Trans-limb embolization for treatment of Type 2 endoleak post EVAR: Case report.

INTRODUCTION: Type 2 endoleaks (T2EL) occur after 10%-25% of endovascular abdominal aortic aneurysm repairs and increase the risk factor of endograft repair failure and rupture. Herein we report a case of endovascular treatment of T2EL where we performed a trans-limb embolization. PRESENTATION OF CASE: A 63-years-old male previously treated for AAA with endovascular aortic aneurysms repair (EVAR), showed an angio-CT scan followup with a type 2 endoleak fed from inferior mesenteric artery (AMI) with growth of AAA greater of 1 cm than preoperative CT-scan and increase of chronic lumbar pain. Due to high risk of rupture was performed a trans-limb embolization with complete sealing. The 6 months CT-angiography showed complete type 2 endoleak exclusion without changes of AAA. DISCUSSION: The risk of aneurysm rupture in the presence of an isolated T2EL is exceptionally low. However, when a persistent T2EL is associated with a significant sac size increase, commonly considered as at least 5 mm over 6 months, should be treated. Detachable coils are repositionable, allowing an extremely precise deployment and subsequent embolization of different targets. CONCLUSION: In this experience trans-limb embolization was feasible and this tool should be taken in account especially when no other surgical options exists.

Transcervical approach for carotid artery stenting with transitory reversal flow: Case report.

INTRODUCTION: Carotid artery stenting (CAS) has been indicated as an alternative to carotid endarterectomy in high risk patients. Sometimes, an aortic arch can be anatomically unfavourable for CAS. Herein we report our experience in a case of CAS with transcervical approach. PRESENTATION OF CASE: A 77-year-old male was referred to our hospital for severe subtotal occlusion of the left internal carotid artery. He had a past medical history of radiation to the head and neck for laryngeal cancer. Previous CT-angiography had shown a type III aortic with bovine arch. CAS via transcervical approach was performed with transitory reversal flow during the placement of RX Spider Filter 6 Fr (Medtronic, Minneapolis, MN). After release of 7 × 30 mm RX Xact carotid stent (Abbott Vascular, Chicago, IL) and ballooning with a 5.5 × 30 mm Rx Submarine balloon catheter (Medtronic Minneapolis, MN), angiography check showed a good result. DISCUSSION: The transcervical approach is an innovative technique where usually a shunt is created, either between the common carotid artery and the internal jugular vein or between the common carotid artery and the common femoral vein. This flow reversal reduces the risk of periprocedural embolic events. In our experience a short proximal clamping with transitory reversal flow, reduces the invasiveness of procedure with good outcomes. CONCLUSION: Transcervical carotid access with transitory reversal flow is a valid alternative in complicated patient with anatomy unfit for CAS.

Penetrating aortic ulcer post migration of thoracic aortic endoprosthesis: Case report.

INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) is the first treatment option for many thoracic aortic pathologies. Especially after aortic dissections, it is possible to have progression during follow-up with appearance of new lesions on arterial wall. Herein, we report a case of Penetrating Aortic Ulcer (PAU) post release of Thoracic endoprosthesis. PRESENTATION OF CASE: A 67-years-old male with hypertension and diabetes mellitus was followed at our hospital after an emergency procedure for Type B aortic dissection (TBAD) complicated by symptomatic large infrarenal AAA and treated with a proximal TEVAR plus chimney for left subclavian artery and PETTICOAT with EVAR for abdominal aortic disease. Follow up at 15 months showed a deep PAU with partial crush of stent in Left Subclavian Artery. Thus, we performed a left carotid-subclavian bypass and subsequently a TEVAR procedure with release of Bolton Relay endoprosthesis (Terumo Aortic, Sunrise, Florida, United States). DISCUSSION: In literature there are few studeis that focus on migration after TEVAR during follow-up. Elongation, changes of tortuosity on thoracic aorta after TEVAR, can help to determine a migration of prosthesis. In this case Bolton Relay endoprosthesis (Terumo Aortic, Sunrise, Florida, United States) has permitted to improve precision and quality of procedure. CONCLUSION: In literature there are few studies reporting complications of TEVAR post prosthesis migration. In this case, Bolton Relay endoprosthesis was useful and safe.

