Continued sac perfusion of popliteal artery aneurysms after ligation and bypass. Relevance of duplex ultrasound surveillance and treatment.

AIM: Conventional management of popliteal artery aneurysms (PAA) through a medial approach may be lon term ineffective. We report our long term rate of continued sac perfusion after ligation and bypass, combined to duplex ultrasound (DUS) surveillance protocol. PATIENTS AND METHODS: Follow-up data of 24 PAA (mean diameter 37.5 ± 8.8 mm) treated by ligation and bypass with eventual adjunctive procedures (direct sac embolization or resection) were collected. The endpoints of the study were the long term rate of continued sac perfusion and the freedom from any reintervention. RESULTS: Twentyfour PAA were treated in 20 patients. Long term follow-up was complete for 19 graft (79.1%). During a median follow-up of 71.2 months (4-168), persistent sac flow was found in 5 legs (26.3%), 4 to 36 months after surgery, without enlargement or rupture. The cumulative Kaplan-Meier survival free from PAA reperfusion at 1, 3, and 6 years was 91.5%, 77.5%, and 71.5%, respectively. Basing on DUS surveillance, late additional procedures were required in 5 patients (25%), to treat sac reperfusion or preserve graft patency. The cumulative Kaplan-Meier survival free from any reintervention at 1, 3, and 6 years was 91.5%, 72.8%, and 67%, respectively. CONCLUSIONS: Conventional management of PAA through a medial approach may be associated to progressive sac expansion. The DUS surveillance protocol remains strongly recommended to detect sac perfusion and suggest the timing of reintervention before rupture occurs. Adjunctive intraoperative procedures could improve the long term results, but further studies on large series are needed. KEY WORDS: Acrylic glue, Duplex ultrasound study, Femoropopliteal bypass, Popliteal artery aneurysm, Ultrasoundguided embolization.

Surgical approach to the suprarenal abdominal aorta.

AIM: The surgical approach to the pararenal aorta can be performed through a midline laparotomy or retroperitoneal approach. The current paper reports the techniques for the suprarenal aortic approach, through the review of technical literature on this topic. METHODS: Forty-six out of 82 technical papers regarding the surgical approach to the suprarenal aorta were reviewed, focusing on relevant technical details, such as the position of patient, type of incision, aortic approach and anatomical limitations. RESULTS: The left retroperitoneal abdominal approach offers numerous advantages, mainly observing some modifications of the original technique (9th intercostal space incision, short radial frenotomy, section of the inferior mesenteric artery). The traditional transperitoneal access, through a midline or bilateral subcostal incision with retroperitoneal medial visceral rotation, is best indicated when an unrestricted approach to the right iliac arteries is needed, but it can be more challenging in patients with "hostile abdomen", for which a retroperitoneal route is probably more appropriate. A more aggressive surgical approach through a 7th-9th space thoracolaparotomy, combined with semicircunferential frenotomy, should be strongly recommended to provide a safe suprarenal aortic aneurysm repair in high risk patients, who often require adjunctive procedures, such as selective visceral perfusion and left heart bypass. CONCLUSIONS: Many technical options can be used to approach the suprarenal aorta, but none can be "radicalized". The surgical strategy must be individualized according to the anatomo-clinical characteristics of the patient and aneurysm morphology as well. KEY WORDS: Abdominal aorta, Aortic aneurysm, Surgical approach.

Kinetics of serum procalcitonin in patients with acute mesenteric ischemia and bowel infarction after cardiac surgery.

