Floating Stent-Graft as a Support to Bridge an Unfavorable Renal Artery During Postdissection TAAA Repair Using a Multibranched Thoracoabdominal Endograft.

Purpose: To report an unusual endovascular technique to manage unfavorable renal artery anatomy encountered in an urgent case of symptomatic postdissection thoracoabdominal aortic aneurysm (TAAA) treated with an off-the-shelf multibranched device. Technique: The technique is demonstrated in a 77-year-old woman who had a history of previous open abdominal aortic aneurysm repair and an emergent procedure to implant a thoracic endograft and an aortic bare Z-stent (PETTICOAT) for acute Stanford type B dissection 7 years prior. The patient presented with a symptomatic, rapidly growing, postdissection TAAA. Endovascular treatment with a Zenith t-Branch was planned. After standard catheterization techniques failed in the left renal artery, a bailout maneuver was utilized to place a "floating" Viabahn stent-graft in the aneurysm sac to create sufficient support to deliver the bridging stent-grafts through the bare stent to the target left renal artery. The procedure was successful in excluding the TAAA and preserving perfusion to all target vessels. No neurological complications occurred. Six-month imaging follow-up confirmed the patency of the bridging stents. Conclusion: Remodeling changes after complex endovascular TAAA procedures often require the use of innovative techniques and materials during secondary procedures. In this case, the presence of a post-PETTICOAT bare aortic stent and hostile target artery anatomy increased the technical difficulty of t-Branch implantation. A "floating" stent-graft could be useful to reach challenging target vessels by providing additional support to bridging stent advancement and deployment.

Intraoperative contrast-enhanced ultrasound for early diagnosis of endoleaks during endovascular abdominal aortic aneurysm repair.

BACKGROUND: The aim of this study was to evaluate the feasibility and utility of intraoperative contrast-enhanced ultrasound (CEUS) for early detection of endoleaks (ELs) during endovascular abdominal aortic aneurysm repair (EVAR) compared with completion digital subtraction angiography. METHODS: Patients undergoing elective EVAR from January 2017 to April 2018 were consecutively enrolled in this prospective study. After endograft deployment, two-digital subtraction angiography (2DSA) with orthogonal C-arm angulations (anteroposterior and sagittal view) were routinely performed. After the endovascular treatment of clear, high-flow type I/III ELs detected by 2DSA, intraoperative CEUS was carried out in sterile conditions on the surgical field before guidewire removal. Presence and type of EL were evaluated with 2DSA and CEUS. CEUS was performed with the vascular surgeon blinded to the 2DSA findings. The primary end point was the level of agreement between 2DSA and CEUS to detect any type of EL and type II EL. Agreement between two diagnostic methods was calculated using Cohen's kappa. The secondary end point was utility of CEUS for intraoperative adjunctive procedure guidance. RESULTS: Sixty patients were enrolled (mean age, 78 ± 6 years; 90% male). 2DSA revealed 11 ELs (18%; 1 type IA, 10 type II), and CEUS 25 ELs (42%; 2 type IA, 23 type II). 2DSA and CEUS were in agreement in 39 cases (65%; 32 no ELs, 7 type II ELs). CEUS detected 17 ELs not identified by 2DSA (28%; 2 type IA, 15 type II); 2DSA detected three ELs not identified by CEUS (5%; 3 type II). In one case, 2DSA and CEUS detected type II and type IA ELs, respectively. For EL and type II EL detection, Cohen's kappa was 0.255 and 0.250, respectively (both "fair agreement"). Intraoperative adjunctive sac embolization was performed under CEUS control in 4 cases and technical success was 100%. CONCLUSIONS: Intraoperative CEUS during EVAR is feasible and can detect a greater number of ELs than 2DSA, in particular type II ELs. Further studies are necessary to assess the reliability of this intraoperative diagnostic examination. In type II ELs, CEUS may represent an additional, useful tool for intraoperative sac embolization guidance.

A systematic review of treatment modalities and outcomes of type Ib endoleak after endovascular abdominal aneurysm repair.

