Early Embolization After Carotid Artery Stenting with Mesh-Covered Stent: Role of Diffusion-Weighted Magnetic Resonance Imaging as Pre-procedural Predictor and Discriminant Between Intra- and Post-procedural Events.

OBJECTIVES: To evaluate the incidence and the time of onset of early micro-embolism after CAS (carotid artery stenting) with two different mesh-covered stents and to assess the role of DW-MRI (Diffusion-weighted magnetic resonance imaging) in their prediction. METHODS: Single-institution prospective study including 50 patients (33 male, median age 74 years) who underwent CAS with Roadsaver® or CGuard™. All patients with primary stenosis (37/50, 74%) had carotid plaque DW-MRI pre-procedure, with both qualitative evaluation of the hyperintensity and ADC (apparent diffusion coefficient) measurement of the plaque. All patients had brain DW-MRI pre-procedure, at 1 h, 24 h and 30 days post-procedure to evaluate the appearance of hyperintense lesions over time. Imaging analysis was performed in a double-blinded fashion by two radiologists. RESULTS: There were no statistically significant differences between the two stents both in the incidence at 1 h (P = 0.23) and 24 h (P = 0.36) and in the volume of new DWI hyperintense brain lesions at 24 h (P = 0.27). Thirty-four new asymptomatic lesions in 19 patients (38%) were reported: 4 (11.8%) at 1 h, 30 (88.2%) at 24 h. The 30-day DWI-MR showed complete resolution of all lesions and no evidence of new lesion. The incidence of new lesions at 24 h resulted significantly higher in patients with DWI hyperintense carotid plaques (12/16, 75% vs. 0/21, 0%, P < 0.0001). This result was paralleled by the difference in ADC value (0.83 ± 0.21 vs. 1.42 ± 0.52). CONCLUSION: The majority of early asymptomatic brain lesion occurred during the first 24 h after CAS. Pre-procedure high DWI signal of the plaque was associated with an increased incidence of post-procedure microembolizations.

Contrast enhanced ultrasound in atherosclerotic carotid artery disease.

AIM: The traditional morphological parameters for the description of a carotid atherosclerotic plaque (degree of stenosis, echogenicity, systolic peak velocity etc.) are insufficient for the prediction of the risk of embolization. Contrast enhanced ultrasound (CEUS), based on the theory of inflammation and neoangiogenesis, seems to have a great potential for the detection of unstable plaques. The purpose of our work was to compare echogenicity of the plaque (evaluated with the Grey Scale Median; GSM), the degree of stenosis and CEUS with the histopathological findings. METHODS: Patients with indication for internal carotid endarterectomy (CEA) underwent a preoperative imaging study with B-mode echo Doppler Ultrasound and with CEUS. The contrast enhancement of the plaque was described with two parameters: the maximum and mean signal intensity (SImax, SImean). After the surgical operation the removed plaque is sent to the pathology laboratory for the measurement of the neoangiogenesis (vessel density, VD). RESULTS: Fifty-one consecutive patients were enrolled (12 symptomatic, 39 asymptomatic). Analysis pointed out significant differences between symptomatic and asymptomatic patients for: GSM median 14 (I quartile 11.5; III quartile 23) versus 32.5 (27-42.25) (P=0.012); SI (%) SImax 30 (29-35.5) versus 24 (19.7-27) (P<0.001) and SImean 23 (20.5-27) versus 15 (8-18.25) (P<0.001); VD (vessels/mm2) 41.5 (30-70) versus 12.6 (7-18.6) (P<0.001), respectively. Moreover, a cut-off value was determined between the two groups for each parameter: GSM:25, SImax:28%, SImean:20%, and VD: 25/mm2. Combined analysis showed that plaques with greater contrast enhancement had more newly formed capillaries and that plaques with lower GSM values correlated with greater vascularization. CONCLUSION: The study confirms that in vitro neoangiogenesis, contrast enhancement and stability of the plaque are strongly connected and CEUS appears to be one of the most promising tools for the stratification of the carotid plaque vulnerability.

Two-stage treatment of a secondary aortoesophageal fistula after thoracic endovascular aneurysm repair.