Multilevel diabetic foot revascularization in COVID 19 patient: Case report.

INTRODUCTION: Coronavirus 2019 (COVID-19) has been associated with endothelial dysfunction. This hypercoagulable state coming from the endothelial injury pones COVID-19 patients to a higher risk for thrombosis. COVID 19 diabetic patients are more exposed to peripheral vascular disease progression. Multilevel peripheral arterial disease is the main cause of critical limb ischemia. Vascular interventions are required to increase distal blood flow and reduce the risk of amputation. PRESENTATION OF CASE: We report a case of complex revascularization in a diabetic patient with aggressive right foot lesions evolution after COVID-19 infection. The patient presenting a Peripheral arterial ischemic involving the infrarenal aorta, iliac, femoral. The simultaneous intervention consisted of an endovascular aortic stent-graft placement and angioplasty of femoral artery. DISCUSSION: Diabetes is a risk factor of severity and deaths in patients infected with pulmonary viruses. In our experience, COVID 19 virus can accelerate the ulcers generation and progression in diabetic patient. Hybrid interventions can be performed simultaneously or staged with benefit given by the complementary role of endovascular and surgical treatments. In the reported case, a complex simultaneous treatment in a patient presenting Multilevel peripheral arterial disease in association to COVID 19 infection was feasible in the same operation. CONCLUSION: Hybrid procedures are safe with high degree of efficacy in terms of revascularization, reduced morbidity and shorter intensive care. In our experience, the use of a hybrid procedure is technically feasible and allowed the treatment of complicated diabetic COVID-19 patient with a good outcome.

Mechanical rotational thrombectomy in long femoropopliteal artery and stent occlusion in COVID-19 patient: Case report.

INTRODUCTION: Coronavirus disease-19 (COVID-19) has been increasingly associated with thromboembolic complications. COVID-19 infection has a thrombogenic potential for stents. Herein, we report a case of stent thrombosis in diabetic obese patient COVID-19 positive where was previously released a Multilayer Flow Modulator stent (MFM) for large popliteal aneurysm. CASE REPORT: A 78-year-old male was referred to our hospital for fever and acute pain in the left leg. At history, the same patient had endovascular procedure for a large symptomatic popliteal aneurysm, treated through release of three MFM. The pulmonary CT scan showed COVID-19 infection with confirm of rhino-laryngeal swab. Duplex ultrasound and CT-angiography showed complete thrombosis of stents. The treatment consisted of mechanical thrombectomy using an 8Fr catheter Rotarex plus release of Vibahn stent-graft. DISCUSSION: COVID-19 patients can present arterial occlusion. In literature are not reported cases about thrombosis peripheral stent. Minimally invasive approaches in redo-procedure reduce risk of infection. Rotarex device was used in revascularization of acute and subacute iliac and femoropopliteal arteries. The goal is to have a debulking, to avoid an incomplete deployment of stent-graft. In our precedent experience, MFM and stent-graft to treatment of popliteal aneurism were safe. It is important to monitor these patients for early identification of failure and rapprochement. In this case, the COVID-19 infection was determinant in promoting thrombosis. CONCLUSIONS: COVID-19 increases risk of thrombosis stent. In our experience debulking through Rotarex and stenting, were decisive factors for revascularization and limb salvage.

Composite femoro-tibial bypass as alternative solution in complicated revascolarization: Case report.

