain amount of time, the lymph peristalsis is paralyzed; this condition soon becomes irreversible and the anatomical restoration does not always guarantee full functional recovery.

It is therefore, ideal to recruit the candidate in the earliest stages of lymphedema, but in reality most of the candidates for the lymphatic reconstruction are referred only when DLT-based therapy fails to prevent the progress of lymphedema so that


there is already significant damage to the lymph-transporting vessels caused by long term lymphatic hypertension.

Therefore, proper timing of the surgical reconstruction before the lymph vessels are completely paralyzed is a crucial factor for success. For this reason, the outcome of the therapy was not generally consistent with poor reproducibility and remained controversial as independent therapy especially on its long term results.

Nonetheless, surgical reconstruction has recently been found to be more effective when combined with DLT, and postoperative maintenance of CDT is essential for good long term outcome. Without appropriate DLT even a flawless technical surgical success becomes futile . Such new approach with surgical therapy is very effective as a supplemental therapy to the non- to poor- response group of DLT when insti-tuted properly.

Especially when done late in not quite ideal condition, DLT has to be fully integrated with the ‘reconstructive’ surgery as “mandatory/obligatory postoperative management”

Ablative (Excisional) Surgery ( 28-34)Lately, based on a new concept of multidisciplinary approach, once abandoned

ablative surgery was selectively adopted to improve the quality of life along the end stage of chronic lymphedema, breaking the vicious cycles of recurrent sepsis and further deterioration of the condition.

Once the lymphedema advances to an irreversible stage (clinical stage III and IV), it has a tendency to progress steadily and often accompanies with increased tendency to recurrent local and/or systemic episodes of sepsis.

The DLT-based therapy becomes often ineffective because of the technical diffi-culties to apply an efficient compression therapy due to its anatomic disfiguration of the limb in this end stage.

Once the multidisciplinary team considers DLT-based therapy failed to arrest pro-gress toward the end stages with evidence of steady deterioration despite maximum treatment, excisional surgery becomes a measure of last resort.

When lymphedema reaches its end stage, most of the normal tissues become fi-brosclerotic and all the remaining lymph vessels are severely damaged leading to an unsalvageable condition. The excisional surgery at this stage therefore, can be justified with no risk of potential damage to the remaining lymphatic system

The original techniques/procedures of various methods introduced throughout the decades (e.g. Charles procedure) were extensively modified to reduce the morbidity and improve long term results of chronic lymphedema management in its end stage (e.g. modified Auchincloss/Homans procedure) (29-32). And palliative surgical therapies are now fully integrated with DLT to improve clinical outcome of the management along the advanced stage of chronic lymphedema.

ConclusionContemporary management of the chronic lymphedema should be based on ‘new

concept’ with a new goal: the improvement of quality of life through proper social adaptation, functional adaptation and psychological adaptation by multidisciplinary team approach.

309Changing concept on the chronic lymphedema

REFERENCE1. Lee BB, Andrade M, Bergan J, Boccardo F, Campisi C, Damstra R, Flour M, Gloviczki

P, Laredo J, Piller N, Michelini S, Mortimer P, Villavicencio JL : Diagnosis and treatment of Primary Lymphedema - Consensus Document of the International Union of Phlebology (IUP)-2009. International Angiology 2010 Oct;29(5):454-70.

2. Lee BB: Chronic lymphedema, no more stepchild to modern medicine! Eur J Lymphol, 14 (42):6-12, 2004.

3. Lee BB: Current issue in management of chronic lymphedema: Personal Reflection on an Experience with 1065 Patients. Commentary, Lymphology 38 (2005): 28 -31.

4. Lee BB, Kim YW, Seo JM, Hwang JH, Do YS, Kim DI, Byun HS, Lee SK, Huh SH, Hyun WS: Current concepts in lymphatic malformation (LM). Vasc Endovasc Surg 39(1) 67-81, 2005.

5. Lee BB, Kim DI, Whang JH, Lee KW: Contemporary management of chronic lymphe-dema – personal experiences. Lymphology 35 (Suppl):450-5, 2002.

6. Lee BB, Laredo J, Neville R, Mattassi R: Primary lymphedema and Klippel-Trenaunay syndrome. Chapter 52. Section XI - Lymphedema and Congenital Vascular Malformation. Page 427-436, LYMPHEDEMA: A Concise Compendium of Theory and Practice. Lee, Byung-Boong; Bergan, John; Rockson, Stanley G. (Eds.), 1st Edition, Springer-Verlag, London, UK, 2011

7. Lee BB, Villavicencio JL: Primary Lymphedema and Lymphatic Malformation: are they the two sides of the same coin? Eur J Vasc Endovasc Surg (2010) 39:646-653

8. Lee BB: Lymphedema-Angiodysplasia Syndrome: a Prodigal form of Lymphatic Malfor-mation (LM). Phlebolymphology, 47:324-332, 2005.

9. Lee BB, Bergan, JJ: New Clinical and Laboratory Staging Systems to Improve Manage-ment of Chronic Lymphedema. Lymphology 38 (3):122-129, 2005

10. Lee BB: Classification and Staging of Lymphedema, Pages 21-30, Chapter 3, Lymphedema-Diagnosis and Treatment. Tredbar, Morgan, Lee, Simonian, Blondeau (eds) Springer-Verlag London Limited 2008.

11. Lee BB, Laredo J, Neville R:. Primary lymphedema as a truncular lymphatic malforma-tion. Chapter 51, Section XI - Lymphedema and Congenital Vascular Malformation Page 419-426, LYMPHEDEMA: A Concise Compendium of Theory and Practice. Lee, Byung-Boong; Bergan, John; Rockson, Stanley G. (Eds.), 1st Edition, Springer-Verlag, London, UK, 2011

12. Lee BB, Laredo J, Neville R: Combined Clinical and Laboratory (Lymphoscintigraphic) Staging. Chapter 13. Section IV - Clinical Diagnosis, Page 97-104, LYMPHEDE-MA: A Concise Compendium of Theory and Practice. Lee, Byung-Boong; Bergan, John; Rockson, Stanley G. (Eds.), 1st Edition, Springer-Verlag, London, UK, 2011

13. Lee BB, Laredo J, Seo JM, Neville R: Hemangiomas and Vascular Malformations. Mattassi, Loose, Vaghi (eds) Chapter 29, Treatment of Lymphatic Malformations. Pages 231-250. Springer-Verlag Italia, 2009, Milan, Italy.

14. Lee BB: Lymphatic Malformation, Pages 31-42, Chapter 4, Lymphedema-Diagnosis and Treatment. Tredbar, Morgan, Lee, Simonian, Blondeau (eds) Springer-Verlag London Limited 2008.

15. Hwang JH, Kwon JY, Lee KW, Choi JY, Kim BT, Lee BB, Kim DI: Changes in lymphatic function after complex physical therapy for lymphedema. Lymphology 32:15-21, 1999.

16. Hwang JH, Lee KW, Lee BB: Improvement of lymphatic function after complex physical therapy. J. Korean Acad. of Rehab. Med. 22(3):698-704, June 1998.

17. Lee BB: Surgical Management of Lymphedema, Pages 55-63, Chapter 6, Lymphedema-Diagnosis and Treatment. Tredbar, Morgan, Lee, Simonian, Blondeau (eds) Springer-Verlag London Limited 2008.

18. Lee BB, Laredo J, Neville R: Current dilemma with controversy. Chapter 45. Section IX


- Surgical treatment - Reconstructive Surgery Section, Page 381-386, LYMPHEDEMA: A Concise Compendium of Theory and Practice. Lee, Byung-Boong; Bergan, John; Rockson, Stanley G. (Eds.), 1st Edition, Springer-Verlag, London, UK, 2011

19. Lee BB, Laredo J, Neville R: Contemporary indication and controversy on excisional surgery. Chapter 49, Section X - Surgical treatment - Excisional/Cytoreductive Surgery Page 403-408, LYMPHEDEMA: A Concise Compendium of Theory and Practice. Lee, Byung-Boong; Bergan, John; Rockson, Stanley G. (Eds.), 1st Edition, Springer-Verlag, London, UK, 2011

20. Lee BB, Laredo J, Neville R: Reconstructive surgery for chronic lymphedema: a viable option, but. Vascular, 19 (4): 195–205, 2011

21. Lee BB, Laredo J, Neville R: Current Status of Lymphatic Reconstructive Surgery for Chronic Lymphedema: It Is Still an Uphill Battle! Int J Angiol 20 (2): 73-79, 2011

22. Baumeister RGH, Siuda S. Treatment of lymphedemas by microsurgical lymphatic grafting: what is proved? Plastic and Reconstructive Surgery 1990;85:64-74.

23. Becker C. Hidden G. Pecking A. Transplantation of lymph nodes: an alternative method for treatment of lymphedema. Progr Lymphol 1990;6:487-93.

24. Campisi C, Boccardo F, Zilli A, Maccio A, Gariglio A, Schenone F. Peripheral lymphedema:new advances in microsurgical treatment and long-term outcome.Microsurgery. 2003;23(5):522-5.

25. Krylov VS, Milanov NO, Abalmasov KG, Sandrikov VA, Sadovnikov VI.Reconstructive microsurgery in treatment of lymphoedema in extremities. Int Angiol. 1985 Apr-Jun;4(2):171-5.

26. Olszewski WL.The treatment of lymphedema of the extremities with microsurgical lympho-venous anastomoses. Int Angiol. 1988 Oct-Dec;7(4):312-21.

27. Gloviczki P, Fisher J, Hollier LH, Pairolero PC, Schirger A, Wahner HW.Microsurgical lymphovenous anastomosis for treatment of lymphedema: a critical review. J Vasc Surg. 1988 May;7(5):647-52.

28. Lee, BB, Kim, YW, Kim, DI, Hwang JH, Laredo, J and Neville, R: Supplemental surgi-cal treatment to end stage (stage IV –V) of chronic lymphedema. Int Angiol. 2008 Oct; 27(5):389-95.

29. Servelle M. Surgical treatment of lymphedema: a report on 652 cases. Surgery. 1987 Apr;101(4):485-95.

30. Dellon Al, Hoopes JE. The Charles procedure for primary lymphedema. Plas. & Reconstr. Surg 1977;60:589.

31. Homans J. The treatment of elephantiasis of the legs. N Engl J Med 1936;215:1099.32. Sistrunk WE. Further experiences with the Kondoleon operation for elephantiasis.

JAMA 1918;71:800. Liposuction combined with controlled compression therapy re-duces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg. 1998 Sep;102(4):1058-67; discussion 1068.

33. Kim DI, Huh S, Lee SJ, Hwang JH, Kim YI, Lee BB. Excision of subcutaneous tissue and deep muscle fascia for advanced lymphedema. Lymphology 1998;31:190-194.

34. SH Huh, DI Kim, JH Hwang, BB Lee: Excisional surgery in chronic advanced lymphe-dema. Surgery Today 2003;34: 434-35



Carotid endarterectomy under cervical plexus block: a single center experienceMarkovic M.1,2, Davidovic L.1,2, Sindelic R.1,2, Pejkic S.2, Koncar I.1,2, Ilic N.1,2, Dragaš M.1,2

1 Faculty of Medicine, University of Belgrade, Serbia 2 Clinic for vascular and endovascular surgery, Clinical center of Serbia, Belgrade, Serbia [email protected], [email protected], [email protected], [email protected], [email protected], [email protected], [email protected]

AbstractBackground: Although the first carotid endarterectomy (CEA) was performed under

the general anesthesia (GA), most of pioneers in this field preferred operation under the local anesthesia. However, after Wells’ report of eventual cerebral protective effect of GA in 1963 generations of physicians followed this technique utilizing variety of imperfect monitoring techniques. After the results of recent GALA and EVEREST studies the selection of anesthetic and surgical strategy is still left to physician’s personal preference and institutional experience.

Materials and methods: A group of 1464 consecutive patients (930 male, 534 female, mean aged 67±8) operated for carotid stenosis from 2007 – 2010 under the cervical plexus block (CPB) anesthesia was analyzed. About one-third of patients was asymptomatic (37.8%), 27.4% had preoperative stroke, 18.6% presented with transitory attacks, 2.9% with amaurosis fugax while 13.3% of patients had non-hemispheric symptoms. Most prominent comorbidity was arterial hypertension (90.6%), coronary artery disease (41.4%) and diabetes mellitus (31.5%). During the procedure the need for intraluminal shunt insertion was estimated upon awake neurologic testing following carotid cross clamping (CCC). No additional neurologic monitoring procedures were performed.

