Combining superficial femoral artery endovascular treatment with distal vein bypass.

AIM: Significant strides have been made using endovascular solutions for the treatment of patients with peripheral vascular disease (PAD) and for tissue loss. But the Trans-Atlantic Inter-Society Consensus (TASC) II classification states that surgery still remains the best solution for C and D lesions, though endovascular management of superficial femoral artery (SFA) can improve inflow for distal origin bypass grafts. Our aim was to evaluate the results of combining endovascular treatment of SFA with distal vein bypass in patients with critical limb ischemia (CLI) and great tissue loss or in the cases where the below-knee endoluminal techniques alone were unable to salvage limbs. METHODS: A retrospective study of the combined interventions carried out from January 2006 and June 2013 was performed. Twenty-seven angioplasties or selective stentings of SFA combined with popliteal-distal bypass in 23 patients with stage 4, 5 or 6 Rutherford classification were performed. There were 14 men and 9 women, four were bilateral. Mean age was 71.5 years (55-91); 21 (91.3%) were diabetic, and in these, there was almost always deep debridement of necrotic or infected tissue. In 17 cases (62.9%) SFA angioplasty was performed alone, a self-expendable stent was released in the other 10 (37.1%). Distal bypass originated from distal SFA in 5 cases (18.5%), from above-knee popliteal artery in 8 (29.6%) and from below-knee popliteal artery in 14 (51.8%). Reversed saphenous vein was used for bypass in all cases. The target vessel was the posterior tibial artery in 6 cases, anterior tibial artery in 10 and dorsalis pedis in eleven. Follow-up ranged from 4 months to 6 years (with a mean of 37 months). RESULTS: There were no deaths, but two early graft failures and three major amputations during the perioperative period. Primary patency rate of both the endovascular SFA and the bypass was 81.6% (N.=22) and secondary patency was 88.8% (N.=24). Three years primary and secondary patency rate were, respectively, 74.1% (N.=20) and 81.6% (N.=22). One-year limb salvage rate was 88.8%, at three years was 86.1% and fifteen minor amputations were performed in 13 patients. CONCLUSION: The endovascular treatment of SFA associated with surgical distal vein bypass is a useful and effective strategy in patients with severe lower extremity arterial disease. This strategy allows a good inflow on SFA in selected patients with the opportunity to perform shorter bypass, use of limited autologous conduit and good expectation of patency.

Inductively heated plasma waste treatment for energy recovery.

An assessment of a decentralized inductively heated plasma waste treatment system for energy recovery has been done. The modular miniaturized high enthalpy plasma source IPG6 is a reference for the system and has been qualified for inert but also chemically aggressive gas compositions. An identification and review of applications were undertaken. Niches of high environmental and societal importance are considered: hospital waste (threshold countries), shipboard waste and marine litter. The wastes are reviewed deriving relevant parameter for a system analysis aiming for the derivation of energy production and efficiencies. The system analysis shows advantageous constellation due to the wastes' energy leading to self-feeding systems.

Results of surgical repair of carotid in-stent restenosis.

AIM: Carotid artery angioplasty and stenting (CAS) has emerged as an alternative treatment for extra cranial carotid artery stenosis in stroke prevention. Nevertheless concerns are remaining about the long-term durability as hemodynamic in-stent restenosis (ISR) after CAS are increasing and usually treated again by endovascular approach. This preliminary study, instead, albeit in a limited series, reports our safe and successful experience of the surgical correction of carotid ISR after CAS. METHODS: From January 2003 to June 2011 seven patients with severe hemodynamic carotid ISR (three symptomatic, four asymptomatic, mean age 76±2), were submitted to surgical operation to remove the carotid stent. The indications for CAS were primary in five cases, secondary to restenosis after carotid endarterectomy (CEA) in two patients. Standard CEA with complete removal of the stent and the entire atherosclerotic plaque was carried out easy and without technical difficulty in the five primary ISR. In the two patients of ISR in post-CEA restenosis, a common carotid to the distal internal carotid artery (ICA) bypass with polytetrafluoroethylene (PTFE) graft was carried out. Mean operation time was 88±26 min. All interventions were performed under general anesthesia with remifentanil preserved consciousness. RESULTS: No death or major complications occurred. Temporary vocal cord impairment by deficit of recurrent inferior laryngeal nerve in one patient with ISR after CAS performed to treat post-CEA restenosis was observed. Intimal hyperplasia was the predominant mechanism to ISR. The mean follow-up of 18 months (range, 4 to 36 months) showed a normal patency of the surgical correction without recurrent restenosis on color-coded duplex ultrasounds (US) examinations. CONCLUSION: The surgical management of carotid ISR appears feasible and effective leading to good long-term outcome.

