Hybrid management of iliac injury during thoracic endovascular aortic repair: A case report.

Thoracic endovascular aortic repair is nowadays the preferred option to manage descending thoracic aorta diseases. However, despite feasibility and safety of the procedures, several complications may occur. We report the case of an 83-year-old female patient with inadvertent iliac rupture occurred during thoracic endovascular aortic repair. To limit massive bleeding, considering the patient's comorbidities contraindicating open surgical repair and the morphology of the arterial injury (circumferential rupture of the artery from its origin), we chose to perform a homolateral hypogastric and common iliac artery embolization and an aorto-uniliac balloon expandable stent graft deployment from the distal aorta to the contralateral common iliac artery. A femoro-femoral crossover bypass graft was performed to restore both lower limbs perfusion. Final angiography documented correct positioning and regular patency of the implanted grafts and bypass with no blood loss from the right iliac vessels. Despite careful preoperative assessment, iliac artery injury can represent a challenging complication of thoracic endovascular aortic repair, particularly in the setting of inadequate iliac diameter, calcification and vessel tortuosity, or when large-caliber introducers are required. The hybrid approach we describe is a valid and effective solution to minimize blood loss and avoid major consequences in the management of iatrogenic iliac artery rupture during endovascular procedures.

Autologous Bone Marrow Stem Cells in Patients With Critical Limb Ischaemia not Eligible for Revascularization: A Single Centre Experience.

We evaluated the use of autologus bone marrow stem cells transplantation in patients with critical limb ischaemia (CLI) not eligible for revascularization. Eighty consecutive patients candidate to amputation were enrolled in a single-centre retrospective study. The primary endpoint was defined as the amputation-free rate from stem cells transplantation. Secondary endpoints were the evaluation of transcutaneous oximetry and its predictive potential for probability of amputation and the evaluation of rest pain. Ankle brachial index, transcutaneous oxygen (TcpO2) and radiological imaging were performed at the enrolment and during the follow-up times. All patients were treated with auto transplant of bone marrow stem cells. Two patients died due to acute renal and acute respiratory failures. 19 patients were amputated from the thigh or leg. In total, 59 of 80 patients intended to thigh amputation saved the limb, preserving the plantar support. TcpO2 was found a predictive metric with an AUC equal to .763, and a threshold for a risk of amputation of 10% and 5% at the values ≤22.7 and ≤26.9 mmHg, respectively. Auto transplant of bone marrow stem cells seems to be a safe and an efficient option for CLI not eligible to revascularizzation.

Challenges and Pitfalls in CT-Angiography Evaluation of Carotid Bulb Stenosis: Is It Time for a Reappraisal?

We aimed to perform an anatomical evaluation of the carotid bulb using CT-angiography, implement a new reliable index for carotid stenosis quantification and to assess the accuracy of relationship between NASCET and ECST methods in a large adult population. The cross-sectional areas of the healthy carotid at five levels were measured by two experienced radiologists. A regression analysis was performed in order to quantify the relationship between the areas of the carotid bulb at different carotid bulbar level. A new index (Regression indeX, RegX) for carotid stenosis quantification was proposed. Five different stenoses with different grade in three bulbar locations were simulated for all patients for a total of 1365 stenoses and were used for a direct comparison of the RegX, NASCET, and ECST methods. The results of this study demonstrated that the RegX index provided a consistent and accurate measure of carotid stenosis through the application of the ECST method, avoiding the limitations of NASCET method. Furthermore, our results strongly depart from the consolidated relationships between NASCET and ECST values used in clinical practice and reported in extensive medical literature. In particular, we highlighted that a major misdiagnosis in patient selection for CEA could be introduced because of the large underestimation of real stenosis degree provided by the NASCET method. A reappraisal of carotid stenosis patients' work-up is evoked by the effectiveness of state-of-the-art noninvasive contemporary carotid imaging.

Chronic abdominal aortic rupture mimicking femoral neuropathy.

Chronic-contained rupture of an aortic aneurysm is a rare subset of ruptured aneurysms. The presentation is unusual, and the diagnosis is frequently delayed. Here, we describe a case of contained rupture of abdominal aortic aneurysm that presented with signs and symptoms of femoral neuropathy. Clinical and radiological findings were initially misinterpreted. The correct diagnosis was formulated belatedly, causing a progressively increased risk of fatal events. Surgical aortic repair was performed and the postoperative course was uneventful. In conclusion, in the presence of a retroperitoneal mass, a diagnosis of chronic-contained rupture of an abdominal aortic aneurysm should be considered.