Results: Eversion endarterectomy was performed in 71% of patients, conventional endarterectomy with the use of patch in 14.7%, graft interposition was done in 6% and some other kind of procedure in 8% of patients. Mean duration of surgery was 90 minutes (30-210) and mean CCC time was 17 min. (6-70). Awake neurologic testing ordered the use of intraluminal shunt in 138 cases (9.4%). Conversion from CPB to GA was performed in 17 pts (1.2%) due to neurologic deterioration (8 pts), toxic effect of CPB (4), CPB failure (3), discomfort (1) and intraoperative myocardial








312 Markovic M., Davidovic L., Sindelic R., Pejkic S., Koncar I., Ilic N., Dragaš M.

infarction (1). Eleven percent of patients required postoperative intensive care (ICU) while the rest were transferred to the surgical ward. Perioperative stroke rate was 2.3% and 0.5% of patients suffered perioperative myocardial infarction. Intrahospital mortality rate was 0.54%.

Conclusion: CAE under the CPB presented as a safe and highly successful proce-dure. It makes costly monitoring procedures unnecessary and enables faster recovery and discharge of patients. Associated with eversion CEA surgical technique it can present significant cost benefit.

Keywords: carotid endarterectomy, cervical plexus block.

IntroductionAlthough the first carotid endarterectomy (CEA) was performed under the general

anesthesia (GA), most of pioneers in this field preferred operation under the local anesthesia [1]. However, after Wells’ report of eventual cerebral protective effect of GA in 1963 generations of physicians followed this technique utilizing variety of imperfect monitoring techniques [2]. At the end of 20th century regional anesthesia for CAE in the United States was used in 17% of procedures; however in the United Kingdom the vast majority of physicians still used GA [3]. In the following years the interest for regional anesthesia especially cervical plexus block (CPB) increased, but large prospective randomized trials failed to present significant advantage of any anesthesiologic technique. After the results of GALA and EVEREST studies the selection of anesthetic and surgical technique is still left to physician’s personal preference and institutional experience [4,5].

Materials and methodsBetween 1992 and 2011 a total number of 5556 CEA was performed at the Clinic

for vascular and endovascular surgery of the Serbian clinical center. The routine use of cervical plexus block (CPB) was introduced in 2004. Till 2011 about 4000 operations under the regional anesthesia were performed. For the purpose of this study a group of 1464 consecutive patients (930 male, 534 female, mean aged 67±8) operated from 2007 – 2010 was selected. Presentation of carotid artery disease is given in table 1.

Table 1. Presentation of carotid artery disease

Clinical presentation No (%)Asymptomatic 553 (37.8%)

Stroke 401 (27.4%)Transitory ischemic attack 273 (18.6%)

Non hemispheric symptoms 194 (13.3%)Amaurosis fugax 43 (2.9%)

Associated comorbidity and patient’s distribution according to American Society of Anesthesiologists (ASA) classification are presented in table 2.

313Carotid endarterectomy under cervical plexus block: a single center experience

Table 2. Associated comorbidity and ASA classification

Concomitant diseases No (%)

Arterial hypertension

Coronary artery disease

Congestive heart failure

Chronic obstructive pulmonary disease

Diabetes mellitus

Renal disease

1326 (90.6%)

606 (41.4%)

187 (12.8%)

147 (10%)

462 (31.5%)

79 (5.4%)

ASA status No (%)

II

III

IV

527 (36%)

746 (51%)

191 (13%)

During the procedure the need for intraluminal shunt insertion was estimated upon awake neurologic testing following carotid cross clamping (CCC). No additional neurologic monitoring procedures were performed.

ResultsEversion endarterectomy was performed in 71% of patients, conventional endar-

terectomy with the use of patch in 14.7%, graft interposition was done in 6% and some other kind of procedure in 8% of patients. Mean duration of surgery was 90 minutes (30-210) and mean CCC time was 17 min. (6-70). Awake neurologic testing ordered the use of intraluminal shunt in 138 cases (9.4%). Conversion from CPB to GA was performed in 17 pts (1.2%). Reasons for conversion are presented in table 3.

Table 3. Reasons for conversion from CPB to GA

Myocardial infarction

5.9%

Discomfort/Restlessness

5.9%

CPB failure 17.6%

Toxic effect of LA 23.5%

Neurologicdeterioration

47.1%


Final outcomes of surgical procedures are presented in table 4.

Table 4. Final outcomes of surgery

Outcome Number (%)

Transferred to ICU

Transferred to ward

161 (11%)

1303 (89%)

In-hospital major adverse eventsStroke 34 (2,3%)

MI 8 (0,5%)

Overall in-hospital mortality rate

8/1464 procedures

(1305 patients)

= 0,54 %

DiscussionCEA under GA requires neurologic monitoring during carotid cross clamping

unless unselective shunting is performed. However shunt insertion carries the risk of potential complications (e.g. arterial dissection, distal embolization). Intraoperative cerebral monitoring methods such as electroencephalogram (EEG), transcranial dop-pler (TCD) or retrograde carotid stump pressure (RCSP) are costly and oversensitive methods referring to shunt insertion rate up to 70%. On the opposite, simple awake testing under CPB requires no additional monitoring and reduces the shunt insertion rate to 5-21% [6]. Since routine use of CPB was introduced in our institution, the need for intraluminal shunting decreased from 38% to 9.4% (Table 5).

Table 5. The incidence of intraluminal carotid shunting at the Clinic for vascular and endo-vascular surgery of the Serbian clinical center

Although the largest multicenter prospective randomized trial failed to prove significant advantage of any surgical technique, the most recent meta-analysis of randomized and non-randomized studies presented significant superiority of eversion

315Carotid endarterectomy under cervical plexus block: a single center experience

endarterectomy over conventional procedure [5,7]. In Serbia, eversion technique is routinely employed in two largest vascular centers for more than ten years with sati-sfying results [8-10]. Eversion endarterectomy can be challenging in patients presen-ting carotid cross-clamping intolerance that requires intraluminal shunting; in those circumstances we usually proceed with conventional procedure instead of eversion. Potentional drawbacks for eversion endarterectomy can also be the the presence of extensive cephalad plaque or recurrent carotid stenosis. However, certain authors use eversion technique even over introduced carotid shunt with very good results [11,12].

According to published data and our personal experience, relying on the outcome of awake testing following carotid cross clamping the use of regional anesthesia reduces the incidence of intraluminal shunting to 9-15%. Therefore the vast majority of procedures can be performed with eversion endarterectomy making whole proce-dure simpler and quicker than conventional operation, without use of disposals such as carotid patch and shunt. Most patients skip intensive unit care stay and can be discharged from hospital on second postoperative day. In addition there is no need for expensive and oversensitive neurologic monitoring (EEG, TCD, and RCSP). For these reasons this strategy can result in significant cost savings as well and therefore be very attractive for developing countries [13,14]. Besides, CPB is more appropriate in patients with significant cardiovascular comorbidity and certain disadvantages of GA can be omitted (endotracheal intubation in patients with chronic obstructive pulmona-ry disease, sore throat, nausea etc.). According to our institutional experience, CPB enables better cerebral blood flow autoregulation in the perioperative period [15,16].

There is still no consensus about the operative strategy in combined carotid and coronary surgical procedures. In most centers they are performed under the GA, however staged anesthesia (carotid operation under the regional anesthesia first, and then GA for coronary surgery) seems to be rational alternative [17]. If the GA is utilized from the beginning of combined procedure, eventual undetected neurologic complications following carotid operation can be worsened by cardio-pulmonary bypass. Yet, there are no published randomized studies regarding this issue.

A fair question can be raised about the patient’s personal satisfaction regarding the operation under the regional anesthesia as there is always possibility of unexpected discomfort, pain and anxiety. However published data reports high level of patients satisfaction regardless of anesthesiologic technique applied [18,19]. Eventual insuffi-cient perioperative pain control and complications related to CPB decrease the level of patient’s satisfaction with regional anesthesia [20].

Conclusion CAE under the CPB presents as safe and highly successful procedure. It makes

costly neurologic perioperative monitoring unnecessary and enables faster recovery and discharge of patients. Eversion CEA surgical technique performed under the CPB can present significant cost benefit.

Acknowledgements

This work was supported by Ministry of Education and Science, Republic of Serbia (grants ON175008 and III41007).


REFERENCES1. Eastcott HHG, Pickering GW, Robb CG. Reconstruction of internal carotid artery in a

patient with intermittent attacks of hemiplegia. Lancet 1954; 2:994-6.2. Wells BA, Keats AS, Cooley DA. Increased tolerance to cerebral ischemia produced by

general anesthesia during temporary carotid occlusion. Surgery 1963; 54:216-23.3. Stoneham MD, Knighton JD. Regional anaesthesia for carotid endarterectomy. Br J Anaesth

1999; 82:910-19.4. GALA Trial Collaborative Group, Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell

PM et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre randomised controlled trial. Lancet 2009; 372:2132–42.

5. Cao P, Giordano P, De Rango P, et al. Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial. J Vasc Surg 2000; 31:19-30.

6. McCleary AJ, Maritati G, Gough MJ. Carotid endarterectomy; local or general anaesthesia? Eur J Vasc Endovasc Surg 2001; 22:1-12.

7. Antonopoulos CN, Kakisis JD, Sergentanis TN, Liapis CD. Eversion versus conventional carotid endarterectomy: a meta analysis of randomized and non-randomized studies. Eur J Vasc Endovasc Surg 2011; 42:751-65.

8. Radak D, Ilijevski N, Nenezic D, et al. Temporal trends in eversion carotid endarterectomy for carotid athetrosclerosis: single-centre experience with 5,034 patients. Vascular 2007; 15:205-10.

9. Markovic D, Davidovic L, Maksimovic Z, Kuzmanovic I, Ilic N. Comparative analysis of conventional and eversion carotid endarterectomy – prospective randomized study. Srp Arh Celok Lek 2008; 136:590-7.

10. Radak D, Davidovic L. Why carotid endarterectomy is method of choice in treatment of carotid stenosis. Srp Arh Celok Lek 2008; 136 Suppl 2:181-6.

11. Shah DM, Darling RC, Chang BB, et al. Carotid endarterectomy by eversion technique – its safety and durability. Ann Surg 1998; 228:471-8.

12. Reigner B, Reveilleau P, Gayral M, Papon X, Enon B, Chevalier JM. Eversion endarterec-tomy of the internal carotid artery: mid-term results of a new technique. Ann Vasc Surg 1995; 9:141-246.

13. Gomes M, Soares MO, Dumville JC, et al. Cost-effectiveness analysis of general anaesthesia versus local anaesthesia for carotid surgery (GALA trial). Br J Surg 2010; 97:1218-25.

14. Hariharan S, Naraynsingh V, Esack A, et al. Perioperative outcome of carotid endarte-rectomy with regional anesthesia: two decades of experience from the Carribean. J Clin Anesth 2010; 22:169-73.

15. Sindelic R, Vlajkovic G, Davidovic L, Vujanac B, Vjestica M. Comparison of the influen-ce of general and regional anesthesia on basic haemodynamic parameters during carotid endarterectomy. Acta Chir Iugosl. 2004; 51:37-43.

16. Sindjelic RP, Vlajkovic GP, Davidovic LB, Markovic DZ, Markovic MD. The addition of fentanyl to local anesthetics affects the quality and duration of cervical plexus block: a randomized, controlled trial. Anesth Analg. 2010; 111:234-7.

17. Madi-Jebara S, Yazigi A, Sleilaty G, et al. Staged anesthesia for combined carotid and co-ronary artery revascularization: a different approach. J Cardiothor Vasc An 2006; 20:803-6.

18. Quigley TM, Ryan WR, Morgan S. Patient satisfaction after carotid endarterectomy using a selective policy of local anesthesia. Am J Surg 2000; 179:382-5.

19. J McCarthy R, Trigg R, John C, Gough MJ, Horrocks M. Patient satisfaction for carotid endarterectomy performed under local anaesthesia. Eur J Vasc Endovasc Surg 2004; 27:654-9.

20. Attigah N, Kutter J, Demirel S, et al. Assessment of patients’ satisfaction in carotid surgery under local anaesthesia by psychometrical testing - a prospective cohort study. Eur J Vasc Endovasc Surg 2011; 41:76-82.

http://www.ncbi.nlm.nih.gov/pubmed/13999872





Management of patients with polyvascular diseasePoredos P., Jezovnik M.K.

