Dehydrated human amnion/chorion membrane allograft with spongy layer to significantly improve the outcome of chronic non-healing wounds.

We investigated the healing effect of a new dehydrated amnion/chorion membrane with a spongy layer over a 30-month period in 32 patients with 53 chronic non-healing wounds of different aetiologies. Wounds with <40% surface reduction after 4 weeks of best wound treatment underwent weekly allograft application by a certified wound specialist based on national guidelines and a standardised protocol until complete healing or definite treatment interruption. The main outcome measure was the percentage of wound surface reduction from baseline calculated using digital planimetry follow-up photographs. Overall, 38 (71.7%) wounds presented a favourable outcome (70%-100% area reduction), with 35 (66%) completely healing over a median time of 77 days (range 29-350 days). Favourable outcomes were observed in 75% of traumatic wounds, surgical wounds, venous leg ulcers and pressure injuries, as well as in 50% of ischaemic wounds. Wounds being present <12 months were significantly more likely to have a favourable outcome than more long-standing wounds (χ2 = 7.799; p = 0.005; OR = 3.378; 95% CI, 1.410-8.092). Thus, treatment with dehydrated amnion/chorion membrane with a spongy layer improves the outcome of non-healing wounds of different aetiologies and, therefore, has to be considered early in the management of refractory wounds.

Symptomatic internal carotid artery stenosis in the presence of a persistent primary hypoglossal artery.

OBJECTIVES: Anatomic variations of the extracranial carotid artery are rare. Persistent primitive hypoglossal artery appears with a reported incidence between 0.03% and 0.2%. We report a case of recurrent transient ischemic attacks originating from proximal internal carotid artery stenosis associated with ipsilateral persistent primitive hypoglossal artery and give a review of the existing literature. METHODS: A 78-year-old patient with a medical history of two previous transient ischemic attacks consulted our emergency department with an acute left hemispheric stroke. Intravenous thrombolysis permitted complete resolution of symptoms. Concurrent Computed Tomography (CT) and Magnetic Resonance (MR) angiography revealed an unstable plaque causing 50% stenosis of the left internal carotid artery with a persistent primitive hypoglossal artery dominantly perfusing the posterior circulation, and bilateral hypoplastic vertebral arteries. RESULTS: Uneventful carotid artery stenting using a proximal protection device was performed, and the patient was discharged after 12 days. Six months follow-up was uneventful with a patent stent in the internal carotid artery. CONCLUSIONS: Treatment of symptomatic carotid artery stenosis in the presence of persistent primitive hypoglossal artery is challenging. Management should be driven by patients' co-morbidities, the anatomical localization of the lesions and local expertise. In the case of a high origin of the persistent primary hypoglossal artery, carotid artery stenting with the use of a proximal cerebral protection device is probably the preferred and simplest approach.

Late open conversion after failed endovascular aortic aneurysm repair.

OBJECTIVE: Endovascular aortic aneurysm repair (EVAR) is widely used for the treatment of abdominal aortic aneurysms. Complications secondary to EVAR are also treated with endovascular techniques. When this is not applicable, open surgical repair is mandatory. This study aims to present our experience in open surgical repair after failed EVAR. METHODS: Within the period from 2004 through 2013, 18 patients (17 men; mean age, 73.9 years) were operated on because of EVAR failure due to persistent type II endoleak (n = 10), type I or III endoleak (n = 3), mixed-type endoleaks (n = 2), stent graft thrombosis (n = 2), and aortoenteric fistulae (n = 1). Stent grafts used for EVAR were Zenith (n = 8), Talent (n = 4), Excluder (n = 4), and Anaconda (n = 2). RESULTS: Mean time interval between EVAR and open conversion was 36 months (range, 2-120 months). Fifteen (83.3%) operations were elective, and three (16.7%) were urgent due to aneurysm rupture (n = 2) and aortoenteric fistula (n = 1). Six (33.3%) patients with type II endoleak were treated with simple ligation of the culprit vessels, without aortic clamping and stent graft explantation. In six (33.3%) patients, the stent graft was partially removed except from the segment attached to the proximal neck, while in five (27.8%) patients, complete removal of the stent graft was necessary. Finally, in one patient, with type III endoleak, a hybrid endovascular and open repair was performed. Clamping of the aorta was necessary in 12 (66.7%) patients (infrarenal, n = 10 or suprarenal, n = 2). Overall operative mortality was 5.6%. Postoperative complications included one abdominal wall defect requiring surgical revision and paroxysmal atrial fibrillation both in the same patient, and one case of pulmonary infection, requiring prolonged intubation and intensive care unit stay for 6 days. CONCLUSIONS: Late open conversion after failed EVAR remains challenging. Avoidance of aortic cross-clamping and if possible, partial or total preservation of the stent graft may improve outcomes in terms of operative mortality and morbidity. Elective operations seem to be associated with better outcomes, prompting thus for close follow-up of EVAR patients and early decision for conversion if other options are doubtful.

Double eversion carotid endarterectomy of tandem carotid lesions.

