Enhanced torque-based impedance control to assist brain targeting during open-skull neurosurgery: a feasibility study.

BACKGROUND: Cooperatively-controlled robotic assistance could provide increased positional accuracy and stable and safe tissue targeting tasks during open-skull neurosurgical procedures, which are currently performed free-hand. METHODS: Two enhanced torque-based impedance control approaches, i.e. a variable damping criterion and a force-feedback enhancement control, were proposed in combination with an image-based navigation system. Control systems were evaluated on brain-mimicking phantoms by 13 naive users and 8 neurosurgeons (4 novices and 4 experts). RESULTS: In addition to a 60% reduction of user effort, the combination of the proposed strategies showed comparable performances with respect to state-of-the-art admittance controller, thus satisfying the clinical accuracy requirements (below 1 mm), reducing the hand tremor (by a factor of 10) and the tissue's indentation overshooting (by 80%). CONCLUSION: Although the perceived reliability of the system should be improved, the proposed control was suitable to assist targeting procedures, such as brain cortex stimulation, allowing for accurate, stable and safe contact with soft tissues. Copyright © 2015 John Wiley & Sons, Ltd.

BRAVISSIMO: 12-month results from a large scale prospective trial.

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

Proctorship for CAS training: a pilot study of safety and reproducibility.

AIM: The literature continues reporting a high complication rate for carotid artery stenting (CAS) during the learning-curve phase (LCP). The aim of this study was to report a simple and reproducible method designed to improve CAS results during the LCP. METHODS: Between February 2007 and December 2009, a qualified vascular surgeon ran a proctorship program for CAS. The program was divided into four practical phases: in the teaching phase (a) the first 20 CAS were performed by the proctor assisted by a trainee surgeon; in the training phase (b) for the 21st to the 50th CAS the trainee surgeon was supervised by the proctor; in the skilled phase (c), between the 51st and the 80th procedure, a trainee surgeon performed CAS while the proctor was scrubbed-in but operating only on demand; in the final phase (d), following the 81st CAS, the procedure was performed without the proctor's presence. The inclusion criterion was carotid stenosis ≥70% and patient selection was performed for the first 40 cases based on patient and lesion characteristics. The procedure for CAS was standardized. RESULTS: Four trainees performed 604 CASs in two centers. The procedural success rate of CAS was 98.8% (N.=594/604) without any differences among the four trainees (P=0.902). The overall TIA, myocardial infarction, minor, major and fatal stroke rate at 30 days was respectively 1.7% (N.=10), 0.8% (N.=5), 1.2% (N.=7), 0.64% (N.=4) and 0.3% (N.=2). The effectiveness of this program was demonstrated by a significant decrease in the proctor's intervention between phase b and phase c (P<0.001) and by a similar trend in the complication rate achieved by the four trainees, in all phases and centers (P=0.075 and 0.788, respectively). CONCLUSION: This preliminary experience of a proctorship program in the LCP, together with patient selection and standardization of the procedure and materials used, seems to be safe and reproducible. Moreover, possibly randomized, studies comparing different CAS training techniques are needed in order to validate our findings.

Combined spinal and epidural anesthesia for open abdominal aortic aneurysm surgery in vigil patients with severe chronic obstructive pulmonary disease ineligible for endovascular aneurysm repair. Analysis of results and description of the technique.

This study evaluated the feasibility of open infrarenal abdominal aortic aneurysm (AAA) surgery under peridural and spinal anesthesia (vigil patient) alone in high-risk patients with severe chronic obstructive pulmonary disease (COPD) ineligible for endovascular aneurysm repair (EVAR) or open surgery in general anesthesia. Between January 2005 and July 2007, seven patients underwent open AAA surgery with combined spinal and epidural anesthesia ([CSEA] without intubation) alone. Regional abdominal anesthesia was established by spinal anesthesia at L2-3 (levobupivacaine plus fentanyl) associated with peridural anesthesia at T7-8 (levobupivacaine). In this series (6 males and 1 female) the average age was 76.5 years (70-87); the AAA measured 7 cm in diameter on average (range 6-12.2). The survival rate was 100% (7/7 patients) at 6-12 months postoperative; no morbidities occurred during the postoperative phase. Owing to the small size of the series, no statistically significant conclusions can be drawn; even so, repair surgery was found to be effective, without the occurrence of morbidities or mortalities. In high-risk patients (severe COPD), open surgical repair of infrarenal AAA may be done with CSEA alone without intubation when, because of the patient's health, general anesthesia would pose too high a risk or when EVAR is unfeasible. Furthermore, the authors believe that surgical AAA repair under CSEA in vigil patients is a valid treatment option in those subjects with a high operative risk (severe COPD) and untreatable by either open AAA surgery under general anesthesia or EVAR.