University Medical Centre Ljubljana, Department of Vascular Disease, Zaloska 7, 1000 Ljubljana, Slovenia

Introduction Atherosclerosis is considered as a systemic disease which can affect any part of the

arterial circulation. Therefore, patients with proven atherosclerotic disease are likely to have atherosclerotic lesions in other vascular beds. With the progression of atheroscle-rosis more and more vascular segments are affected and the prognosis is worsening. There are many epidemiological data which confirmed the interrelationship between atherosclerotic diseases in different territories. Overlapping was shown in symptomatic as well as in asymptomatic atherosclerotic diseases [1,8]. With the progression of proven atherosclerotic disease the prevalence of other atherosclerotic diseases is increasing. It was shown that in patients with mild claudication the prevalence of coronary heart disease (CHD) accounts about 15% and in patients with critical limb ischemia the prevalence of CHD is about 90%. However, the coincidence of atherosclerotic diseases e.g. periph-eral arterial disease (PAD) and CHD depends on diagnostic test used for identification of different atherosclerotic diseases. Dormandy showed that in case if only history and EKG are used, the prevalence of CHD in PAD patients is between 20 and 50%. If stress test or angiography were included in diagnostic procedures the coincidence of PAD and CHD was found in 60 – 90% [2]. Cardiovascular events depend on the progression of the atherosclerotic process and it’s widespread. REACH registry showed that the prevalence of cardiovascular events is strongly associated with the number of affected vascular beds and the incidence of cardiovascular death, non-fatal myocardial infarction and non-fatal stroke is highest in subjects with the presence of atherosclerotic lesions in three vascular territories [10]. The data from REACH registry also showed that one year cardiovascular outcome among patients with established atherosclerotic disease are dependent on the number of the affected arterial segments. It was shown that the risk of all-cause mortality in patients with single disease bed is 2.45 and in patients with polyvascular disease 4.08 [9]. The widespread of atherosclerotic disease influences postoperative mortality after the major vascular surgical procedures. Kuijk with co-workers that all-cause mortality is 2-3 times higher in subjects with the affected three vascular beds in comparison to single atherosclerotic disease [12].

318 Poredos P., Jezovnik M.K.

Diagnostic access to the patient with polyvascular atherosclerotic diseaseAs atherosclerosis is a systemic disease a systemic - global investigation is needed.

However, systemic or whole body diagnostic procedures are time-consuming, expensi-ve and some of them related to complications. Therefore, cost-benefit considerations have to be taken into account. Modern imaging techniques like magnetic resonance arteriography (MRA), computer tomography (CT) are expensive, some of them rela-ted to radiation and contrast complications. Ultrasound as the friendliest diagnostic procedure is accompanied by limited accessibility and is sometimes time consuming.

Suggested basic investigations in suspicion of different atherosclerotic diseasesPeripheral arterial disease (PAD)

– diagnostic techniques for the identification of peripheral arterial lesions (Doppler ankle brachial pressure index– ABI, ultrasound, angiography)

– identification of atherosclerotic lesions in other vascular beds (EKG, stress test?, myocardial scintigraphy?, carotid ultrasound ?)

– abdominal ultrasound for the detection of abdominal aortic aneurysm

Coronary heart disease (CHD)– identification of coronary lesions (EKG, stress test, cardiac catheterisation?)– atherosclerotic lesions in other vascular beds (ABI, carotid ultrasound)

Cerebrovascular disease (CVD)– identification of carotid lesions (ultrasound, angiography)– other atherosclerotic diseases (EKG, ABI).The diagnostic algorithm and the suggested investigations are different in different

patient populations and depend on the clinical symptomatology and widespread of proven atherosclerotic disease.

Treatment of patients with polyvascular diseaseThe basis of management of patients with atherosclerotic disease is the management

of risk factors for atherosclerosis and in patients with advanced stenotic atherosclerotic lesions also revascularisation procedures are needed. The presence of risk factors of atherosclerosis is similar or identical in different atherosclerotic diseases. However, the influence of different risk factors differs in different vascular territories. The data indicates that the strongest risk factor for CHD is hypercholesterolemia. Hyperten-sion is probably most important in the development of the cerebrovascular disease and smoking is most significantly involved in the development of PAD. Also in the development of atherosclerotic abdominal aneurysm is smoking besides hypertension the most important risk factor in its ethiopathogenesis.

The efficacy of drugs used for the prevention of atherosclerosis in different arterial territories is mostly comparable however there are some differences in the efficacy of most frequently used drugs for the prevention of different atherosclerotic diseases. The Trialists’ meta-analysis showed that antiplatelet drugs are most effective in coro-

319Management of patients with polyvascular disease

nary bed, particularly in patients with unstable angina pectoris in whom a relative risk reduction is significantly higher than in patients with ischemic stroke, PAD or stable angina pectoris [11]. There are also differences in the efficacy of different antiplatelet drugs. As it was shown in CAPRIE study clopidogrel most effectively prevents cardiovascular events in patients with PAD [1]. In PAD subgroup of pa-tients’ clopidogrel in comparison to aspirin resulted in 23.8% relative risk reduction of cardiovascular events.

Statins are most frequently used drugs in the prevention of atherosclerosis and related cardiovascular complications. It was shown that each reduction of LDL cholesterol for 1% is related to 2% risk reduction for cardiovascular events [6]. Heart protection study -HPS and meta-analyses showed that statins are effective in the prevention of cardiovascular events not only in patients with coronary artery disease but also in PAD patients and patients with CVD [3,4] and that the effect is comparable between different patient groups and accounts between 22 – 25%. Further, it was shown that in some vascular beds, statins may have additional - pleiotropic effects. Treatment of PAD patients with statins improved pain free walking distance and quality of life [7].

Also the inhibitors of the angiotensin – converting enzyme (ACE inhibitors) were shown to be effective in the prevention of cardiovascular events in different atherosclerotic diseases. Subgroup analysis of HOPE study indicated that the absolute benefit of the ramipril treatment depends on the total risk and the extension of the atherosclerosis and is subjects with symptomatic or asymptomatic PAD (ABI < 0.90) twice as large in comparison to those with normal ABI [13].

Revascularisation procedures in polyvascular patientsPolyvascular patients are at higher risk for intraoperative and postoperative com-

plications and have higher postoperative mortality rate. Jeremias with co-workers showed that in patients with acute myocardial infarction (AMI) and PAD the major cardiovascular events as well as the mortality rate were three times higher than in group of patients with AMI only. Therefore, PAD was independently associated with increased in-hospital mortality [5].

One of the crucial questions is the priority of revascularisation procedures in patients with polyvascular disease. Revascularisation should be first performed in vascular bed or organ with life treating symptomatology or hybrid procedures with simultaneous operation in different regions should be performed.

ConclusionsAtherosclerosis is a systemic disease which simultaneously or successively affects

different territories of the arterial system. Polyvascular atherosclerotic disease is rela-ted to increased morbidity and mortality. However, the importance of the individual risk factor may differ from vascular bed or on the location of the atherosclerosis. Management of patients with polyvascular disease is based on the prevention and elimination of risk factors of atherosclerosis. In the development of the atherosclerotic diseases in different vascular territories similar or identical risk factors are involved. In spite of that in patients with polyvascular disease the same preventive measures and medications are used, but polyvascular patients would need more intensive ma-nagement of risk factors than patients with a single vascular disease. Prevention of

320 Poredos P., Jezovnik M.K.

cardiovascular events in polyvascular patients should include combination of drugs with proven efficacy.

In patients with polyvascular disease the revascularisation procedures are accom-panied by high operative and postoperative morbidity and mortality. Revascularisation should be first performed in organ with the most life treating symptomatology. There are two options for revascularisation in two or more vascular territories: successive access or simultaneous – hybrid surgical procedures.

References1. Committee C.S. A randomised, blinded, trial of clopidogrel versus aspirin in patients at

risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 348(9038):1329-1339, 1996.

2. Dormandy J., Mahir M., Ascady G., Balsano F., De Leeuw P., Blombery P., Bousser M.G., Clement D., Coffman J. and Deutshinoff A. Fate of the patient with chronic leg ischaemia. A review article. J Cardiovasc Surg (Torino) 30(1):50-57, 1989.

3. Group H.P.S.C. MRC/BHF Heart Protection Study of antioxidant vitamin supplementation in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 360(9326):23-33, 2002.

4. Group H.P.S.C. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 360(9326):7-22, 2002.

5. Jeremias A., Gruberg L., Patel J., Connors G. and Brown D.L. Effect of peripheral arterial disease on in-hospital outcomes after primary percutaneous coronary intervention for acute myocardial infarction. Am J Cardiol 105(9):1268-1271, 2010.

6. Kastelein J.J. The future of best practice. Atherosclerosis 143 Suppl 1:S17-21, 1999.7. Mondillo S., Ballo P., Barbati R., Guerrini F., Ammaturo T., Agricola E., Pastore M.,

Borrello F., Belcastro M., Picchi A. and Nami R. Effects of simvastatin on walking per-formance and symptoms of intermittent claudication in hypercholesterolemic patients with peripheral vascular disease. Am J Med 114(5):359-364, 2003.

8. Poredos P. and Jug B. The prevalence of peripheral arterial disease in high risk subjects and coronary or cerebrovascular patients. Angiology 58(3):309-315, 2007.

9. Steg P.G., Bhatt D.L., Wilson P.W., D’Agostino R., Ohman E.M., Röther J., Liau C.S., Hirsch A.T., Mas J.L., Ikeda Y., Pencina M.J., Goto S. and Investigators R.R. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA 297(11):1197-1206, 2007.

10. Suárez C., Zeymer U., Limbourg T., Baumgartner I., Cacoub P., Poldermans D., Röther J., Bhatt D.L., Steg P.G. and Investigators R.R. Influence of polyvascular disease on cardiovascular event rates. Insights from the REACH Registry. Vasc Med 15(4):259-265, 2010.

11. Tran H. and Anand S.S. Oral antiplatelet therapy in cerebrovascular disease, coronary artery disease, and peripheral arterial disease. JAMA 292(15):1867-1874, 2004.

12. van Kuijk J.P., Flu W.J., Welten G.M., Hoeks S.E., Chonchol M., Vidakovic R., Verhagen H.J., Bax J.J. and Poldermans D. Long-term prognosis of patients with peripheral arterial disease with or without polyvascular atherosclerotic disease. Eur Heart J 31(8):992-999, 2010.

13. Yusuf S., Sleight P., Pogue J., Bosch J., Davies R. and Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 342(3):145-153, 2000.



Peripheral Artery Disease - indicator of systemic atherosclerosisPoredos P.

University Medical Centre Ljubljana, Department of Vascular Disease, Zaloska 7, 1000 Ljubljana, Slovenia

IntroductionAtherosclerosis is considered a systemic (generalized) disease. Namely, patients with

proven atherosclerotic disease are likely to have similar or identical atherosclerotic lesions in other vascular beds. Further, different atherosclerotic diseases (coronary, peripheral or cerebrovascular) have similar or identical ethiopathogenesis and the development of atherosclerotic cardiovascular complications is related to similar risk factors of atherosclerosis. The overlapping between different atherosclerotic diseases was confirmed in epidemiologic and interventional studies 1, 2. About one third of patients with peripheral artery disease (PAD) have clinically manifest coronary and/or cerebrovascular disease and most of them preclinical atherosclerotic lesions in other vascular beds.

Peripheral arteries are an important indicator of atherosclerosis. Because of their easy accessibility for diagnostic investigation peripheral arteries can be used as a surrogate marker and a “window” to the systemic atherosclerotic disease.

PAD - indicator of risk for cardiovascular morbidity and mortalityPatients with PAD generally have widespread atherosclerotic diseases and PAD is

indicator of diffused and advanced atherosclerosis. At least 20% of patients with PAD have cerebrovascular disease and 28% coronary heart disease 3. Dormandy showed that PAD itself is because of the local problems not very serious disease, namely, only in 2 % of patients with intermittent claudication in five years amputation of the diseased leg is needed. However, mortality of these patients is very high (30% in 5 years and 70% in 15 years) because of accompanied cerebrovascular and cardiovascular diseases 4. Regardless whether PAD is symptomatic or asymptomatic, PAD patients are 6-times more likely to die in 10 years in comparison to subjects without PAD. It was also shown that preclinical peripheral atherosclerosis - pathological ankle brachial pressure index (ABI < 0.90) represents high risk for cardiovascular morbidity and

322 Poredos P.

mortality and that with the progression of PAD, the risk is exponentially increasing and is in the subjects with critical limb ischaemia 3 - 4 times higher than in patients with early stages of the disease.

The detection of PAD is based on simple diagnostic procedures.Ankle brachial index (ABI) represents a basic screening procedure which is non-

invasive, simple and inexpensive. Ankle brachial index is not used only for the detec-tion of local - peripheral disease, but is a very useful risk assessment tool. Decreased ABI, including borderline values (0.90) is related to increased risk of cardiovascular events 5, 6. It was shown that an ABI < 0.90 predicts all cause mortality with a rela-tive risk ratio of 3.8. Further, it was shown that ABI < 0.60 indicates generalised atherosclerotic process and is related to very high mortality - 10 years survival is < 50% 7. Analysis of the relationship between ABI and risk of cardiovascular events and death showed that each decrease of ABI for 0.1 is related to 10.2 % increased risk for cardiovascular events and death in 5 years.

PAD and coronary artery diseaseRecent studies showed that the rate of morbidity and mortality from coronary heart

disease is in patients with PAD significantly higher than in subjects without PAD 8. Patients with PAD also have more widespread coronary atherosclerosis 9. The sever-ity of coronary atherosclerosis progresses with the severity of PAD 8. In the SPRINT study it was shown that patients with acute myocardial infarction and concomitant PAD have significantly more frequent paroxysmal atrial fibrillation, cardiogenic shock and atrial-ventricular block than those coronary patients without PAD.