INTRODUCTION: Peripheral Arterial Disease (PAD) in diabetic patients is a significant cause of Morbility. Long arterial occlusion in patient previously treated can require unusual and complex solution. Herein we report a case of complicated bypass in diabetic patient with history of bypass for bilateral popliteal aneurysm. PRESENTATION OF CASE: A 51-year-old male, smoker, with hypertension and diabetes mellitus was referred to our hospital for rest pain in left limb and peripheral cyanosis. Ultrasound doppler (US) showed an occlusion after common femoral artery with patency of Anterior-tibial artery (ATA) two centimeters after the origin. The unavailability of adequate autologous conduit necessitated an alternative solution and was chosen a composite femoro-anterior tibial artery bypass with successive ATA angioplasty to ensure the patency of graft. DISCUSSION: The autogenous vein is the preferred conduit in below-knee vascular reconstructions but in redo-procedures in the absence of vein, synthetic or biologic vascular prostheses must be considered as graft material. In these cases tibial angioplasty can improve the outflow and the patency. CONCLUSION: Composite Femoro-ATA bypass with tibial angioplasty is an alternative technique for critically ischemic legs with limited autologous vein material. In our experience this approach was safe and effective.

Iliac-femoral stent-graft infection after hybrid procedure redo: Case report.

INTRODUCTION: Stent-graft infection in peripheral arteries is rare and potentially dangerous. The use of hybrid procedures, in complicated patients previously treated, involves an increase of infective risk especially in no collaborative patients. PRESENTATION OF CASE: We report a case of rare stent-graft infection in a patient treated for a Rutherford IV Multiple Peripheral Arterial Disease (MPAD) involving the right iliac-femoral axis with stenosis on deep femoral artery due to a previously stenting procedure for Superficial Femoral artery (SFA) stenosis. The first simultaneous hybrid intervention consisted of an endovascular iliac stent-graft placement and a surgical common femoral patch angioplasty. After two months the patient was readmitted to our unit for a purulent secretion through a fistulous channel and a suspect infection of stent-graft. Subsequently, the stent-graft was completely removed without possibility to have a surgical revascularization. An amputation major amputation was needed for irreversible ischemia of right leg. DISCUSSION: The incidence of stent-graft infection after endovascular aortic aneurysm repair had been reported as 0.4-1.0% while Aortoiliac graft infection occurs in 2-6% of patients. Hybrid procedures are secure and need close follow-up for cases of redo and patient with comorbidities. CONCLUSIONS: Graft infection is a rare complication after endovascular treatments. Hybrid procedures outcomes are good with less morbidity but in patient with high risk of infection is important a close follow-up.

Staged acute mesenteric and peripheral ischemia treatment in COVID-19 patient: Case report.

INTRODUCTION: COVID-19 is an infectious disease that has been associated not only with respiratory complications. The COVID-19 disease includes, also damage to other organ systems as well as coagulopathy. The present report describes a case of COVID-19 presenting with acute mesenteric ischemia (AMI) and subsequent acute limb ischemia (ALI). PRESENTATION OF CASE: An 84-years old hospitalized female patient presenting diabetes and recent COVID-19 reported acute onset of abdominal pain and typical findings of AMI. The CT-angiography confirmed the AMI secondary to a superior mesenteric artery (SMA) occlusion. The patient was managed through an endovascular approach using a SMA mechanical thrombectomy and stenting with a good result. DISCUSSION: Treatment of this life-threatening condition includes surgical resection of the necrotic bowel, restoration of blood flow to the ischemic intestine and supportive measure - gastrointestinal decompression, fluid resuscitation, hemodynamic support. Endovascular management of AMI is preferred over the standard surgical approach due to a reduced mortality and morbidity rates. Imaging findings of intestinal necrosis, however, represent an indication for AMI surgical treatment with explorative laparotomy. Different endovascular solutions have been employed to address AMI including mechanical thrombectomy, local thrombolysis, and PTA-stenting. CONCLUSION: COVID-19 clinical presentation can be atypical, including gastrointestinal symptoms. If a first embolic event occurs, an aggressive anticoagulation treatment could be inefficient to reduce the risk of subsequent embolization events. The limited life expectancy of such revascularization procedures should orientate towards less invasive treatments.