Visceral artery aneurysms: series of 17 cases treated in a single center.

AIM: The aim of this study is to evaluate early and long term results obtained with a retrospective review in 8-year experience with surgical/endovascular treatment of visceral artery aneurysm (VAA) in a single center. METHODS: Between 2001 and 2008 in our vascular surgery unit visceral artery aneurysms were diagnosed with CT and/or angiography in 17 patients (9 male), mean age 66 years old (range: 18 to 78). All patients underwent surgical or endovascular treatment of splanchnic artery aneurysm. In 14 patients the localization was single, in 3 it was multiple. The arteries involved were: splenic artery 53%, superior mesenteric artery 17.7%, pancreaticoduodenal artery 17.7%, celiac axis 5.8% and hepatic artery 5.8%. The 29.4% of the patients presented with aneurysm rupture. Coil embolizzation was used in 11.6% of the cases while surgery was used in 88.4% of the cases. RESULTS: Total survival rate was 94.2%, the survival rate in emergency cases was 80% while it was 100% in elective cases. Follow-up revealed excellent results after an average of 46 months (range: 8-102). CONCLUSION: The worst prognosis for ruptured cases associated with the good result of the surgical/endovascular treatment in elective cases, suggests active interaction for such pathologies; in emergency cases the mortality incidence is too high. Today endovascular treatment presents lower morbidity and mortality rates and shorter hospitalization, but surgery is still a good therapeutic option for the treatment of the VAA, in subjects with low surgical risk, determining a definitive and long-lasting correction of the aneurysmal pathology and guaranteeing the correct perfusion of the organs, by grafts; moreover many aneurysms are not suitable for endovascular treatment.

Isolated aneurysm of the inferior thyroid artery repair with coil embolization.

A 68-year-old female patient with a suspected aneurysm of the inferior thyroid artery was admitted to the authors' Unit of emergency after an accident. The echography of the thyroid revealed a ''suspected'' aneurismal dilation of the inferior thyroid artery (max. diameter 30 mm.). The patient underwent an angiograph of the supra-aortic trunk, which detected a small round formation at the base of the left inferior thyroid artery (found to be unaffected by aneurismal pathologies), the aneurysm was excluded by coil embolization. The postoperative course was uneventful and the patient was discharged in one day without complications. The follow-up with colour Duplex, at 4-8 months, showed the normal vascularization of the neck arterial vessels and was confirmed the absence of aneurysmal dilations. Aneurysms of the inferior thyroid artery are extremely rare, in scientific literature only 28 cases have been reported of which 32.9% regard ruptured aneurysms in the thyroid artery and 10.7% led to mortality. They may cause dysphagia and/or respiratory difficulties. Therefore, treatment is always recommended, even in asymptomatic cases, by surgical exclusion or coil embolization.

Photodynamic therapy with verteporfin for subfoveal choroidal neovascularization secondary to toxoplasmic chorioretinal scar.

BACKGROUND: To assess the effect of photodynamic therapy in the treatment of subfoveal choroidal neovascularization consecutive to a toxoplasmic chorioretinal scar. HISTORY AND SIGNS: Three patients with a previous history of toxoplasmic chorioretinal scar noticed a decrease in visual acuity and metamorphopsia. Fundus examination and fluorescein angiography revealed the presence of subfoveal choroidal neovascularization at the edge of the toxoplasmic chorioretinal scar. THERAPY AND OUTCOME: The first patient, aged 78, was treated by photodynamic therapy followed by three subsequent treatments of feeder vessel by laser photocoagulation. Visual acuity decreased during follow-up in the presence of recurrence of choroidal neovascularization and subretinal fibrosis. The second patient, a 20-year-old lady, was treated with three sessions of photodynamic therapy for a subfoveal choroidal neovascularization related to a toxoplasmic scar. Visual acuity was stabilized on the last follow-up visit at 0.3. The third patient, aged 53, received four treatments with photodynamic therapy at an interval of 3 - 4 months. choroidal neovascularization was stabilized and the last visual acuity was 0.2. CONCLUSIONS: This preliminary report suggests that photodynamic therapy with verteporfine may be an effective therapeutic modality for subfoveal choroidal neovascularization related to a toxoplasmic chorioretinal scar. Further assessment is needed in order to confirm this preliminary findings.

[Computed tomography and pneumoconioses]. / Tomografia assiale computerizzata e pneumoconiosi.