PAD and carotid atherosclerosisIn the Second Manifestation of ARTerial disease (SMART) it was shown that

the prevalence of internal carotid atherosclerosis increases to as much as 50 % in patients who have PAD and additional risk indicators, like age over 67 years and pulse pressure above 74 mmHg 10. The prevalence of cerebrovascular disease was in symptomatic as well as in asymptomatic PAD patients significantly higher than in subjects without PAD 11. Pathological ABI was also shown to be related to intima media thickness (IMT) as an indicator of preclinical atherosclerosis. Individuals with ABI < 0.90 had significantly greater IMT than those with normal ABI. Individuals with ABI < 0.90 were twice as likely to have asymptomatic plaques in comparison to healthy subjects 6. Similarly in Rotterdam study significant inversed association between common carotid IMT and ABI was demonstrated. An increase of IMT for 0.1 mm was associated with the reduction of the ABI of 0.026 12. Also in one of our studies a significant inverse interrelationship between ankle brachial pressure index and IMT of carotid arteries was indicated 13. In this study most of PAD patients (73 %) had clinically manifest or preclinical atherosclerotic lesions (increased IMT and more atherosclerotic plaques in internal carotid arteries).

323Peripheral Artery Disease - indicator of systemic atherosclerosis

ConclusionsAtherosclerosis is a systemic disease and usually simultaneously or successively

affects different territories of arterial circulatory system. Peripheral arterial atheroscle-rotic disease is an example of atherosclerotic manifestation with easy accessibility and identification. Therefore, peripheral arteries represent surrogate marker and window to the whole circulatory system and to identification of atherosclerosis as general disease. PAD is closely related to coronary and carotid atherosclerosis. Further, PAD is a ma-nifestation of diffuse and disseminated disease. Symptomatic as well as asymptomatic PAD is associated with an increased risk of cardiovascular complications including myocardial infarction and stroke. The detection of PAD is based on simple non-invasive and inexpensive diagnostic procedures. Basic screening test is ankle brachial index (ABI), which is not only diagnostic tool for identification of PAD but is an indicator of generalised atherosclerosis and independent predictor of cardiovascular morbidity and mortality. Therefore, screening of PAD using ABI should be performed in subjects with high total risk and in patients with different atherosclerotic disease. Detection of preclinical or clinical PAD enables identification of subjects at highest risk, who need more aggressive management of risk factors of atherosclerosis.

References

1. Poredos P, Jug B. The prevalence of peripheral arterial disease in high risk subjects and coronary or cerebrovascular patients. Angiology 2007;58(3):309-15.

2. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee. Lancet 1996;348(9038):1329-39.

3. Vogt MT, Wolfson SK, Kuller LH. Lower extremity arterial disease and the aging process: a review. J Clin Epidemiol 1992;45(5):529-42.

4. Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC). J Vasc Surg 2000;31(1 Pt 2):S1-S296.

5. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA 1991;265(24):3255-64.

6. Zheng ZJ, Sharrett AR, Chambless LE, Rosamond WD, Nieto FJ, Sheps DS, et al. Asso-ciations of ankle-brachial index with clinical coronary heart disease, stroke and preclinical carotid and popliteal atherosclerosis: the Atherosclerosis Risk in Communities (ARIC) Study. Atherosclerosis 1997;131(1):115-25.

7. Fowkes FG, Murray GD, Butcher I, Heald CL, Lee RJ, Chambless LE, et al. Ankle bra-chial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA 2008;300(2):197-208.

8. Criqui MH, Denenberg JO. The generalized nature of atherosclerosis: how peripheral arterial disease may predict adverse events from coronary artery disease. Vasc Med 1998;3(3):241-5.

9. Hussein AA, Uno K, Wolski K, Kapadia S, Schoenhagen P, Tuzcu EM, et al. Peripheral arterial disease and progression of coronary atherosclerosis. J Am Coll Cardiol;57(10):1220-5.

10. Simons PC, Algra A, Eikelboom BC, Grobbee DE, van der Graaf Y. Carotid artery stenosis in patients with peripheral arterial disease: the SMART study. SMART study group. J Vasc Surg 1999;30(3):519-25.

324 Poredos P.

11. Hooi JD, Stoffers HE, Kester AD, Rinkens PE, Kaiser V, van Ree JW, et al. Risk factors and cardiovascular diseases associated with asymptomatic peripheral arterial occlusive disease. The Limburg PAOD Study. Peripheral Arterial Occlusive Disease. Scand J Prim Health Care 1998;16(3):177-82.

12. Bots ML, Hofman A, Grobbee DE. Common carotid intima-media thickness and lower extremity arterial atherosclerosis. The Rotterdam Study. Arterioscler Thromb 1994;14(12):1885-91.

13. Poredos P. Endothelial dysfunction in the pathogenesis of atherosclerosis. Int Angiol 2002;21(2):109-16.



Asymptomatic Carotid artery stenosis. CEA or CAS? Work in progressLa Barbera G., Vallone M.*, Ferro G., Valentino F., Parsaei D.M., Cassaro L., Filippone G., Talarico F.

Vascular Surgery Unit – Benfratelli Civic Hospital – Palermo (Italy). Chief: Prof. F. Talarico *Interventional Radiology Section – Benfratelli Civic Hospital – Palermo (Italy)

IntroductionIn the last years the endovascular revasculation with stent of the carotid stenosis

(CAS) has been on the increase. The rates of the CAS, with neurological protec-tion, in the group of patients with high surgical risk, are expected to be comparable to the Carotid EndoArterectomy (CEA) (1,9). On the other hand various trials, in symptomatic patients, proved the incidence of an higher periprocedural risk in CAS (7,8). Many scientific societies according to the recent elaboration of the guide-lines for the treatment of carotid stenosis don’t demonstrate univocity about the indications to the CEA or CAS in symptomatic and asymptomatic patients (2-6). An ongoing heavy debate concerne the endovascular or surgical treatment, given that 2/3 of ca-rotid stenosis are asymptomatic and that the indications to the revascularization of the asympto-matic carotid is related to variables such as gender and life expectancy. Nowadays the carotid revasculation with PTA + stent is indicated for selected cases, in high volume patients centers. The Authors show their past and current results in surgical and endovascular asym-ptomatic ICA revascularization.

Materials and methodsFrom January 2006 to December 2011, 356 Internal Carotid Artery (ICA) revasculariza-

tions have been done. We compared the group of 131 asymptomatic ICA (89 men-42 women) with the group of 225 symptomatic ICA (156 men- 69 women) in relation to the incidence of the following pre-operative variables : 30-d mortality and Myocardial Infarction (MI) . As next step we focused on the 131 asymptomatic ICA: we compared the Group 1 (PTA + Stent) 37 ICA, with the Group 2 (CEA) 94 ICA, considering as 30-day po-stoperative end-point, the rate of neurological freedom in function of the preoperative variables. During the 6 years FU and 40- months mean FU we evaluated the survival, restenosis and the stroke freedom rate.

326 La Barbera G., Vallone M., Ferro G., Valentino F., Parsaei D.M., Cassaro L., Filippone G., Talarico F.

ResultsTwo patients / 225 symptomatic had postoperative MI (0.8%) and one of them

died (0.4%), while there were no deaths and MI in the group of 131 asymptomatic patients. Among asymptomatic pts, the Group 1 average age, was significantly higher (75 vs 68.8 aa; p<.0005), than Group 2. Tab 1 compares the incidence of the preo-perative clinic variables on the amount of 356 ICA by distinguishing asymptomatic and the symptomatic patients. Tab 2 compares Group 1 with Group 2 showing the postoperative neurological freedom rate in function of the examined clinical variables:

Tab. 1: Preoperative clinical variables distribution in asymptomatic and symptomatic ICA(CAB: Coronary Artery Bypass)

Asymptomatic ICA Symptomatic ICA pAge = > 75 aa 44/131 (34%) 8/225 (37%) .5Associated Disease 51/131 (39%) 104/225 (46%) .1+ Brain CT 26/131 (20%) 95/225 (42) .05Men 89/131 (68%) 156/225 (69%) .7CAB 12/131 (9%) 9/225 (4%) .05MI 26/131 (20%) 47/225 (21%) .8Opposite ICA lesion 36/131 (27%) 69/225 (31%) .5Opposite ICA Stenosis 21/131 (16%) 58/225 (26%) .03Opposite ICA Occlusion 15/131 (11%) 12/225 (5%) .04Calcium Plaque 81/131 (62%) 138/225 (61%) .9’06 – ‘08 41/131 (31%) 102/225 (45%) .009’09 – ‘11 90/131 (69%) 123/225 (55%)

ConclusionsThe clinical trials and the guidelines have not the same approach about the

indication to the revasculation of asymptomatic ICA stenosis (2-6) so far. In our experience, 2 out 225 symptomatic pts reported a post-operative MI and 1 of them died, so comparing with the 131 asymptomatic patients we reported a postoperative cardiac morbility and mortality rate, respectively, of 0.8% e 0.4% versus 0% e 0%, with 0,3% total mortality rate on 356 patients. These better results in asymptomatic patients are in line with those that are reported in the CREST study where distin-guishing 1181 asymptomatic patients and 1321 symptomatic patients, the cumulative post-operative rate of stroke + IMA + Exitus was respectively 3.5% vs 6% (9), even though its necessary to observe that the study does not represent a sufficient power to compare the subgroup of 1181 asymptomatic pts (10) . Focusing on the influence of pre-operative clinical variables (Tab. 1) we can note that asymptomatic ICA have an important lower percentage of positive brain CT (20% vs 42%), no matter the side, as a mark of a reduced embolic risk of opposite ICA stenosis (16% vs 26%) allowing a better cerebral perfusion (Figure 1), and are less frequent in the first period of our study 2006 – 2008 (31% vs 45%) showing the learning curve improvement (10-12). Furthermore asymptomatics ICA have a higher percentage of past BAC (9%

327Asymptomatic Carotid artery stenosis. CEA or CAS? Work in progress

vs 4%) supporting the cardiac disease correlation and have a higher percentage of occlusions of the opposite ICA (11% vs 5%), probably reducing the embolic stroke risk of the opposite stenosis.

Tab. 2: Postoperative neurologic freedom in Group 1 and Group 2 asymptomatic ICA (PTCA: percutaneous transluminal coronary angioplasty; CAB: coronary artery bypass)

Postoperative Neurologic Freedom

Group 1 CAS p Group 2 TEA pAge = > 75 aa 18/20 (90%) .1 24/24 (100%) .3Age < 75 aa 17/17 (100%) 67/70 (96%)Associated Disease 15/15 (100%) .2 35/36 (97%) .8NO 20/22 (91%) 56/68 (97%)+ Brain CT 10/10 (100%) .3 60/62 (97%) .9- Brain CT 25/27 (93%) 31/32 (97%)Men 26/27 (96%) .4 60/62 (97%) .9Women 9/10 (90%) 31/32 (97%)PTCA / CAB 4/6 (90%) .001 17/18 (95%) .5NO 31/31 (100%) 74/76 (98%)Opposite lCA Lesion 9/10 (90%) .4 26/26 (100%) .2NO 26/27 (97%) 65/68 (96%)Opposite ICA Stenosis 5/5 (100%) .5 16/16 (100%) .4NO 30/32 (94%) 75/78 (97%)Opposite ICA Occlusion 4/5 (80%) .1 10/10 (100%) .5NO 31/32 (97%) 81/84 (97%)Calcium Plaque 28/30 (93%) .4 50/51 (98%) .4NO 7/7 (100%) 41/43 (95%)2006 – 2008 7/8 (87%) .3 32/33 (97%) .92009 - 2011 28/29 (97%) 59/61 (97%)

Tab. 2 shows post-operative neurological freedom in asymptomatic patients. Pa-tients who were previously treated with PTCA/BAC have significantly worse results in the CAS group (90% vs 100%, p <.001) than CEA group (95% vs 98%, p ns), probably because the presence of coronary disease is responsable of worse cardiac cinesis, and negative hemodynamic factors, affecting the neurological postoperative course in CAS. On the contrary the CREST study shows an higher risk of post operative MI (2.3% vs 1.1%, p<.03) in the CEA group demostrating anyway the importance of the coronary disease as indicator of cardiac mortality (10). Besides, in CAS group, we observed better results, even though not statistically relevant, in patients with age =< a 75 aa (100% vs 90%), probably because a lower athesclero-tic involvement of the cerebral district, in patients with patent opposite ICA (97% vs 80%), allowing an efficient hemodynamic supply, and in the second period of our experience (2009 – 2011) as mark of skinless improvement (Figure 2) (10-12). In the 40 months mean FU we achieved an actuarial survival, restenosis, and stro-ke freedom rate, respectively of 97% in the group 1, and of 96% in the group 2. In conclusion, our experience, even if on a small number of patients, is promising,


but because the variety of orientations evidenced by the different Guidelines, up-to-date there aren’t concluding data about the indication of CEA or CAS treatment in asymptomatic ICA stenosis, even in the light of a more effective medical therapy. We are waiting for the results of the ongoing ACT I study, selectively focused on asymptomatic ICA (14). Until then, the treatment of the asymptomatic carotid ste-nosis must be performed in in high volume patients centers with low postoperative morbidity/mortality rate.

