A Pearl-Like 30-Year-Old Moving Phlebolith in the Left Cephalic Vein.

BACKGROUND: Phleboliths are a common finding, especially in the pelvic veins. There are generally multiple thrombi associated with vascular malformations, trauma, or iatrogenic or noniatrogenic intravenous foreign bodies. METHODS: Herein, we report a unique case of a single moving phlebolith in the cephalic vein of a 65-year-old man, not associated with any vascular lesion, trauma, or foreign body. RESULTS: Too many cases of phleboliths have been reported in the literature since 1948, referred to vascular disorders, injuries, or foreign bodies. Only this work we are presenting refers to a phlebolith not associated with other vascular, pathological, or traumatic lesion. CONCLUSION: Phleboliths not associated with other vascular lesions are not common and less rare when not associated with injuries or iatrogenic interventions. Clinicians should be aware of the existence of this pathology and include it as the differential diagnosis of various pathological conditions.

Reversal of Acute Mesenteric Ischemia by Salvation of the Meandering Mesenteric Artery with Stenting of the Left Internal Iliac Artery.

The presence of the meandering mesenteric artery, which is a nonconstant tortuous arterial component unifying the peripheral intestinal circulation, is evidence of chronic occlusive disease of the main intestinal arteries. This collateral intestinal arterial pathway, when present, must be preserved in any abdominal intervention, as it is often the only remaining arterial supply of the intestine; its ligation can be accompanied by intestinal ischemia. We present herein, the case of a 42-year-old man, heavy smoker, who had chronic mesenteric ischemia without particular clinical manifestations till the hospitalization for acute myocardial infarction for which he underwent balloon angioplasty and stenting of the left circumflex coronary artery. Three days later, he experienced acute-on-chronic intestinal ischemia with crescendo clinical manifestations; intra-arterial angiography revealed the presence of a meandering mesenteric artery in a milieu of celiac, superior and inferior mesenteric, and right internal iliac artery occlusion accompanied by a tight stenosis of the left internal iliac artery. Successful stenting of the orifice of the left internal iliac artery was followed by a well-defined dilatation of the meandering artery, revascularization of the peripheral branches of the inferior-through the superior hemorrhoidal artery-and superior mesenteric arteries and complete resolution of the acute mesenteric ischemia. Thus, time was gained for the patient in order to have, if needed, a future elective open revascularization of the mesenteric artery, when the perioperative risk of mortality from the recent myocardial infarction and the coronary angioplasty and stenting will be minimal.

Left Gastroepiploic Artery True Aneurysm: Case Report and Review of the Literature.

Although the aneurysm of the splenic artery represents the third most common abdominal arterial aneurysm next to the aortic and iliac aneurysms, the aneurysm of the gastroepiploic artery is extremely rare occurring at a frequency of 3-4% of all visceral arteries' aneurysms; only 17 cases have been reported in the English literature. We present the case of a 65-year-old woman with an asymptomatic visceral artery aneurysm, which was an incidental ultrasonography finding. Magnetic resonance imaging showed an arterial aneurysm close to the peripheral splenic artery with intense tortuosity of the celiac and splenic artery. Abdominal computed tomography angiography confirmed the existence of an arterial aneurysm with a diameter of 2.3 cm near the splenic hilus without identifying the involved vessel. Endoluminal treatment was considered cumbersome due to anticipated anatomic obstacles; the patient underwent an elective open surgery in which the tortuosity of the celiac and splenic arteries and the aneurysm of the left gastroepiploic artery were revealed. The aneurysm was resected after proximal and distal ligation of the gastroepiploic artery; the flow of the splenic artery was intact. Histologically, it was a true aneurysm. The patient left the hospital on the fourth postoperative day without any complication. Historically, most aneurysms of the gastroepiploic arteries have been observed in men in the sixth decade of their life and after rupture; in modern times, their early incidental apocalypse is frequent due to the widespread use of imaging studies. Diagnostic approach and preoperative planning is of paramount importance to avoid complications. Current therapeutic modalities include catheter-based techniques or laparoscopic surgery.

Immunohistochemical expression patterns of S100, synaptophysin, chromogranin A and neuron specific enolase in predicting malignant behaviour in paragangliomas.