BACKGROUND: The present study reported perioperative changes in PCT levels occurring in cardiac patients with acute mesenteric ischemia (AMI) undergoing laparotomy. The aim of this study was to demonstrate that PCT kinetics may confirm the presence of AMI after cardiac surgery, distinguishing between bowel infarction and diffuse ischemia. METHODS: PCT values from adult patients undergoing laparotomy for AMI after elective or urgent cardiac surgery (January 2010-December 2019) were determined at the ICU admission after cardiac surgery, 24 hours later and at the onset of clinical symptoms. Patients affected by diffuse intestinal ischemia with no need for bowel resection were allocated to Group A (N. 8), patients presented with intestinal necrosis requiring small or large bowel resection were allocated to Group B (N. 12). RESULTS: At the beginning of the abdominal symptoms, PCT levels increased in both groups, compared to those immediately after cardiac surgery. The PCT increasing resulted much more evident in patients presenting with intestinal necrosis in Group B (20.65 ng/mL [IQR8.47-34.5] vs. 4.31 ng/mL [IQR 8.47-34.5], P<0.05), rather than in those with diffuse ischemia in Group A (13.25 ng/mL [IQR 5.97-27.65] vs. 10.4 ng/mL [IQR 3.68-14.05], P=0.260). This trend was confirmed in the subgroup of patients undergoing CVVHD and in patients who experience AMI recurrence. CONCLUSIONS: Increasing PCT values after cardiac surgery are proportional to the severity of wall ischemia and high levels of PCT are predictive of intestinal necrosis. Routine PCT monitoring after cardiac surgery should be considered extremely useful in suggesting the possibility of abdominal complications, alerting medical staff to the need of prompt treatment.

Towards a better comprehension of acute mesenteric ischemia after cardiac surgery. An analysis of 33 patients.

BACKGROUND: Acute mesenteric ischemia (AMI) after cardiac surgery is a rare but serious complication associated to high mortality. The time of onset is the key point to correctly evaluate the clinical scenarios. METHODS: Data from adult patients who underwent laparotomy for AMI after elective or urgent cardiac surgery were reviewed (January 2005 - December 2019) to report their anatomoclinical features in relationship to time of onset. Early events (within 48 hours) were allocated to Group 1, whereas late onsets were allocated to Group 2. RESULTS: The incidence of risk factors for non occlusive mesenteric ischemia was higher in Group 1 (chronic renal failure 80% vs 38.8%, P <0.05, use of inotropes 60% vs 5.5%, P <0.01, early oligo-anuria requiring CRRT 80% vs 16.6%, P <0.01, prolonged ventilation 46.6% vs 5.5%, P <0.05), where a significative occurrence of postoperative de novo atrial fibrillation was noted in Group 2 (55% vs 5.5%, P <0.01). The number of patients who required bowel resection was proportionally higher in the Group 2. CONCLUSIONS: Two well distinct categories of AMI after cardiac surgery can be classified. The first consists of patients with well-known risk factors developing ischemia as a result of severe visceral hypoperfusion The second consists of patients with low comorbidity who experience late AMI as a consequence of "trigger events", mainly de novo atrial fibrillation. This classification may be useful to better alert the medical staff to the possibility of bowel ischemia at any time after cardiac surgery, promoting early diagnosis and treatment. KEY WORDS: Mesenteric ischemia, Cardiovascular pathology.

Long-Term Outcomes of Coronary and Carotid Artery Disease Revascularization in the FRIENDS Study.

OBJECTIVES: The aim of this study is to assess long-term-outcomes of patients with concomitant CAD and COD treated with different revascularization strategies. BACKGROUND: Multisite artery disease is common and patients with combined disease have poor prognosis. The best therapeutic strategy for patients with concomitant carotid obstructive disease (COD) and coronary artery disease (CAD) remains controversial. METHODS: This observational registry enrolled, between January 2006 and December 2012, 1022 consecutive patients from high volume institutions with concomitant CAD and COD suitable for endovascular, surgical, or hybrid revascularization in both territories selected by consensus of a multidisciplinary team. RESULTS: The cumulative incidence of 5-year major cardiovascular events (MACCE) including cardiovascular death, myocardial infarction (MI), or stroke in the overall population was 12%. The incidence of 5-year MACCE was not statistically different in the surgical, endovascular, or hybrid patients group (10.1% vs. 13.0% vs. 13.2%, P = .257, respectively). However, the hybrid group exhibited rates of myocardial infarction, chronic kidney disease, and cumulative incidence of all clinical events higher than the surgical group. After propensity score matching, the incidence of 5-year MACCE was similar in the three groups (13.0% vs. 15.0% vs. 16.0%, p = .947, respectively). CONCLUSIONS: An individualized revascularization approach of patients with combined CAD and COD yields very good results at long-term follow-up, despite the high risk of this multilevel population even when the baseline clinical features are equalized.