Secondary aortoesophageal fistula is a relatively rare but very often lethal complication that may develop after thoracic endovascular aneurysm repair (TEVAR). The clinical syndrome is well explained by the Chiari triad: midthoracic pain and/or dysphagia, and sentinel minor hematemesis followed by massive hematemesis. The incidence of this serious complication has increased with the growing number of patients undergoing TEVAR. This case report describes a patient who was seen in the emergency department at this hospital because of fever, sepsis and thoracic pain radiating to the back and unresponsive to drug therapy, diagnosed with a secondary aortoesophageal fistula and subsequently treated with a two stage surgical procedure.

Hybrid treatment of aberrant subclavian artery aneurysm. Case report.

A 62-year-old man was incidentally diagnosed with a completely asymptomatic aberrant right subclavian artery (ARSA) aneurysm with a maximum diameter of 4.5 cm. This condition presents a postrupture mortality rate of 50% and the morbidity-mortality rates reported in the literature with traditional open repair procedures are of 25%. In our patient we planned a hybrid procedure and excluded the aneurysm by performing, first, a right carotid-subclavian bypass with ligation of the subclavian artery upstream from the vertebral artery and the internal mammary artery and, the day after, by covering its origin from the aortic arch with the placement of a thoracic endoprosthesis. A third session was necessary, three days later, because of a leak; a complete resolution of the condition was achieved by embolizing the still perfused residual aneurysmal sac with Balt metallic coils.

Isolated dissection of the superior mesenteric artery: conservative approach in a selected patient.

The authors present the case report of effective conservative treatment in a patient with spontaneous, self-limiting, non-atherosclerotic dissection of the superior mesenteric artery (SMA) without fixed obstruction of the vessel lumen and signs of intestinal ischemia. Treatment with both anti-coagulant and anti-hypertensive agents succeeded in limiting the progression of intimal dissection and in preventing the potential dramatic sequelae of this rare clinical condition. Conservative treatment of spontaneous SMA dissection may be an alternative to surgery, if residual blood flow is maintained.

Leiomyosarcoma of the inferior vena cava: a clinicopathologic review and report of four cases.

AIM: This article describes four cases of leiomyosarcoma treated in the University Hospital of Turin and reviews current understanding of the biological behavior of the tumor, together with essential diagnostic procedures and established approaches to treatment. METHODS: Between February 2004 and December 2005, four patients (two men and two women; mean age 57.5 years) with leiomyosarcoma of the interior vena cava (IVC) were treated at the Vascular Surgery Unit. Resection and excision of the tumor were carried out (4/4 patients), with resection of the IVC above and below the mass (2/4) and reconstruction of the vein with a Dacron prosthesis with termino-lateral reimplantation of the renal vein in one and placement of a polytetrafluorethylene graft in the other. RESULTS: The postoperative course was unremarkable; the patients were discharged between postoperative days VIII and XI. Oral anticoagulant therapy with dicumarol (3/4) was given to maintain venous or prosthesis patency during the follow-up period. The mean length of follow-up was 23 months (range, 16-28). All patients recovered without local recurrence of disease. CONCLUSION: This malignant slow-growing tumor produces late clinical manifestations, making the study of its natural history clinically important. Currently, surgical excision is the only therapy that can alter disease progression and improve survival. The utility of adjuvant chemo- and radiotherapy remains controversial.

Radiofrequency minimally invasive endovascular treatment of lower limbs varicose veins: clinical experience and literature review.