Objectives To collect specific literature on type Ib endoleak after aorto-iliac endografting for abdominal aortic aneurysm, reporting data on diagnosis, treatment, and follow-up results. Methods Publications about type Ib endoleak after aorto-iliac endografting for abdominal aortic or iliac aneurysm were searched in PubMed, Web of Science, and Scopus. Considered studies were in English and published until 3 November 2016. Research methods and reporting were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Inclusion criteria were: (1) reporting on abdominal aortic or iliac aneurysm as primary diagnosis; (2) reporting on distal endoleak after aorto-iliac endografting. Patient data, data on endovascular treatment, endoleak, reintervention, and follow-up were collected by two independent authors. Results Included studies were 11 (five original articles, six case reports), corresponding to 29 patients and 30 type Ib endoleak. Excluding missing data (2/30, 6.7%), type Ib endoleak was treated intra-operatively, within six months and after six months in six cases (21.4%), eight cases (28.6%), and fourteen cases (50%), respectively. Treatment of type Ib endoleak was endovascular in 27 cases (90%) (7 embolizations + extender cuffs, 10 extender cuffs, 8 embolizations without extender cuff, 1 Palmaz stenting and 1 iliac branched endograft), hybrid in 1 case (3.3%) and surgical in 2 cases (6.6%). Buttock claudication occurred in two cases (6.7%). One-month mortality was 3.4% (2/29) without events due to type Ib endoleak. In 14 cases (46.7%), median follow-up was six months (interquartile range: 2.75-14; range: 0.75-53). Type Ib endoleak persisted or reappeared in three cases (10%), all after endovascular treatment. Two of these (2/3, 66.7%) needed endovascular reintervention. No death during follow-up was reported. Conclusions Few specific data are available in literature about type Ib endoleak after aorto-iliac endografting for abdominal aortic aneurysm. About 50% of type Ib endoleak occurred after six months from the endovascular abdominal aneurysm repair procedure. Treatment is mainly endovascular and distal endograft extension is the main and effective treatment. Buttock claudication is the most frequent complication in case of exclusion of internal iliac artery. Persistent type Ib endoleak is possible, and adjunctive endovascular procedures are necessary.

Early and mid-term results in the endovascular treatment of popliteal aneurysms with the multilayer flow modulator.

Background The endovascular approach became an alternative to open surgical treatment of popliteal artery aneurysm over the last few years. Heparin-bonded stent-grafts have been employed for endovascular popliteal artery aneurysm repair, showing good and stable results. Only few reports about the use of multilayer flow modulator are available in literature, providing small patient series and short follow-up. The aim of this study is to report the outcomes of patients with popliteal artery aneurysm treated with the multilayer flow modulator in three Italian centres. Methods We retrospectively analysed a series of both symptomatic and asymptomatic patients with popliteal artery aneurysm treated with the multilayer flow modulator from 2009 to 2015. Follow-up was undertaken with clinical and contrast-enhanced ultrasound examinations at 1, 6 and 12 months, and yearly thereafter. Computed tomography angiography was performed in selected cases. Primary endpoints were aneurysm sac thrombosis; freedom from sac enlargement and primary, primary-assisted and secondary patency during follow-up. Secondary endpoints were technical success, collateral vessels patency, limb salvage and aneurysm-related complications. Results Twenty-three consecutive patients (19 males, age 72 ± 11) with 25 popliteal artery aneurysms (mean diameter 23 mm ± 1, 3 symptomatic patients) were treated with 40 multilayer flow modulators during the period of the study. Median follow-up was 22.6 ± 16.7 months. Complete aneurysm thrombosis occurred in 92.9% of cases (23/25 cases) at 18 months. Freedom from sac enlargement was 100% (25/25 cases) with 17 cases of aneurysm sac shrinkage (68%). At 1, 6, 12 and 24 months, estimated primary patency was 95.7%, 87.3%, 77% and 70.1%, respectively. At the same intervals, primary-assisted patency was 95.7%, 91.3%, 86% and 86%, respectively, and secondary patency was 100%, 95.7%, 90.3% and 90.3%, respectively. Technical success was 100%. The collateral vessels patency was 72.4%. Limb salvage was 91.4% at 24-month follow-up. One multilayer flow modulator fracture was reported in an asymptomatic patient. Conclusions Multilayer flow modulator seems a feasible and safe solution for endovascular treatment of popliteal artery aneurysms in selected patients.

Infrarenal endograft clamping in late open conversions after endovascular abdominal aneurysm repair.