In the last two decades the use of Computed Tomography (CT) has played an important role in the diagnosis of pneumoconioses because of its spatial resolution and lack of technical limitations if compared to traditional chest radiography, first of all in the early stages. Nevertheless the staging of these diseases is still based on the International Labour Office (ILO) classification issued in 1980, whose application is obtained comparing radiographical findings with a standard set of radiographs provided by ILO itself. Starting from the early nineties many studies attempted to propose a classification system similar to the ILO one, combining different symbols to describe a CT thoracic finding or introducing a "score system" to classify different CT patterns (fibrosis, pleural plaques, etc.) and their severity. Despite these efforts no classification system has been accepted yet. After a short description of technical and practical issues of using CT in the diagnosis of pneumoconioses, this article aims at summarizing different classification attempts.

Feasibility of intraoperative balloon angioplasty and additional stent placement of isolated stenosis of the brachiocephalic trunk.

OBJECTIVE: We sought to evaluate the feasibility and results of intraoperative balloon angioplasty and additional stent placement of isolated stenosis of the brachiocephalic trunk. PATIENTS AND METHODS: Between May 1993 and October 1996, we treated eight patients with local stenosis of the innominate artery. Seven lesions were situated in the proximal and one in the middle third of the brachiocephalic trunk. Five patients were men and three were women, with ages ranging from 55 to 72 years (mean 59.5 years). All stenoses provoked severe blood flow reduction and caused clinical symptoms. Procedures were performed in an operating suite with fluoroscopic imaging capabilities. Through an anterolateral cervical approach the right common carotid artery was surgically exposed and then clamped to avoid atheroembolization during the subsequent procedure. Retrograde catheterization was performed to reach the stenosis of the brachiocephalic trunk. The lesion was dilated with a balloon catheter and successively stented. Follow-up examinations (color-coded duplex sonography, accompanied by clinical inspection and systolic blood pressure) were scheduled every 6 months. RESULTS: In all patients the dilation of the stenosis of the innominate artery and the stent placement were successful without any side effects. No embolic events or other complications occurred. The postintervention angiography showed successfully dilated stenoses and patent stents in all cases. The technical success rate was 100%. CONCLUSIONS: On the basis of our preliminary data, we believe that, in selected patients, intraoperative balloon angioplasty of stenosis of the innominate artery with stent placement from the right common carotid artery approach is a safe and effective alternative to conventional operations.

[Peripheral nerve injuries during carotid endarterectomy]. / Lesioni nervose periferiche durante l'endoarteriectomia della carotide.

Our experience with patients undergoing carotid endoarteriectomy over a 10 year period has been retrospectively reviewed. Nerve injuries were detected by reviewing postoperative progress and clinical notes. One hundred thirty-four procedures were performed on 120 patients, to 15 of whom (9%) occurred major nerve injuries. These included seven vagal nerve injuries causing ipsilateral vocal cord paralysis and hoarseness, five injuries of the marginal mandibular nerve and three injuries of the hypoglossal nerve. None of the patients with nerve injury had a stroke as a result of carotid operation. Vocal cord paralysis was documented by laryngoscopy. The incidence of cranial nerve injury during carotid endoarteriectomy appears to be higher than expected, particularly if asymptomatic patients are controlled.

[Thrombosis of the renal vein after transplantation. Description of a case]. / Trombosi della vena renale dopo trapianto. Descrizione di un caso.

The Authors report a case of renal vein thrombosis after kidney transplantation, which occurred early in the postoperative period and was treated successfully. The treatment is described as are the factors contributing to the good result: early diagnosis and surgical procedure, removal of the transplant and perfusion with cold heparin solution through the artery and the vein, reconstruction of a new vein to vein anastomosis, in a more favorable site.

[Clinical aspects of persistent sciatic artery. Description of 2 cases with angiographic demonstration]. / Aspetti clinici della persistenza dell'arteria ischiatica. Descrizione di due casi dimostrati angiograficamente.

We report 2 additional cases with angiographic demonstration. The embryology and radiological findings are discussed. This anomaly should be kept in mind in the clinical assessment of a patient with unexplained sciatic or buttock pain or a pulsatile buttock mass with or without symptoms of peripheral vascular disease. It also represents a potential hazard during renal transplant surgery.

[Extra-anatomical bypass in the treatment of stenotico-obstructive lesions of the subclavian and vertebral arteries]. / I by-pass extra-anatomici nel trattamento delle lesioni stenotico-ostruttive delle arterie succlavie e vertebrali.

The haemodynamic premises for extra-anatomical by-pass in the treatment of stenosis and obstructions of the subclavian and vertebral arteries are discussed with a report on a surgically treated series.

[A case of giant lumbar neurinoma]. / Su un caso di neurinoma "gigante" lombare.

A rare case of a giant extradural neurinoma of the IV lumbar root with an anterior development and a soft neurological picture is reported. The Authors stress the important role of CT both in the neurinoma diagnosis and in the correct preoperative evaluation of its extension and its relationship with contiguous organs.