The influence of aneurysm size on early outcome of abdominal aortic aneurysm repair in female patients.

AIM: The purpose of this study was to examine the influence of aneurysm size on early outcome in women undergoing abdominal aortic aneurysm (AAA) repair, with suggestion of lowered threshold for intervention. PATIENTS AND METHODS: Retrospective cohort study on the early outcome of 25 females undergoing elective endovascular (EVAR) and open AAA repair, compared to 340 males from 2005 to 2017. The study was focused on 30-days mortality (primary endpoint) and incidence of non fatal major adverse events - MAE (secondary endpoint) of two subgroups of women: AAA diameter <50 mm (n.14, group F1), AAA diameter ≥ 50mm (n.11, group F2). RESULTS: The incidence of the primary endpoint at 30 days was 4% in females, and 1.1% in males, respectively (p=ns). Similarly, females showed a higher rate of MAE compared to males (16% vs 9.4%, p=ns). Women who underwent surgery with small aneurysms (F1 group) had an early outcome similar to men (30-day death 0% vs 1.1%, p=ns; MAE 7.1% vs 9.4%, p=ns) and significantly better than women with larger aneurysms (30-day death 0% vs 9%, p=ns; MAE 7.1% vs 27.2, p=ns). CONCLUSIONS: Although poorly significant from a statistical point of view, the present report seems to confirm that the AAA diameter is a relevant marker of disease severity in women, assuming that repair at smaller size may be associated with less comorbidity and better outcome. KEY WORDS: Abdominal aortic aneurysm, Abdominal aortic aneurys open repair, Endovascular aortic aneurysm repair, Female gender.

Anatomical variations of cervical vein drainage in candidates for neck surgery.

The knowledge of both normal and abnormal anatomy of the veins of the neck may be important for surgeons performing neck surgery, to avoid inadvertent injury to vascular structures. In a 75-year-old man candidated to carotid endarterectomy preoperative CT-scan showed a rare anomaly of the venous drainage in the area of the anterior jugular vein (AJV), that usually begins in the suprahyoid region via the confluence of several superficial veins, to open into the ipsilateral external jugular vein. A large left sided venous trunk, originating from an anomalous proximal confluence with the internal jugular vein, descended in the AJV anatomical position, to cross over the sternum draining into the right subclavian vein. The knowledge of this abnormal anatomy allowed to perform a safe carotid bulb isolation avoiding inadvertent injury to vascular structures. KEY WORDS: Anatomic variations, Anterior jugular vein, Jugular veins, Carotid endarterectomy, Neck surgery.

Acute mesenteric ischemia after cardiac surgery. Role of the abdominal compartment syndrome treatment.