OBJECTIVE: The aim of this study was to report the technical aspects and outcomes of late open conversion (LOC) after endovascular aneurysm repair (EVAR) in a single center by using exclusively infrarenal clamping of the endograft as an alternative to suprarenal or supraceliac aortic clamping. METHODS: A retrospective analysis of EVAR requiring late explantation (>30 days) from January 1996 to October 2016 was performed. Patients' demographics, type of endograft, duration of implantation, reason for removal, extent of stent graft removal, type of reconstruction, 30-day mortality, postoperative complications, and long-term survival were obtained for analysis. RESULTS: During the study period, 28 patients required LOC. The mean age at conversion was 75.11 ± 6.65 years; 26 of 28 (92.86%) were male. Grafts were excised after a median of 41.4 months (range, 5.97-112.67 months), with 21 of 28 explantations (75%) performed electively. Multiple types of EVAR devices have been explanted; suprarenal fixation was present in 75% of the cases. The indication for LOC was the presence of an endoleak in 27 cases (20 type I, 4 type II associated with aneurysm growth, 3 type III, and 3 endotensions; in 3 cases, multiple types of endoleak were present) and graft thrombosis in 1 case. All patients underwent a transperitoneal approach with infrarenal clamping. No patient required revascularization of visceral or renal vessels. Complete removal of the stent graft was performed in 8 of 28 cases, partial removal in the remaining 20 cases (with conservation of the proximal portion in 16 of 20 cases). Technical success was 100%. Overall 30-day mortality was 7.14% (2/28). The 30-day mortality was 9.5% in elective patients and 0% in the urgent setting; this difference was not statistically significant (P = .56). Postoperative kidney injury rate was 7.7% (2/26). Mean follow-up was 47.37 ± 55.67 months (range, 0.23-175.07 months). The estimated 5-year survival rate was 78%. No aneurysm-related death or additional procedure occurred during follow-up. CONCLUSIONS: LOC after EVAR using infrarenal clamping of the endograft is a feasible and effective technique, with satisfactory postoperative mortality and morbidity. This method allows simplification of the surgical technique and may avoid renal and visceral complications related to suprarenal or supraceliac clamping.

Endovascular Management of Para-prosthetic Aortocaval Fistula: Case Report and Systematic Review of the Literature.

The aim of this article is to report a case of asymptomatic para-anastomotic aortocaval fistula (ACF) treated by endovascular aortic repair, and to review data of the literature on arteriovenous fistulae secondary to abdominal aortic surgery. A 78-year-old male complained of worsening pain in the right lower limb since 2 months. He presented a history of right femoropopliteal bypass for peripheral arterial occlusive disease and elective surgical treatment for a non-ruptured infrarenal aortic aneurysm (Dacron tube graft). Duplex ultrasound revealed an occlusion of the right common femoral artery and bypass graft. The digital subtraction angiography confirmed these findings and showed progression of the contrast medium from the aorta to the inferior vena cava at aortic carrefour level, suggestive of ACF. An abdomen/pelvis computed tomography angiogram (CTA) confirmed the arteriovenous communication at distal anastomosis of the aortoaortic Dacron graft. An urgent endovascular placement of AFX™ (Endologix, Inc., Irvine, CA) aorto-biiliac stent graft was performed, associated with endarterectomy of the right common and deep femoral artery. The postoperative course was regular without complications. The 5-day and 1-month CTA showed complete exclusion of the ACF. A systematic review of the literature was also performed regarding ACF secondary to aortic surgery.

Perioperative and Late Outcomes after Endovascular Treatment for Isolated Iliac Artery Aneurysms.

