Hybrid treatment of large extracranial carotid artery aneurysm.

An extracranial carotid artery aneurysm (ECAA) is a rare condition. The major complications are rupture and thromboembolism. Therefore, treatment is generally recommended. We report the case of a young woman affected by an ECAA, with a cervical pulsatile mass. A multidisciplinary evaluation was performed to ensure the best treatment in terms of safety and efficacy, and the patient underwent hybrid treatment. The 6-month computed tomography angiogram revealed patency of the carotid artery stents and the venous graft, in the absence of any relevant complications. An ECAA is a serious clinical condition. The treatment is challenging, and a multidisciplinary evaluation and precise planning are recommended.

Transcranial ultrasonography imaging of a suprasellar meningioma: A case description and technical notes.

Background: Computed tomography (CT) and magnetic resonance (MR) represent the gold standard for evaluating intracranial tumours, such as meningiomas; most meningiomas can be managed by surveillance and clinical follow-up, therefore, the ideal technology should be cheap, non-invasive, safe and able to reduce radiation exposure. Transcranial colour-coded duplex sonography (TCCS) can detect space-occupying lesions, but its full potential for clinical practice is still unexpressed. Aims and Methods: We describe the ability of TCCS to directly and accurately image, in a 77-year-old woman hospitalised for septic shock and coma, a suprasellar meningioma with a spatial resolution very similar to CT. Results: The meningioma was clearly visualised as a roundish mass, with well-defined borders, heterogeneously hyperechogenic compared with the surrounding brain structures; multiple intralesional calcifications were detectable as highly echogenic spots. Latero-lateral and antero-posterior diameters were well measurable. Discussion: TCCS should not be considered as an alternative to CT and MR imaging, but it might have a complementary role, useful for use at the bedside in uncooperative or non-transportable patients and for follow-up, when an adequate acoustic window is guaranteed. Neurologists and neuroradiologists should further explore the full potential of this technology.

Skin Ulcers are Predictors of 30-Day Hospital Readmission, But are Under-represented in the DRG Coding: A Retrospective Case-Control Study From an Italian Internal Medicine Unit.

This study retrospectively analyzes all consecutive patients who underwent during a year hospital readmissions, defined as an admission to a hospital within 30 days of discharge, to an Italian Internal Medicine ward. All these data were compared with those from patients who underwent only 1 hospital admission in the same period. The aim of this study was to identify potential novel risk factors for hospital readmissions. In 2018, a total of 3012 patients were hospitalized. Among these, 14.1% (n = 426; mean age, 79.7 ± 11.9; range, 23-100) were defined as readmissions; data were compared with controls (n = 420; 13.9%; mean age, 75.9 ± 14.7; range, 22-99) who had only 1 hospitalization. Cases showed a significantly higher prevalence than controls regarding cerebrovascular disease (77.2% vs 48.1%), cognitive impairment (51.8% vs 26.9%), congestive heart failure (47.6% vs 20.2%), chronic kidney disease (31.7% vs 13.1%), and chronic obstructive pulmonary disease (23.0% vs 14.5%). Skin ulcers were significantly more prevalent among cases (45.1% vs 17.6%). Diagnosis-related group (DRG) analysis showed a higher proportion of "infectious disease" (24.4% vs 15.0%) among the cases than in controls. Despite skin ulcers were very frequent among cases and controls (45.1% vs 17.6%), they were codified as "skin wound" DRG only in 1.4% and 0.2%, respectively. At the DRGs analysis, sepsis (31.6% vs 19.1%), pneumonia (17.1% vs 7.6%), and kidney failure (9.6% vs 3.8%) represented the main significant cause of death in cases compared to controls. Our study confirms that readmissions to Internal Medicine departments are related to the severity of chronic diseases affecting patients. Skin ulcers are present in about half of patients who will be early readmitted within 30 days, but they are almost never reported in DRGs, so more accurate coding is needed. Key challenges for the future are sepsis prevention measures and investing resources in chronic disease assistance, including skin ulcer chronic management.