CT angiography-based radiomics as a tool for carotid plaque characterization: a pilot study.

PURPOSES: Radiomics is a quantitative method able to analyze a high-throughput extraction of minable imaging features. Herein, we aim to develop a CT angiography-based radiomics analysis and machine learning model for carotid plaques to discriminate vulnerable from no vulnerable plaques. MATERIALS AND METHODS: Thirty consecutive patients with carotid atherosclerosis were enrolled in this pilot study. At surgery, a binary classification of plaques was adopted ("hard" vs "soft"). Feature extraction was performed using the R software package Moddicom. Pairwise feature interdependencies were evaluated using the Spearman rank correlation coefficient. A univariate analysis was performed to assess the association between each feature and the plaque classification and chose top-ranked features. The feature predictive value was investigated using binary logistic regression. A stepwise backward elimination procedure was performed to minimize the Akaike information criterion (AIC). The final significant features were used to build the models for binary classification of carotid plaques, including logistic regression (LR), support vector machine (SVM), and classification and regression tree analysis (CART). All models were cross-validated using fivefold cross validation. Class-specific accuracy, precision, recall and F-measure evaluation metrics were used to quantify classifier output quality. RESULTS: A total of 230 radiomics features were extracted from each plaque. Pairwise Spearman correlation between features reported a high level of correlations, with more than 80% correlating with at least one other feature at |ρ|> 0.8. After a stepwise backward elimination procedure, the entropy and volume features were found to be the most significantly associated with the two plaque groups (p < 0.001), with AUCs of 0.92 and 0.96, respectively. The best performance was registered by the SVM classifier with the RBF kernel, with accuracy, precision, recall and F-score equal to 86.7, 92.9, 81.3 and 86.7%, respectively. The CART classification tree model for the entropy and volume features model achieved 86.7% well-classified plaques and an AUC of 0.987. CONCLUSION: This pilot study highlighted the potential of CTA-based radiomics and machine learning to discriminate plaque composition. This new approach has the potential to provide a reliable method to improve risk stratification in patients with carotid atherosclerosis.

Combined Treatment With Carotid Endoarterectomy and Coronary Artery Bypass Grafting: A Single-Institutional Experience in 222 Patients.

INTRODUCTION: Carotid atherosclerotic disease is a known independent risk factor of post operative stroke after coronary artery bypass grafting (CABG). The best management of concomitant coronary artery disease and carotid artery disease remains debated. Current strategies include simultaneous carotid endoarterectomy (CEA) and CABG, staged CEA followed by CABG, staged CABG followed by CEA, staged transfemoral carotid artery stenting (TF-CAS) followed by CABG, simultaneous TF-CAS and CABG and transcarotid artery stenting. METHODS: We report our experience based on a cohort of 222 patients undergoing combined CEA and CABG surgery who come to our observation from 2004 to 2020. All patients with >70% carotid stenosis and severe multivessel or common truncal coronary artery disease underwent combined CEA and CABG surgery at our instituion. 30% of patients had previously remote neurological symptoms or a cerebral CT-scan with ischemic lesions. Patients with carotid stenosis >70%, either asymptomatic or symptomatic, underwent CT-scan without contrast media to assess ischemic brain injury, and in some cases, if necessary, CT-angiography of the neck and intracranial vessels. RESULTS: The overall perioperative mortality rate was 4.1% (9/222 patients). Two patients (.9%) had periprocedural ipsilateral transient ischemic attack (TIA) which completely resolved by the second postoperative day. Two patients (.9%) had an ipsilateral stroke, while 7 patients (3.2%) had a stroke of the controlateral brain hemisphere. Two patients (.9%) patients were affected by periprocedural coma caused by cerebral hypoperfusion due to perioperative heart failure. There were no statistically significant differences between patients in Extracorporeal Circulation (ECC) and Off-pump patients in the onset of perioperative stroke. CONCLUSION: Our experience reported that combined surgical treatment of CEA and CABG, possibly Off-Pump, is a feasible treatment procedure, able to minimize the risk of post-operative stroke and cognitive deficits.

Atherosclerotic Plaque Fissuration and Clinical Outcomes in Pre-Diabetics vs. Normoglycemics Patients Affected by Asymptomatic Significant Carotid Artery Stenosis at 2 Years of Follow-Up: Role of microRNAs Modulation: The ATIMIR Study.