BACKGROUND: The aim of the study is to report early and follow-up outcomes of the endovascular treatment with iliac endografts for isolated iliac artery aneurysms (IIAAs). METHODS: Records of patients who underwent elective endovascular repair for IIAA (both primary and para-anastomotic) from 2005 to 2015 in 2 Italian centers were retrospectively examined. Demographic data, preoperative patient comorbidities, iliac aneurysm characteristics, contralateral iliac axis involvement, patency of hypogastric arteries and inferior mesenteric artery (IMA), and data of endovascular treatment were obtained for analysis. Early end points were technical success (TS), perioperative morbidity, clinical success (CS), freedom from reintervention (FFR) and survival. Follow-up end points were CS, FFR, survival, evolution of the aneurysmal sac, and endoleak (EL). RESULTS: Thirty-two IIAAs were treated through an endovascular approach in 30 patients (male 96.7%; mean age 74.2 years ± 7.6, range 55-86). Aneurysms were para-anastomotic in 11 (34.4%) cases. Mean diameter was 42.9 ± 15.6 mm (range 30-100). Twenty (62.5%) aneurysms involved exclusively the common iliac artery, 7 (21.9%) the hypogastric, and 5 (15.6%) both arteries. Ipsilateral hypogastric artery was stenotic or occluded in 4 (12.5%) and 1 (3.1%) patient, respectively. Contralateral hypogastric artery was occluded in 2 (6.3%) cases. IMA was patent in 9 (30%) patients. The ostium of the hypogastric artery was preserved in 5 cases (15.6%) and voluntarily covered in 27 (84.4%). Endovascular embolization of hypogastric artery was obtained with a plug device in 8 cases (25%). Hypogastric surgical revascularization was performed in 2 cases (6.3%). TS was 96.9%. Thirty-day morbidity was 6.3% (2/32). CS was 96.9% (1 endograft limb stenosis). Thirty-day FFR was 90.6% (1 transluminal angioplasty, 2 inguinal revisions). Thirty-day survival was 100%. At 1, 3, and 6 years, CS was 93.4%, 85.6%, and 85.6%, respectively (1 endograft limb thrombosis, 1 endograft limb stenosis, 1 hypogastric type II EL with sac enlargement). At 1, 3, and 6 years, FFR was 87.5%, 76.8%, and 76.8%, respectively (1 fibrinolytic therapy and stenting, 1 stenting, 1 surgical ligation of hypogastric artery). At 1, 3, and 6 years, survival was 100%, 96.3%, and 81.3%, respectively. No IIAA-related deaths were reported. During follow-up, aneurysmal diameter was unchanged in 12 cases (37.5%), decreased in 19 (59.4%), and increased in 1 (3.1%). Type II EL from hypogastric artery was detected in 3 cases (9.4%) and led to sac enlargement requiring surgical treatment in 1 case. CONCLUSIONS: Endovascular treatment of isolated iliac aneurysm is safe and effective, providing that strict anatomical requirements are respected. Aneurysm embolization with vascular plugs was not associated with pelvic complications in this series. Endograft stenosis and thrombosis are the most frequent complications, which can be easily managed with endovascular approaches.

Hybrid Treatment of Acute Abdominal Aortic Thrombosis Presenting with Paraplegia.

Acute thrombotic or embolic occlusion of the abdominal aorta is a rare vascular emergency associated with high morbidity and mortality rates. Classically, the clinical presentation is a severe peripheral ischemia with bilateral leg pain as the predominant feature. Aortic occlusion presenting as an isolated acute onset of paraplegia due to spinal cord ischemia is very rare and requires improved awareness to prevent adverse outcomes associated with delayed diagnosis. We report the case of a 54-year-old man who presented with sudden paraplegia due to the thrombotic occlusion of the infrarenal aorta involving the first segment of the common iliac arteries on both sides; emergent transperitoneal aorto iliac thrombectomy combined with the endovascular iliac kissing-stent technique were performed achieving perioperative complete regression of the symptoms.

Endovascular stent grafting of a posterior tibial artery pseudoaneurysm secondary to penetrating trauma: case report and review of the literature.

Endovascular treatment of posttraumatic pseudoaneurysms has become a viable less-invasive option when compared with open repair. In this study, we present a case of a posttraumatic pseudoaneurysm of the posterior tibial artery in a 34-year-old man treated with endovascular stent grafting. An extensive review of the literature has been performed.

Clinical, electrocardiographic and echocardiographic features in patients with major arterial vascular disease assigned to surgical revascularization.

BACKGROUND: Preoperative cardiac assessment may essentially contribute to estimate the operative risk in vascular surgery.This study was undertaken to depict the clinical conditions and cardiac status in patients before elective major vascular surgery. PATIENTS AND METHODS: 143 patients with asymptomatic critical aortic abdominal aneurysm, 119 with high-grade carotid stenosis, and 138 with advanced symptomatic ischemia due to peripheral artery disease were assigned to surgical revascularization. Preoperatively, all subjects completed detailed medical history, physical and laboratory examinations, electrocardiogram, and transthoracic echocardiography. RESULTS: In patients with peripheral artery disease we identified more smokers (p < 0.05), diabetes (p < 0.01), hypertriglyceridemia (p < 0.05), previous myocardial infarction (p < 0.01); the asymptomatic aortic abdominal aneurysm group had a higher body mass index (p < 0.05), diastolic hypertension (p < 0.05), and most had left ventricular anterior hemiblocks (p < 0.001). Patients with critical carotid stenosis were older (p < 0.01), with greater systolic hypertension (p < 0.01), and with a less compromised left ventricular systolic function. CONCLUSIONS: Patients with peripheral artery disease were mostly affected by severe metabolic diseases and by worst cardiac conditions; patients with asymptomatic abdominal aortic aneurysms were of robust physique, and often had left ventricular anterior hemiblocks. Patients with critical carotid stenosis were older and had less cardiomyopathies.