Figure 1: Eversion CEA of an amorphous shaggy atherosclerotic plaque at high risk of embolization

329Asymptomatic Carotid artery stenosis. CEA or CAS? Work in progress

Figure 2: (a) preoperative arteriography: bulbar carotid stenosis. (b) postoperative arteriography: efficient dilatation of the stenotic ICA after CAS.

References1) Yadav JS, Wholey MH, Kuntz RE, et al. Protecetd carotid-artery stentung versus endar-

terectomy in High risk patients. N Engl J med 2004;351:1493-501.2) Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, et al. 2011 ASA/

ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Associa-tion of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Neuro-Interventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation 2011; 124:e54-130.

3) Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK, et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg 2011;54:e1-e31.

4) Authors/Task Force Members, Tendera M, Aboyans V, Bartelink ML, Baumgartner I, Clément D, Collet JP, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J 2011;32:2851-906.


5) Carotid stenting guidelines committee: an intercollegiate committee of the RACP (AN-ZAN, CSANZ), RACS (ANZSVS) and RANZCR. Guidelines for patient selection and performance of carotid artery stenting. Int Med J 2011;41:344-7.

6) UK National Institute for Health and Clinical excellence carotid artery stent placement for asymptomatic carotid artery stenosis. 2011. Available at: http://www.nice.org.uk/nicemedia/live/13026/54241/54241.pdf. Accessed October 17, 2011.

7) International Carotid Stent Study investogators. Carotid artery stenting compared with en-darterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study: an interim analysis of a randomised controlled trial. Lancet 2010;375:985-97.

8) Carotid Stenting Trialists’ Collaboration. Short term outcome after stenting versus en-darterectomy for symptomatic carotid stenosis: a preplanned metanalysis of individual patients. www.thelancet.com Published on line September10, 2010 DOI:10.1016/S0140-6736(10)61009-4

9) Brott TG, Hobson RW, Howard G, Roubin GS, Clark WM, Brooks W, et al. Stenting versus endarterectomy for treatment of carotid – artery stenosis. N Engl J Med 2010;363:11-23.

10) Chaturvedi S, Wechsler R. Carotid revascularization strategies: the need for more data. Stroke 2012;43:929-930

11) George JC, White CJ. Carotid artery stenting. Lessons from CREST (Carotid Reva-scularization Endarterectomy versus Stenting Trial). JACC: Cardiovascular Intervenion 2010;9:988-990

12) Mas JL, Chatellier G, Beyssen B, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J med 2006;355:1660-71.

13) The SPACE Collaborative Group. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 2006;368:1239-47.

14) Blackshear JL, Cutlip DE, Roubin GS et al. Myocardial infarction after carotid stenting and endarterectomy: results from the carotid revascularization endarterectomy versus stenting trial. Circulation 2011;123:2571-2578.

http://www.thelancet.com

©2012 by MEDIMOND s.r.l. 331PX11C0004


Venous Valve Repair by OSES technique: results on 39 cases at 4 years f-uCamilli D.1, Camilli S.2

1. Vascular Surgery, Snt Andrea Hosp, La Sapienza University Medical School, Roma, Italy 2. Vascular Surgery, Private Office - via Lombardia 30, Roma, Italy (e-mail: [email protected])

AbstractVaricose veins (VVs) treatment comprises several techniques, most of them aiming

to destroy or ablate diseased veins. All of them show good results at short-term f-u, but an unresolved problem is the varicose recurrence at mid/long term f-u in a large number of cases. In this regard conservative rather than ablative strategy shows better results in the recent literature. Material and methods. An innovative conservative/restorative technique has been introduced in clinical practice, the venous stretching Valvuloplasty by OSES technique (V-OSES). The technique, by means of a traction action onto the inter-commissural diameter of an incompetent valve, may restore the valve function thus curing the reflux. A clinical series of 39 interventions in 38 patients is reported, 18 of them observed for more than 48 months. Results. In one patient, bilateral V-OSES onto femoral vein revealed full competence at every US-scanning, the last performed at 60th month f-u. In 35 out of 37 V-OSES onto saphenous terminal and/or pre-terminal valve, competence was recovered in 66%, improved in 26%, and unchanged in 8% at 1 mo. f-u; while in 73% - 15% - 12% respectively at 24 mo. f-u of 26 cases, and in 78% - 17% - 5% at the last f-u of 18 cases after 48 months. Conclusions. The clinical series show promising results in this widely spreading disease. The valve competence seems to get better over time; the reasons are unclear, but in some cases a saphenous diameter reduction was evident at mid-term f-u. A large trial is needed. The V-OSES might be a reasonable complement to the hemodynamic technique (e.g. CHIVA) and even the key for a new conservative strategy in VVs treatment.

Key words: valvuloplasty, valve incompetence, venous reflux, varicose veins, ve-nous insufficiency.

IntroductionIn the treatment of Chronic Venous Insufficiency (CVI) and Varicose Veins (VVs)

332 Camilli D., Camilli S.

we currently apply several ablative techniques on the Greater/Smaller Saphenous Vein (GSV/SSV). Meanwhile they show good results at short-term f-u, unfortunately at long-term f-u all of them show recurrent varices (ReVas) in a large number of cases. It depends on many factors, but the physiologic one is the GSV ablation “per se”. Actually we commonly ablate a GSV drainage conduit, being confident on the deep system compliance. Nevertheless this implicit presumption is not true in many cases on which the GSV ablation may overload a defective deep system thus developing collateral veins that easily become ReVas.

The conservative techniques have an hemodynamic approach and aim to minimize GSV loss (e.g. CHIVA strategy [1]). Although the data need further confirmation, some recent trials showed CHIVA strategy had halved the ReVas recurrence rate against GSV ablation [2,3].

The possibility of reparative/restorative techniques of venous valves (valvuloplasty) has also been demonstrated, some of them being more suitable for deep veins [4-6] while others for GSV [7-8]. Unfortunately these techniques didn’t spread; the reasons are several, but the most important is the lack of an easy and effective technique suitable for GSV, being competitive (in terms of costs, time consuming, results) against the ablative ones.

Recently, a new working concept and technique have been introduced in clinical practice: the stretching valvuloplasty [9-13]. We show the clinical and Ultrasound (US) results of this technique in a series of 39 interventions at 4 years f-u.

The working concept and the OSESTM medical deviceThe working concept is innovative; it aims to apply a traction force onto the

opposite inter-commissural walls, parallel to the cusp’s free edge. The effect is to give a new shape to the valve bulb; the traction force stretches the inter-commissural diameter so moving the valve cross-section from the substantially circular into an oval one. The results are that the cusp’s extra-length is retrieved, the coaptation is recovered, and the valve function is repaired [Fig. 1].

Fig. 1. A schematic drawing of the “working concept” of the venous stretching Valvuloplasty by OSES technique (V-OSES). The incompetent valve bulb (A) shows circular cross section and slackened cusps/lea-flets, involving valve reflux and incompetence. The correct placement of the OSESTM

(Oval Shaped External

Support) device and suture to the vein wall (a’, a”) move the valve to have an oval shaped cross section (B) by stretching action onto the inter-commissural diameter, thus retrieving the slackened cusps and finally restoring the valve competence. A proper over-sized device, as regard to the native diameter, acts like a spring of gentle action.

333Venous Valve Repair by OSES technique: results on 39 cases at 4 years f-u

To apply the traction force we use the OSESTM (Oval Shaped Extra-venous Support) medical device1. It looks like an oval metallic stent (NiTi material alloy) prepared for super-elastic performance and extreme flexibility; it acts as a spring of gentle action; it is suitable for superficial as well as deep venous system [Fig. 2-3]. The OSESTM device has to be surgically implanted around the incompetent valve; to give the traction effective, it must have an oversized diameter (mean about 30% more than native diameter) and needs being sutured to the vein wall in correspondence at the apices of the opposite commissures. The second model of OSESTM device may be useful for a contemporary repair of two near valves.

Fig. 2-3. The first (on the left) and second (on the right) model of OSESTM device. They are constituted by NiTi material alloy receiving thermal treatment for super-elastic performance as to work as a spring of gentle action. The second one is composed by two oval arches (A-B) which are the active elements; they are provided by multiple eyelets (c-c’, d-d’) for a better diametric compliance and easy suturing to vein wall. The two arches (A-B) are connected by a long element (e) giving longitudinal flexibility and compliance, while the tread (f) in the middle is a temporary means (useful for intra-operative valve wrapping) to be discarded soon after device placement and suture.

Material and MethodsBetween 2007 and 2012 a non-consecutive series of 38 patients, provided with

signed consent, underwent 39 operations as Valvuloplasty by OSES technique (V-OSES). Pre-operative full clinical and ultra-sound (US) examination showed valve incompetence and truncal reflux. One patient have had multi-recurrent varices on both legs (after bilateral VGS ablation and 5 previous re-interventions!) and were suffering bilateral severe primary deep venous insufficiency (PDVI), confirmed of 4th grade (according to Kistner) at descending venography; the patient underwent a bilateral V-OSES intervention onto femoral vein in different times. 37 patients were affected by primary VVs (classified CEAP: C2-C5); 9 males and 28 females of mean age 34 years old (range 24-55 y) received V-OSES intervention onto the terminal [Fig. 4] and/or pre-terminal GSV’s valve.

Inclusion criteria were: age < 60 y, clinical onset of VVs by < 10 y (except for the patient with PDVI), no history of phlebitis, US visibility and mobility of valve cusps. Exclusion criteria were: US frozen or prolapsed or asymmetric cusps.

All V-OSES interventions on saphenous system were carried out under local ana-

1 The OSES™ medical device is manufactured by Assut Europe SpA, Italy


esthesia setting, lasting a mean time of 18 minutes (range 10 to 39 min.). The valve to be cured had been visually identified in about 60% of cases (commonly revealed on the wall by a reversed V shape of commissures and inter-commissural darker shading), while in the others we were obliged to refer to pre-operative US measures.

Fig. 4. Intra-operative picture representing V-OSES intervention onto the GSV’s terminal valve.

All patients received associated interventions (e.g. selective ligation of incompe-tent tributaries, or VVs stub avulsion, or US-guided foam sclerotherapy), in the same surgical session or as outpatient at the scheduled f-u. None of them had antiplatelet or anticoagulant drugs.

ResultsVarious clinical and US examination were done as f-u. They showed the patient

suffering bilateral severe PDVI to have the treated valves competent at every f-u, the last at 60 months after intervention; nevertheless the patient slowly developed bilateral new but not severe ReVas, mostly dependent by superficial system ablation. Among the 35 out of 37 patients treated by V-OSES onto the terminal and/or pre-terminal valve, the f-u showed a recovered competence in 23 (66%), improved competence in 9 (26%), and not repaired valve in 3 (8%) at 1 mo. f-u; while in 19 (73%), 4 (15%) and 3 (12%) respectively at 24 mo. f-u of 26 cases, and in 14 (78%), 3 (17%) and 1 (5%) at the last f-u of 18 cases after 48 months [Fig. 5]. No patient suffered in-fection or device intolerance; nobody needed GSV ablative surgery in the f-u period; all have declared satisfaction as QoL after operation.

DiscussionThe V-OSES technique is easy to be carried out, not time consuming, safe, not

losing future therapeutical chance for both the patient and phlebologist. Moreover it mostly shows excellent or good results on valve competence, which are stable or even improving over time. This observation is unusual and unclear by now; it may follow the whole hemodynamic improvement, which is common after operation and

335Venous Valve Repair by OSES technique: results on 39 cases at 4 years f-u

partially dependant on associated intervention. In some cases a saphenous diameter reduction was evident at mid-term f-u.

Fig. 5. Diagrammatic representation of clinical results (%) of V-OSES intervention in the series of Patients after 1-24-48 months f-u (see the text).

The V-OSES technique is innovative because it aims to apply a traction force onto the valve wall by calibrated stretching of the intercommissural diameter thus fitting the cusp’s coaptation, meanwhile other external techniques apply a compressive force that narrows the valve resulting in uncertain and erratic cusp’s relocation; it is also interesting because easily applicable to GSV junction, where internal techniques are unsuitable.

US-visibility and leaflets mobility are crucial pre-conditions for patient eligibility to V-OSES; in some cases B-flow performance may be useful for valve diagnostics. Anyway a full preoperative examination is needed, including superficial and deep venous system. The drawing of an hemodynamic map is also very useful for a single case evaluation and a proper planning. The critical point of the V-OSES technique is the stitching of the device at the level of commissural apices, especially in case of difficult intra-operative visual characterization; in these cases, the US-measures for valve position and diameter are helpful.

