Peroperative Intravascular Ultrasound for Endovascular Aneurysm Repair versus Peroperative Angiography: A Pilot Study in Fit Patients with Favorable Anatomy.

BACKGROUND: The aim of this study was to compare intravascular ultrasound (IVUS) assistance for endovascular aortic aneurysm repair (EVAR) to standard assistance by angiography. METHODS: From June 2015 to June 2017, 173 consecutive patients underwent EVAR. In this group, 69 procedures were IVUS-assisted with X-ray exposure limited to completion angiography for safety purposes because an IVUS probe does not yet incorporate a duplex probe (group A), and 104 were angiography-assisted procedures (group B). All IVUS-assisted procedures were performed by vascular surgeons with basic duplex ultrasound (DUS) training. The primary study endpoints were mean radiation dose, duration of fluoroscopy, amount of contrast media administered, procedure-related outcomes, and renal clearance expressed as the glomerular filtration rate (GFR) before and after the procedure. Secondary endpoints were operative mortality, morbidity, and arterial access complications. RESULTS: Mean duration of fluoroscopy time was significantly lower for IVUS-assisted procedures (24 ± 15 min vs. 40 ± 30 min for angiography-assisted procedures, P < 0.01). Moreover, mean radiation dose (Air KERMA) was significantly lower in IVUS-assisted procedures (76m Gy [44-102] vs. 131 mGy [58-494]), P < 0.01. IVUS-assisted procedures required fewer contrast media than standard angiography-assisted procedures (60 ± 20 mL vs. 120 ± 40 mL, P < 0.01). The mean duration of the procedure was comparable in the two groups (120 ± 30 min vs. 140 ± 30 min, P = 0.07). No difference in renal clearance before and after the procedure was observed in either of the two groups (99.0 ± 4/97.8 ± 2 mL/min in group A and 98.0 ± 3/97.6 ± 5 mL/min in group B) (P = 0.28). The mean length of follow-up was nine months (6-30 months). No postoperative mortality, morbidity, or arterial access complications occurred. No type 1 endoleak was observed. Early type II endoleaks were observed in 21 patients (11%), 12 in the angiography-assisted group (11%) and nine in the IVUS-assisted group (12%). They were not associated with sac enlargement ≥5 mm diameter and therefore did not require any additional treatment. CONCLUSIONS: Compared with standard angiography-assisted EVAR, IVUS significantly reduces renal load with contrast media, fluoroscopy time, and radiation dose while preserving endograft deployment efficiency. Confirmation from a large prospective study with improved IVUS probes will be required before IVUS-assisted EVAR alone can become standard practice.

Endovascular strategy for the elective treatment of concomitant aortoiliac aneurysm and symptomatic large bowel diverticular disease.

BACKGROUND: The purpose of this study was to evaluate the strategy for treatment of patients presenting with asymptomatic diverticular disease of the large bowel associated with an asymptomatic aortoiliac aneurysmal (AAA) disease. METHODS: Sixty-nine patients were included in this retrospective study. The patients were divided into 5 groups according to the type and sequence of the surgical treatment: 32 patients (47%) underwent colectomy followed by a staged open AAA repair (group A); 10 patients (14%) were treated with open AAA repair followed by a staged colectomy (group B); 13 patients (18%) received endovascular aneurysm repair (EVAR) followed by a staged bowel resection (group C); 8 patients (12%) had a bowel resection followed by staged EVAR (group D); and 6 patients (9%) underwent simultaneous open AAA repair and bowel resection (group E). Primary end points were mortality and complications after any of the procedures. Secondary end point was the time interval between the staged procedures. RESULTS: The cumulative death rate for delayed treatment of AAA was 6.5% and 0% for delayed treatment of diverticular disease [P=0.22]. The mean time interval between the staged procedures was 11 days for EVAR/colon resection (group C and group D) and 73 days for open AAA repair/colon resection (group A and group B; P<0.01). CONCLUSIONS: EVAR allows a significant reduction in the time required between AAA repair and colon resection, but no definite rule can be established regarding the sequence of staged procedures. Combined procedures should be reserved for selected cases.

Colorectal cancer associated with abdominal aortic aneurysm: results of EVAR followed by colectomy.