PURPOSE: The purpose of this study was to evaluate the role of immunohistochemical markers in the prediction of malignancy in paragangliomas. METHODS: Our institute's patient records between 1990-2012 were retrieved in order to identify patients who were treated for paragangliomas. Size and location of the tumour, existence of concurrent metastatic disease, patient demographics and survival were recorded. Haematoxylin-eosin stained slides were reviewed and all tumours were stained specifically for neuron specific enolase (NSE), chromogranin, synaptophysin and S100 protein positivity. Positivity and expression patterns of the above markers were evaluated and compared between malignant and benign tumours. Malignant behaviour was defined when patient had concurrent or subsequent lymph node involvement, local recurrence and/or metastases. RESULTS: A total of 22 patients with a diagnosis of paraganglioma were treated in our institutes. Female to male ratio was 1.75: 1. The mean age was 43.5 and 51.6 years for women and men, respectively. In 5 patients the tumors had malignant clinical behavior. Their mean size was 3.65 cm for benign and 4.56 cm for malignant neoplasms. NSE expression was diffuse in 47.1% and 0% for benign and malignant tumors, respectively (p=0.10). S100 expression in the periphery of the tumour was typical in 88.2% and 0% for benign and malignant tumors, respectively (p<0.001). CONCLUSION: Immunohistochemical profile from the combination of NSE, synaptophysin chromogranin and S100 staining patterns can serve as a cheap and valuable tool for correctly distinguishing between malignant and benign paragangliomas with high diagnostic accuracy.

Dorsalis Pedis Artery Aneurysm: A Case Report and Review of the Literature.

Aneurysms of the foot arteries are rare. A case of a true dorsalis pedis artery aneurysm in a 69-year-old man, with no history of local trauma or injury on his foot, is presented. Clinical examination and ultrasonic imaging confirmed the aneurysm. Dorsalis pedis artery aneurysm was resected and an end-to-end anastomosis was performed, without complications. Arterial duplex scan findings, operative procedure, and literature review are presented and discussed.

Carotid endarterectomy in a young symptomatic patient with B-thalassemia major.

ß-Thalassemia major promotes atherosclerotic process, although the debating literature concerning the lipidic profile of young patients; it is well accepted that there is early vascular destruction in these homozygous patients either as a direct consequence of the genetic disorder per se or because of the repeated transfusions and the iron overload. Despite the potential of the disease for local brain thrombotic events, accelerated atheromatosis can lead to early thromboembolic events. We present an interesting case of a 36-year-old man with unilateral embolic infarcts (repeated transient ischemic attacks) originated from a near occlusion right carotid stenosis with additional peripheral thrombus. The patient underwent a successful carotid endarterectomy with primary arterial closure with uneventful postoperative course, confirmed by a clear postoperative angiography; he remains asymptomatic 18 months later. To the best of our knowledge, this is the first case of a young symptomatic patient with ß-thalassemia major who underwent carotid repair.

Surgical Considerations for the Management of an Ectopic Main Renal Artery Originating from an Abdominal Aortic Aneurysm.

Ectopic major renal arteries are rare but anatomically important because they can complicate aortic surgery and make the operation challenging for vascular surgeons. A 68-year-old male was presented with a 5.5-cm aneurysm of the infrarenal abdominal aorta combined with an ectopic main right renal artery arising from the middle of the aneurysm sac, perfusing a normotopic right kidney. The patient also had small right common iliac artery aneurysm. Open repair was performed with reimplantation of the right renal artery on the aortic tube graft, the right kidney was perfused with cold heparinized lactated Ringer solution during operation. The right common iliac artery aneurysm was wrapped with a polyester band. The patient's postoperative courses were uneventful, with normal renal function during 5 years of follow-up. Preoperative planning is important for achieving optimal results in treating complex aneurysms with ectopic main renal artery.

Eversion Carotid Endarterectomy: Cardiac Troponin Assessment.