Thrombin injection and compression with removable guidewire in the treatment of postcatheterization femoral pseudoaneurysm.

AIM:The purpose of our study was to determine the efficacy of percutaneous thrombin treatment for iatrogenic femoral artery pseudoaneurysms (FAP) and to identify those criteria that may help to predict increased treatment failure risk and complications. METHODS: A number of 32 iatrogenic femoral pseudoaneurysms were treated with US-guided thrombin injection (group A), while four elderly patient with complex femoral pseudoaneurysm underwent compression assisted by removable "guidewire" (group B). Twenty-five were classified as simple (single lobe) and 11 as complex (at least two lobes with a single neck to the native vessel). Pseudoaneurysm volume, classification, thrombin dose, anticoagulation therapy status, and sheath size were considered independent prognostic factors. RESULTS: All the 36 patients (pts) had initial complete femoral pseudoaneurysms thrombosis. The aneurysm was thrombosed on a Doppler ultrasound (US) follow-up in all the cases but four (group A), those who required the additional thrombin injection. A fatal complication occurred in one patient with complex FAP (group A). CONCLUSION: Preliminary data suggest that US-guided percutaneous thrombin injection is a safe and effective method to treat iatrogenic pseudoaneurysms. Simple iatrogenic femoral pseudoaneurysms benefit a single injection of up to 500 units of topical thrombin. We recommend more caution in complex pseudoaneurysms treatment; it is preferable to perform thrombin injection first into the lobe which is not directly joined to the femoral artery. A longer bed rest and closer observation are mandatory during the subsequent 24 hours. If the lobe communicating with the femoral artery is still patent, it can be retreated. Alternatively, we propose a new strategy approach through compression assisted removable "guidewire".

High-risk patients for carotid endarterectomy: turned down cases are rare.

AIM: The increasing use of carotid artery stenting (CAS) is justified in patients at high-risk for carotid endarterectomy (CEA). The aim of this study was to evaluate the hypothesis that the high-risk patients can be submitted to CEA without increased risk of stroke and death. METHODS: A retrospective analysis of 625 consecutive CEA in 545 patients (M/F 386/159, age 75 ± 7) performed from January 2005 to December 2010 was carried out. Definite anatomical and pathophysiological high-risk cohort of patients (N.=173, 31.7%) was evaluated and compared to normal risk patients. Univariate, multivariate and Kaplan-Meier analysis were used as appropriate. Poisson regression (Pr) model was used to study all univariate criteria in combination. A P value <0.05 was statistically significant. RESULTS: The overall 30-day stroke and death rate was 0.96%. No difference between high-risk vs. normal patient cohort regarding physiological and anatomical risk factors was detected. Univariate and multivariate analysis did not show statistical difference for 30-day outcome in any of the variables examined. No increase of risk in cases of presence of more risk factors resulted to the Pr analysis. The 24-month survival rate was worse in high-risk patients, especially when more physiologic risk as chronic renal failure, severe pulmonary and cardiac diseases and age over eighty were present. CONCLUSION: CEA is a safe procedure in patients at high-risk carotid artery disease. A better classification of high-risk patients may be necessary because trials criteria appear ineffective to define the patients at real high surgical risk. Long-term outcome was affected by the presence of severe comorbidities.

Prosthetic carotid bypass graft for in-stent restenosis performed for post-endarterectomy recurrent stenosis: technical details.

AIM: Carotid artery stenting (CAS) is the treatment of choice for recurrent stenosis after carotid endarterectomy (CEA). However a significative incidence of in-stent restenosis could be occurred. Despite classical CEA leads to good results, in selective cases bypass graft may be the best treatment of in-stent restenosis. CASE REPORTS: We describe two cases of carotid bypass graft performed to treat a recurrent in-stent stenosis after CAS for post-CEA restenosis. No death and cardiac complication occurred and no cranial nerves impairment was detected. CONCLUSION: Prosthetic bypass graft is safe and effective in treatment of in-stent recurrent restenosis after CEA restenosis.