Atherosclerotic plaque instability and rupture in patients with asymptomatic carotid artery stenosis (ACAS) is a leading cause of major adverse cardiac events (MACE). This could be mainly evidenced in patients with pre-diabetes. Indeed, the altered glucose homeostasis and insulin resistance could cause over-inflammation of atherosclerotic plaque, favoring its conversion to unstable phenotype with rupture and MACE. Notably, metformin therapy reducing the metabolic distress and the inflammatory burden could reduce MACE in ACAS patients with pre-diabetes. In this setting, the microRNAs (miRs) could be used as molecular biomarkers of atherosclerosis progression, plaque rupture, and worse prognosis in normoglycemics (NG) versus pre-diabetics metformin users (PDMU) versus pre-diabetics non-metformin users (PDNMU). However, our study aimed to investigate a wide miRNA panel in peripheral blood exosomes from patients with ACAS divided in NG versus PDMU versus PDNMU, and to associate the circulating miRNA expression profiles with MACE at 2 years of follow-up after endarterectomy. The study included 234 patients with ACAS divided into NG (n = 125), PDNMU (n = 73), and PDMU (n = 36). The miRs' expression profiles of circulating exosomes were determined at baseline and at 2 years of follow-up by Affymetrix microarrays from the patients' plasma samples from any study cohort. Then we collected and analyzed MACE at 2 years of follow-up in NG versus PDMU versus PDNMU. Prediabetics versus NG had over-inflammation (p < 0.05) and over expressed miR-24 and miR-27 at baseline. At 2 years of follow-up, PDNMU versus NG, PDMU versus NG, and PDNMU versus PDMU over-expressed inflammatory markers and miR-24, miR-27, miR-100, miR-126, and miR-133 (p < 0.05). Finally, at the end of follow-up, we observed a significant difference about MACE comparing PDNMU versus NG (n = 27 (36.9%) versus n = 8 (6.4%); p < 0.05), PDNMU versus PDMU (n = 27 (36.9%) versus n = 6 (16.6%); p < 0.05); and PDMU versus NG (n = 6 (16.6%) versus n = 8 (6.4%); p < 0.05). Admission glucose values (HR (hazard ratio) 1.020, CI (confidence of interval) 95% (1.001-1.038), p = 0.029), atheromatous carotid plaque (HR 5.373, CI 95% (1.251-11.079), p = 0.024), and miR-24 (HR 3.842, CI 95% (1.768-19.222), p = 0.011) predicted MACE at 2 years of follow-up. Specific circulating miRs could be over-expressed in pre-diabetics and specifically in PDNMU versus PDMU after endarterectomy. MiR24, hyperglycemia, and atheromatous plaque could predict MACE at 2 years of follow-up.

Intramural haematoma of the thoracic aorta: A case series.

We reported four cases of intramural haematoma of the descending thoracic aorta. Four patients, aged 55-82 years, hypertensive, were transferred from the emergency room of other hospitals due to the appearance of epigastric pain and left thorax pain. All patients underwent computed tomography angiography reporting the presence of intramural haematoma. Three patients underwent a drug therapy to maintain a controlled hypotension. A computed tomography revaluation was performed documenting (1) an increase in the thickness of the intramural haematoma, (2) the appearance of a penetrating ulcer within the haematoma and (3) the appearance of several penetrating lesions throughout the thoracic aorta. Patients required the placement of one or two thoracic aorta endoprosthesis. For the fourth patient, the hyperdense appearance of the intramural haematoma and the presence of pleural effusion suggested an urgent treatment intervention. All patients underwent a placement of cerebrospinal fluid catheter and drainage before treatment. All patients were treated with endovascular intervention with 100% technical success and absence of migration or retrograde type A dissection. There were no complications related to femoral surgical access or access routes. Perioperative mortality was null; no patient had paraplegia. No strokes, transient ischemic attack or perioperative myocardial infarction were observed. The average hospitalization was 5 days. After 3 months, angio-computed tomography reported for all patients a complete reabsorption of the intramural haematoma and a complete exclusion of the penetrating ulcer of the aortic wall present at the time of the intervention. There have been no cases of distant thoracic aortic tears. Endovascular treatment must be considered the preeminent treatment for thoracic aortic haematoma. Best timing to perform the endovascular procedure depends on the patient clinical picture and on stability of hemodynamic parameters.