Primary septic arthritis of the knee caused by Neisseria meningitidis serogroup B in an elderly patient. Case report and review of the literature.

PURPOSE: Primary meningococcal arthritis (PMA) represents an uncommon clinical presentation of meningococcal infection, mainly reported among young people. Herein, a case of PMA of the knee in an elderly patient is described. CASE PRESENTATION: On January 2022, an 87-year-old patient arrived at hospital with continuous fever persisting for three days and a picture of pain, swelling, redness, and warmth of her left knee. An arthrocentesis was promptly performed and the inoculated synovial fluid turned positive with numerous Gram-negative diplococci at the microscopic examination. The identification of bacteria was done in 48 h using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF) MS systems (VITEK®MS-bioMérieux) and standard microbiological procedures (VITEK®2 NH ID card-bioMérieux). Both methods identified the strain as N. meningitidis. The meningococcal isolate belonged to the serogroup B (MenB), Sequence type (ST)-162/clonal complex (cc)162. Two grams of ceftriaxone twice a day were administered for 21 days; than cefditoren pivoxil 400 mg twice a day for further 6 weeks after discharge. In Italy, from 2018 to January 2022, among 135 MenB, 31 MenB/cc162 were identified, of which only the case here reported was associated with an atypical clinical presentation. REVIEW OF THE LITERATURE: A total of 41 cases of PMA caused by N. meningitidis was reported in the literature, but only four occurred in elderly. To our knowledgements, no cases of PMA caused by MenB were previously reported among patients of more than 65 years of age.

A Severe Necrotizing Inflammatory Reaction of Leg Wounds Following Autologous Peripheral Blood Total Nucleated Cells Treatment in an Old Patient With Rheumatoid Arthritis and No-Option Chronic Limb-Threatening Ischemia: Is Cell Therapy Suitable for All Patients?

Chronic limb-threatening ischemia (CLTI) represents an unfavorable evolution of peripheral artery disease, characterized by pain at rest, ulceration, and gangrene and also by an increased risk of cardiovascular events, amputations, and death. According to scientific literature, in almost one third of cases affected by CLTI, defined as no-option CLTI patients, revascularization strategies are not feasible. In the past decade, several studies investigated the role of therapeutic angiogenesis through cell autologous therapy, administered through intramuscular injections or multiple local intralesional and perilesional injections. In this article, we report the case of a necrotizing inflammatory reaction in a patient affected by CLTI and chronic leg wounds that occurred on the multiple injection sites after autologous peripheral blood-derived mononuclear cells (PB-TNCs) transplantation. Since the patient was affected by corticosteroid-induced skin atrophy and rheumatoid arthritis, we hypothesize that an increased skin fragility and a mechanism of immune-mediated pathergy could have been main factors leading to worsening of wounds. This case report strongly suggests the urgent need to better define the indications and contraindications of cell therapy, and further studies of adequate methodology are required to definitively assess the efficacy and safety of autologous cell therapy by local injections of PB-TNCs in patients with chronic inflammatory disorder, such as rheumatoid arthritis, especially in case of concomitant marked skin atrophy. Pending definitive evidence from literature, a strong caution is needed in patients affected by chronic systemic inflammatory diseases, since multiple injections, acting as mechanical stimulus and pathergy trigger, might exacerbate a severe and uncontrolled inflammatory response.

Infection of Prosthetic Patches after Femoral Endarterectomy: An Unreported Complication.