Pulmonary emboli due to venous aneurysm of extremities.

Venous aneurysms are uncommon but they can have devastating consequences, including pulmonary embolism, other thromboembolic events and death. We report six cases of venous aneurysm of the extremities, in which the first sign of presence was acute pulmonary embolism. Surgical resection is recommended whenever possible. Our experience suggests that prophylactic surgery is cautiously recommended for low-risk patients with venous aneurysms of the abdomen and strongly recommended for extremity deep and superficial venous aneurysms for their potential risk of developing thromboembolic complications despite adequate anticoagulation. Other venous aneurysms should be excised only if they are symptomatic or enlarging.

Open and endovascular combined procedures in lower limb arterial reconstructions.

INTRODUCTION: The association of open and endovascular procedures in patients with obstructive disease of the lower limbs gives the opportunity to treat in a single step multi-segmental lesions which were currently treated in the past by more demanding open procedures. PATIENTS AND METHODS: From January 2003 to May 2009, 52 patients with peripheral occlusive chronic arterial disease of the lower limbs were submitted to combined open and endovascular procedures. In 37 patients (71.2%) a femoro-popliteal/pedidial bypass was carried out after Percutaneous Transublimal Arterio (PTA)/stenting of the iliac/femoral arteries, while in the remaining 15 patients (28.8%) the endovascular procedures were performed following open approach, that consisted in a femoro-popliteal bypass. Iliac stenting interested the common iliac artery in 19 patients (51.3%), the common and external iliac artery in 11 patients (29.7%) and the external artery in 7 (19%). In this same group a fem-pop bypass below knee was carried out in 28 (75.6), a fem-pop above knee in 6 (16.2%), a fem-pop and jump on the posterior tibial in 2 (5.4%) and a superficial femoral-pedal in the last one (2.8%). In the other group the fem-pop bypass below knee was followed by a PTA of the tibial vessel in 12 cases (80%) and by a stenting in only 3 cases (20%). RESULTS: Three patient was lost to follow-up. Three (8.1%) iliac stents became occluded and the sudden onset of an acute ischemia of the limb required in all cases an aorto-femoral bypass. The occlusion of tibial stent in 2 patient (13.3%) was no clinical relevant, and the failure of the PTA procedure in other 4 patients with the reocclusion of the tibial arteries was followed by thight amputation. Occlusion of the femoro-popliteal bypass occurred in 9 of 37 patients (24.3%) submitted to iliac stenting and in 4 of 15 (26.6%) patients with PTA of the tibial vessels. The overall patency rate was 69.2%. Limb salvage was 77.5% CONCLUSIONS: Combination of the open and endovascular procedures to treat lesions of the lower limbs is effective and durable in terms of patency and complication rate. For validation this new approach needs the recruitment of much more patients and prospective protocol studies.

Fatal complication after thrombin injection for post-catheterization femoral pseudoaneurysm.

Femoral artery pseudoaneurysm (FAP) is one of the most common vascular complications after cardiac and peripheral angiographic procedures. Ultrasound-guided thrombin injection is the standard procedure for the treatment of FAP. Complications such as thrombotic events with leg ischemia after thrombin leakage into the femoral artery or immunogenic consequences are rare. Our experience indicates the need for caution when treating FAP, as severe complications can occur after thrombin injection in a femoral pseudoaneurysm, leading to a fatal event.

Surgical removal of a ruptured, detached angioplasty balloon after popliteal stenting.

Balloon catheter entrapment after stent implantation is a potential interventional complication. However, angioplasty balloon disconnection from the catheter shaft and in-stent entrapment is a very uncommon event that could have serious thrombotic or embolic consequences. The management of this event may be interventional or surgical, depending on the patient's status and the position of the balloon inside the vessel. We describe a case of acute lower limb ischemia after popliteal self-expandable stenting, due to loss of the balloon along with a portion of its shaft. Surgical retrieval was accomplished without any further complications.

Short longitudinal versus transverse skin incision for carotid endarterectomy: impact on cranial and cervical nerve injuries and esthetic outcome.