BACKGROUND: The management of abdominal compartment syndrome (ACS) has been included as a standard of care in our therapeutic algorithm after diagnosis of acute mesentheric ischemia (AMI), following cardiac surgery. This report is an updated review of our results compared to previous experience. MATERIALS AND METHODS: A retrospective, observational, cohort study on a series of 26 patients (20 males, 6 females, mean age 75.2 years, min 64, max 83) who developed AMI, out of 7.719 patients undergoing cardiac operations (january 2005 - December 2014). The initial treatment consisted of laparotomy with abdominal decompression and temporary abdominal closure, performing visceral resections just in case of gangrenous tracts and providing for a "secondlook" during the variable period of resuscitation and vacuum assisted dressing. RESULTS: A non-occlusive mesentheric ischemia with diffuse visceral underperfusion was confirmed in every case. Temporary abdominal closure was applied to treat ACS in every case, 13 patients required associated resection of gangrenous tracts (50%). Seventeen patients died following first operation as a consequence of multiple organ failure (65.4%). Nine patients survived (34.6%) and underwent re-establishment of intestinal continuity and definitive closure of abdominal wall within 30 DAYS. DISCUSSION AND CONCLUSIONS: AMI occuring after cardiac surgery is associated with an increase of intra-abdominal pressure and subsequent ACS. Basing on this case series, an early ACS treatment using open abdomen techniques may be results in a better outcome of critically injured cardiac patients. These results compared favourably with literature experiences (mortality rate > 85%). KEY WORDS: Abdominal compartment syndrome, Acute mesentheric ischemia, Cardiac surgery.

Coronary risk in candidates for abdominal aortic aneurysm repair: a word of caution.

BACKGROUND: Current guidelines do not recommend routine coronary evaluation preceding abdominal aortic aneurysms (AAA) repair in low-risk patients. The purpose of the present study is to report the incidence of coronary lesions in candidates for AAA repair with a Revised Cardiac Risk (Lee) Index (RCRI) < 2, which are usually excluded from preoperative cardiological work-up. Early-term and long-term results of prophylactic myocardial revascularization are also reported. METHODS: A retrospective, observational, cohort study collecting clinical data on a series of 149 consecutive patients undergoing preoperative coronary angiography and myocardial revascularization (percutaneous coronary intervention, PCI; coronary artery bypass grafting, CABG) before elective open or endovascular AAA repair (January 2005-December 2012). RESULTS: Severe coronary artery disease (CAD) was revealed in 43 patients (28.9%), who underwent successful myocardial revascularization by means of PCI (n.35) or off-pump CABG (n.8). The incidence of severe CAD in patients resulted at low risk on the basis of risk models was approximately 25%. The incidence of severe CAD in asymptomatic patients was 29.8%. Endovascular (n.52, 35.1%) and open (n.96, 64.9%) AAA repair was performed with low morbidity (0.6%) and mortality (0.6%) in 148 patients. The long-term estimated survival (freedom from fatal cardiovascular events) was 97% at 60 months and 82% at 90 months. CONCLUSIONS: The incidence of severe correctable CAD is not negligible in low-risk patients scheduled for AAA repair. Waiting for further recommendations based on large population studies of vascular patients, a more extensive indication to coronary angiography and revascularization should be considered in many candidates for AAA repair.

A prospective registry on carotid artery revascularisation selected by consensus of a cardiovascular team.

AIMS: This prospective registry was designed to evaluate the early and long-term incidence of clinical events in patients with carotid obstructive disease (COD), after carotid artery revascularisation selected by consensus of a cardiovascular team. METHODS AND RESULTS: 403 consecutive patients with COD scheduled for carotid revascularisation were included: 130 were treated with carotid endarterectomy (CEA) and 273 with carotid artery stenting (CAS). Propensity score matching was performed to assemble a cohort of patients in whom all baseline covariates would be well balanced. The occurrence of major adverse cardiac and cerebrovascular events (MACCE), including any death, non-fatal myocardial infarction or stroke, was assessed at 30 days and at long-term follow-up. The incidence of MACCE at 30 days was 4.0% (95% confidence interval: 2.1 to 6.0), without any significant difference between the CAS and CEA groups in unmatched and matched populations. The cumulative freedom from MACCE at two-year follow-up was 80.5%±0.94%, with no statistically significant differences between the CAS and CEA groups, both in the total population and in the matched cohort. CONCLUSIONS: In this registry of patients undergoing carotid artery revascularisation selected by consensus of a cardiovascular team, the early and long-term incidence of clinical events is up to standard.

Emergency treatment of a salmonella-infected abdominal aortic aneurysm associated with spondylodiscitis.