TEVAR and periscope graft technique to treatment of huge aneurysm of aortic isthmus: Case report.

INTRODUCTION: Thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of thoracic aortic aneurysms. Innovative techniques as chimney and periscope grafts can improve the outcomes of procedure. Herein, we report a case in emergency of huge Thoracic aortic aneurism. PRESENTATION OF CASE: An 86-year-old male with hypertension, diabetes mellitus, was referred to our hospital for chest pain. CT-angiography showed a huge aneurysm of aortic isthmus with signs of rupture. The patient was considered unfit for open surgery and an endovascular approach was chosen. This patient underwent endovascular repair with TEVAR, using the periscope graft technique to preserve patency in left subclavian artery (LSA). DISCUSSION: Symptomatic ischemia from LSA coverage has been reported to occur in only a modest 6-10% of patients and is often sacrificed with impunity given coverage rates between 10 and 50%. In this case reported the lack of revascularization of LSA increased the risk of neurological manifestations or stroke. Periscope technique is feasible and safe to maintain perfusion to the subclavian artery, with a 93% primary patency at 2 years. CONCLUSIONS: Our experience using TEVAR with periscope graft technique as solution to address thoracic aneurysm of aortic isthmus was feasible and safe.

Type 1A endoleak detachable coil embolization after endovascular aneurysm sealing: Case report.

INTRODUCTION: Endovascular aneurysm sealing (EVAS) with the Nellix system was introduced to reduce endovascular aneurysm repair (EVAR) perioperative complications, especially endoleaks. Herein we report a case of successful type 1A endoleak managed with detachable coils embolization after EVAS. PRESENTATION OF CASE: A 77-year-old male was referred for abdominal pain. The angio-CT scan confirmed the previous EVAS procedure and showed a type Is2 endoleak below the right renal artery resulting in a 2.5 cm aortic blister with contrast medium filling the space between the aortic wall and the endobags. The patient was considered unfit for conventional open surgery and an endovascular approach with coil embolization Concerto Helix Detachable Coil System was chosen under local anesthesia. After intervention, a complete abdominal pain regression was registered. The 12- month CT follow-up showed endoleak sealing and Nellix system stability. DISCUSSION: EVAS has been associated to a high endoleaks and complications incidence when compared to EVAR. The EVAS different device concept led to a different endoleak classification and management. Endoleak management main options include the Nellix system explantation or the Nellix in Nellix application, however these are nearly always not applicable, respectively, due to the high surgical risk condition and the Nellix system availability, especially in emergent setting. Despite the use of coil embolization is controversial, this tool is off-the-shelf and leads to a disease resolution in most of patients without other surgical options. CONCLUSION: Proximal type Is2 embolization after EVAS is feasible with limited invasiveness.

A Single-Center Experience on Below-The-Knee Endovascular Treatment in Diabetic Patients.

Diabetic ulceration of the foot is a major global medical, social and economic problem and is the most frequent end-point of diabetic complications. A retrospective analysis from February 2017 to May 2019 of diabetic patients presenting below-the-knee artery disease (PAD) was carried out. Only patients treated with endovascular techniques as first choice treatment were evaluated. Outcome measured was perioperative mortality and morbidity. Freedom from occlusion, secondary patency and amputation rate were all registered. Additional maneuvers including stenting or angioplasty with drug eluting balloon (DEB) were reported. A total of 167 (101 male/66 female) patients with a mean age of 71 years were included in the study. A Rutherford 3, 4, 5 and 6 categories were reported in 5, 7, 110 and 45 patients, respectively. No perioperative mortality was reported. Morbidity occurred in 4 (4.4%) cases and consisted of pseudoaneurysm. Additional stenting during first procedure was required in 7 (4%) patients, drug eluting balloon was needed in 56 (33%) patients. At 1-year follow-up, estimated freedom from occlusion and secondary patency was 70% and 80% respectively. Major amputation rate was 2.4%, minor amputation rate was 41.9%. In our experience, extreme revascularization in search of distal direct flow reduce the rate of amputations with an increase in ulcer healing. New materials and techniques such as drug eluting technology, used properly, can improve outcome.