BACKGROUND: The femoral prosthetic patch is a surgical procedure frequently used to treat atherosclerotic lesions involving femoral artery bifurcation. Even though it is an easy to perform procedure, surgical management of complications, first of all graft infection, may be challenging, with a high morbidity and mortality risk for patients. We report our experience on surgical treatment of femoral patch infections. MATERIALS AND METHODS: Between April 2012 and April 2018, 26 patients (26 limbs) were referred to the emergency department at our institution for the treatment of femoral prosthetic patch infections. None of the patients had been previously treated at our institution. All patients underwent a wide debridement of the infection site. Blood flow was restored through a vein interposition graft anastomosed at least 4-5 cm from the site of infection. End points of the study were death-related events, major or minor limb loss (major loss for above or below the knee amputation and minor for foot or toe), vein interposition graft failures, recurrent graft infections, or surgical wound healing. RESULTS: A total of 26 patients (21 male and 5 female patients) underwent surgical treatment. The mean age of patients was 69 years. The majority of our patients (54%) had been previously treated with an isolated femoral artery prosthetic patch. Three (11%) patients had been treated with a bilateral prosthetic femoral patch, but only one side was infected. After debridement of the infection site, we used the great saphenous vein to revascularize the lower limb in 22 (85%) cases, whereas the cephalic vein was used in only 4 cases (15%). The 5-year survival rate was 81% (standard error [SE] = 0.12). The 5-year primary patency rate was 70% (SE = 0.14). During follow-up, 4 graft occlusions occurred, and in 2 cases, a major amputation was required. The limb salvage rate at 5 years was 81% (SE = 0.13). CONCLUSIONS: An infection can complicate the femoral prosthetic patch carrying a high rate of morbidity, mortality, and limb loss. Surgical indication for a primary procedure must be restricted to critical limb ischemia, and it must be associated to a multilevel correction of the atherosclerotic disease.

Spontaneous Deep Femoral Artery False Aneurysm Simulating a Neoplasm: A Rare Case and Literature Review.

A 70-year-old woman presented to our attention with a painless pulsating mass at the level of the upper left thigh without any previous history of trauma, arterial surgery, or puncture of the femoral artery. Duplex ultrasound showed a nodular angiomatous-like formation with deep venous compression; computed tomographic angiography and magnetic resonance imaging reported the presence of capsulated lesion vascularized by muscular branch of deep femoral artery (DFA). The patient underwent surgical excision of a very rare thrombized DFA branch false aneurysm. Spontaneous DFA false aneurysm, although rare, will be considered in absence of trauma or vascular catheterization or previous aneurysmal rupture.

Is the Endovascular Treatment of Mild Iliac Stenoses Worthwhile to Improve Wound Healing in Patients Undergoing Femorotibial Bypass?

BACKGROUND: After an infrapopliteal reconstruction, minor amputations are frequently required, but even in the case of successful revascularization, wound healing is a major concern. We studied the role of iliac artery inflow correction in patients undergoing infrapopliteal vein grafts to improve the heal of midfoot amputation. METHODS: Thirty-eight patients affected with Rutherford grade III category 5 peripheral arterial disease, who underwent successful simultaneous iliac endovascular procedure, infrapopliteal reversed vein bypass graft, and minor amputation, were enrolled in this retrospective study. The population was divided in group 1 (20 patients) with inflow vessels Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC) II type B atherosclerotic lesions and group 2 (18 patients) with TASC II type A atherosclerotic lesions determining an invasive pressure drop greater than 15 mm Hg. Fifteen patients (group 3) undergoing infrapopliteal reversed vein bypass graft without associated inflow procedures (TASC II type A and invasive pressure drop greater than 15 mm Hg) were matched with group 2 based on propensity score. Healing was calculated by subtracting the final ulcer area from the initial ulcer area and dividing by the number of follow-up months to obtain the total area healed per month (cm2/month). Stepwise logistic regression analysis adjusted for demographics and medical comorbid conditions was used to test the association between wound healing and treatment modalities. RESULTS: Forty-three patients were available for further analysis. Ten patients were excluded because of graft occlusion with consequent impairment of wound healing. After midfoot amputations, mean wound diameter was 20 ± 8 cm2, and mean healing time was 10 ± 4 months (range 3-20 months; median 9 months). Wounds of groups 1 and 2 healed faster than those of group 3 at 4 and 8 months (P < 0.02 and P < 0.001, respectively; P < 0.04 and P < 0.001, respectively). Multivariate analysis demonstrated the association between wound healing and inflow correction (P < 0.001). CONCLUSIONS: An aggressive treatment is necessary to obtain the heal of the ischemic wounds. The most important predictive factor for nonhealing wounds is the absence of inflow correction. We demonstrated that the inflow should be also corrected in the presence of subclinical lesions.

