Hyperthermic Intraperitoneal Chemotherapy with Mitomycin C versus Oxaliplatin after Cytoreductive Surgery for the Treatment of Peritoneal Metastases of Colorectal Cancer Origin.

Background: Mitomycin C and oxaliplatin are considered the main chemotherapeutic agents used in the context of hyperthermic intraperitoneal chemotherapy (HIPEC) after the performance of cytoreductive surgery for peritoneal metastases of colorectal cancer origin. However, there is lack of a generally accepted consensus regarding the optimal choice between them as upfront chemo-therapetic agent. Our paper aims to summarize in a comprehensive manner the available evidence, while individualised schemes with targeted therapies are under development. Methods: We conducted a comprehensive, narrative review of the literature including all previous studies until 03/2022, which reported perioperative and/ or oncological outcomes after the use of mitomycin C and/ or oxaliplatin as main hyperthermic chemotherapy agents after cytoreductive surgery for colorectal peritoneal metastatic disease. Results: Data from a total of 23 single-agent and 13 comparative studies were included in our review. Despite the demonstrated safety profile of both chemotherapeutics, the heterogeneity of the included studies, their retrospective nature and the absence of relevant randomized trials prohibits the drawing of safe conclusions regarding the superiority of one of the two agents. However, it seems that perioperative morbidity is less with oxaliplatin-based HIPEC, while mitomycin C appears as a more cost-effective option. Conclusions: Selection of the optimal intraperitoneal chemotherapy agent for peritoneal metastases of colorectal cancer origin after the completion of cytoreductive surgery is still a matter of debate, with significant institutional variation. Further randomized clinical trials between the two commonest HIPEC agents are required, assessing the differences in perioperative outcomes, oncological outcomes, healthcare-associated costs and patientsâ?? quality of life.

Predictors of Operative Mortality of 928 Intact Aortoiliac Aneurysms.

BACKGROUND: The aim of this study is to identify preoperative and intraoperative factors associated with in-hospital mortality of intact abdominal aortoiliac aneurysm repair. METHODS: In this observational study, prospectively collected information included demographics, risk factors, comorbidities, aneurysm characteristics (including special aneurysm presentation, i.e., inflammatory, mycotic/infected, aortocaval fistula), investigations, and operative variables. Receiver operating characteristic) curve analysis of the Glasgow aneurysm score (GAS) and the Vascular Study Group of New England (VSGNE) score was performed in the subgroup of bland aneurysms undergoing isolated elective repair. RESULTS: A total of 928 cases with intact aortoiliac aneurysms had an elective (n = 882) or urgent (n = 46) repair, associated with an in-hospital mortality of 1.7% and 8.7%, respectively (P = 0.01). Open repair (n = 514) was a predictor of higher mortality (3.3% vs. 0.5% for endovascular aneurysm repair [EVAR], n = 414, odds ratio [OR] 7.1, P = 0.003), and so was the pre-EVAR era (4.8% vs. 1.3% in the EVAR era, OR 4.0, P = 0.004). Other significant predictors included the presence of abdominal/back pain (7.5% vs. 1.3%, OR = 6.0, P = 0.001), preoperative angiography (7% vs. 1.6%, OR = 4.5, P = 0.01), special aneurysm presentation (10.9% vs. 1.5%, OR = 8.1, P < 0.001), concomitant major procedures (19% vs. 1.7%, OR = 14.0, P < 0.001), serious intraoperative complications (9.1% vs. 1.5%, OR = 6.6, P = 0.001), median number of transfused units of blood intraoperatively (2 and 0 for cases with and without mortality, respectively, P < 0.001), and procedure duration (270 and 150 min for cases with and without mortality, respectively, P < 0.001). Open repair (OR = 4.5, P = 0.05), special aneurysm presentation (OR = 6.58, P = 0.001), and concomitant major procedures (OR = 14.3, P < 0.001) were independent predictors of higher mortality. ROC curve analysis for the GAS (P = 0.87) and VSGNE score (P = 0.10) failed to demonstrate statistical significance in the subgroup of bland aneurysms undergoing isolated elective repair. CONCLUSIONS: Our study has demonstrated independent risk factors for mortality, which should be considered when contemplating aortoiliac aneurysm repair. We failed to externally validate the GAS and VSGNE score.

Validation of the 3D SYM VEIN Symptom Assessment Tool.