Spontaneous rectus sheath hematoma: The utility of CT angiography.

We described the utility of computed tomography (CT) angiography in detection of bleeding vessels for a rapid percutaneous arterial embolization of the spontaneous rectus sheath hematoma. A 70-year-old woman comes to our attention with acute abdominal pain and a low hemoglobin level. An unenhanced CT was performed demonstrating a large rectus sheath hematoma. A conservative management was initially established. Despite this therapy, the abdominal pain increased together with a further decrease of hemoglobin values. A CT angiography was then performed, demonstrating an active bleeding within the hematoma and addressing the patient to a rapid percutaneous arterial embolization.

Incidental Finding of Dual Ectopic Thyroid on Computed Tomography Angiography.

The presence of simultaneous two ectopic foci of thyroid tissue (dual ectopic thyroid) is rare, and few cases have been reported in the literature. The ectopic thyroid tissue is an extremely uncommon embryological aberration due to the alterations occurring during the embryological development with incomplete migration of thyroid precursors. Commonly ectopic thyroid tissue is a midline structures, but the lateral location is possible but very rare. Ectopic thyroid is common in women and can vary in size from a microscopic focus to a few centimeters. The normal process of migration of the thyroid can be interrupted at various levels determining a lingual ectopy, a sublingual ectopic, prelaryngeal ectopy, or mediastinic ectopy. Intrathoracic and subdiaphragmatic organs are other sites where the ectopic thyroid tissue may be present. In most of the cases, ectopic tissue is a lingual thyroid and this condition can be totally asymptomatic, discovered incidentally, or occurs with symptoms such as dysphonia, dysphagia, dyspnea, and hemoptysis. Sublingual or suprahyoid ectopia is rare and even rarer are the cases of two foci of ectopic thyroid tissue simultaneously present. On imaging, the ectopic tissue shows the same characteristics of orthotopic thyroid tissue and similarly can undergo goiterous and cancerous transformation. We report a case of incidental dual ectopic thyroid in lingual and suprahyoid level in a 72-year-old female patient, asymptomatic and with normal thyroid function, who underwent computed tomography (CT) angiography before vascular surgery for the treatment of carotid stenosis. The presence of a lingual thyroid can lead to a difficult and dangerous intubation, with possible fatal consequences. For this reason, the discovery of these abnormalities has totally changed the patient management who has been subjected to endovascular treatment, instead to the classical surgery.

Endovascular treatment of persistent sciatic artery aneurysm with the multilayer stent.

PURPOSE: To describe the successful management of a symptomatic persistent sciatic artery (PSA) aneurysm using the Multilayer Aneurysm Repair System (MARS). CASE REPORT: A 50-year-old man with history of smoking, hypertension, and hypercholesterolemia suddenly developed pain in the buttock radiating to the left lower limb, mimicking sciatica. The ∼57×54-mm incomplete type PSA aneurysm was treated with two 14×80- and 14×60-mm MARS devices through a surgical left axillary artery access. There were no periprocedural complications. Thirty-day imaging documented patency of the stents and a minor reduction (∼47×55 mm) in the aneurysm, with slightly hyperdense content and no signs of perfusion. At 6 months, duplex and computed tomographic angiography showed complete thrombosis of the sac, patency of the multilayer stents, and further aneurysm shrinkage (40×37 mm). CONCLUSION: The multilayer stent can alter the hemodynamics inside a peripheral aneurysm to promote sac thrombosis and redirect flow to collaterals originating from the sac.

Lethal nature of ischemic gastropathy: a case report of celiomesenteric vascular insufficiency.

Celiomesenteric ischemia has an insidious onset and the non-specific symptoms are often misdiagnosed as cholecystitis or peptic ulcer disease with a consequential delay between the onset of symptoms and radiological evidence of vascular occlusive disease. A elderly man was hospitalized after a 2-3 week history of acute abdominal pain, frequent vomiting, and chronic diarrhea associated with bloody stools. Upper gastrointestinal endoscopy showed a cobblestone gastric pattern with multiple ulcerated areas and the specimens indicated focal full thickness coagulative necrosis of the mucosa. A magnetic resonance angiography (MRA) revealed a widespread and severe atheromatous disease characterized by a hemodynamically significant stenosis of the celiac tripod, pre-occlusive stenosis of the superior mesenteric artery and complete occlusion of the inferior mesenteric artery. MRA is now the best and most accessible noninvasive examination to help establish a diagnosis, providing high-quality three-dimensional images of the celiac axis and mesenteric arteries. However, the various features observed in this case such as the clinical history, the presence of a cobblestone pattern with multiple ulcerated areas in the stomach, the coagulative-type necrosis and ischemic atrophy of the adjacent mucosa were considered diagnostic of gastric ischemia.