AIM: To report surgical treatment of a ruptured abdominal aortic aneurysm (AAA) associated with spondylodiscitis due to Salmonella in emergency setting. CASE REPORT: A 69-year-old male with an history of hypertension, presented with a ruptured AAA infected by nontyphoidal Salmonella (type H), associated with spondylodiscitis. Patient underwent an emergency operation consisting in surgical debridment of infected tissue and aortic replacement with a prosthetic Dacron graft impregnated with Gentamycine. The postoperative course was uneventful and the patient was discharged at day 20 after the index procedure in good clinical condition. antimicrobial therapy was continued for 8 weeks. A CT scan and nuclear medicine studies performed two months later demonstrated minimal sign of residual aortitis. A CT scan 21 months after the procedure showed complete anatomic resolution of the disease. CONCLUSIONS: A rare but increasing number of aneurysms as a consequence of Salmonellosis can be observed with a high rate of morbidity and mortality, mainly in patients with a concurrent infection of the spine and paravertebral tissue. Combined antimicrobial therapy and one-stage surgical treatment can be associated with good outcome. KEYWORDS: Abdominal aorta aneurysm, Mycotic aortic aneurysms, Salmonellosis, Spondylodiscitis.

Clinical outcome after endovascular, surgical or hybrid revascularisation in patients with combined carotid and coronary artery disease: the Finalised Research In ENDovascular Strategies Study Group (FRIENDS).

AIMS: To assess the 30-day clinical outcome of endovascular and surgical revascularisation procedures in patients with carotid obstructive disease (COD) and concomitant coronary artery disease (CAD). METHODS AND RESULTS: Between January 2006 and December 2009, 659 patients with COD and concomitant CAD were treated. The incidence of the primary endpoint (composite of death, MI and stroke) was 4.25% (0.9%, 1.1% and 2.3%, respectively). Acute renal insufficiency occurred in 2.4% and major bleedings in 4.4% of patients. According to the treatment forms patients were divided into three groups: surgical, 185 patients (28.1%), endovascular, 378 (57.4%), and hybrid, 89 (13.5%). Seven patients (1%) were managed medically only. The primary endpoint of the study occurred in 4.8%, 2.4% and 8.6%, respectively, p=0.01. The secondary endpoint, that included the occurrence of renal or respiratory insufficiency and major bleedings occurred in 10.1%, 6.5% and 23.8%, respectively, p<0.001. At multivariate logistic regression analysis renal insufficiency (OR=2.517; 95%CI=1.077-5.883, p=0.03) and treatment group (endovascular: OR=0.369; 95%CI=0.168-0.813, p=0.01 or hybrid: OR=3.098; 95%CI=1.359-7.060, p=0.007) predicted the primary endpoint. CONCLUSIONS: Surgical and endovascular treatments yield very good immediate results; the later being less invasive, may be particularly suited to these fragile and complex patients. Long-term follow-up is under assessment.

[Emergency laparoscopic surgery]. / Chirurgia laparoscopic in urgenza.

The laparoscopic approach has represented a major step forward in general and emergency surgery. Its application in the emergency setting still raises a number of concerns that limit its more widespread use. To assess the true scope of laparoscopic surgery in the acute abdominal setting, we retrospectively evaluated our experience. From February 2003 to June 2007, 314 patients underwent an emergency laparoscopic operation, for low abdominal pain (193 patients), acute cholecystitis (78 patients), bowel obstruction (18 patients), diffuse peritonitis (16 patients), blunt abdominal trauma (6 patients), and acute pancreatitis (3 patients). Laparoscopy yielded a good diagnostic definition in all cases. The conversion rate was 16.6% (52 patients). Mean operative time was 63 +/- 29 minutes. The general major morbidity rate was 1.5% (4 patients) and the mortality rate was 0.4% (1 pt.). The laparoscopic approach in patients with abdominal emergencies is a useful tool that yields a reliable diagnostic definition in uncertain cases and allows minimal access treatment of the causative disease in the majority of cases.