AIM: Varicose veins of the legs are a common condition affecting 10-15% of men and 20-25% of women in the western world. This high prevalence is responsible of high medical and social costs. Most primary varices are associated with greater saphenous vein (GSV) incompetence. A new method, radiofrequency (RF) endovenous obliteration (VNUS-Closure'' procedure), recently has been described as a less invasive and cost-saving alternative to stripping for the treatment of refluxing GSV. METHODS: Twenty-four patients with varicose veins underwent endovenous obliteration of the above knee GSV by VNUS Closure'' procedure. The vein diameters were from 5 to 10 mm. The RF catheter was inserted via percutaneous puncture or through a small skin incision. All operations were performed in local, tumescent anesthesia, under ultrasound guidance. All patients were discharged 2 h after operation. Clinical and ultrasound follow-up was performed at 1 week, and at 1, 6, 12, 24 months. RESULTS: The complete or partial occlusion of the treated segment of the GSV has been achieved in 23 cases. In only one patient persisting patency of the GSV was immediately detected after the procedure. That was successfully treated by ultrasound guided foam sclerotherapy. All patients could resume all normal activities within 3-5 days. Every patient had reduction of varicosities, leg pain, fatigue and oedema. Adverse sequelae were minimal: 2 patients had transient thigh paresthesias. We didn't report deep venous thrombosis or pulmonary embolism (mean follow-up 26.7 months, range 15-33 months). CONCLUSION: A literature review and the authors'experience reveal that, in absence of significant complications, such as deep vein thrombosis and pulmonary embolism, there are significant advantages in the RF endovascular obliteration of the GSV. In effect, the Closure'' procedure, in selected patients, offers reduced postoperative pain, shorter sick leaves, faster return to normal activities compared with vein stripping, and it appears to be cost-saving for society. The mid-term (36 months) recurrence rates after RF obliteration seem to be similar to the results of the conventional surgical management.

A thermodynamic and structural study of myelin basic protein in lipid membrane models.

Myelin basic protein (MBP) is a major protein of the myelin membrane in the central nervous system. It is believed to play a relevant role in the structure and function of the myelin sheath and is a candidate autoantigen in demyelinating processes such as multiple sclerosis. MBP has many features typical of soluble proteins but is capable of strongly interacting with lipids, probably via a conformation change. Its structure in the lipid membrane as well as the details of its interaction with the lipid membrane are still to be resolved. In this article we study the interaction of MBP with Langmuir films of anionic and neutral phospholipids, used as experimental models of the lipid membrane. By analyzing the equilibrium surface pressure/area isotherms of these films, we measured the protein partition coefficient between the aqueous solution and the lipid membrane, the mixing ratio between protein and lipid, and the area of the protein molecules inserted in the lipid film. The penetration depth of MBP in the lipid monolayer was evaluated by x-ray reflectivity measurements. The mixing ratio and the MBP molecular area decrease as the surface pressure increases, and at high surface pressure the protein is preferentially located at the lipid/water interface for both anionic and neutral lipids. The morphology of MBP adsorbed on lipid films was studied by atomic force microscopy. MBP forms bean-like structures and induces a lateral compaction of the lipid surface. Scattered MBP particles have also been observed. These particles, which are 2.35-nm high, 4.7-nm wide, and 13.3-nm long, could be formed by protein-lipid complexes. On the basis of their size, they could also be either single MBP molecules or pairs of c-shaped interpenetrating molecules.

Symptomatic carotid stenosis. Diagnosis and treatment guidelines. Juridical and medico-legal approach.

An increasing body of health care regulations and the growing concern of physicians and patients about health care services have sharpened the debate surrounding the concept of quality in medicine. Once unknown terms such as audit, peer review, accreditation, ISO 9000, quality assurance (QA), continuous quality improvement (CQI) and risk management have become more familiar but also less clear. Following recent reports, medical error has been cited as a result of a health care system that has not yet fully embraced the tenets of quality management. A clearer explanation of definitions, knowledge and procedures is therefore needed. In Italy, the general debate on surgical risk led to a proposal to implement control systems that would monitor the work of each team member in the operating room, from the patient's arrival to transfer to the floor. But to understand the dynamics of doubtful cases, we need to start from new concepts that release the surgeon from the role of ''high priest in the surgery temple.'' Such concepts would underpin a process analysis of how much is effectively done and by whom. This means, on one hand, developing a greater awareness of one's role and competences, and on the other, delineating the stages within which each health care professional is expected to operate. Entering into the debate are the guidelines scientific societies have drawn up to rationalise and improve health care delivery through recommendations directed at optimizing the efficacy and efficiency of surgical intervention as the result of scientific evaluation and clinical observation. However, the critics in question do not always allow the surgeon to work under a medico-legal ''guarantee'' that covers his medical conduct. Further-more, they can be a double-edged sword in court if not adequately considered and critically evaluated with regard to a specific case, the object of censure and charge. In fact, they can be ''exploited'' as an instrument of accusation or defence in an arena where the mass media rush to blame the surgeon but later forget to duly report the acquittal of charges held against the surgeon. The present article examines the light and dark sides of guidelines, taking as an example those profiled by the Italian Society of Vascular and Endovascular Surgery and based on international guidelines for the treatment of symptomatic carotid stenosis.