AIM: Nerve injuries, wound complications and especially poor cosmetic results still have an important impact on the carotid endarterectomy (CEA) morbidity. Introduction of the mini skin incision in clinical practice seems to be safe with reduction in postoperative pain and superficial and cranial nerves lesions, and better aesthetics outcomes. The objective of this retrospective study was to compare the results between the short longitudinal with the short transverse cervical incision and to evaluate their impact on cranial and cervical nerves and aesthetic outcomes. METHODS: From January 2007 to December 2009 266 patients underwent 300 consecutive primary CEA procedures. Two-hundred nineteen patients were submitted to short longitudinal cervical incision (group A), in eighty one a short transverse cervical skin incision (group B) was performed. The average of skin incision was about 4-5.5 cm. In all cases a preoperative CEA duplex ultrasounds (US) assisted skin marking was carried out. All patients were submitted to the general anesthesia with Remifentanyl conserved consciousness. Routinely synthetic patch and selective policy intraluminal shunts were used. Incisions were extended when shunts were required or in case of high carotid bifurcation. Preoperative and postoperative cranial nerves evaluation was always performed and a questionnaire about the satisfaction of the aesthetic outcome was proposed to all patients to the discharge and six months follow-up. Stroke/TIA, death, wound complications, cranial and cervical nerves injuries and restenosis rate were reported and analyzed through statistical analysis (χ2 and Student's t test). RESULTS: The 30 days mortality was 0.3% (1/300). The TIA rate was 0.91% in group A and 1.2 % in group B (P>0.9). Wound complications were 1.8% and 1.2 % respectively (P>0.1). No statistically differences were reported in the incidence of cranial and cervical nerves injuries between the two groups (P>0.9). No difference in restenosis rate was detected (P>0.9). In case of lengthening of the incision for high internal carotid (ICA) stenosis and especially to the need of shunt deployment, the longitudinal approach showed unequivocally to be easier and safer. CONCLUSION: No differences were achieved between short longitudinal and transverse incision in term of stroke, wound complications or nerves impairment. A good cosmetic outcome was gained in both groups. The Duplex US skin markings pre-CEA permitted localization and limits of the plaque with appropriate short incision. A longitudinal cervical approach is to prefer as can lead to an easier proximal and distal lengthening in cases of atherosclerotic extension of the plaque and shunt deployment.

[Results of open repair of infrarenal abdominal aortic aneurisms in patients unfit for endovascular treatment]. / Risultati della chirurgia tradizionale nel trattamento degli aneurismi dell'aorta addominale sottorenale con controindicazione alla terapia endovascolare.

INTRODUCTION: Purpose of the study was to assess how the introduction of endovascular treatment has affected mortality and morbidity of the traditional surgery for infrarenal abdominal aortic aneurysms (AAA). PATIENTS AND METHODS: From January 2002 to December 2009 we treated 230 patients with AAA (mean age 71.6; 121 male 70.7%); 171 (74.4%) were treated with surgery, 59 (25.6%) underwent to endovascular exclusion .We divided the patients into two groups: Group A, before the beginning of our "endovascular"; Group B, after the beginning of our endovascular experience. A total of 171 patients were treated with traditional surgical intervention, 99 in Group A and 72 in Group B. We evaluated the morbidity and mortality between the two groups by statistical analysis (by Student t test and χ ² test) considering a significant p-value <0.001. RESULTS: e 30-day mortality was 4% respectively in group A and 5.5% in group B (P = not significative, n.s.). The incidence of renal and ischemic peripheral complications was, respectively, 2% and 4% in group A, and 4.1% and 8.3% in group B showing statistical significance (P <.001). There were no documented statistically significant differences between the two groups in terms of cardiac and respiratory complications (P = n.s.). CONCLUSIONS. The results of the traditional surgery for the infrarenal AAA not suitables for endovascular repair suffer from the difficult anatomy of aorto-iliac district. Although the incidence of complications of open surgery is increased, the mortality is similar to anatomical not complicated aneurysms.

[Renal artery aneurysm. Treatment by ex-vivo reconstruction and autotransplantation: three cases and literature review]. / Autotrapianto renale ex vivo negli aneurismi delle arterie renali. Analisi di tre casi e revisione della letteratura.