Pseudoaneurysm after patch-free carotid bifurcation endarterectomy: a case report.

The purpose of this report is to present the case of a 59-year-old man affected by multivessel coronary artery disease and sterile pseudoaneurysm of the right carotid bifurcation presenting as a pulsating neck mass 1 month after patch-free carotid endarterectomy. The surgical approach included median sternotomy and incision parallel to the anterior margin of the right sternocleidomastoid muscle. The pseudoaneurysm was excised after control of the brachiocefalic trunk and insertion of a Pruit-Inahara shunt, and the carotid vessels were directly sutured without using any prosthetic or autologous material. Concomitant coronary bypass grafting was performed. The postoperative course was uneventful and there was no evidence of recurrence of pseudoaneurysm at 6-month follow-up. On the basis of this experience and of pertinent literature, the options for the management of such rare entities are discussed.

Evaluation of less invasive method for saphenous vein harvest in patients with type II diabetes.

BACKGROUND: Diabetes mellitus is an established risk factor for leg wound healing complications after great saphenous vein harvest. Leg healing complications occur in 1-25% of coronary artery bypass graft patients, and are often underestimated. PATIENTS AND METHODS: The records of 230 patients enrolled in a prospective trial to evaluate a minimally invasive approach compared with conventional longitudinal harvest were reviewed. Of 100 patients with diabetes, 49 had undergone minimally invasive harvest (group A). Forty-nine patients from the pool without diabetes who underwent minimally invasive harvest were selected using propensity scoring analysis (group B), and 46 diabetic patients operated using a conventional technique (group C) were matched to group A patients. Ninety-five patients with and 49 without diabetes finally entered the study. The quality of leg wound healing was quantified by ASEPSIS score by two independent surgeons in a blinded manner. The occurrence of complications was compared between groups. RESULTS: Fewer leg wound healing complications occurred in diabetic patients in the minimally invasive compared with the conventional group (P < 0.0001). Rates of complications were comparable among diabetic and non-diabetic patients operated using the minimally invasive technique. The intraoperative flow of vein grafts obtained by the minimally invasive technique was comparable to that of veins harvested using the conventional technique. CONCLUSION: These data suggest that postoperative leg wound morbidity can be significantly attenuated by the adoption of a less invasive approach, even in high-risk patients with diabetes. The advantages are not offset by the co-existence of other cardiovascular risk factors or by a long history of diabetes.

Open clip-free radial artery harvesting with the harmonic shears.

BACKGROUND: The Ultracision Harmonic Scalpel is associated with several advantages in radial artery (RA) harvesting. It allows fewer hemostatic clips to close the collateral branches, less thermal injury of the conduit, and reduced time of harvesting in comparison with the conventional RA harvesting technique with electrocautery and hemostatic clips. We recently started open RA harvesting with the harmonic shears (HSH). In this study, we aimed at evaluating the feasibility of this simplified ultrasonically activated harvesting technique, and report the results of RA harvesting with HSH. METHODS: The RA harvesting with HSH was performed in 20 patients operated on for myocardial revascularization from July 2004 to December 2005. RESULTS: The harvest of the RA was completed in little time, without any complication. Neither bleeding from the collateral branches nor spasm alongside the entire length of the RA was observed. No bleeding occurred from the muscles of the forearm. CONCLUSION: This technique of RA harvesting with HSH is impressive in terms of short time of harvest, complete absence of clips for the collateral branches, and no thermal injury of the conduit.

Thoracic radiation therapy and suitability of internal thoracic arteries for myocardial revascularization.