Endovascular Treatment with Drug-Eluting Balloon for Severe Subclavian Artery Stenosis Involving the Origin of the Vertebral Artery.

The first line approach for subclavian steal syndrome is PTA-stenting of subclavian artery. When the ipsilateral vertebral artery origin is involved or in closed proximity of the atherosclerotic lesion in the subclavian artery PTA-stenting is at risk of ipsilateral vertebral artery coverage. Herein we report our experience with DEB to address lesions involving the subclavian artery and the origin of the ipsilateral vertebral artery. From January 2017 to February 2019, patients presenting subclavian artery lesion involving the origin of the ipsilateral vertebral artery and treated using primary DEB, were included. Three patients, with left subclavian steal syndrome, were identified. The perioperative mortality and morbidity were outcomes evaluated. Freedom from occlusion, secondary patency, amputation rate was registered. A total of 3 (2 female) patients were included in the study. No complication, symptoms recurrence, restenosis or occlusion were reported at duplex scan during 12-month follow-up. Indication for stenting was arterial dissection. In our limited experience, the use of DEB in association to embolic protection device in the treatment of atherosclerotic subclavian lesion involving the origin of the vertebral artery was safe and technically feasible.

Home therapy for deep vein thrombosis and pulmonary embolism in cancer patients.

Outpatient treatment of deep vein thrombosis (DVT) has become a common practice in uncomplicated patients. Few data are still present in patients with comorbidity (such as cancer) or concomitant symptomatic pulmonary embolism. Cancer patients with DVT are often excluded from home treatment because they have a higher risk of both bleeding and recurrent DVT. We tested the feasibility and safety of the Home Treatment (HT) program for acute DVT a PE in cancer patients. Patients were treated as outpatients unless they required admission for other medical problems, were actively bleeding or had pain that requires parenteral narcotics. Outpatient treatment was with low molecular weight heparin (LMWH) followed by warfarin or with LMWH alone. An educational program for patients was implemented. Two-hundred and seven patients with cancer were evaluated, 36 (17.4%) of whom had metastatic disease. Treatment with LMWH and warfarin was prescribed to 106 (51.2%) and LMWH alone to 102 (48.8%). One hundred and twenty-seven patients (61.3%) were entirely treated at home. There were no differences between patients treated at home and hospitalized patients with regard to gender, mean age, site of cancer, presence of metastases, and treatment. After 6 months, recurrent thrombo-embolism occurred in 8.7% of patients treated at home and in 5.6% of hospitalized patients (P=0.58); major bleeding in 2.0% and 1.5%, respectively (P=0.06). Twenty-seven patients (33%) in the hospitalized, and 33 (26%) in the home-treatment group, died after a follow-up of 6 months. These results indicate that, regarding cancer patients with acute DVT and/or PE, there is no difference between hospitalised and home-treated patients in terms of major outcomes.

[Bacterial endocarditis. Unusual complications of acute diverticulitis]. / L'endocardite batterica. Complicanza rara della diverticolite acuta.

BACKGROUND: Colon diverticular disease represents an affection with high prevalence in the western countries. It appears particularly insidious in the elderly population for the presence of concomitant illnesses. CLINICAL CASE: A patient (> 80 years old) is submitted to surgical intervention in emergency sec. Hartman for acute diverticulitis and pelvic abscess. The post-operating time has been complicated for the arising of a fever resistant to the common antibiotic therapy, in absence of abdominal and respiratory objectivity. An accurate clinical examination has set the suspect of bacterial endocarditis, confirmed to the echocardiographic examination. DISCUSSION: The acute complicated diverticulitis therapy variates in according to the clinical presentation, the complications and the experience of the different Authors. A first conservative approach foresees the Total Parenteral Nutrition (TPN) and the wide spectrum antibiotic therapy and the eventual percutaneous drainage. The surgical treatment, realized with "open" or laparoscopic method, foresees the resection of the sick intestinal tract and the packing of a temporary preternatural anus. However, some Authors prefer an intestinal anastomosis performed in single time with the resection. Among all the complications, the most frequent are those affecting the respiratory and cardiovascular apparatus, as well as the sepsis. The bacterial endocarditis is not signalled in most recent international Literature. CONCLUSION: The bacterial endocarditis must be suspected in case of common antibiotic therapy resistant fever, with negative abdominal and pulmonary objectivity, arising after a septic surgical intervention.