The association of colorectal cancer and abdominal aortic aneurysm (AAA) is infrequent but poses special problems of priority of treatment under elective circumstances. The purpose of this study was to retrospectively evaluate the outcome of 16 consecutive patients undergoing endovascular aneurysm repair (EVAR) followed by colectomy. Operative mortality was nil. Operative morbidity included two transient rise of serum creatinine level and one extraperitoneal anastomotic leakage which evolved favourably with conservative treatment. EVAR allowed a very short delay of treatment of colorectal cancer after aneurysm repair, minimizing operative complications.

Dual antiplatelet treatment in patients candidates for abdominal surgery.

UNLABELLED: With the increasing diffusion of percutaneous interventions (PCI), surgeons are often faced with the problem of operating on patients under dual antiplatelet treatment. Replacing dual antiplatelet regiment with low molecular weight heparin may expose to the abrupt thrombosis of coronary stent and massive myocardial infarction. The purpose of this study was to test the hypothesis that abdominal operations can be safely performed under dual antiplatelet treatment. Eleven patients underwent 5 colectomies, 3 nefrectomies, 2 gastrectomies and 1 hysterectomy under aspirin and plavix without any significant perioperative hemorrhage. These preliminary results show that abdominal operations can be safely performed under dual antiplatelet regimen. KEY WORDS: Abdominal surgery, Dual antiplatelet treatment.

Surgical outcomes for liposarcoma of the lower limbs with synchronous pulmonary metastases.

BACKGROUND AND OBJECTIVES: Surgical resection of pulmonary metastases from soft tissues sarcomas has typically yielded disparate results, owing to the histologic heterogeneity of various series and the presentation times relative to primary tumor discovery. It was our hypothesis that with expeditious, curative surgical resection of both, primary and metastatic disease, patients with liposarcoma of the lower limb and synchronous, resectable, pulmonary metastases might achieve satisfactory outcomes. METHODS: A consecutive sample clinical study, with a mean follow-up duration of 30 months. Twenty-two patients (mean age, 50 years), each presenting with a liposarcoma of the lower limb and synchronous, resectable, pulmonary metastases, underwent curative resection of both the primary mass and all pulmonary metastases within a mean of 18 days from presentation (range 9-32 days). RESULTS: Mean overall survival was 28 months, disease-related survival (SE) was 9% at 5 years (±9.7%), and disease-free survival was 9% at 5 years (±7.6%). CONCLUSION: Expeditious, curative resection of both--primary and metastatic lesions--yields acceptable near-term results, with potential for long-term survival, in patients with liposarcoma of the lower limb and synchronous pulmonary metastases.

Management of carotid Dacron patch infection: a case report using median sternotomy for proximal common carotid artery control and in situ polytetrafluoroethylene grafting.

We report on a 58-year-old male who presented with an enlarging cervical hematoma 3 months following carotid endarterectomy with Dacron patch repair, due to septic disruption of the Dacron patch secondary to presumed infection. The essential features of this case are the control of the proximal common carotid artery gained through a median sternotomy, because the patient was markedly obese with minimal thyromental distance, and the treatment consisting of in situ polytetrafluoroethylene bypass grafting, due to the absence of a suitable autogenous saphenous vein. Median sternotomy is rarely required in case of reintervention for septic false aneurysms and hematomas following carotid endarterectomy but should be considered whenever difficult control of the common carotid artery, when entering the previous cervicotomy, is anticipated. In situ polytetrafluoroethylene grafting can be considered if autogenous vein material is lacking.

Results of a pancreatectomy with a limited venous resection for pancreatic cancer.

PURPOSE: The indications for a pancreatectomy with a partial resection of the portal or superior mesenteric vein for pancreatic cancer, when the vein is involved by the tumor, remain controversial. It can be assumed that when such involvement is not extensive, resection of the tumor and the involved venous segment, followed by venous reconstruction will extend the potential benefits of this resection to a larger number of patients. The further hypothesis of this study is that whenever involvement of the vein by the tumor does not exceed 2 cm in length, this involvement is more likely due to the location of the tumor being close to the vein rather than because of its aggressive biological behavior. Consequently, in these instances a pancreatectomy with a resection of the involved segment of portal or superior mesenteric vein for pancreatic cancer is indicated, as it will yield results that are superposable to those of a pancreatectomy for cancer without vascular involvement. METHODS: Twenty-nine patients with carcinoma of the pancreas involving the portal or superior mesenteric vein over a length of 2 cm or less underwent a macroscopically curative resection of the pancreas en bloc with the involved segment of the vein. The venous reconstruction procedures included a tangential resection/lateral suture in 15 cases, a resection/end-to-end anastomosis in 11, and a resection/patch closure in 3. RESULTS: Postoperative mortality was 3.4%; morbidity was 21%. Local recurrence was 14%. Cumulative (standard error) survival rate was 17% (9%) at 3 years. CONCLUSION: A pancreatectomy combined with a resection of the portal or superior mesenteric vein for cancer with venous involvement not exceeding 2 cm is indicated in order to extend the potential benefits of a curative resection.