[Femoropopliteal arterial thrombosis in a young patient with heterozygous V Leiden factor mutation. Case report]. / Trombosi arteriosa femoro-poplitea in giovane portatore di mutazione eterozigote per il fattore V di Leiden. Caso clinico.

Activated C protein resistance is a common coagulation defect caused by factor V Leiden mutation and is associated with an augmented risk of predominantly venous thrombosis. Augmented tendency to arterial thrombosis is sporadically reported. This case report describes femoropopliteal thrombosis in a young patient with heterozygous V Leiden factor mutation. Progressive thrombotic occlusion required amputation of the forefoot which resulted in stump dehiscence. Poor blood supply to the perilesional substrate delayed wound healing. An optimal though not yet definitive result was achieved after months of accurate medication. The criticality of lower limb ischemia in an otherwise healthy young patient underscores the grave impact this condition can have on the patient's quality of life and on health care costs.

Vascular surgeon and endovascular practice: legal possibility or absolute prohibition?

In Italy the diagnostic and therapeutic radiology practice is regulated by special laws, which are changed acting in accordance with EURATOM directive so that other specialists can use radiological instrument, such as orthopedic surgeons and cardilogists do. Medical and technological progress enables vascular surgeons to choose other treatments alternative to conventional surgery in the treatment of some vascular diseases by the use of radiological instruments. In our country there are special laws for the practice of radiology, so we verify if vascular surgeons can legally perform endovascular procedures using radiological techniques.

A case of carotid bifurcation anomaly discovered during a thyroidectomy operation.

The anatomic anomalies of the supra-aortic trunks and their branches are comparatively frequent observations. They often remain asymptomatic throughout life although in some cases, especially if nothing is known of them, they may complicate surgical interventions involving that anatomical region. The case of a female patient who, during thyroidectomy, suffered the ligature of her external carotid artery which was taken mistakenly for the thyroid, is reported. Dissection of the area made it possible to identify an anomaly of the vascular structures with a carotid bifurcation which turned out to be very low, a very deep internal carotid artery on the prevertebral fascia and an absent lower thyroid artery. In the postoperative period, the patient was subjected to MR of the neck. This showed an anatomical anomaly of the left carotid bifurcation which was much lower than normal. An attempt was made to reconstruct the external carotid artery with a saphenous vein but unsuccessfully. The incident did not have serious complications for the patient but it might be asked whether, given the low cost and the absolute non-invasiveness of the examination, it might not be worth while to carry out a duplex scan of the supra-aortic trunks before going ahead with any operation in the cervical region, in consideration above all of the dangerous nature of these vascular structures and of the usefulness of studying pathologies that often remain silent until the occurrence of an event which might well be catastrophic.

Cystic adventitial disease of the popliteal artery. Report of 1 case and review of the literature.