Visceral ischaemia and organ dysfunction after hybrid repair of complex thoraco-abdominal aneurysms.

BACKGROUND: The visceral hybrid repair of thoracoabdominal aneurysms (TAAAs) is a feasible and relatively safe alternative to traditional open repair in a cohort of patients at high surgical risk, averting the need for thoracotomy and supra-coeliac aortic cross clamping. The visceral ischaemia-reperfusion syndrome and organ dysfunction following visceral debranching is still unkown. This study investigates the relationship between visceral ischemia and multi system organ dysfunction. PATIENTS AND METHODS: 18 consecutive patients undergoing elective, urgent and emergent hybrid repair of TAAAs between February 2005 and October 2007 were prospectively analyzed. Preoperative organ dysfunction and intraoperative risk factors (operating time, extent of the aneurysm, number of visceral vessels by passed) were assessed and compared with postoperative organ dysfunction (pulmonary, hepatic, renal, pancreatic and haematological disorders). Blood sampling for neutrophil CD 11b quantification was performed at baseline, on postoperative days 1, 3, 7 and before discharge. RESULTS: Perioperative Multi System Organ Dysfunction (MSOD) was diagnosed in 22.2% of patients (n = 4/18). Three of these patients died within 30 days (16.7%, n = 3/18). No relationship between preoperative organ dysfunction, blood loss, or operative time and postoperative organ dysfunction was observed. A significant correlation between the visceral retrograde revascularization and postoperative neutrophil expression in MSOD patients regardless of preoperative neutrophil baseline, TAAA extent and number of vessels by passed was present. CONCLUSIONS: Upregulation of neutrophils may be responsible for the higher incidence of MSOD and it may be an important marker predicting a severe multiple organ failure following visceral debranching in hybrid procedures.

Endovascular repair of an abdominal aortic aneurysm using bifurcated stent-graft in a patient with bilateral external iliac artery occlusion.

Abdominal aortic aneurysm (AAA) in association with external iliac artery (EIA) occlusion is a rare entity which may limit endovascular aortic aneurysm repair (EVAR) feasibility. We describe the case of an 84-year-old man affected by a 64mm infrarenal inflammatory abdominal aortic aneurysm with complete bilateral occlusion of EIA and patency of both common and internal iliac arteries. The common femoral arteries (CFA) were patent, and the patient was asymptomatic for lower limb claudication. The treatment was performed by EVAR using a bifurcated stent-graft after the recanalization of the left EIA, achieving technical success.

Extracranial Internal Carotid Artery Aneurysms: case report of a saccular wide-necked aneurysm and review of the literature.

PURPOSE: To describe a case of atherosclerotic Extracranial internal Carotid Artery Aneurysm (ECAA) with an unique "diverticulum-like" morphological structure, surgically treated and to review the experiences of major referral centers. CASE REPORT: A 76-year-old woman presented with persistent dysphagia and transient hypophonia caused by a growing pulsatiling mass of the neck; duplex ultrasonography and angio-CT scan demonstrated a wide-necked, saccular aneurysm at the origin of the right Internal Carotid Artery (ICA). A total aneurysmectomy with patch angioplasty of the aneurysm of the neck on the carotid wall was successfully performed. No perioperative complications were encountered; at one year follow-up the patient was asymptomatic without any neurological complication and with carotid patency. CONCLUSIONS: Open surgery remains the gold standard for the treatment of extracranial internal carotid artery aneurysms in terms of patency and reduced risk of adverse complications; endovascular procedures may, in selected cases, provide a valuable additional tool in the armoury of the physician.

Carotid endarterectomy with mini-invasive access in locoregional anaesthesia.