OBJECTIVE: The aim was to validate the SYM VEIN consensus 3D scoring tool in chronic venous disease (CVD). METHODS: This was a prospective cohort study with a total of 35 consecutive patients with CVD. Patients with CVD undergoing saphenectomy were assessed with the revised Venous Clinical Severity Score (r-VCSS), the CIVIQ-20 quality of life score questionnaire, and the SYM VEIN consensus statement 3D system, pre-operatively and four weeks post-operatively. The total 3D score was tested for reliability, construct validity, and responsiveness. RESULTS: The total 3D score demonstrated good reliability and internal consistency (Cronbach's alpha 0.85). Principal component analysis identified three groups of symptoms (paraesthesia, burning pain, and pruritus, vs. heaviness, sensation of swelling and aching/pain, vs. restless leg and throbbing pain) demonstrating a high intragroup correlation and likely to share similar pathophysiology, indicative of adequate construct validity. The total 3D score showed a significant correlation with r-VCSS and CIVIQ-20 score (rho .46, p = .005 and rho .65, p < .001, respectively) indicative of adequate convergent validity. After saphenectomy, significant reductions (p < .001) of the total 3D, and 3D scores for all but two individual venous symptoms were observed, indicative of excellent responsiveness. Median total 3D score was reduced from 31 to 6 (83.8% decrease, p < .001), median r-VCSS was reduced from 6 to 0 (100% decrease, p < .001), and median CIVIQ-20 score was reduced from 24 to 14 (40% decrease, p < .001). The difference of median percentage change between r-VCSS and CIVIQ-20 score vs. total 3D score was significant (p = .005 and p < .001, respectively). CONCLUSION: The total SYM VEIN 3D score has good reliability, construct validity and excellent responsiveness, although less prone to change after saphenectomy compared with r-VCSS.

Improved effectiveness of the repositionable GORE EXCLUDER AAA endoprosthesis featuring the C3 delivery system compared with the original GORE EXCLUDER AAA endoprosthesis for within the instructions for use treatment of aortoiliac aneurysms.

OBJECTIVE: To compare two endograft types, the original GORE EXCLUDER AAA endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz) with the repositionable GORE EXCLUDER featuring the C3 delivery system, which allows repositioning of the proximal part of the graft to achieve accurate placement in relation to the renal arteries, in unselected patients with aortoiliac aneurysms. In a second nested, substudy we investigated the relative effect of the standard Gore and Gore Dryseal introducer sheaths on intraoperative transfusion needs. METHODS: We retrospectively analyzed prospectively collected information. The primary composite outcome measure was the intraoperative misdeployment or migration of the endograft's main body, proximally or distally to the renals (leading to technical failure or requiring either placement of aortic cuff extenders or conversion to open repair). Secondary outcome measures included the composite long-term event of rupture and/or type I/III endoleak. RESULTS: A total of 313 consecutive patients (303 males; median age, 73 years) had either an original GORE EXCLUDER device (n = 174) or the new device (n = 139) placed between 2004 and 2011 and 2011 and 2017, respectively, to treat an infrarenal aortoiliac aneurysm or an isolated common iliac artery aneurysm. The primary composite outcome measure occurred more often in patients who had the original GORE EXCLUDER device placed (10.9% vs 3.6% for the new device; odds ratio, 0.30; 95% confidence interval, 0.11-0.84; P = .016), confirmed by multivariate logistic regression analysis. This difference between the two groups was exclusively driven by distal misdeployment or migration of the endograft (10.3% vs 2.9% for the new device; P = .01), mostly requiring aortic extender placement. Intraoperative blood transfusion rates were lower in patients who had the GORE Dryseal introducer sheath used (1.1% vs 18.9% for the original GORE introducer sheath; OR, 0.05; 95% confidence interval, 0.006-0.35; P < .001). At a mean follow-up of 1.7 years (maximum, 13 years), 11 patients developed the composite event. On univariate Cox analysis, significant predictors included female gender (P = .003), absence of dyslipidemia (P = .023), the primary outcome measure (P = .006), and failure to cannulate (P = .009), but not device type or other variables. On multivariate Cox regression, female gender (hazard ratio, 37; P < .001), chronic obstructive pulmonary disease (hazard ratio, 3.99; P = .045), the primary outcome measure of the study (hazard ratio, 8.9; P = .002), and failure to cannulate (hazard ratio, 43; P = .003) were all independent predictors. CONCLUSIONS: Our study has demonstrated that the repositionable GORE EXCLUDER has important safety characteristics compared with the original device and equivalent long-term effectiveness. Additional benefit was obtained with the use of the Gore Dryseal introducer sheath.