Cystic adventitial disease (CAD) of the popliteal artery is a rare but well-known cause of intermittent claudication, especially in young patients. The etiology of the disease is still controversial and the literature reports various hypotheses for its origin. Diagnosis starts with thorough history taking and physical examination; non invasive diagnostic studies comprise color duplex scanner (ECD), computed tomography (CT), better if elicoidal (3D CT) and magnetic resonance imaging (MRI), which can aid in establishing correct recognition of the disease in most cases. A 48-year-old man presented with intermittent right calf claudication that had begun 4 months earlier; the symptom-free interval was about 100 m. MRI and MR angiography of right popliteal fossa revealed the presence of an oval cystic (maximum diameter 45 mm). The caudal aspect of the cyst showed pedicles protruding between the popliteal vein and the popliteal artery that compressed the artery, causing complete occlusion of its lumen. Surgery was performed through the posterior approach using an S-shaped incision; the affected segment of the popliteal artery was successfully excised and replaced with an autogenous external saphenous vein graft. A follow-up is underway, both clinical and with; no cyst recurrence has so far been detected either clinically or by duplex scanner during the 15-month postoperative follow-up period; the graft is patent and the patient is completely symptom free. Severe claudication in young patients, possibly without significant vascular risk factors, should prompt the clinical suspicion of adventitial cystic disease of the popliteal artery. Medical history, clinical examination and non invasive instrumental investigations, such as duplex scanner, elicoidal CT and/or MRI, may aid in establishing the correct diagnosis.

Aneurysms of the hypogastric artery following surgery of the abdominal aorta. A report of two cases and review of the literature.

Isolated aneurysms of the hypogastric artery are very rare and account for between 0.04% and 0.4% of all intra-abdominal aneurysms. In 85% of cases they are monolateral and are present in association with an aneurysm of the infrarenal abdominal aorta and of the common and external iliac arteries, they make up part of a poly-aneurysmal disease. Unless the patient is an extremely poor condition, surgical treatment is generally indicated for aneurysms greater than 3 cm; close monitoring of those with smaller aneurysms is recommended. Two patients presented with isolated aneurysm of an internal iliac artery which had developed several years after aortoiliac surgery. The one received surgical treatment; the other, who was in poor general conditions and at high risk for surgery, underwent endovascular embolization. Both procedures were successful, with a current follow-up between 15 and 18 months. Endovascular embolization, as performed in the 2(nd) patient, provided an alternative to the surgical procedure. After injection in the aneurysmal sac of the Gianturco spirals, a covered stent was placed in the iliac axis to exclude the inflow of the hypogastric artery. According to our experience of 2 patients, the one treated surgically and the other submitted to a less invasive endovascular procedure, we can state that both methods are practicable. The final choice lies with the vascular surgeon, after weighing the multiple factors that each case involves.

Small aorta syndrome: hypothesis or reality?

A syndrome of peripheral obliterating arterial disease characterised by aortoiliac steno-occlusion is reported in the literature under the name small aorta syndrome, occurring in young women of small stature with relatively typical risk factors. Starting from an analysis of the studies reported in the literature and on the basis of our own results, we have attempted to ascertain whether small aorta syndrome represents an independent nosological entity. By analysing studies on the small aorta syndrome and in the light of a recent study made by our group on arterial diameters measured in cadavers, which highlights a significant correlation between aortic diameter and age, it can be affirmed that a pathology of this nature does not respond to absolute criteria for existence. Therefore, the aortoiliac diameter in women suspected of being affected by small aorta syndrome appears to be broadly in proportion to that expected in healthy women of the same age. Small aorta syndrome does not therefore appear to represent a separate nosological entity. It takes the form of a hypoplastic vascular disorder, which is probably congenital, correlated to other arterial districts in the same subject. However, it may encourage the onset of early symptoms in women of small stature.

Left-sided inferior vena cava in patients submitted to aorto iliac surgery. Our experience and review of the literature.

We present two cases of left sided inferior vena cava, one unexpectedly observed during an operation of aorto bifemoral bypass in a patient with severe Leriche syndrome and almost complete obstruction of the infrarenal aorta, the second in a patient with an aneurysm of the abdominal aorta, in whom the anomaly was recognized before the operation. This very rare congenital malformation (0.2-0.5%) was not recognized in the first patient by the duplex scanner performed preoperatively, probably because of the low level of suspicion carried on by an experienced operator. Computer tomography angiography or magnetic resonance angiography, which would have surely shown us the anomaly, were not done in the first patient because, in the lack of an aneurysmal disease or other abdominal pathological situations, these investigations were not required before operation. The possible hazards of such an unrecognized malformation are great, mostly in terms of uncontrollable intraoperative hemorrhages, but the final outcome of this case was positive.