Renal artery aneurysms (RAAs) is a rare clinical entity: the prevalence is approximately 0.01%-1% in the general population. Complex aneurysms of the first ramification of the main renal artery often require nephrectomy for adequate excision. From December 2002 to July 2007, we treated 3 patients with complex RAA. All the patients were treated with ex vivo reconstruction of the renal artery followed by autotransplantation of the kidney into the ipsilateral iliac fossa. Observation is suggested for asymptomatic complex renal artery aneurysms measuring less than 2 cm in diameter. Surgical treatment by aneurysmectomy and reconstruction in vivo or ex vivo technique is indicated for RAA causing renovascular hypertension, dissection, embolization, local expansion and for those in women of childbearing age with a potential for pregnancy, or asymptomatic more than 2 cm in diameter. Ex vivo repair and renal autotransplantation is a safe and effective treatment for the management of complex renal artery aneurysms.

[Hypoglossal artery and carotid endarterectomy. Case report]. / Persistenza dell'arteria ipoglossa ed endoarteriectomia carotidea. Case report

The persistence of hypoglossal artery is a rare malformation. Association of carotid stenosis with persistent hypoglossal artery can lead to cerebral posterior symptoms due to ischemia intolerance. The Authors report a case of unexpected intraoperative detection of this anomaly in a patient with high grade stenosis of the right internal carotid artery. Right carotid endarterectomy was performed, and no shunt was used. The postoperative course was normal. The literature was reviewed.

Carotid endarterectomy: general anaesthesia with remifentanyl conscious sedation vs loco-regional anaesthesia.

AIM: To retrospectively evaluate and compare the safety and efficacy of general anesthesia with remifentanyl conscious sedation (RCS) vs local-regional anesthesia (LA) for carotid endarterectomy (CEA). METHODS: From January 2004 to January 2008, 390 CEA performed in 325 patients (M/F 214/111, age 75 +/- 7) were collected in 2 groups: RCS group included 275 consecutive CEA in 230 patients carried out under remifentanyl conscious sedation with stopping of the remifentanyl infusion at the carotid clamping time to evaluate the clinical neurological status; LA group was composed of 115 consecutive CEA in 95 patients, performed under local-regional anesthesia. We evaluated complications, postoperative morbidity and mortality, need for shunt insertion and compared the results by means of Student's t-test and chi2 analysis. P value <0.05 (T=2.28) was considered significant. RESULTS: The 30 days mortality was 0.35% in the RCS group and 0% for LA group (P=NS). The 30 days stroke rates were 0.3% and 0% respectively (P=NS). TIA/RIND rates were 0.3% for RCS group and 1.7% for LA group (P=0.47); shunt usage was 20% for RCS group and 17% for LA group (P=0.26). We found higher postoperative nausea/vomiting in the RCS group (3.9% vs 0.8%, P<0.05). CONCLUSIONS: General anesthesia with remifentanyl conscious sedation seems to be a safe technique, allowing monitoring of the neurological status, cerebral protection during arterial clamping, better control of the airway and a good compliance to both the surgeon and the patient. A randomized control trial is needed to prove RCS to be effective as LA.

Prejudices and realities in the use of 'unsuitable' saphenous vein graft for infrapopliteal revascularization.

BACKGROUND: Aim of this paper is to evaluate the safety and the patency rate of the infrapopliteal bypass grafts performed with the great saphenous vein (GSV) with small (<2.5 mm) or large calibre (>5 mm). PATIENTS AND METHODS: Between January 2003 and May 2007, 73 infra-genicular bypass with autologous saphenous vein were performed in patients affected by atherosclerotic femoropopliteal disease. In 8 cases a bypass grafts with small saphenous vein (diameter 2.2-2.5 mm) were performed, in 4 cases a bypass with segmental varicose saphenous vein (diameter 5.7-6.4 mm ) were carried out. In 64 cases the bypass was carried out with the reversed technique, in 9 cases with the in situ technique. RESULTS: Thirty day mortality was 3/82 (3.6%) and 30 day cumulative patency rate was 95.1% (78/82) with limb salvage of 96.3% (79/82). All the patients with small diameter vein showed a normal patency at the follow-up and at the duplex scan examination no complications occurred. The mean calibre of the arterialized vein increased to 2.6-3,4 mm at 1 week with maintenance during the follow-up. Patients with varicose vein implanted present a mean dilatation of 6.4-7.2 mm at 1 week and no dilatative complication were detected at the follow-up. CONCLUSION: The risk of stenosis, graft thrombosis or aneurysm degeneration doesn't seem to be higher respect normal GSV either for small or for large veins. Large series and longer follow up are mandatory for an extensive clinical application.