Spot Stenting of Supra-aortic Branch Vessels for Residual Type A Dissection.

The purpose of this report was to describe the exclusion of the false lumen in a residual type A aortic dissection (TAAD) by the deployment of 2 covered stents: one in the right common carotid artery (RCCA) and one in the left subclavian artery (LSA). A 77-year-old female, already treated with ascending aorta replacement for acute TAAD, was referred to our center for a 97-mm post-dissection arch aneurysm. A computed tomography angiography (CTA) showed false lumen patency by reperfusion from secondary tears located at the level of RCCA and LSA. No primary aortic tear was noted. Under local anesthesia and by transfemoral percutaneous approach, the tears at the level of RCCA and LSA were covered by a 9-mm Viabahn stent graft (Gore, Flagstaff, AZ), and a 10-mm V-12 stent graft (Maquet, Rastatt, Germany), respectively. The false lumen was finally occluded by the deployment of a 6-mm vascular plug at the level of LSA re-entry tear, by left transbrachial puncture. The procedure was completed uneventfully. Twelve-month CTA showed exclusion of the false lumen, patency of all supra aortic trunks, and initial shrinkage of the aneurysm. Spot stenting of secondary re-entry tears, already described for visceral branches, seems to be safe and effective also for supra-aortic trunks in selected patients.

A Steerable Sheath to Deploy Hypogastric Bridging Stent by Contralateral Femoral Approach in an Iliac Branch Procedure after Endovascular Aneurysm Repair.

Aneurysmal degeneration of distal landing zones after endovascular aneurysm repair (EVAR) can be a potential cause of late failure of this technique. Aneurysmal degeneration of common iliac arteries increases the risk of rupture of the iliac aneurysm itself as well as of the abdominal aortic aneurysm owing to aneurysm's reperfusion as a type Ib endoleak. Reoperation consists in plugging and covering the internal iliac artery (IIA), by extension into the external iliac artery, or preservation of antegrade flow in IIA by iliac branch devices (IBDs) or sandwich technique. The management of common iliac aneurysms after EVAR with the purpose of preserving antegrade flow into IIA generally requires a brachial or axillary access. However, this approach may be theoretically associated with local or systemic complications. We report a case of IBD implantation after EVAR, using a steerable sheath for IIA bridging stent deployment via contralateral femoral approach.

A Rare Presentation of an Isolated Internal Iliac Artery Aneurysm: Report of a Case and Literature Review.

Isolated internal iliac artery aneurysms (IIIAAs) are extremely rare. We present the case of a 75-year-old white Caucasian male patient admitted for right lower limb deep venous thrombosis and low-risk pulmonary embolism due to the compression of the external iliac vein from an IIIAA. A review of the literature was also performed to identify the epidemiologic, clinical characteristics and diagnostic and operative strategies of this disease. At present, a recommendation for the best operative strategy in the presence of an IIIAA is difficult. Our analysis demonstrated controversial results, but we are confident to recommend the endovascular treatment in an elective setting.

True Aneurysm of the Inferior Thyroid Artery: A Case Report and Literature Review.

Aneurysms of the inferior thyroid artery (ITA) are extremely rare and potentially determine severe sequelae. We report a case of true ITA aneurysm in a 45-year-old Caucasian woman treated with endovascular embolization; postoperative course was uneventful and, at 6-month follow-up, the aneurysm is completely thrombized. A systematic review of the literature has been also performed to identify the epidemiologic and clinical characteristics and diagnostic and operative options of this disease. Size alone is not able to predict the fate of the aneurysm and an aggressive treatment seems to be justified because of the high risk of complications in case of rupture. In an emergency setting, the endovascular procedures associated to hematoma evacuation or open surgery should be rapidly performed to save patient life.