AIM: To assess the validity of a carotid endarterectomy (CEA) with a mini-invasive access via a 3-7 cm cutaneous incision in locoregional anaesthesia as a viable alternative to the traditional access with a cutaneous incision longer than 7 cm. MATERIALS AND METHODS: We carried out a retrospective analysis of 76 consecutive patients (Group A) who had undergone carotid CEA in locoregional anaesthesia with cervical mini-access (3-7 cm incision), compared to a preceding series of 95 patients (Group B) who had undergone the same operation through a traditional access (incision > 7 cm). All patients in Group A were examined solely by means of duplex ultrasound scanning. RESULTS: No mortality occurred in Group A and the morbidity rate was as follows: 1.3% strokes, 2.6% minor neurological events and 6.5% transitory deficit of peripheral nerves. In Group B, the mortality rate was 1%, with the following morbidity rate: 2% strokes, 1% minor neurological events and 7.3% transitory deficit of peripheral nerves. Statistical analysis revealed the two groups as being compatible for age, sex, associated pathologies and type of surgery. No statistically significant differences emerged between the two series of patients with regards to neurological morbidity or operative mortality. CONCLUSIONS: In addition to being more aesthetically pleasing, mini-invasive access is a viable alternative to the traditional access for patients undergoing carotid CEA in locoregional anaesthesia.

Endovascular treatments for type Ib endoleaks after aorto-iliac aneurysms exclusion: mid-term results.

BACKGROUND: To report early and mid-term results of endovascular treatments for type Ib endoleaks (IbEL) after endovascular aneurysm repair (EVAR) for aorto-iliac aneurysms (AAA). METHODS: Patients with IbEL after EVAR were retrospectively analyzed. Cases of IbEL treated in two centers from January 2009 to February 2017 were considered. Patients' demographics and comorbidities, interval between EVAR and IbEL diagnosis, type of endograft, site of sealing, oversize and length of iliac sealing zone, type of IbEL treatment were collected. Main endpoints were freedom from IbEL recurrence and freedom from reintervention. RESULTS: Thirty-five IbEL were treated in 29 patients (mean age: 76±7years; male: 100%). Mean time between EVAR and IbEL detection was 43±30months. IbEL was symptomatic in 4 (14%) and bilateral in 6 (21%). Endograft was bifurcated in 26 patients (90%) and aorto-uniiliac in 3 (10%). Distal landing zone was achieved in common and external iliac artery in 33 (94%) and 2 cases (6%), respectively. Mean oversize of endograft limb was 11±9%, mean length of sealing zone was 22±15 mm. Endovascular treatments included: 34 iliac extensions (8 cases [24%] with hypogastric artery coverage), and 1 embolization. Concomitant embolization of hypogastric artery was performed in 3 (9%) cases. Technical success was 100%, with no procedure-related complication. Considering patients with hypogastric exclusion, buttock claudication developed in 2/8 cases (25%). Mean follow-up was 20±19 months. Freedom from IbEL was 100% and no reintervention was necessity for IbEL during follow-up. At 12, 24 and 36 months, survival was 88%, 82% e 61%, respectively, with no IbEL-related death. CONCLUSIONS: IbEL can be easily managed by endovascular means, typically with distal extensions with landing zones in the common or external iliac artery. Mid-term results are favourable, with no recurrent IbEL or reintervention.

One-year experience in carotid endarterectomy combining general anaesthesia with preserved consciousness and sequential carotid cross-clamping.

BACKGROUND AND AIM OF THE WORK: We report 1-year single-centre experience in carotid endarterectomy (CEA) combining general anaesthesia with preserved consciousness (GAPC) and standardized carotid sequential cross-clamping, for our protocol effectiveness evaluation in reduction of perioperative stroke, death or cardiologic complications. METHODS: We considered all patients who underwent CEA in 2016. All patients underwent superficial cervical plexus block and GAPC with Remifentanil. The surgical technique consisted of common carotid artery (CCA) cross-clamping, carotid bifurcation isolation, external (ECA) and internal carotid artery (ICA) cross-clamping. After CCA cross-clamping, we performed a neurological tolerance test (NTT); this allowed selective shunting only for positive NTT. Primary end-points were: transient ischemic attack (TIA)/stroke, myocardial infarction, death in perioperative period. Secondary end-points were: carotid shunting, peripheral cranial nerves injuries (PCNI), GAPC intolerance, other complications, reintervention in perioperative period, length of hospital stay. RESULTS: 104 consecutive patients underwent CEA with this protocol in the considered period. Twenty-seven (25.9%) patients were symptomatic. Mean clamping time was 48±13.5 minutes. Five cases (4.8%) requested internal carotid artery shunting. No TIA/stroke, myocardial infarction or death were recorded in the perioperative period. PCNI were observed in 19 cases (18.2%) in the immediate post-operative period; 16 of them (84.2%) showed complete or partial resolution at discharge. Only one patient (0.9%) showed GAPC intolerance. No other complication occurred. Three patients (2.9%) underwent reintervention for neck haematoma drainage. Mean hospital stay were 3±0.9 days. CONCLUSIONS: GAPC associated with sequential carotid cross-clamping appeared to be safe and effective in prevention of major neurological and cardiologic complications during CEA.