A large trial is needed to compare this technique in face of others, ablative and conservative, in the treatment of VVs and CVI. Should the trial confirm the good results of this limited experience, we may suppose a spreading indication for eligibility: optimal in young patients, with a short history of primary VVs and with US visible and mobile valve leaflets; recommendable in case of secondary varices (e.g. in post-thrombotic patients, on which the varicogenesis is apart from constitutional factors but linked to superficial overload as a consequence of deep resistance); complemen-tary in all GSV’s conservative treatments (CHIVA, ASVAL [14], others) because the maintenance of SF junction implements the hemodynamic venous drainage meanwhile stops or at least reduces the junctional reflux.

ConclusionsThis V-OSES clinical experience seems promising. The technique is suitable for

both deep and superficial valve repair, especially in the first stage of VVs. It seems


to be safe and effective; moreover it is reasonably adequate to perform the GSV junctional valvuloplasty. We need a large trial to confirm it.

The V-OSES technique spreading should improve the results of the conservative techniques and may lead to a more GSVs sparing and even become the key for a new conservative strategy in VVs treatment. We are convinced that a more functional, hemodynamic and conservative approach to VVs and CVI may improve the long term treatment results and might spare, instead of current one, a greater number of GSVs by removing them from excessive ablation trend.

References1. Franceschi C. Théorie et pratique de la cure CHIVA. L’Armançon Ed. 21390 Précis sous

Thil, 1988, France.2. Carandina S, Mari C, De Palma M, Marcellino MG, Cisno C, Legnaro A, Liboni A,

Zamboni PM. Varicose vein stripping Vs. hemodynamic correction (CHIVA): a long term randomized trial. Eur J Vasc Endovasc Surg 2008;35(2):230-237.

3. Parés JO, Juan J, Tellez R, Mata A, Moreno C, Quer FX, Suarez D, Codony I, Roca J. Varicose vein surgery: stripping versus CHIVA method: a randomized controlled trial. Ann Surg 2010;251(4):624-631.

4. Kistner RL. Surgical repair of a venous valve. Straub Clin Proc. 1968;24:41-43.5. Sottiurai VS. Technique in direct venous valvuloplasty. J Vasc Surg 1988;8:646-648.6. Tripathi R, Ktenedis KD. Trapdoor internal valvuloplasty – a new technique for primary

deep vein valvular incompetence. Eur J Vasc Endovasc Surg 2001;22:86-89.7. Jessup G, Lane RJ. Repair of incompetent venous valves: a new technique. J Vasc Surg

1988;8:569-575.8. Incandela L, Belcaro G, Nicolaides AN, Agus G, Errichi BM, Cesarone MR, De Sanctis

MT, Ricci A, Sabetai M, Mondani P, De Angelis R, Bavera P, Griffin M, Geroulakos G. Superficial vein valve repair with a new external valve support (EVS). The IMES (Inter-national Multicenter EVS Study). Angiology 2000 Aug;51(8 Pt 2):S39-52.

9. Camilli S, Camilli D. La valvuloplastica venosa per trazione: una nuova tecnica. It J Vasc Endovasc Surg 2008;15-Suppl 1 to No.4:104.

10. Camilli S, Camilli D. The stretching valvuloplasty for venous valve repair: preliminary results of the new technique. La Medicina Estetica. Abstract Book. 2011;35(2):181-183.

11. Camilli S, Camilli D. The Stretching Valvuloplasty and OSES device implant. 2011, avai-lable from: http://www.youtube.com/results?search_query=stretching+valvuloplasty&aq=f

12. Camilli D, Camilli S. The external stretching valvuloplasty: a new technique for venous valve repair. J Vasc Endovasc Surg 2012;19:37-40.

13. Camilli D, Camilli S. La valvuloplastica venosa con tecnica OSES: risultati clinici in 32 casi. Flebologia 2012;1:38-9.

14. Pittaluga P, Rea B, Barbe R. Méthode ASVAL (Ablation Sélective des Varices sous Ane-sthésie Locale): Principes et Résultats Préliminaires. Phlébologie 2005;58(2):175-181.

http://www.youtube.com/results?search_query=stretching+valvuloplasty&aq=f

©2012 by MEDIMOND s.r.l. 337


Matrix Metalloproteinase-9 (MMP-9) is a high sensitive marker for monitoring joint disease remissionKarakin E., Müller-Zahm K., Neumann M., Wilke I.

Research Centre for Medical Techniques and Biotechnology, 99947 Bad Langensalza, Germany.

SummaryUsing semi-quantitative catalogue of synovial MMP-9 activities, three main variants

of osteoarthritis disease remission were discovered.

IntroductionIn a large group of diseases which are related to joint of horses, the highest per-

centage is represented by osteoarthritis (OA). Disease remission requires sensitive molecular markers for monitoring healing process after surgical treatment. Therefore semi-quantitative version of Zymography was developed for post-surgical monitoring of synovial proMMP-9 (s-pM-9) activity using joint osteoarthritis dissecans (OCD) on foals as a model.

Materials and MethodsInitial SF samples from joints of foals with aseptic OCD diagnosis were obtained

prior to arthroscopy (11 tarsocrural joints from 8 foals), lesions were bilateral in 3 foals. Zymograms were obtained by techniques described by Clegg and Carter (1999).

ResultsIt is known that after the development of enzymatic reaction in gels it may be

estimated the only two parameters of MMP activity: i) an area of white band, and ii) an intensity of one. Their increasing testifies to increasing relative concentration of enzyme. SF from healthy joints displayed no s-pM-9 activity or a low one. Based on comparative estimations of visible differences in relative enzyme activities in gels, Zymography CATALOGUE consisting of 7 distinguishable s-pM-9 Groups was

338 Karakin E., Müller-Zahm K., Neumann M., Wilke I.

suggested (Fig. 1). Its quantification by dilution of synovial fluids with the highest s-pM-9 levels in titration experiments showed that Zymography test enables one to estimate differences in s-pM-9 content between Group 1 and Group 7 in a range of more than a 1000-fold.

Fig.1. Two versions of s-pM-9 OA CATALOGUE which permit to classify the differences in both relative activities and relative contents of this enzyme according to visible (A) and quantitative (B) distinguishable groups. A. Clinic version of CATALOGUE. SF samples were taken from joints with different forms of traumatic OA diseases (s-pM-9 Groups 2 – 6, lanes 3 – 7 respectively). Group 1 demonstrates no or low pM-9 activity (SF sample was taken from healthy joint, lane 2). Group 7 is characterized by maximal activity of s-pM-9 (SF sample was taken from joint with heavy trauma, lane 8). 5 µl of native synovial fluid was analyzed in each well. B. Titration version of CATALOGUE. Estimations of relative content of s-pM-9 in SF from joint with heavy trauma (5 µl of SF, lane 2) compared to SF from healthy joint (5 µl of SF, lane 3). Titration experiment, with diluted samples of SF from joint with heavy trauma (as in lane 2) is presented (lane 4 – 9): 3 µl of native SF (lane 4); 1 µl of native SF (lane 5); “0.1” µl of the same SF (lane 6); “0.01” µl of the same SF (lane 7); “0.001” µl of the same SF (lane 8); “0.0001” µl of the same SF (lane 9, approximately Group 2 or Group 1 equivalents in comparison with 1 A, lanes 3 and 2). The comparison of the results (1 A and 1 B) shows that the differences in relative contents of s-pM-9 between Group 1 and Group 6 lie in range of more than a 1000-fold. Group 7 displays maximal s-pM-9 activity (lane 8 in 1 A, lane 2 in 1 B).

339Matrix Metalloproteinase-9 (MMP-9) is a high sensitive marker for monitoring joint disease remission

Fig.2. Synovial pM-9 monitoring of post-surgical consequences during OCD disease remission: examples of different dynamics of s-pM-9 activities which were revealed by Zymography. The observations were carried out at a week intervals. A. “Gauss” distribution of relative s-pM-9 activities is presented, 7 weeks of the observations (lanes 6 – 13). The last weeks are characterized by s-pM-9 Group 2. Lanes 2 – 5 contain synovial MMP patterns which were revealed from joints of aged horses with severe OA forms (arthrosis). B. The first “oscillatory” variant of distribution of s-pM-9 activities, 9 weeks of monitoring (“pure oscillator”, lanes 2 – 11). The last weeks are characterized by s-pM-9 Group 1. C. The second “oscillatory” variant of distribution of s-pM-9 activities, 8 weeks of monitoring (“constitutive oscillator”, lanes 2 – 10). The last weeks are characterized by s-pM-9 Group 4.

A comparison of kinetic curves of s-pM-9 activities which were obtained during monitoring of disease remission in 11 joints of foals with OCD showed that they may be arranged into three distinguishable Classes reflecting healing process (Fig. 2). We found that the first one (I) points to “ideal” disease remission which is characterized by one maximum peak of s-pM-9 activity during 6-9 week-long observations (“asym-metric Gauss” of the distribution of s-pM-9 activities during monitoring). ”Oscillatory” versions of dynamics of s-pM-9 activity may reflect: (II) - unstable healing process and (III) - probably the beginning of chronic disease (Fig. 3).

340 Karakin E., Müller-Zahm K., Neumann M., Wilke I.

Fig.3. Two variants of presentation of the results which were revealed by synovial s-pM-9 monitoring of post-surgical consequences during OCD disease remission: Table (left side, at the top) and graphs (a – k). An absence of a column (for example in d, e, and g) signifies lacking SF sample at the week. These presentations of relative s-pM-9 activity/content reflect the data which were obtained by Zymography and sorted by s-pM-9 CATALOGUE (Fig 1).

341Matrix Metalloproteinase-9 (MMP-9) is a high sensitive marker for monitoring joint disease remission

ConclusionsWe concluded that s-pM-9 is a useful marker for monitoring osteoarthritis disease

remission using Zymography.

ReferencesCLEGG, P.D. and CARTER, S. Matrix metalloproteinase – 2 and – 9 are activated in joint

diseases. Equine vet .J. 31, 324-330, 1999.

©2012 by MEDIMOND s.r.l. 343J412R0001


Quality of life in various types of schizophreniaMariana Adelina M.1, Claudiu Dacian R.2, Delia Marina P.1

1 “Vasile Glodis,” Western University of Arad, Faculty of medicine, pharmacy and dentistry Arad, România 2 Individual practice of psychology Arad, România

AbstractNowadays psychiatrists, patients, their families, and the community are showing a

great interest in quality of life. The purpose of this research is to evaluate the quality of life of patients diagnosed with different types of schizophrenia. The study comprises a total of 150 subjects (50 healthy subjects and 100 diagnosed with schizophrenia). Diagnosis of schizophrenia was established according to operational criteria of DSM-IV-TR (1994) and ICD-10 (1992). Regarding depreciation in living environment, those diagnosed with paranoid schizophrenia appear to be in a significantly worse position compared with those diagnosed with other forms of schizophrenia.

Keywords: quality of life, paranoid schizophrenia, other forms of schizophrenia.

Introduction Nowadays psychiatrists, patients, their families, and the community are showing

a great interest in quality of life.“Quality of life is defined as an individual’s perception of their position in life

in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.” (the WHOQOL Group, 1995)

Numerous quality of life assessment scales investigate different areas, such as: physical health, mental health, health care, safety and security, food, housing, edu-cation, interpersonal ties, finance, activities, environment, dependence, leisure, work, spirituality, up from personal experience (self-fulfillment, harmony with oneself, happiness, joy, love).(3)

For chronic schizophrenia patients, the concept of life quality differs from that used to describe physical and less-debilitating psychiatric illnesses. People who are chroni-cally ill with schizophrenia have particular needs that exert a profound influence on their existence and subjective well-being. For example, these patients must deal with the stigma associated with mental illnesses, poor resources and lifetime disability.(12)

The most used quality of life scales are:•CAF (CommunityAdjustmentForm )(SteinL. I.&TestM.A.,1980) It contains

344 Mariana Adelina M., Claudiu Dacian R., Delia Marina P.

140 items. Areas being taken into account are: leisure quality, residence quality, pro-fessional status and employment history, sources and levels of income, food, contact with friends and family, legal issues, life satisfaction, self-esteem, health care.

•OQLQ(OregonQualityofLifeQuestionnaire)(Bigelow,Brodsky,Olson,1982)investigating: dissatisfaction-psychopathological suffering, psychological wellbeing, stress tolerance, overall satisfaction of basic needs, independence, interpersonal inte-ractions, family role (husband/wife), social support, work and home, readiness to be engaged, work and service, meaningful use of time, negative consequences of alcohol and other drug use.(7)

•QOLI(LehmanAF,WardNC,LinnLS,1982): livingsituation, familyrelations,social relations, leisure, finance, security and legal issues, work and school, health.

•QLI-MH (Becker M, Diamond R. et all., 1993): occupational activities, psy-chological wellbeing, physical health, daily activities, social relations, economic and financial situation, psychopathological symptoms, open questions regarding the improvement and treatment.

•QOL(Qualityof life) (TheWHOQOLGroup,DivisionofMentalHealth,1995)scale of quality of life is divided into 6 areas and 24 dimensions with 100 items, rated from 0 to 5 points: physical health, mental health, level of independence, so-cial relationships, living environment, quality of spiritual life related to religion and beliefs, membership in a religious organization.