Acute Effects of Graduated Elastic Compression Stockings in Patients with Symptomatic Varicose Veins: A Randomised Double Blind Placebo Controlled Trial.

OBJECTIVES: To investigate the effectiveness of graduated elastic compression stockings (GECS) below the knee in improving symptoms in patients with varicose veins in the absence of high quality evidence. METHODS: This was a randomised double blind placebo controlled trial. Thirty patients with no experience of elastic stockings, presenting with primary varicose veins causing calf pain or aching were randomised to a GECS (18-21 mmHg at the ankle level, n=15) or a placebo stocking (0 mmHg, n=15). Pain or aching of the index leg after 1 week was the primary outcome measure. In patients with bilateral varicose veins the leg with the most severe pain/aching was considered. Other defined symptoms were secondary outcome measures. All symptoms were scored on a visual analogue scale (VAS). RESULTS: The two study groups were well balanced at baseline. At the completion of the study after 1 week, GECS were more effective than placebo stockings in reducing pain or aching (VAS score 1.7±3.0 vs. 4.5±2.8 for placebo, p=.02), while non-significant trends were observed for some of the remaining symptoms of the index leg, including feeling of swelling (VAS score 0.9±1.9 vs. 3.3±3.5 for placebo), paraesthesiae (VAS score 0.2±0.6 vs. 2.1±3.1 for placebo), and the number of symptoms other than pain or aching (1.3±1.1 vs. 2.8±1.7 for placebo). Number needed to treat (95% CI) for a 50% or complete improvement of pain or aching in the index leg was 2 (95% CI 1.2-5.5) and 2 (95% CI 1.2-5.3), respectively. Mean daily use of the placebo stockings and GECS was 8.0 hours and 10.2 hours, respectively (p=.13). CONCLUSIONS: Among patients with varicose veins, GECS seem effective in ameliorating symptoms, particularly pain or aching, compared with placebo stockings after 1 week of use. Long-term studies are justified.

Vacuum-Assisted Thrombo-Aspiration for Paradoxical Embolism in Left Renal Artery: A Case Report and Literature Review.

Paradoxical embolism through the foramen ovale is a rare and devastating event requiring urgent treatment. Herein, we present the case of a 23-year-old male who presented with a pulmonary embolism complicated by a left renal artery paradoxical embolism. Urgent vacuum-assisted thrombo-aspiration restored normal perfusion of the left kidney within 5 hours. The patient had a patent foramen ovale and heterozygous thrombophilia. However, a radioisotopic scan performed 2 years later revealed an unexpected decrease in left renal perfusion. Therefore, despite the angiographic success, functional evaluation using a renal scan should be performed to assess renal function.

Endotension as a Rare Complication to Endovascular Abdominal Aortic Aneurysm Repair.

Endotension remains an enigmatic rare cause of endovascular abdominal aortic aneurysm repair failure leading to aneurysm growth and/or rupture. We present a patient with a long-standing endotension treated with open reconstruction and graft explantation. We also provide a unique clinical video, which gives a key view of the intrasac operative findings.

FACTORS INFLUENCING FLUOROSCOPY TIME IN ENDOVASCULAR TREATMENT OF ABDOMINAL ANEURYSMS: A RETROSPECTIVE STUDY.

Patients who undergo endovascular aortic aneurysm repair (EVAR) may require prolonged radiation exposure affected by several factors. The objectives of this study were to document fluoroscopy time (FT) during EVAR and identify possible factors that influence it. A retrospective analysis of a 180 patients' database with abdominal infrarenal aortic aneurysms submitted to EVAR during a 7-y period was performed. The FT is evaluated regarding risk factors and comorbidities, graft type and patient-related, clinical and technical parameters. FT's median (interquartile range) was 1011 (698-1500) s. Excluder and C3 Excluder were associated with significantly lower FT values when compared with other grafts. Hypertension, dyslipidemia, age ≥ 70 y, maximum aneurysm diameter ≥ 6 cm and procedure duration ≥2 h resulted in higher FT values. A significantly lower FT was found for the operations performed in the 7th y of the study's period compared with the previous 6 y, mainly because of the use of Excluder or C3 Excluder grafts. However, these grafts did not show any significant difference in FT values during the 7 y. A significant correlation between FT with age and procedure duration was found. Nevertheless, procedure duration is a poor FT predictor in linear and logistic regressions, although is significantly correlated with FT. Dyslipidemia, procedure duration and graft type are independent predictors of FT larger than the median, whereas only the procedure duration is a predictor for FT larger than the 75th percentile value. The identified factors regarding radiation protection issues should be considered when contemplating abdominal aortic aneurysm repair, however, without compromising the procedure's efficacy. Further work is necessary to identify more potential anatomical, clinical and technical factors affecting procedures' complexity and FT and patient radiation dose during EVAR interventions.