Myocardial infarction (MI) is an eversion carotid endarterectomy (eCEA) complication, but most events are unknown, and true incidence and correlation remain controversial. Routine cardiac troponin measurement is a commonly used method for assessing early identification and treatment of MI and stratifying high-risk patients. The aim of the present study is to evaluate the effect of troponin elevation levels following eCEA and to investigate a possible correlation between adverse cardiovascular events and the incidence of postoperative myocardial infarction following emergent vascular surgery. The study included 54 patients who underwent eCEA. High-sensitive troponin I (hsTnI) levels were routinely monitored pre- and postoperatively, with an upper reference range of 34.5 pg/mL for men and 15.6 pg/mL for women. Increases were correlated with demographic and clinical risk factors, as well as clinical or subclinical cardiovascular events. hsTnI was increased in percentage (13%) postoperatively, and non-ST segment elevation MI was diagnosed in eight patients. No patient had clinical symptoms of MI and only two of them presented with simultaneous electrocardiographic changes. Increased levels did not correlate with comorbidities or other surgical risk factors. hsTnI elevation may occur in patients after eCEA and mostly correlates with silent non-ST segment elevation MI that occurred in the early postoperative phase, indicating a possible value as a tool for cardiovascular event diagnosis during the patient's hospitalization.

The contribution of oncovascular surgery in a young patient with idiopathic retroperitoneal fibrosis.

Surgical resection remains the cornerstone for the treatment of oncological disease. When a critical arterial or venous structure is involved in a tumor mass, successful relief of symptoms and long-term oncological control are achieved through careful preoperative planning by an interdisciplinary team that necessarily includes a vascular surgeon. We describe the involvement of a vascular surgeon in the oncology of a 22-year-old woman, who is diagnosed with idiopathic retroperitoneal fibrosis.

Vena cava balloon occlusion for pulmonary embolism prevention during resection of giant uterus fibroids.

We report the case of a single 46-year-old woman presenting with huge uterine fibroids growing for the last 12 years, resulting in a recent common iliac vein thrombosis. Due to the high risk for pulmonary embolism, an occluding balloon was inserted through the right jugular vein before the abdominal incision and occluded the vena cava just inferior to the renal veins. The tumor was easily mobilized, and the vena cava bifurcation was exposed and controlled until the uterus with the masses was resected. We recommend this method for oncovascular surgeries involving deep vein thrombosis and vein thromboembolism.

Chronic rupture of abdominal aortic aneurysm.

Although the mortality rate after abdominal aortic aneurysm rupture approximates 90% despite the urgent management, a few cases of chronic rupture and delayed repair have been reported in the world literature; anatomic and hemodynamic reasons occasionally allow for the fortunate course of these patients. We report in this article the case of 76-year-old man with a ruptured abdominal aortic aneurysm who was transferred to our facility 4 weeks after his initial hospitalization in a district institution and who finally had a successful open repair.

Arterial Stiffness Assessed by Cardio-Ankle Vascular Index in Patients With Abdominal Aortic Aneurysm and Its Alterations After Treatment.

PURPOSE: The aim of the present study was to investigate a potential difference on the arterial stiffness among aneurysm patients and non-aneurysm controls, as well as to explore potential changes between patients treated either with endovascular or open repair. MATERIALS AND METHODS: A 110 patients with an infrarenal AAA were prospectively enrolled in this study. Fifty-six patients received an EVAR, whereas 54 patients received an open surgical repair. Moreover, 103 gender and age-matched subjects without AAA served as controls. The cardio-ankle vascular index (CAVI) was applied for measurement of the arterial stiffness. RESULTS: CAVI values were statistically higher in the AAA patients when compared with control subjects. Although at 48 hours postoperatively the CAVI values were increased in both groups when compared to baseline values, the difference in CAVI had a tendency to be higher in the open group compared to the endovascular group. At 6 months of follow up the CAVI values returned to the baseline for the patients of the open repair group. However, in the endovascular group CAVI values remained higher when compared with the baseline values. CONCLUSION: Patients with AAAs demonstrated a higher value of CAVI compared to healthy controls. A significant increase of arterial stiffness in both groups during the immediate postoperative period was documented. The increase in arterial stiffness remained significant at 6 months in EVAR patients. Further studies are needed to elucidate the impact of a decreased aortic compliance after stentgraft implantation on the cardiac function of patients with AAA.

Disobliteration of an Occluded Common Carotid Artery with Patent Bifurcation via Antegrade Ring Stripping.

There is a lack of guidelines concerning common carotid artery (CCA) occlusive disease in the presence of a patent internal carotid artery (ICA). A novel surgical technique that disobliterates an occluded CCA was successfully performed in three cases. The detailed surgical steps are presented herein. After proximal division of the CCA behind the sternoclavicular junction, the occluded CCA was endarterectomized via antegrade ring stripping. After removal of the atheromatous core, the CCA was everted, and the wall remnants were cleaned under direct vision. Simultaneous eversion endarterectomy of the ICA was performed when necessary. After reversion of the CCA, it was transposed and anastomosed to the ipsilateral subclavian artery distal to the orifice of the vertebral artery. This novel technique can be used in selected cases by experienced surgeons.