Material and methodThe purpose of this research is to evaluate the quality of life of patients diagnosed

with different types of schizophrenia. The study comprises a total of 150 subjects (50 healthy subjects and 100 diagnosed with schizophrenia). Diagnosis of schizophrenia was established according to operational criteria in DSM-IV-TR (1994) and ICD-10 (1992). The group of schizophrenic patients was hospitalized in the psychiatric de-partment of Arad, between 2009-2011.

Group of healthy subjects (A) consists of 50 people, aged between 20 and 65 years, who participated voluntarily in this study. Group A was divided into three subgroups in relatively equal proportions: 20-35 years; 35-50 years; 50-65 years

Group B consists of 100 patients diagnosed with schizophrenia divided in two subgroups: B1 subgroup of 50 patients diagnosed with paranoid schizophrenia and B2 subgroup of 50 patients diagnosed with other types of schizophrenia (undifferen-tiated, simple, catatonic, disorganized, residual). For a more accurate data evaluation of patients we also used additional information provided by the family regarding workplace performance, behavior and social relations of patients.

Patients were assessed using a semi-structured interview to determine demographic and clinical characteristics: age, gender, educational level, marital status, residence, age at onset and pharmacological treatment. The research was conducted in accordance with the ethical standards of the Declaration of Helsinki (1964).

EvaluationQuality of life was assessed using Scale quality of life (QOL). All assessments

were conducted by a psychiatrist. The scale is applied in approximately 60 minutes and provides a global score and scores for each of the six areas. Quality of life scale

345Quality of life in various types of schizophrenia

is divided into 6 areas and 24 dimensions with 100 items, score from 0 to 5 points: physical health with three dimensions (energy and fatigue, pain and discomfort, sleep and rest), mental health by 5 dimensions (personal appearance, positive and negative emotional status, self-esteem and self-confidence and cognitive abilities, thinking, lear-ning, memory and concentration), degree of independence with 4 dimensions (physical mobility, performance in daily activities and drug dependence, medical devices, ability to work), social relationships with 3 dimensions (interpersonal relationships, social support, sexual activity) living environment with 8 dimensions (financial, physical movement, freedom, security and safety, accessibility and ability to care and social assistance, housing, personal development and access to information, participation in leisure activities, quality of the environment, chemical pollution, noise, traffic intensity, physical climate, availability of access to transport), the spiritual life which refers to beliefs and religious faith, membership in a religious organization.

ResultsProcessing, data analysis and hypothesis testing was performed using the statisti-

cal program SPSS 10.0 for Windows. Dependent variables are: gender, age, marital status, employment status, educational level, area of residence, type of schizophrenia, age at onset, type of treatment. Independent variables are the six areas of quality of life: physical health, mental health, level of independence, social relationships, living environment and spiritual life.

If in the areas of physical health, mental health, degree of independence and living environment, relation with age seems to be rather negative, however in the areas of social and spiritual status, the relationship with age appears to be positive.

Significant correlation indices are found at p <0.05 for physical health, mental health and level of independence. Physical health is negatively correlated (r = -0.314) with age, indicating a decreasing trend of the degree to which subjects perceive their physical health with increasing age. Mental health is negatively correlated (r = - 0.166) with age so that we observe a trend of decreased perception of individuals on their own mental health with age. Degree of independence is negatively correlated (r = - 0.226) with age, indicating a decreasing trend of the individual’s independence as they grow older. In conclusion, age seems to play a significant role in some aspects of quality of life such as the areas of physical health, mental health and the degree of indepen-dence, with older subjects showing lower levels in the three areas of quality of life.

For the dependent variable marital status (married, unmarried, divorced and wido-wed) values of F are significant for the areas: mental health (F = 5.769 to p = 0.001) and social relations ( F = 3.792 to p = 0.012). Post-hoc analysis shows the following:

• In theareaofmentalhealth, themarriedobtainsignificantlyhigher scores thanthe unmarried and widowed groups, indicating that married people perceive a higher level of mental health than those that are unmarried and divorced;

•Intheareaofsocialrelationships,marriedpeopleobtainsignificantlyhigherscoresthan those who are widowed, indicating the presence of an intense social activity and a social network that extends to married persons, as compared to widowed persons.

In conclusion, we can say that marital status influences individual perception of quality of life, particularly in the areas of mental health and social interaction. Relevant differences were found between the married and the widowed, the first perceiving themselves as being mentally healthy and active in the field of social relations.

346 Mariana Adelina M., Claudiu Dacian R., Delia Marina P.

F values and the materiality in relation to occupational status (workers-farmers, technicians-clerks, students-intellectuals, unemployed and retired) indicates statistically significant values for the indicator for all six areas of quality of life which point to significant differences between the five groups of subjects according to occupational status, the perception of quality of life in all six areas of concern. Students-intellectuals have the best rate for all six quality of life areas, and the retired have the lowest scores for all six areas. In conclusion, we can state that there is an influence of occupational status on quality of life. This influence can be either direct or indirect, by other variables such as age or income.

Indicator values and materiality in terms of educational level show that only in the spiritual life area ( F= 4.141, p = 0.018) there is a significant difference between educational level groups. Post-hoc analysis points out that the difference is caused by the fact that people with higher education obtain significantly higher scores than those with primary education, indicating a spiritual life richer and more intense for those with a higher educational level. So the variable educational level affects quality of life, even if only partially , in terms of spiritual life.

In terms of the dependent variable, the type group we found materiality below the minimum accepted standard of 0.05 indicating statistically significant F values for the all six areas of quality of life.

For the areas of physical health, mental health, degree of independence, living environment and social relations, values of F are not statistically significant at a threshold less than or equal to 0.05, so we cannot say that the age of onset of schi-zophrenic disorder - of whatever form - affects those areas of quality of life. Age of onset, however, appears to play a significant role for the spiritual life (F = 5.143 to p = 0.008). Post-hoc analysis indicates a significant difference between those with onset age below 20 years and those with age of onset over 25 years, meaning that those with a disorder onset older than 25 years have higher scores the area of spiritual life.

Regarding the dependent variables: gender, area of residence and type of treatment our study not found statistically significant results.

DiscussionsAccording to our study, in terms of occupational status, perception of a lower

physical and mental health in retirees is a factor that determines a lower perception of social activism- their degree of independence. Obviously, an occupation may pro-vide income that can facilitate or limit independence and social activism. Another moderating variable could be marital status, as long as the widowed lower scores on specific areas of quality of life and usually are older and therefore are more numerous in the population at age of onset. Analysing disease and its correlation with impaired quality of spiritual life we can say by reference to Kohlberg’s theory that as you move from one stage to another, you consider a larger portion of social life. The sequence of steps begins with thinking about oneself (step 1), progressing to consideration of others directly involved in the problematic situation (step 2), then consideration of others who become aware of the situation and assess it (step 3), proceed to consider society as a whole (step 4) and finally consider the universal principles of humanity (stage 5). According to Kohlberg, stages represents a true breakthrough in human development, meaning that to reach a certain stage, one must first go through the

347Quality of life in various types of schizophrenia

previous stages. Thinking inside a stage and discovering within that way of thinking, man will find motivational force to progress to the next stage.

ConclusionsIn conclusion in every aspect of quality of life, physical, mental, social, relational,

intellectual and spiritual, there is a marked impairment in people diagnosed with pa-ranoid schizophrenia. For people diagnosed with other forms of schizophrenia, there is also present an impairment of quality of life, but less so in terms of spiritual life. Largely, in terms of physical and mental health and the degree of independence and socio-relational life, there do not appear to be significant differences depending on the type of schizophrenia. Regarding depreciation in living environment, those diagnosed with paranoid schizophrenia appear to be in a significantly worse position compared with those diagnosed with other forms of schizophrenia. While the spiritual life of those diagnosed with other forms of schizophrenia seems to not depreciate significantly compared with healthy people.

References1. Anderson J. P., Bush J. W. & Berry C. C. (1986) Classifying function for health outcome

and quality-of-life-evaluation : self versus interview modes. Medical Care, 24, 454-469.2. Awad, A.G., Voruganti, L. N. P. & Heslegrave, R. J. (1997) Measuring quality of life in

patients with schizophrenia. Pharmacoeconomics, 11, 32-473. Becker M. si colab. - A new patient focused index for measuring quality if life in persons

with severe and persistent mental illness. Quality of life resarch, 1993, 2,239-251.4. Bobes J. si colab. - Quality of life in schizophrenia in Quality of life in mental disorders.

Ed. de Katschni H., Freeman H. John Wiley & Sons, Chichester, 1997.5. Greenley, J. R. & Greenberg, J. (1994)Measuring Quality of Life : A New and Practical

Survey Instrument, Paper Series 38, Madison, WI : Mental Health Research Centre6. Heinrichs D. W., Hanlon T. E. & Carpenter W.T. (1984) The quality of life scale : an

instrument for rating the schizophrenic deficit syndrome. Schizophrenia Bulletin, 10, 388-398

7. LazarescuM. -Calitatea vietii în psihiatrie. InfoMedica,Bucuresti, 1999.8. Lehman AF. - A quality of life interview for the chronically mentally ill. Evaluation and

Program Planning, 1988,11,51-62.9. Lehman AF. si cplab. - Convergent validation of quality of life assessments for persons

with severe mental illnesses. QOL Research, 1993, 2,327-333.10. Orley J., Saxena S. & Herrman H. (1998) Quality of life and mental illness. Reflections

from the perspective of the WHOQOL. British Journal of Psychiatry, 172, 291-293.11. Revicki DA, Genduso LA, Hamilton SH, Ganoczy D, Beasley CM: Olanzapine versus

haloperidol in the treatment of schizophrenia and other psychotic disorders: quality of life and clinical outcomes of a randomised clinical trial. Qual Life Res 1999, 8(5):417-426.

12. Sartorius N. (1997) Fighting schizophrenia and its stigma. A new World Psychiatric As-sociation educational program. Br J 1997;170:297.

13. Stein LI. si colab. - Alternative to mental hospital treatment. Arch General Psychiatr, 1980, 37:392-397.

14. Seulin C, Gerin P - Evalution de la qualite de vie en sante mentale in Epidemiologie psychiatrique.Ed. Rouillon F, Lepine JP, Terra JL P&U, Paris.

©2012 by MEDIMOND s.r.l. 349J412R0002


Co(II) and Mn(II) binding to a multihistidinic peptidePeana M.a, Medici S.a, Zoroddu M.A.a

a Department of Chemistry and Pharmacy, University of Sassari, ITALY e-mail: [email protected]

SummaryA multi-histidinic (T

1R

2S

3R

4S

5H

6T

7S

8E

9G

10)

3 peptide fragment from Cap43 protein, has

been investigated for Mn(II) and Co(II) binding, in order to relate its coordination behaviour to the biological implications in the protein structure. UV-Visible spectroscopy together with 1H NMR measurements have been used to investigate the role of multi-histidinic sites in coordinating metals. Both ions showed common binding donor atoms: manganese and cobalt binding centre was mainly associated with histidines. The specific perturbation of NMR resonances indicated that coordination involves imidazole of His

6, with the pos-

sibility of involvement of carboxyl γ-O of Glu9 and hydroxyl γ-O of Thr

7 in the minimal

model peptide (9-aa). Manganese and cobalt coordination involves, primarily, all the three imidazolic nitrogens of His

6, His

16, His

26, and, probably, carboxyl γ-O of Glu

9, Glu

19, and

Glu29

, in the three repeats, the 30-aminoacid fragment (30-aa).

IntroductionCap43 is a nickel-, cobalt- and calcium-inducible gene that has been recognized

to play a significant role in cancer metastasis and invasion, as well as in the primary growth of malignant tumours, possibly through its ability to induce differentiation.1–4 The Cap43 gene (also referred to as NDRG-1, N-Myc down-regulated gene 1) expres-ses a 3.0 kb mRNA that encodes a M

r 43,000 cytoplasmic protein. The expression of

Cap43 protein is low in normal tissues; however, Cap43 is overexpressed in cancer cells, including lung, brain, melanoma, liver, prostate, breast, and renal cancers. The low level of expression of Cap43 in some normal tissues compared to their cancerous counterparts, combined with the high stability of Cap43 protein and mRNA, makes the Cap43 gene an important marker for diagnosing cancer diseases at the early stages.4–7 The most striking feature of this protein lies in its C-terminal moiety, where a 10 amino acid monohistidinic sequence (TRSRSHTSEG) is repeated consecutively three times to give an interesting site for examination under metal-coordination conditions.

350 Peana M., Medici S., Zoroddu M.A.

The C-terminal sequence, being external to the whole protein, is more accessible for metal ion binding. For this reason, one of the aspects we wished to study was the possibility of multiple coordination of the C-terminus with different metal ions.

It is known that rich repeat domains in peptides can be of interest as models for the study of molecular phenomena related to metal ion binding in proteins involved in neurodegenerative disorders.