Erratum to "Eccentric saccular aneurysm formation of the infrarenal aorta from an arterial wall tear" [Radiology Case Reports 16 (2021) 1854-1856].

[This corrects the article DOI: 10.1016/j.radcr.2021.04.046.].

The Aftermath of Bariatric Surgery: Can the Average Emergency Surgeon Deal with Its Complications? Comment on Zawadzka et al. Current Knowledge and Perceptions of Bariatric Surgery among Diabetologists and Internists in Poland. J. Clin. Med. 2022, 11, 2028.

We read with great interest the article by Zawadzka et al. [...].

Adjunct internal iliac artery procedures in the context of endovascular abdominal aortic aneurysm repair: anything to stress on the consent form?

Adjunct internal iliac artery (IIA) procedures, such as preoperative embolisation or coverage with iliac branch extensions, are not infrequent in the context of endovascular repair of abdominal aortic aneurysms. Moreover, on many occasions, these procedures are performed in a multi-stage approach by interventional radiologists prior to the main operation. Bearing in mind the potential complications of IIA occlusion when revascularization is not initially deemed necessary, various issues arise spanning from appropriate patient counselling to medicolegal consequences. Herein, we aim to provide a roadmap regarding appropriate patient consenting, highlighting the need for multidisciplinary approach of these patients.

Surgical and pharmaceutical treatment of superficial vein thrombosis of the lower limbs: what has changed over the last 5 years?

INTRODUCTION: Superficial vein thrombosis of the lower limbs is a common condition encountered by a wide spectrum of clinical specialties. In contrast to deep vein thrombosis of the lower limbs though, there is significant variability in terms of its treatment with respect to the type and duration of pharmacotherapy, as well as regarding the potential role of operative management. METHODS: Systematic review of the literature in a best evidence topic manner, including only prospective and randomized controlled studies on the treatment of lower limb SVT, focusing on the emerged data over the last 5 years. RESULTS: A total of 17 prospective observational and randomized clinical studies met our set criteria. Despite the major differences in study designs, outcomes and intervention types, upfront pharmaceutical treatment with fondaparinux or intermediate dose of low molecular weight heparins, combined with regular clinical and radiological follow-up, seem to be effective and safe as first-line approaches. Upfront surgical treatment of lower limb SVT can also be safely performed in selected cases in the presence of clinical expertise. CONCLUSIONS: Our review revealed the presence of considerable variability in the therapeutic options of the lower limb superficial venous thrombosis, highlighting the need for further randomized controlled trials in the field in order to establish and standardize its optimal treatment.

A rare combination of tibial artery aneurysm and traumatic arteriovenous fistula: a case report.

Aneurysms of the tibial arteries are rare, and they most commonly occur due to trauma of the lower extremities. Acquired arteriovenous fistulas of the tibial arteries are a recognized complication of trauma of the lower extremity and they are related to the mechanism of the injury. Although the natural history of stable arteriovenous fistula is relatively benign, the aneurysms of the tibial arteries should be repaired with autologous vein bypass grafts, if there is distal ischemia. Endovascular repair has been reported as an effective alternative treatment for traumatic tibial artery aneurysms. The case of a 60-year-old male with the rare combination of a tibial artery aneurysm and traumatic arteriovenous fistula of the left lower extremity is reported in view of its rarity and the modern holistic endovascular approach used for treatment. A covered stent graft in the anterior tibial artery was used for the treatment of both the aneurysm and the arteriovenous fistula. The patient was discharged under dual antiplatelet treatment for three months, continued by clopidogrel as monotherapy. At the six-month follow-up, the patient has restored palpable peripheral pulses and no sign of recurrence or complication was recognized. A total endovascular approach can be an effective treatment for these complicated traumatic aneurysms.

Chronic Limb Ischemia due to Thrombosis of an Aneurysmal Degeneration of the Autogenous Vein Graft: A Case Report.

Nonanastomotic aneurysmal degeneration of a great saphenous vein graft is an unusual condition, despite the common use of this conduit in arterial reconstructions. Vein grafts are at risk of degenerative changes, but the real cause remains unknown. Postoperative graft surveillance with duplex ultrasound scanning is important for maintaining patency of the venous graft. We present a rare case of chronic limb ischemia due to partial thrombosis of an aneurysm of the great saphenous vein graft.