Early increases in cardiac troponin levels after major vascular surgery is associated with an increased frequency of delayed cardiac complications.

OBJECTIVE: To evaluate changes in cardiac troponin-I levels after major vascular surgery and their association with early and late postoperative cardiac complications. DESIGN: Prospective, observational investigation. SETTING: University teaching hospital. PATIENTS: 75 consecutive patients undergoing major vascular surgery. INTERVENTIONS: All patients received a standard sevoflurane-fentanyl anesthesia during the procedure. Blood levels of creatine kinase with MB subtype and cardiac troponin-I were assessed before surgery and then everyday for the first 3 days after surgery. At the same time, 12-lead electrocardiography was also performed, and occurrence of any cardiac adverse event was recorded. Patients were then followed up for 1 month after surgery. MEASUREMENT AND MAIN RESULTS: Troponin-I levels increased in 25 patients (33%) during the first 3 days after surgery; 9 of these patients (12%) had myocardial infarction. At univariate analysis, uncontrolled hypertension was the only risk factor for perioperative infarction (odds ratio, 16; (95% confidence interval, 3-74); however, multivariate logistic regression analysis failed to show statistically significant associations. Increases in troponin-I had a 100% sensitivity and 75% specificity in detecting myocardial ischemia with a 36% positive and 100% negative predictive values. Severe cardiac complication 1 month after surgery was reported in 5 patients (6.6%). The increase of cardiac troponin-I levels during the first 3 postoperative days was associated with an increased frequency of major cardiac complication at 1-month follow-up (P = 0.003), with a 100% sensitivity, 71% specificity, and 100% negative predictive value. CONCLUSIONS: Myocardial infarction after major noncardiac vascular surgery occurs in up to 12% of cases. Perioperative monitoring of troponin-I plasma levels may help to identify patients at increased risk for cardiac morbidity not only early after surgery but also during the first postoperative month.

Superior Mesenteric Artery Aneurysm Caused by Aortic Valve Endocarditis: The Case Report and Review of the Literature.

Infectious aneurysms of the superior mesenteric artery are a rare but life-threatening condition due to the risk of visceral ischemia, sepsis, or hemorrhage. In this study, we report the case of a superior mesenteric artery aneurysm (SMAA) secondary to a bioprosthetic valve endocarditis, successfully managed with aneurysm resection and saphenous vein interposition graft. We performed an extensive PubMed-based rewiew of the literature of the last 10 years on SMAA, which include the detection of 38 articles quoting 41 SMAAs. The case histories were divided in 2 groups: 18 cases belonged to nonmycotic group A and 23 cases were included in mycotic group B. In group A, 44.4% of patients were treated surgically, whereas in group B, 90.5%. The 2 study groups significantly differed (P = .01) in terms of surgical treatment. The surgical approach still remains the first choice of treatment in mycotic aneurysm.

Mini-invasive aortic surgery: a 2 year experience.

The aim of this study was to evaluate a less invasive technique for the exposure of the infrarenal aorta and its impact on the treatment of patients with abdominal aortic aneurysms (AAA). Fortyfour patients with AAA we re prospectively selected f o r minilaparotomy a ortic exposure and repair using asmall periumbilical midline incision, intra-abdominal nondisplaced retraction of the small bowel and conventional hand-sewn vascular anastomosis. Perioperative comparisons with a contemporary group of AAA patients treated with long, open midline incision and extracavitary small bowel retraction were made. There were no significant differences between the minilaparotomy and open surgical control group concerning operating room time, intraoperative and perioperative morbidity or mortality. Significant differences were shown between the two groups regarding intensive care unit stay; the return to a general diet and the length of hospitalization. Minilaparotomy exposure is safe and effective for the treatment of infrarenal AAA. This technique maintains quality outcome while reducing postoperative ileus, hospital stay and resource utilization.