Carotid Body Baroreceptor Preservation and Control of Arterial Pressure in Eversion Carotid Endarterectomy.

The technique of the eversion carotid endarterectomy (ECEA), as an alternative to the conventional endarterectomy with primary or patch angioplasty, is an established technique for managing internal carotid artery stenoses and recently its application has been upgraded through the European Society for Vascular Surgery guidelines (Recommendation 55: Class 1, Level A). However, the typical eversion method has been associated with postoperative hypertension due to loss of the baroreceptor reflex; the standard oblique transection at the bulb performed in the eversion endarterectomy interrupts either the baroreceptor sensoring tissue, which is mostly located in the adventitia at the medial portion of the proximal internal carotid artery, or even the proper Hering nerve, a branch of the glossopharyngeal nerve. These actions deregulate the natural negative feedback of the carotid baroreceptor. Guided by the anatomical location of the baroreceptor sensor we have elaborated a slight modification of the classical ECEA to maintain as much as possible of the viable carotid baroreceptor sensoring surface. By extending the oblique incision distal to the carotid bifurcation in the medial part of the internal carotid artery stem, an eyebrow-like part of the proximal internal carotid artery is maintained and the axis from the sensoring tissue to the nerve of Hering is protected and following the endarterectomy, postoperative arterial blood pressure levels are lower than in the classical ECEA due to the maintenance of the efficiency of the baroreceptor reflex. During the period from September 2016 to November 2018, carotid endarterectomy was performed in 57 patients. Twenty-eight of them underwent the typical ECEA and 29 patients had the modified eyebrow eversion carotid endarterectomy (me-ECEA). The changes of blood pressure baseline during the postoperative course in ECEA and me-ECEA group were analyzed and compared. Postoperative hypertension was defined as an elevation of systolic blood pressure (SBP) greater than 140 mm Hg. Patients who underwent typical ECEA had significantly higher postoperative blood pressure values compared with those who underwent me-ECEA. Actually, the mean postoperative SBP was 172.67 ± 24.59 mm Hg in the typical ECEA group compared with 160.86 ± 12.83 mm Hg in the me-ECEA group ( p = 0.023). The mean diastolic blood pressure in the ECEA group was 65.42 ± 11.39 mm Hg compared with 58.06 ± 9.06 mm Hg in the me-ECEA group ( p = 0.009). Our proposed me-ECEA technique seems to be related to lower rates of postoperative hypertension compared with the typical ECEA, probably due to the sparing of the main mass of the baroreceptor apparatus; this improved modification (me-ECEA) of the typical eversion procedure could represent an alternative ECEA technique with its inherent advantages.

Insulin Metabolism and Assessment of Hepatic Insulin Extraction During Liver Regeneration. A Study in a Rat Model.

Background: Liver regeneration is a complex procedure in which insulin metabolism has been implicated. The aim of this experimental study was to evaluate the role of insulin in rat hepatic regeneration following major hepatectomy (70%), employing an isolated perfused rat liver (IPRL) model to assess the extraction of insulin from the regenerating liver. Methods: Eighty-six male rats were randomized in 9 groups. A group of rats was studied at postoperative day (POD) 1 having a sham operation while control rats had no operation. All other animals were subjected to 70% hepatectomy. In phase B, at POD 1, 2, 3, 5, 7, and 14, the IPRL was applied. The regenerating liver was perfused with insulin (450 mu/ml) at a flow of 1.4 ml/gr liver/min for 20 min. Animal weight, liver weight, glucose, lactate, aspartate transferase (AST), alanine transferase (ALT), total bilirubin, albumin, prothrombin time (PT), insulin clearance, and tissue proliferating cell nuclear antigen (PCNA) expression were recorded. Results: We observed reduction of the liver's biochemical activities resulting in increase of AST (684%), ALT (532%), PT (27.7%), international normalized ratio (72%), and total bilirubin (82.8%) at first POD, while a normalization of the essential liver's functions occurs at fifth POD. Endogenous insulin concentration increased, while insulin extraction by the liver was reduced at the first POD in animals who underwent hepatectomy (13.94 ± 0.8 vs 7.97 ± 1.80 u/ml, p = 0.0005 and 71 ± 9.9 vs 165.88 µU/gr liver/min, respectively, p = 0.0005). Conclusions: Insulin seems to take part in hepatic regeneration, as the pancreas increases insulin production and the liver absorbs less despite the reduced hepatic mass and function.