Distal or Traditional Transradial Access Site for Coronary Procedures: A Single-Center, Randomized Study.

OBJECTIVES: This study aimed to compare the efficacy and safety of the distal transradial approach (dTRA) versus the conventional transradial approach (TRA) for coronary angiography and percutaneous coronary interventions. BACKGROUND: The recommended approach for coronary procedures is TRA. However, it is associated with radial artery occlusion (RAO). The dTRA could potentially decrease the incidence of RAO. METHODS: One thousand forty-two consecutive patients were randomized (1:1) to right dTRA or TRA. The primary endpoint was the rate of RAO, which was evaluated by Doppler ultrasound at 60 days after randomization. RESULTS: Five hundred eighteen and 524 patients were randomized to dTRA and TRA, respectively. Follow-up Doppler evaluation of the radial artery was accomplished in 404 (78.0%) patients in the dTRA group and 392 (74.8%) in the TRA group. The rate of RAO was significantly reduced in the dTRA group compared with TRA group (3.7% vs 7.9%, respectively; P = 0.014). The rate of successful sheath insertion was lower in the dTRA group compared with the TRA group (78.7% vs 94.8%, respectively; P < 0.001). More punctures (median = 2 [IQR: 1-3] vs median = 1 [IQR: 1-2]; P < 0.001) and a longer time (120 vs 75 seconds; P < 0.001) were required for sheath insertion in the dTRA group compared with the TRA group. The hemostasis time was shorter in the dTRA group compared with the TRA group (60 vs 120 minutes; P < 0.001). The dose area product was higher in the dTRA group (median = 32,729 in the dTRA vs 28,909 cGy/cm2 in the TRA group; P = 0.02). No significant differences were observed in the secondary safety endpoints (bleeding [Bleeding Academic Research Consortium ≥2] and severe radial artery spasm). CONCLUSIONS: According to our study, dTRA was associated with a lower rate of forearm RAO, a shorter time of hemostasis, a higher crossover rate and dose area product, and a longer procedural time compared with TRA.

Endovascular treatment of a ruptured true superficial femoral artery aneurysm.

Isolated true aneurysms of the superficial femoral artery are rare and less common than those of the common femoral artery. They occurred commonly in elderly men in about 87% and most of them are located in the middle third of the artery. Due to the deep anatomic location of the middle and distal third of the superficial femoral artery, most of these aneurysms reach a mean diameter of 8.4 cm at diagnosis. The most common clinical presentation includes a pulsatile thigh mass associated with pain, but rupture and distal ischemia can occur as well. The treatment of the true superficial femoral artery aneurysm consists of exclusion with bypass or interposition graft. Endovascular treatment has been used recently as an alternative treatment, in both emergency and least urgent cases. We present a rare case of a male patient with a huge thigh hematoma due to a ruptured true superficial femoral artery aneurysm.

Eccentric saccular aneurysm formation of the infrarenal aorta from an arterial wall tear.

Eccentric saccular aneurysms result from a focal weakness of the arterial wall that may be due to a focal tear or a partial disruption of the arterial wall. Saccular morphology itself is often used as a factor for immediate intervention, because the risk of rupture is higher than that of the common fusiform aneurysms. We present a case of a 72-year-old female patient with a huge saccular aneurysm of the infrarenal aorta. In this case report, we discuss the algorithm that can be used for the differential diagnosis of any saccular shape aneurysm and that the main parameter that needs to be clarified before the endovascular treatment of any saccular aneurysm is the presence or absence of infection of the arterial wall.

The "double carotid artery" sign: A rare case of spontaneous carotid dissection.

Carotid artery dissection, which accounts for up to 20% of strokes in young patients, usually extends distally and leads to acute stenosis, occlusion and aneurysmal changes with increased risk for thromboembolic events, especially in young people.

Custom-Made Bifurcated Prosthetic Graft for Aortoiliac Aneurysm Repair.

Revascularization of the internal iliac artery during open repair of aortoiliac aneurysms can be challenging, especially if there is a significant distance between the orifices of the internal and external iliac arteries owing to common iliac aneurysmal dilatation. We describe a technique involving insertion of an 18-mm tube graft between the proximal aortic neck and aneurysmal common iliac artery bifurcation. Revascularization of the contralateral external iliac artery is accomplished through an 8-mm side arm graft.