Results in a consecutive series of 83 surgical corrections of symptomatic stenotic kinking of the internal carotid artery.

BACKGROUND: Although there is a growing body of evidence to document the safety and efficacy of operative treatment of carotid stenosis, surgical indications for elongation and kinking of the internal carotid artery remain controversial. The goal of this study was to evaluate the efficacy of surgical correction of internal carotid artery kinking in patients with persistent hemispheric symptoms despite antiplatelet therapy. METHODS: A consecutive series of 81 patients (mean age, 64 years) underwent 83 surgical procedures to correct kinking of the internal carotid artery either by shortening and reimplanting the vessel on the common carotid artery, inserting a bypass graft, or transposing the vessel onto the external carotid artery. Mean follow-up was 56 months (range, 15-135 months). Study endpoints were 30-day mortality and any stroke occurring during follow-up. RESULTS: No postoperative death was observed. The postoperative stroke rate was 1%. Primary patency, freedom from neurologic symptoms, and late survival at 5 years (x +/- standard deviation) were 89 +/- 4.1%, 92 +/- 4%, and 71 +/- 6%, respectively. CONCLUSIONS: The findings of this study indicate that surgical correction for symptomatic stenotic kinking of the internal carotid artery is safe and effective in relieving symptoms and preventing stroke. Operative correction should be considered as the standard treatment for patients with symptomatic carotid kinking that does not respond to antiplatelet therapy.

Primary leiomyosarcoma of the innominate vein.

Primary venous leiomyosarcoma is rare. We report the case of a primary leiomyosarcoma of the left innominate vein, with neoplastic thrombus extending into the left jugular and subclavian veins. The tumor was curatively resected en bloc with anterior mediastinal and laterocervical lymphatics, through a median sternotomy prolonged into left cervicotomy. Primary venous sarcomas may be associated with prolonged survival in individual cases, with curative resection recommended as the standard treatment, in the absence of distant spread.

Prosthetic replacement of the infrahepatic inferior vena cava for leiomyosarcoma.

HYPOTHESIS: Resection of the infrahepatic inferior vena cava associated with prosthetic graft replacement for caval leiomyosarcoma is an acceptable procedure to obtain prolonged and good-quality survival. DESIGN: A consecutive sample clinical study with a mean follow-up of 40 months. SETTING: The surgical department of an academic tertiary center and an affiliated secondary care center. PATIENTS: Eleven patients, with a mean age of 51 years, who have primary leiomyosarcoma of the infrahepatic inferior vena cava. INTERVENTIONS: All of the patients underwent radical resection of the tumor en bloc with the affected segment of the vena cava. Reconstruction consisted of 10 cavocaval polytetrafluoroethylene grafts and 1 cavobiliac graft. An associated right nephrectomy was performed in 2 cases. The left renal vein was reimplanted in the graft in 3 cases. MAIN OUTCOME MEASURES: Cumulative disease-specific survival, disease-free survival, and graft patency rates expressed by standard life-table analysis. RESULTS: No patients died in the postoperative period. The cumulative (SE) disease-specific survival rate was 53% (21%) at 5 years. The cumulative (SE) disease-free survival rate was 44% (19%) at 5 years. The cumulative (SE) graft patency rate was 67% (22%) at 5 years. CONCLUSION: Radical resection followed by prosthetic graft reconstruction is a valuable method for treating primary leiomyosarcoma of the infrahepatic inferior vena cava.

Infrascrotal, Perineal, Femorofemoral Bypass for Arterial Graft Infection at the Groin.