Of these ions, it has been reported that manganese binding to PrP is detrimental and causes a conformational change in the protein. In particular, although PrP can bind the same number of manganese atoms as of copper atoms, the resulting protein became proteinase resistant, formed fibrils and lost function.8-10

In addition, previous studies have shown that PrP isolated from brains has man-ganese bound.11

Regarding cobalt, a novel low-affinity binding site for Co(II) was discovered between PrP residues 104 and 114, with residue His

111 being the key amino acid for

coordinating Co(II). Thus, despite the interest for manganese and cobalt binding to PrP, a thorough

analysis of the interaction of both metals with proteins related to brain disorders has not yet been reported and needs further in-depth studies.

Materials and MethodsPeptides were chemically synthesized using solid phase Fmoc chemistry in an

Applied Biosystems Synthesizer.12 After removal of the resin by filtration, peptides were precipitated with tert-butylmethyl ether, centrifuged and the pellets resuspended in 50% acetic acid and lyophilized. Crude peptides were reconstituted in 1 ml 50% acetic acid in H

2O and low molecular weight contaminants were removed by gel

filtration on Sephadex G-25. The column was eluted at a flow rate of 9 ml min-1 by a linear gradient of 0.1% TFA–acetonitrile on 0.1% TFA–H

2O, rising within 60 min

from 10% to 100%. The optical density of the eluate was monitored at 220 or 280 nm. Fractions were collected and analyzed by MALDI-TOF MS. Fractions containing the peptides of the expected molecular weight were pooled and lyophilized.

1D NMR experiments were performed on a Bruker AscendTM 400 MHz spectro-meter using 2.5 mM solutions and different metal to ligand molar ratios.

UV–visible (UV–Vis) spectra were recorded with a Model U-2010 double beam spectrophotometer (Hitachi instruments, Milan, Italy).

ResultsManganese and cobalt complexes with the multi-histidinic Ac-(T

1R

2S

3R

4S

5H

6T

7S

8E

9G

10)

3-

Am (30-aa) and, for comparison, with the minimal model, the mono-histidinic Ac-R

2S

3R

4S

5H

6T

7S

8E

9G

10-Am (9-aa) fragment, were investigated by means of a combina-

tion of spectroscopic techniques. The effects of peptides titration with the two metals have been followed by the paramagnetic line-broadening in the 1D NMR spectra at different pH values and at different ligand to metal molar ratios. Substoichiometric amounts ranging from 0.01:1 to 1:1 for the 9aa- and for the 30aa-peptide, metal to ligand molar ratios, were used. UV-Vis measurements gave additional information on the nature of the donor atoms and the conformational geometry of the metal com-

351Co(II) and Mn(II) binding to a multihistidinic peptide

plexes. The 9aa and 30aa free peptides have already been extensively characterized through 1D and 2D NMR spectroscopy in our previous studies.13-18

Manganese binding to the minimal model fragmentAddition of Mn(II) to the peptide solution at pH 6 yields a dramatic line broad-

ening of His signals, with the imidazole ring protons Hd2

and He1

mainly affected by paramagnetic metal interaction, pointing to the involvement of histidine in the coordi-nation. Also the severe effect on the aliphatic side chain (Q

γ and H

b) and amidic (H

N)

resonances of Glu9 strongly supports the proximity of glutamic residue to manganese

binding site. When the pH was raised, stronger effects appear in the 1D spectra in-dicating that, at physiological pH, manganese binds to the 9-aa peptide stronger than at slightly acidic pH. All the other residues are almost unaffected, although a general decreasing in intensity of the signals is appreciable.

Fig. 1 Superimposition of 1D 1H NMR spectra in the aromatic a) and aliphatic region b) for the 30-aa fragment, 2,5 mM, pH 6, T 298 with increased amount of Mn2+ from 0.01:1 to 1:1 metal to ligand molar ratio.


Manganese binding to the multihistidinic fragmentIncremental addition of manganese to the 30aa fragment causes selective and

progressive line-broadening of the NMR signals and large proton paramagnetic relax-ation enhancements which allowed us to map the residues that have a non-vanishing dipolar and/or scalar interaction with the electron spin located at the metal nucleus (Fig 1a,b). Interestingly, the affected signals during the titration of the long peptide with Mn(II) are the same found for the short one, indicating an involvement of all the three histidine residues in the complex formation, giving a macrochelate species. Mn(II) progressively affected the relaxation rates of the aromatic and aliphatic pro-tons of His

6,16,26 and those of Glu

9,19,29. The 1D NMR spectrum shows a decrease in

intensity for the Qγ protons of Thr

7,17,27 similar to that recorded for the smaller peptide.

Cobalt binding to the minimal model fragmentParamagnetic NMR showed remarkable broadening and lowering of the H

d2 and

He1

imidazole ring protons at very low cobalt concentration, together with Ha and H

b2,3 aliphatic histidine protons. With the gradual addition of the metal, also the backbone H

N resonance from the E

9 residue starts to be affected. This, together with the large

broadening of the E9 H

b2,3 and Q

γ aliphatic resonance, suggests that paramagnetic

centre would approach its carboxylic group. This result suggests a selective binding of cobalt to some amino acids of the peptide and point out to the involvement of the His imidazole ring in metal binding, acting as an anchoring site for the metal through imidazole nitrogen.

Cobalt binding to the multihistidinic fragmentCobalt(II) induced significant NMR changes in the 1D spectra of the 30-aa peptide

(Fig 2a,b). The aromatic region of the spectrum shows the severe loss in intensity of the signals relative to the aromatic protons of histidine H

6, H

16 and H

26, overlapping

together at the same frequencies. Also the glutamate residues are influenced by the metal ions, since the resonance of their Q

γ and H

b completely disappeared in the

1:1 metal:peptide system. Like for the monohistidinic peptide, also in this case, the Thr

7,17,27 seems to sense the closeness to the metal. By rising the pH above 7 the NMR

spectra did not show appreciable differences respect to those measured at lower pH suggesting an identical coordination mode for the cobalt ions. All the detected 1D NMR broadening signals suggest Co(II) binding to the His imidazole nitrogen atoms. The UV-Vis electronic spectrum suggests an octahedrally coordinated cobalt(II) with the 30aa-peptide.

ConclusionsThe length of the peptide plays an important role in stabilizing its metal com-

plexes, probably through the conformational organization of the peptide itself which can better shield the metal coordination site from the attack of water molecules. This stabilization adds to that of the side-chains organization promoted by the metal itself upon coordination.

353Co(II) and Mn(II) binding to a multihistidinic peptide

Fig. 2 Superimposition of 1D 1H NMR spectra in the aromatic a) and aliphatic region b) for the 30-aa fragment, 2,5 mM, pH 6, T 298 with increased amount of Co2+ from 0.01:1 to 1:1 metal to ligand molar ratio.

The work here presented shows that manganese and cobalt can replace different metal ions at the same binding sites in the 30-aminoacid fragment. Further studies are in progress in order to shed light on the relative geometry of the coordination sphere and on the structure of the entire fragment

Multi-imidazol coordination mode may be critical for biological implication and it is possible that any factor that can affect the structure can be of interest. Our results may give insight to fully understand the complexity of the roles of different metals and proteins in aggregation and toxicity mechanisms in neurodegenerative disorders.

References1. D. ZHOU, K. SALNIKOW and M. COSTA, Cap43, a novel gene specifically induced by

Ni2+ compounds, Cancer Res., 58, 2182–2189, 19982. K. SALNIKOW, D. ZHOU, T. KLUZ, C. WANG and M. COSTA, Metal and Genetics,


New York, ed. A. Sarkar, Kluwer Academic, Plenum Publishers, 131–144, 1999 3. R. J. GUAN, H. L. FORD, Y. FU, Y. LI, L. M. SHAW and A. B. PARDEE, Drg-1 as a

differentiation-related, putative metastatic suppressor gene in human colon cancer, Cancer Res., 60, 749–755, 2000

4. T. P. ELLEN, Q. KE, P. ZHANG AND M. COSTA, NDRG1, a growth and cancer related gene: regulation of gene expression and function in normal and disease states, Carcino-genesis, 1, 2–8, 2008

5. H. CANGUL, K. SALNIKOW, H. YEE, D. ZAGZAG, T. COMMES and M. COSTA, Enhanced expression of a novel protein in human cancer cells: a potential aid to cancer diagnosis, Cell Biol. Toxicol., 18, 87–96, 2002

6. S. NISHIO, K. USHIJIMA, N. TSUDA, S. TAKEMOTO, K. KAWANO, T. YAMAGU-CHI, N. NISHIDA, T. KAKUMA, H. TSUDA, T. KASAMATSU, Y. SASAJIMA, M. KAGE, M. KUWANO and T. KAMURA, Cap43/NDRG1/Drg-1 is a molecular target for angiogenesis and a prognostic indicator in cervical adenocarcinoma, Cancer Lett., Volume 264, 1, 36–43, 2008

7. T. FUJII, G. YOKOYAMA, H. TAKAHASHI, R. NAMOTO, S. NAKAGAWA, U. TOH, M. KAGE, K. SHIROUZU and M. KUWANO, Preclinical studies of molecular-targeting diagnostic and therapeutic strategies against breast cancer, Breast Cancer, 15, 73–78, 2008

8. D. R. BROWN, F. HAFIZ, L. L. GLASSSMITH, B. S. WONG, I. M. JONES, C. CLIVE, S. J. HASWELL, Consequences of manganese replacement of copper for prion protein function and proteinase resistance, Embo Journal, 19, 1180-1186, 2000

9. C. J. CHOI, A. KANTHASAMY, V. ANANTHARAM, A. G. KANTHASAMY, Interaction of metals with prion protein: possible role of divalent cations in the pathogenesis of prion diseases, Neuro Toxicology, 27, 777-787, 2006

10. R. N.TSENKOVA, I. K. IORDANOVA, K. TOYODA, D. R. BROWN, Prion protein fate governed by metal binding, Biochem. Biophys. Res. Comm., 325, 1005-1012, 2004

11. R. DELONCLE, O. GUILLARD, J. L. BIND, J. DELAVAL, N. FLEURY, G. MAUCO, G. LESAGE, Free radical generation of protease-resistant prion after substitution of man-ganese for copper in bovine brain homogenate, Neuro Toxicology, 27, 437-444, 2006

12. J. MEIENHOFER, M. WAKI, E. P. HEIMER, T. J. LAMBROS, R. C. MAKOFSKE and C. D. CHANG, Solid phase synthesis without repetitive acidolysis. Preparation of leucyl-alanyl-glycyl-valine using 9-fluorenylmethyloxycarbonylamino acids, Int. J. Pept. Protein Res., 13, 35–42, 1979

13. M. A. ZORODDU, T. KOWALIK-JANKOWSKA, H. KOZLOWSKI, K. SALNIKOW, M. COSTA, Ni(II) and Cu(II) binding with a 14-aminoacid sequence of Cap43 protein, TRSRSHTSEGTRSR, J Inorg Biochem., 84, 47-54, 2001

14. M. A. ZORODDU, M. PEANA, T. KOWALIK-JANKOWSKA, H. KOZLOWSKI and M. COSTA, Nickel(II) binding to Cap43 protein fragments, J. Inorg. Biochem., 98, 931-939, 2004

15. M. A. ZORODDU, T. KOWALIK-JANKOWSKA, M. PEANA, S. MEDICI and H. KO-ZLOWSKI, Copper(II) binding to Cap43 protein fragments, Dalton Trans., 44, 6127-6134, 2008

16. M. A. ZORODDU, M. PEANA, S. MEDICI, R. ANEDDA, An NMR study on nickel binding sites in Cap43 protein fragments, Dalton Trans., 28, 5523-5534, 2009

17. M. A. ZORODDU, S. MEDICI, M. PEANA, Copper and nickel binding in multi-histidinic peptide fragments, J. Inorg. Biochem., 103, 1214-1220, 2009

18. M. A. ZORODDU, S. MEDICI, M. PEANA, R. ANEDDA, NMR studies of zinc binding in a multi-histidinic peptide fragment, Dalton Trans., 39, 1282-1294, 2010

©2012 by MEDIMOND s.r.l. 355

Author Index

Aluigi L., 289

Banzic I., 297

Camilli D., 331Camilli S., 331Cassaro L., 325Claudiu Dacian R., 343

Davidovic L., 297, 311Delia Marina P., 343Dragaš M., 297, 311

Ferro G., 325Filippone G.,

Ilic N., 297, 311

Jezovnik M.K., 317

Karakin E., 337Koncar I., 297, 311

La Barbera G., 325Laredo J., 305Lee B.B., 305

Mariana Adelina M., 343Markovic M., 311Medici S., 349Müller-Zahm K., 337

Neumann M., 337

Parsaei D.M., 325Peana M., 349Pejkic S., 311Poredos P., 317, 321

Sindelic R., 311

Talarico F., 325

Valentino F., 325Vallone M., 325

Wilke I., 337

Zoroddu M.A., 349

vol. 3, n. 4 - edlearning

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