An unexpected anatomical variant of the femoral artery in a patient with acute lower limb ischemia: case report.

We report a case of acute embolic ischemia of the right lower limb in a patient with unexpected intraoperative anatomic variant of femoral artery. In this anomaly, the deep femoral artery arises from the external iliac artery, 2 cm above the inguinal ligament, runs with a parallel course with the superficial femoral artery, and placed between the branches of femoral nerve. In consideration of the difficulty to achieve extensive and optimal control of the external iliac artery with the femoral approach, a retrograde embolectomy of the iliac artery by two separate arteriotomies on the deep and superficial femoral arteries were successfully performed. The literature reviewed about this anomalies. In these unexpected intraoperative cases a ductile and ingenious approach seems to be mandatory to perform a safe operation with low systemic impact.

Classic and endovascular surgical management of isolated iliac artery aneurysms.

AIM: Isolated iliac artery aneurysm is a rare pathology that is often asymptomatic for long periods; this late diagnosis exposes patients to a high risk of death following aneurysm rupture. The aim of this study was to establish the most suitable diagnostic approach, the correct indications for treatment, and the most appropriate tactics and surgical technique. METHODS: Twenty-eight patients were observed over 13 years. Aneurysmal involvement was unilateral in 22 cases and bilateral in the remaining 6 patients. Preoperative diagnostic tests included eco-colour Doppler (ECD) and angio-CT in all cases, with angio-MR and angiography as more selective procedures. Seventeen patients underwent conventional open surgery with prosthetic replacement of the aneurysmatic tract, 7 patients were treated using endovascular exclusion, and lastly 4 were monitored over time. RESULTS: There was no perioperative mortality for either treatment. During the postoperative period following conventional open surgery, complications included one case of severe respiratory failure, one microembolism of the lower limb, and 2 periprosthetic hematoma. During the follow-up, we observed one pseudo-aneurysm, 3 cases of retrograde ejaculation and one patient with erectile dysfunction after traditional surgery; there was one minor endoleak after endovascular exclusion. CONCLUSIONS: Our experience suggests that ECD is a useful method for arriving at an early diagnosis, while angio-CT imaging is essential for a correct preoperative study. Aneurysms with a diameter equal or greater than 3 cm or that present annual increases in excess of 5 mm represent a correct indication for treatment. Conventional open surgery is the treatment of choice for young patients in good general conditions. Endovascular exclusion is indicated when the patient's clinical conditions contraindicate open surgery and the morphology of the aneurysmal arterial district allows the endoprosthesis to be safely implanted.

[Exposure of distal internal carotid artery through mandibular vertical ramus osteotomy]. / Accesso chirurgico all'arteria carotide interna distale medicante osteotomia mandiobolare verticale.

Exposure of the distal internal carotid artery at the level of the second cervical vertebra required manoeuvers such as division of digastric muscle or mandibular subluxation. These increase the exposure but may not provide adequate access and are associated with significant cranial nerves or temporal mandibular joint complications. Vertical Ramus Osteotomy (VRO) provided access of the internal carotid artery (ICA) up to the base of the skull, with low incidence of cranial nerve injury temporo-mandibular joint (TMJ) pain and no preincision preparation. We report two cases in which vertical division of the mandibular ramus provided access of the ICA up to the base of the skull. Preoperative Duplex Scan examination and in the second case the arteriography revealed ICA preocclusive stenosis within 1.5 cm of the skull base. VRO was performed trouhgh a standard neck incision and miniature titanium plates were used to reapproximate the mandible after vascular procedure. There were no death, cranial nerve injury, mandibular nonunion, malocclusion or TMJ pain. We found that VRO is useful when carotid artery pathology extends beyond the usual field of exposure, avoiding nerve injury or TMJ lesion and requires no additional pre-incision preparation.