[Iatrogenic pseudoaneurysms of the peripheral arteries]. / Pseudoaneurismi iatrogeni delle arterie periferiche.

The aim of the study was to report our clinical experience with the surgical treatment of iatrogenic pseudoaneurysms of the peripheral arteries. The study is a retrospective review of 101 consecutive patients (52 males, 49 females, mean age 66.2 years, range 33-86), with iatrogenic pseudoaneurysms of the peripheral arteries, surgically treated in a vascular unit from October 1990 to June 2006. Duplex ultrasound scanning was employed to support the clinical findings. The surgical treatment consisted in direct closure with polypropylene sutures and, occasionally, patch angioplasty or bypass. Ultrasound compression was effective in one of 4 small aneurysms (< 2.5). No limb loss occurred. There were 4 wound complications (3.9%), one pulmonary embolism (0.99%), and 3 deaths (2.9%), 2 of which not related to vascular repair and one secondary to femoral endoarteritis and septic shock, unrelated to previous implantation of a percutaneous femoral closure device. Although iatrogenic pseudoaneurysms of the peripheral arteries are rarely observed in clinical practice, a significant number of peripheral artery complications may occur after cardiac catheterisation and coronary angioplasty. Failure of conservative treatment requires a traditional surgical repair. The results of our series included a significant mortality rate (2.9%), resulting from the severity of cardiac disease in 2 cases and from the vascular repair itself in one case (femoral endoarteritis). These results substantiate the common observation that patients who require surgery for an iatrogenic pseudoaneurysm are often affected by advanced cardiovascular disease and are liable to suffer the occurrence of complications, with a high risk of death. Therefore, any surgical treatment should be performed with strict adherence to sound vascular surgical principles.

[Appropriateness of simultaneous carotid endarterectomy and coronary revascularization]. / Appropriatezza degli interventi simultanei di endoarteriectomia carotidea e rivascolarizzazione miocardica.

BACKGROUND: The presence of significant carotid artery disease in patients undergoing coronary artery bypass grafting has been reported to be as high as 17%. The optimal management of patients with significant coronary and carotid artery disease remains controversial. In this study, we analyze our recent experience with patients who underwent synchronous carotid endarterectomy (CEA) and coronary artery bypass grafting. METHODS: We reviewed the early outcome of 68 patients (56 males, 12 females, mean age 71.1 years, range 53-88 years) who underwent simultaneous CEA and coronary artery revascularization between January 2005 and June 2007. The frequency of unstable or ulcerated plaques was determined in symptomatic and asymptomatic patients. RESULTS: Death for myocardial infarction occurred in 3 patients (4.4%). Stroke was found in 1 patient (1.4%). Combined 30-day stroke/mortality rate was 5.8%. The frequency of unstable or ulcerated plaques was 60.3% (41/68). An unstable stenosis was present in 23 out of 42 asymptomatic patients (54.7%). CONCLUSIONS: Patients suffering from a concomitant coronary and carotid artery occlusive disease represent a high-risk population whose management is still controversial. A modern approach to combined CEA and coronary artery bypass grafting may be safe. The high frequency of unstable carotid lesions in asymptomatic patients suggests to treat every stenosis > 75% in candidates to coronary artery bypass grafting. Carotid artery stenting should be avoided in the majority of cases, considering the possibility of unstable carotid stenosis and the atherosclerotic involvement of aortic arch.

Fate of excluded popliteal artery aneurysms: should we change our current treatment?

Surgical repair of popliteal artery aneurysms is usually performed by vascular exclusion and femoro-popliteal bypass grafting via a medial route. The vascular exclusion of a popliteal artery aneurysm may, however, prove ineffective long-term. We report on a patient with a large popliteal artery aneurysm observed twelve years after conventional surgical treatment and discuss alternative surgical options to be considered for long-lasting effective popliteal artery aneurysm treatment.