Pancreas preserving surgery for duodenal gastrointestinal stromal tumor removal.

BACKGROUND: We reported our experience with high-risk, non-metastatic second portion duodenal gastrointestinal stromal tumor (GIST)s in patients who underwent 1-month neoadjuvant cycles with imatinib therapy followed by pancreas-preserving surgery and 12-month of adjuvant chemotherapic regimen including imatinib. This study was conducted to evaluate the short and long-term results. METHODS: The study was conducted between January 2010 and May 2015. Medical charts and operative logbooks of patients were retrospectively reviewed. RESULTS: Nine patients form the basis of the current analysis. All patients underwent curative resection with pancreas preservation, and all specimens had histologically negative margins. The median follow-up was 35 months. Eight patients were alive, 1 patient died for myocardial infarction at a mean follow-up of 10 months, 1 patient had a recurrence at a mean follow-up of 32 months and no patients developed distant metastases. CONCLUSIONS: We are confident to suggest the use of neoadjuvant and adjuvant Imatinib therapy to those patients affected with D2, high-risk, duodenal GISTs to allow a limited resection.

Deep gluteal grounding pad burn after abdominal aortic aneurysm repair.

Although skin burns at the site of grounding pad are a known risk of surgery, their exact incidence is unknown. We first report the case of a patient who presented a deep gluteal burn at the site of the grounding pad after an abdominal aortic aneurism repair, the etiology and the challenging treatment required to overcome this complication.

A multidisciplinary approach to a complex case of lower limb trauma.

INTRODUCTION: Blunt trauma of the popliteal fossa is an uncommon cause of lower limb ischemia and it is associated with a high risk for limb loss. REPORT: The case of a young man with anterior dislocation of the right knee joint causing post-traumatic popliteal artery occlusion and severe lower limb ischemia is reported. DISCUSSION: To our knowledge we first report a multidisciplinary approach involving the vascular and plastic surgical teams to treat a wide soft tissue damage after a blunt injury to the popliteal artery.

Predictive role of renal resistive index for clinical outcome after revascularization in hypertensive patients with atherosclerotic renal artery stenosis: a monocentric observational study.

BACKGROUND: The present study evaluated the predictive value of renal resistive index (RI) for renal function and blood pressure (BP) outcome in hypertensive patients with unilateral atherosclerotic renal artery stenosis submitted to successful revascularization. METHODS: In 158 hypertensive patients with atherosclerotic renal artery stenosis RI was acquired. Twelve months after revascularization, they were classified on the basis of renal function and BP outcome as benefit (BP < 140/90 mmHg or diastolic BP reduction > 15 mmHg with the same of reduced drugs; decrease in glomerular filtration rate > 20%), or failure. RESULTS: Regarding renal function outcome, RI in the stenotic and in the contralateral kidney were significantly higher in patients with failure (n = 20) than in those with benefit (0.72 ± 0.11 vs 0.61 ± 0.11 and 0.76 ± 0.08 vs 0.66 ± 0.09, p < 0.05). Among different cutpoints generated, RI in the contralateral kidney >0.73 provided the largest area under the curve (0.77), and the highest sensitivity (80%) and specificity (72%). In the multivariate logistic regression analysis, RI in the contralateral kidney >0.73 was an independent predictor of a failure in renal function outcome.Regarding BP outcome, patients with no benefit from revascularization (n = 60) had similar RI in the stenotic and contralateral kidney (p = ns), but presented higher pulse pressure, albuminuria and hypertension duration in comparison to patients with improved BP control. CONCLUSIONS: RI in the contralateral kidney is an independent predictor of renal function outcome after successful revascularization in hypertensive patients with unilateral atherosclerotic renal artery stenosis, whereas it is not able to predict blood pressure outcome.