HYPOTHESIS: Infrascrotal, perineal, femorofemoral bypass is an acceptable procedure for treating infection of a prosthetic arterial graft limited to a unilateral groin. DESIGN: A consecutive sample clinical study with a mean follow-up of 29 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Nineteen patients with a mean age of 68 years with prosthetic graft infection at the outflow anastomosis on a femoral artery at the Scarpa triangle underwent an infrascrotal, perineal, femorofemoral bypass, with excision of the graft material limited at the groin. The recipient artery was the profunda femoris artery in 12 cases, the superficial femoral in 5, and the distal common femoral artery in 2. MAIN OUTCOME MEASURES: Cumulative survival, recurrence of sepsis, primary graft patency, and limb salvage rates expressed by standard life-table analysis. RESULTS: Postoperative mortality rate was 5%. Cumulative (SE) survival rate was 65% (11.6%) at 3 years. Cumulative (SE) rate of freedom from recurrent sepsis was 88% (8.6%) at 3 years. Cumulative (SE) primary patency and limb salvage rates were 86% (9.4%) and 91% (7.9%), respectively, at 3 years. CONCLUSION: Femorofemoral bypass with an infrascrotal perineal approach is a valuable procedure for the treatment of femoral arterial graft infection limited at a unilateral groin.

Infrascrotal, perineal, femorofemoral bypass for arterial graft infection at the groin.

HYPOTHESIS: Infrascrotal, perineal, femorofemoral bypass is an acceptable procedure for treating infection of a prosthetic arterial graft limited to a unilateral groin. DESIGN: A consecutive sample clinical study with a mean follow-up of 29 months. SETTING: The surgical department of an academic tertiary care center and an affiliated secondary care center. PATIENTS: Nineteen patients with a mean age of 68 years with prosthetic graft infection at the outflow anastomosis on a femoral artery at the Scarpa triangle underwent an infrascrotal, perineal, femorofemoral bypass, with excision of the graft material limited at the groin. The recipient artery was the profunda femoris artery in 12 cases, the superficial femoral in 5, and the distal common femoral artery in 2. MAIN OUTCOME MEASURES: Cumulative survival, recurrence of sepsis, primary graft patency, and limb salvage rates expressed by standard life-table analysis. RESULTS: Postoperative mortality rate was 5%. Cumulative (SE) survival rate was 65% (11.6%) at 3 years. Cumulative (SE) rate of freedom from recurrent sepsis was 88% (8.6%) at 3 years. Cumulative (SE) primary patency and limb salvage rates were 86% (9.4%) and 91% (7.9%), respectively, at 3 years. CONCLUSION: Femorofemoral bypass with an infrascrotal perineal approach is a valuable procedure for the treatment of femoral arterial graft infection limited at a unilateral groin.

Simultaneous repair of abdominal aortic aneurysm and resection of unexpected, associated abdominal malignancies.

BACKGROUND AND OBJECTIVES: The management of unexpected intra-abdominal malignancy, discovered at laparotomy for elective treatment of an abdominal aortic aneurysm (AAA), is controversial. It is still unclear whether both conditions should be treated simultaneously or a staged approach is to be preferred. To contribute in improving treatment guidelines, we retrospectively reviewed the records of patients undergoing laparotomy for elective AAA repair. METHODS: From January 1994 to March 2003, 253 patients underwent elective, trans-peritoneal repair of an AAA. In four patients (1.6%), an associated, unexpected neoplasm was detected at abdominal exploration, consisting of one renal, one gastric, one ileal carcinoid, and one ascending colon tumor. All of them were treated at the same operation, after aortic repair and careful isolation of the prosthetic graft. RESULTS: The whole series' operative mortality was 3.6%. None of the patients simultaneously treated for AAA and tumor resection died in the postoperative period. No graft-related infections were observed. Simultaneous treatment of AAA and tumor did not prolong significantly the mean length of stay in the hospital, compared to standard treatment of AAA alone. CONCLUSIONS: Except for malignancies of organs requiring major surgical resections, simultaneous AAA repair and resection of an associated, unexpected abdominal neoplasm can be safely performed, in most of the patients, sparing the need for a second procedure. Endovascular grafting of the AAA can be a valuable tool in simplifying simultaneous treatment, or in staging the procedures with a very short delay.