Internal carotid artery dissection related to abnormalities of styloid process: is it only a matter of length?

INTRODUCTION: Vascular Eagle syndrome, due to impingement of the extracranial internal carotid artery (ICA) by the styloid process (SP), is an uncommon and not yet widely recognized cause of ICA dissection. Up to now, this diagnosis is still presumptive, based mainly on the length of the SP. However, given the discrepancy between the much higher prevalence of an elongated SP in the population compared to the reported rate of Eagle syndrome, other anatomical factors beyond the length itself of this bony structure seem to be involved. MATERIAL AND METHODS: We performed a retrospective single center case-control study of ICA dissection related to abnormalities of styloid process and age- and sex-matched controls affected by ICA dissection not related to abnormal relationship with the styloid process. In our work instead of considering SP length as the main criteria to differentiate the two groups, we decided to consider styloid process-internal carotid artery distance (at the dissection point) as the main factor to define a styloid process related dissection (SPRD). In fact in some patients, the distance between the dissected artery and the bony prominence was virtual. RESULTS: Our study showed that in patients with SPRD the styloid process angulation on the coronal plane tends to be more acute and that styloid process-C1 distance is significantly shorter at the side of the dissection. This data reinforces the idea that ICA dissection risk in the vascular Eagle syndrome has probably a multifactorial pathogenesis.

Femoral Artery Leiomyosarcoma: Case Report and Literature Review.

BACKGROUND: Vascular leiomyosarcoma is a rare type of malignant tumor which arises from the smooth muscle tissue of blood vessel walls; it involves veins five times more frequently than arteries. There are only a few cases published in the literature and consequently there is limited experience regarding treatment and prognosis. METHODS: A 66-year-old woman presented with left lower limb swelling and a left inguinal mass. Imaging revealed a seven-by-five cm well-circumscribed oval inguinal mass that incorporated the common femoral artery including its bifurcation and compressed the common femoral vein. Other malignancies or metastatic disease were excluded. The patient underwent en bloc resection of the tumor, including the common femoral artery and its bifurcation and arterial reconstruction, using the inverted contralateral great saphenous vein, was carried out. Histopathological examination of the mass revealed moderately-differentiated leiomyosarcoma arising from the femoral artery wall without invasion of the intima. The postoperative course was uneventful. 12 months after the procedure the patient was in good clinical conditions and a contrast enhanced CT scan showed patency of the arterial reconstruction without local recurrence or metastatic disease. RESULTS: A systematic literature search identified nine cases of femoral artery leiomyosarcoma; in the eight patients for whom follow-up data were reported, recurrent or metastatic disease developed in five and only three were alive and free of disease. CONCLUSIONS: As with any soft tissues sarcoma, complete surgical resection is the cornerstone of treatment and any directly involved adjacent structures must be sacrificed, as well as a margin of uninvolved normal tissue; consequently, a vascular reconstruction is almost always necessary.

Eagle Syndrome and Internal Carotid Artery Dissection: Description of Five Cases Treated in Two Italian Institutions and Review of the Literature.

Eagle syndrome is a rare pattern of symptoms (0.16% of the general population) due to the conflict with adjacent anatomical structures by an elongated styloid process or a calcified stylohyoid ligament; 2 variants of this condition have been described in the literature, classical and vascular. The classical form is caused by compression of the glossopharyngeal nerve and the surrounding structures from an abnormal stylohyoid apparatus, causing odynophagia and neck pain and is usually treated by an otorhinolaryngologist. The vascular form, determined by the conflict between the osteoligamentous malformation and the extracranial carotid artery, can cause neurological symptoms due to the compression of the vessel or in some cases the dissection of the carotid artery itself. However, an elongated styloid process occurs in about 4% of the general population, and the most recent literature shows that the vascular form of Eagle syndrome could be an underestimated cause of carotid artery dissection (CAD) and should be considered in the differential diagnosis of this condition. In addition to the literature many different treatment options for this condition are reported, either medical and/or surgical, but an ideal approach has not yet been fully identified. We report 5 cases of internal CAD due to the vascular variant of Eagle syndrome treated in 2 different Italian institutions (Department of Vascular and Endovascular Surgery, Galliera Hospital, Genoa and Department of Vascular Surgery, Santi Filippo e Nicola Hospital, Avezzano, L'Aquila) and a careful and analytical review of the available literature on this topic.

Ultrasound-guided fascia closure as bailout technique for large-bore percutaneous femoral access failure: Report of two cases.

Percutaneous endovascular abdominal aortic aneurysm repair is nowadays considered a safe and effective procedure and has gained widespread globally acceptance. However, intraoperative persistent bleeding due to percutaneous access closure device failure can occur. Open conversion is first-line treatment to manage this complication. The fascia suture technique was introduced as an alternative to access closure device or as a solution to manage unsatisfactory hemostasis during percutaneous endovascular abdominal aortic aneurysm repair. In this article, we report a new simple minimally invasive ultrasound-guided fascia suture technique as a bailout method to manage persistent bleeding after percutaneous endovascular abdominal aortic aneurysm repair avoiding open conversion. This technique was successfully used in two cases at our center with satisfactory hemostasis and no further complications. Ultrasound-guided fascia suture technique can be proposed as a minimally invasive bailout technique for access closure device failure.

An Alternative Technique to Achieve Haemostasis During PEVAR Using Perclose ProGlide.

INTRODUCTION: Percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) using the Perclose ProGlide suture mediated closure device is currently performed on a global scale. A safe, effective, and cheap technique for achieving haemostasis during PEVAR is described that allows the reversible downsizing of the arteriotomy, without using any other devices. TECHNIQUE: The procedure consists of pulling the blue thread of the pre-implanted ProGlide, advancing the knot close to the arterial wall by pushing it with the dilator of a small introducer sheath, and maintaining the system under tension by grasping the end of the blue thread with a haemostat until bleeding control is achieved. DISCUSSION: Seventeen PEVAR femoral access downsizing procedures have been performed between February and June 2018 and no complications were observed. The technique could be useful in everyday practice and has now become the author's standard practice.

Endovascular treatment with flow-diverting stents of symptomatic superior mesenteric artery after dissection aneurysm.

Isolated and spontaneous superior mesenteric artery dissection is a rare cause of acute abdominal pain. Whereas there is widespread consensus on conservative treatment of asymptomatic forms, revascularization would seem indicated in symptomatic complicated cases. A 73-year-old man presented with worsening epigastric pain. A computed tomography scan revealed an isolated and spontaneous superior mesenteric artery dissection with aneurysmal evolution of the false lumen, involving multiple side branches. The postdissection aneurysm was treated by endovascular exclusion with flow-diverting stents. The abdominal pain was completely relieved, and the patient remained asymptomatic at follow-up.