Surgical techniques for the management of enteroatmospheric fistulae.

BACKGROUND: An intestinal fistula in the "open abdomen" is called "enteroatmospheric" and is a great challenge for the surgeon because of the high mortality and morbidity rates associated with it. This report is a study of the surgical strategy for treating patients with enteroatmospheric fistulae. METHODS: During a 3-year period (2005-2007), two males and one female patient with a mean age of 63 years were referred to our surgical department for management of enteroatmospheric fistulae that developed after operations carried out for severe peritonitis, which was a consequence of sigmoid diverticulum rupture in two cases and disruption of an entero-enteric Roux-en-Y anastomosis after total gastrectomy for cancer in one. RESULTS: All patients were appropriately supported in a surgical intensive care unit, with administration of total parenteral nutrition and appropriate antibiotics to eliminate secondary infections. Several re-operations were necessary to treat the enteroatmospheric fistulae. Eventually, all patients were discharged after a lengthy hospital stay (45-145 days). CONCLUSIONS: The essential principles of our operative strategy are: (1) early intervention; (2) a lateral surgical approach via the circumference of the open abdomen to avoid further damage to the exposed viscera; (3) excision of the involved bowel loop with an end-to-end anastomosis; (4) temporary abdominal closure and coverage of the open abdomen with an absorbable mesh, promoting tissue granulation; (5) skin grafting attempts; and (6) selective use of vacuum-assisted closure.

The introduction of a simple maneuver to reduce the risk of postoperative bleeding after major hepatectomies.

BACKGROUND/PURPOSE: In major hepatectomies, postoperative increases in central venous pressure (CVP) may cause suture failure and massive bleeding. The aim of our study is to test the application of an intraoperative maneuver to reduce the risk of postoperative bleeding. METHODS: Our study included 172 consecutive patients who had major liver resection with selective hepatic vascular exclusion and sharp transection of the liver parenchyma. An intraoperative maneuver (5 s occlusion of the hepatic vein) was applied in an alternating way, and the patients were assigned to two groups: Cohort A (n = 86), that was granted the maneuver, and Cohort B (n = 86), that was used as a control group. RESULTS: In Cohort A, application of the maneuver was successful in demonstrating bleeders under low CVP levels. Cohort A had lower rate of massive bleeding requiring emergency reoperation (2.3 vs 5.8%, P = 0.049), less postoperative blood transfusions (13 vs 24%, P = 0.042), lower morbidity (20 vs 35%, P < 0.045) and shorter hospital stay compared to Cohort B. CONCLUSIONS: Hepatectomies conducted under low CVP are prone to postoperative hemorrhage which can be prevented if the final bleeding control is performed under high pressure in the hepatic veins. Application of our testing maneuver effectively unmasked previously undetectable bleeding veins.

The influence of total plasma homocysteine and traditional atherosclerotic risk factors on degree of abdominal aortic aneurysm tissue inflammation.

OBJECTIVE: Modulating effects of genetic and environmental risk factors on severity of human abdominal aortic aneurysm (AAA) tissue inflammation remain unclear. We investigated the influence of total plasma homocysteine (tHcy) and traditional atherosclerotic risk factors (ARF) on degree of AAA tissue inflammation. METHODS: Aneurysm specimens were obtained from 89 male patients aged 52 to 83 years, underwent asymptomatic not ruptured AAA (mean diameter 5.5 cm) open repair and graded for degree of histologic inflammation. Multivariate analysis was used to determine the association of tHcy and ARF, with degree of inflammation. RESULTS: Current cigarette smoking, odds ratio (OR) 4.4, 95% confidence interval 1.3 to 15.2, P = .01 and no other ARF, neither tHcy levels OR 0.9 (0.9-1.02), P = .2 were associated with high-grade tissue inflammation. CONCLUSION: These results provide evidence against a major effect of tHcy levels on AAA tissue inflammation, while current cigarette smoking is a significant modulating factor.