INTRODUCTION AND BACKGROUND: Myocardial revascularization using internal thoracic arteries (ITAs) has been associated with superior clinical outcome. This study addresses the question of whether internal mammary arteries are unsuitable for grafting due to radiation-based damage in patients with history of thoracic radiation therapy. We review our experience in this subset of surgical candidates. PATIENTS AND METHODS: Forty-nine patients undergoing elective coronary artery bypass grafting with use of at least one ITA were enrolled and matched to 49 comparable nonirradiated individuals by propensity scoring system. Preoperative and postoperative data were collected and compared. A 18-month clinical follow-up was performed. RESULTS: Intraoperative mammary artery flow was assessed by transthoracic Doppler echocardiography probe, and there was no significant difference between irradiated and nonirradiated individuals (36 +/- 8.3 mL/min vs 39 +/- 7.2 mL/min, p = 0.15). The two study groups were also comparable in terms of survival (overall mortality, 2%) and recurrence of angina and perfusion defect at control stress perfusion nuclear scan (p = 0.99 and p = 0.77, respectively). One arterial graft showed stenosis at postoperative angiography. The dose of radiation therapy administered did not correlate with graft flow values after anastomosis. CONCLUSION: Our data suggest that the use of a monolateral or bilateral ITA is not associated with early graft failure in patients with history of chest/mediastinal irradiation. Skeletonization harvesting technique might be recommended because of the frequent presence of fibrous tissue around the in situ vessel. Arterial graft stenosis in thorax-irradiated patients should be attributed to the primary atherosclerotic disease rather than to irradiation itself.

Intravascular ultrasound in the endovascular management of atherosclerotic peripheral occlusive disease.

This study is a retrospective analysis of the impact of intravascular ultrasound in addiction to conventional angiography in 36 patients with 55 stenotic peripheral arterial lesions treated with angioplasty and/or stenting. Before treatment, intravascular ultrasound imaging showed that the vessel diameter was underestimated with angiography in 6 cases. The correlation index between angiography and intravascular ultrasound measurements, however, was significant in 27 arterial lesions. After endovascular treatment, angiography showed 3 vessel dissections and no incomplete stent deployment, whereas intravascular ultrasound showed 15 dissections and 5 instances of stent underdeployment. If we consider the intravascular ultrasound data as the gold standard, the specificity of angiography is 100%, while its sensitivity is 56% for vessel dissection and 75% for stent deployment. In the follow up of the 16 patients treated for iliac lesions with intravascular ultrasound control, re-stenosis occurred in 5% (primary patency 94.7%); in a control group of 15 patients treated in the same period without intravascular ultrasound control, re-stenosis occurred in 15.8% (primary patency 83.4%, difference not statistically significant). In conclusion, in the peripheral arteries intravascular ultrasound is more accurate than arteriography in evaluating dissection and stent deployment, but the routine use of intravascular ultrasound in every case of iliac PTA or stenting would not appear justified.

[Diverticular disease: complications and treatment]. / La malattia diverticolare: complicanze e trattamento.

This study reports on 10 years of experience in observing diverticular disease. The study considers 77 patients, 41 males and 36 females, aged from 50 to 88 years (mean age: 70 years), observed from January 1991 to December 2001. Sixty-two patients were admitted from the Accident and Emergency Unit and 15 were elected patients. Five patients underwent emergency surgery, while 72 received only antibiotic therapy. The overall mortality rate was 0. The morbidity rate was 22% in those patients undergoing emergency surgery. In only one of the elected patients was wound suppuration detected. Diverticular disease, in most cases, is treated by antibiotic therapy alone, but in 30% of cases surgery is necessary. Colon resection and immediate anastomosis are the first choice operation also in the emergency setting, provided local conditions (inflammation, septic contamination) make anastomosis safe. In patients with major peritoneal contamination, Hartman's operation and subsequent recanalization after 6 months are to be preferred.

Benign multicystic mesothelioma of the peritoneum: a case report.

The aim of this study is to report the experience of a case of benign multicystic mesothelioma of the peritoneum presented with acute appendicitis symptomatology. A 28 years old man with right lower and upper abdominal pain was admitted into hospital. Because of the clinical picture, the symptomatology and the leukocytosis a diagnosis of acute appendicitis was made and the patient underwent appendicectomy according to Mc Burney. At laparotomy some cc of purulent fluid were sucked and a cystic mass that contained clear fluid was revealed. In consequence of the incidental diagnosis a following middle laparotomy was made with a careful surgical excision of the mass and of the appendix. Macroscopically the lesion was identified like a neoplastic mass 25 centimeters in diameter, with a multicystic and fibrous-adipose aspect, with cysts 5 centimeters in diameter. The cystic spaces were lined by a layer of eptelial cells which presented positive reaction for cytokeratin and EMA, whereas endothelium markers were absent. The ultrastructural, morphological and immunohistochemical findings were diagnostic of a benign multicystic mesothelioma.