BACKGROUND: We describe an original method to treat tandem lesions of the internal carotid artery (ICA) and the common carotid artery (CCA). In this manuscript, we describe a "double eversion carotid endarterectomy" technique (DECE) and report our results. METHODS: A retrospective review in the medical records of patients that underwent DECE over a 15-year period was performed. Patient characteristics, operative details, preoperative imaging and lesion characteristics, perioperative outcomes, and follow-up data were documented and analyzed. Patients with ostial and mediastinal lesions were excluded from our study. Operations were divided into 2 categories: "planned," when the lesions were identified during preoperative imaging, and "necessary" when performed for secondary defects of the CCA detected intraoperatively. RESULTS: Between 1996 and 2011, a total of 15 patients with 17 tandem lesions underwent DECE. The mean age was 74.3 years. The mean degree of stenosis was 76.3% for the ICA and 61.5% for the CCA, with the majority of the lesions being asymptomatic (12/17). All procedures were performed under general anesthesia, and in 1 case an intraluminal shunt was used. The mean operative time was 83.4 min, with a mean primary clamping time of 29.2 min. In cases of secondary lesions, the mean reclamping time was 16.2 min. There was no mortality or major neurologic event within 30 days postoperatively. Postoperative complications included 2 major cardiac events and 1 case of cranial nerve XII injury that resolved during follow-up. There were no deaths or neurologic events during a mean follow-up of 27.5 months (range: 1-188 months). One patient required a reintervention after 5 years because of restenosis of the ICA. CONCLUSION: DECE is an alternative surgical technique for select tandem, nonostial carotid lesions. In addition, DECE can be performed as a "bailout" procedure for secondary CCA defects during conventional eversion carotid endarterectomy.

Retrograde mesenteric perfusion from the deep femoral artery in a patient with a recurrent anastomotic aneurysm in the groin: a case report.

In patients with atherosclerotic disease in two of the three main vessels in the splanchnic circulation, symptoms of chronic mesenteric ischemia may arise, depending on the disease chronicity and the presence of mesenteric collateral pathways. The most commonly described collateral pathways are between the celiac artery (CA), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA); and between the IMA and the internal iliac artery (IIA). Another collateral network between the deep femoral artery and the IIA can also become important, especially in patients with aorto-iliac occlusion. Here we report a patient with a symptomatic anastomotic aneurysm of the right femoral artery after a previous aorto-bi-femoral bypass. This patient's bowel viability relied on a well-developed collateral network from the ipsilateral deep femoral artery. This unusual anatomy required special surgical considerations and planning, to minimize the risk of perioperative mesenteric ischemia. During open repair, distal femoral debranching with a distal-to-proximal anastomotic sequence allowed minimizing of the ischemic time, and avoidance of potential ischemic complications from the visceral circulation. This case emphasizes the importance and benefit of the deep femoral artery and its collaterals as a reserve network of the splanchnic circulation. Favorable outcomes can be achieved with careful analysis of the preoperative imaging and proper planning, with adaptation of the surgical strategy.

Treatment paradigms for ductus arteriosus aneurysms in adults.

We report two symptomatic cases of ductus arteriosus aneurysm (DDA) in adults treated in our department over a 5-years period. One patient underwent an open off-pump surgical procedure, while the second one was treated with partial aortic arch debranching and endovascular stent-grafting. DDA in adults is an uncommon condition and can present with rupture, hoarseness or symptoms of airway obstruction. Although indications for intervention are not clearly established, most authors advocate that DDAs should be treated regardless of their size, to avoid the risk of rupture, while others reserve intervention for symptomatic patients. We report on the management of these patients and provide an updated review of the current literature.

Multiple aneurysms of the inferior pancreaticoduodenal artery: a rare complication of acute pancreatitis.

Inferior pancreaticoduodenal artery (IPDA) aneurysms are uncommon, representing nearly 2% of all visceral aneurysms, and sporadically associated with celiac artery stenosis. Multiple IPDA aneurysms have been rarely reported. We report a case of a 53-year-old female patient with a history of prior pancreatitis, who presented with two IPDA aneurysms combined with median arcuate ligament-syndrome-like stenosis of the celiac trunk. The patient was treated successfully with coil embolization under local anesthesia. The procedure is described and illustrated in detail and the advantages and technical considerations of such an approach are also being discussed.

Management of a complicated ruptured infected pseudoaneurysm of the femoral artery in a drug addict.

Infected pseudoaneurysm of the femoral artery represents a devastating complication of intravenous drug abuse, especially in the event of rupture. Operative strategy depends upon the extent of arterial injury and the coexistence of infection or sepsis. Options range from simple common femoral artery (CFA) ligation to complex arterial reconstruction with autologous grafts (arterial, venous, or homografts). We report herein the management of a 29-year-old male patient who was urgently admitted with a ruptured pseudoaneurysm of the right CFA, extending well above the inguinal ligament. Multidisciplinary approach with multiple arterial reconstructions and subsequent coverage of the tissue defect with a rectus abdominis musculocutaneous flap transposition was performed.

Clinical manifestations of aortocaval fistulas in ruptured abdominal aortic aneurysm: report of two cases.

Aortocaval fistula (ACF) is an unusual complication of ruptured abdominal aortic aneurysm (AAA), involving less than 3-6% of all ruptured cases. The clinical presentation is often obscure, depending on the coexistence of retroperitoneal rupture and hemodynamic instability. Prompt preoperative diagnosis is essential in order to plan the operative approach and improve patient's outcome. We report the surgical treatment of two patients presented in the emergency department with ACF due to ruptured AAA, each with different clinical presentation, emphasizing the high index of suspicion needed by the clinician to early diagnose and treat this often lethal condition. Operative strategy and special considerations in the management of this subgroup of patients are also discussed.