Adductor canal compression syndrome: a forgotten disease.

Superficial femoral vessels entrapped at the level of the adductor canal are rarely described. We first report the case of a young patient who practices professional soccer, affected with superficial femoral vein and artery occlusion due to a hypertrophied vastus medialis and adductor magnus at the Hunter's canal outlet. A careful literature search through MedLine was performed to elucidate the fascinating aspect of this occurrence.

The usefulness of a Trauma Registry and the role of the general surgeon in the multidisciplinary approach to trauma patients: 3-year experience at Sant'Andrea University Hospital in Rome.

The purpose of this study is to verify the usefulness of a multidisciplinary Trauma Registry in the evaluation of trauma, particularly in relation to the number of specialists involved, and to analyze the effective role of the general trauma surgeon in an integrated trauma care system. The present study was performed by analyzing data from the Trauma Registry of the University Hospital Sant'Andrea in Rome, which was set up in March 2006. Data recorded between March 2006 and March 2009 was considered for the present study. The severity of trauma was categorized by dividing patients into 4 subgroups based on the value of ISS: minor injuries (ISS 1-8), moderate (ISS 9-15), severe (ISS 16-24) and very severe (ISS> 24). Patients who had an ISS greater than 9 were taken into account for further analysis and comparison. To evaluate the significance of the multidisciplinarity the patients were stratified in subgroups considering the number of specialists involved in relation to the anatomic location of injuries. In the 1386 trauma patients entered in the registry, the mean and median ISS value were 10.7 ± 8.4 and 9 respectively. The overall mortality and morbidity were 4.1% and 7.4% respectively. There was a statistically significant linear relationship between the number of specialists involved and the ISS (multidisciplinarity / ISS r = 0.493, p <0.001). Patients with ISS greater than 9 were 358, 25.8% of all cases. The mean ISS was 21.4 ± 10.3. Mortality and morbidity rates were 9.8% (35 patients) and 22.1% (79 patients) respectively. The average number of specialists involved was 2.4 ± 1.1, median 2 (range 1- 6). Results confirmed the significance of the multidisciplinary treatment for patients with trauma and the central role played by the general surgeon.

The prognostic significance of thoracic and abdominal trauma in severe trauma patients (Injury severity score > 15).

The aim of the present study was to assess the prognostic significance of thoracic and abdominal trauma in severely injured patients. A retrospective analysis was performed based on data from the period from March 1 2006 to December 31 2007, taken from the Trauma Registry of the University Hospital "SantAndrea" in Rome. A total of 844 trauma patients were entered in a database created for this purpose, and only patients with an Injury Severity Score (ISS) > 15, (163 patients, 19.3%), were selected for the present study. These patients were divided into 2 groups: Group A (103 patients, 63.2%), consisting of patients with at least one thoracic injury, and Group B (46 patients, 28.2%) consisting of patients with concomitant thoracic and abdominal injuries. The impact of thoracic and abdominal trauma was studied by analyzing mortality and morbidity, in relation to patient age, cause and dynamics of trauma, length of hospital stay, and both ISS and New ISS (NISS). In a vast majority of cases, the cause of trauma was a road accident (126 patients, 77.3%). The mean age of patients with ISS > 15 was 45.2 +/- 19.3 years. The mean ISS and NISS were 25.7 +/- 10.5 and of 31.4 +/- 13.1 respectively. The overall morbidity and mortality rates were 18.4% (30 patients) and 28.8% (47 patients) respectively. In Group A the mortality rate was 23.3% (24 patients) and the morbidity rate was 33.9% (35 patients). In Group B mortality and morbidity rates were 369% (17 patients) and 43.5% (20 patients) respectively. It was shown that the presence of both thoracic and abdominal injuries significantly increases the risk of mortality and morbidity. In patients with predominantly thoracic injuries, NISS proved to be the more reliable score, while ISS appeared to be more accurate in evaluating patients with injuries affecting more than one region of the body.