Surgical treatment of morbid obesity with biliopancreatic diversion and gastric banding: report on an 8-year experience involving 235 cases.

STUDY AIM: Developments have recently been made in bariatric surgery outside the USA. The aim of this retrospective non-randomized study was to report on our experience regarding biliopancreatic diversion (BPD) and non-adjustable gastric banding (GB) in a population of 235 obese patients. PATIENTS AND METHODS: From March 1990 to March 1998, 235 obese patients were operated on, 142 by BDP and 93 by GB, via laparotomy after rigourous selection of the patient population. RESULTS: The mean duration of surgery was 2 h 50 minutes for BPD and 1 h for GB. One postoperative death occurred due to massive pulmonary embolism. Early major complications were frequent in the BPD group (n = 21) but rare in the GB group (n = 1). Mean duration of hospitalization was 16 days in the BPD group versus 9 days in the GB group. Mean percentage excess weight loss was 48% for the GB group and 60% for the BPD group after two years. Late mortality was limited to the BPD group (3.5%). Late complications were evenly distributed between the two groups, with a prevalence of malnutrition in the BPD group and outlet stenosis in the GB group. A high incidence of band removal was recorded related to this complication (17.2%). Incisional hernias were present in both groups. CONCLUSIONS: GB and BPD are techniques which can induce weight loss and bring about subsequent health benefits. Nevertheless, in a few patients further intervention or adaptation of the approach due to clinical failure or to a high complication rate is required. Additional research is needed regarding determination of the surgical treatment that is best adapted to the case in question, i.e., taking into consideration both the restrictive and malabsorbative aspects.

[Intestinal cystic pneumatosis and gastric banding. Etiopathogenic considerations on a clinical case]. / Pneumatosi cistica intestinale e "gastric banding". Considerazioni etiopatogenetiche su un caso clinico.

The authors describe a case of intestinal cystic pneumatosis in a patient submitted to gastric banding and then proceed with a critical review of the literature on the subject, examining the state of the art with regard to the pathogenetic hypotheses and the clinical manifestations of the disease and outlining the advantages of the instrumental investigations employed. On the basis of clinical considerations, an integrated pathogenetic hypothesis is advanced which takes account of the various indications expressed in the literature. In particular, recurrent vomiting is believed to bring about epithelial microlesions which, in the presence of severe respiratory impairment, the execution of endoscopic examinations and a mainly carbohydrate-based diet, are thought to cause onset of cystic pneumatosis.

[Current role of the surgeon in the treatment of venous thromboembolism]. / Il ruolo del chirurgo, oggi, nella terapia del tromboembolismo venoso.

The most frequent complications of deep venous thrombosis (DVT) are post-thrombotic syndrome (PTS) and pulmonary embolism (PE); the main purpose of DVT therapy is to prevent their onset. A range of treatment is now available, including physical, medical and surgical forms. Physical: elastic compression mobilization postural therapy. Medical: anticoagulants (heparin, LMW heparins, oral anticoagulants), thrombolytic agents. Surgical: if DVT is diagnosed at an early stage, anticoagulant treatment may be accompanied by attempted surgical deobstruction, above all if DVT is localised at the popliteal and femoral confluents (greater risk of evolution towards severe "ischemic" forms potential cause of venous gangrene). These treatments include locoregional endogenous thrombolysis followed after phlebography, by surgical thrombectomy in the event of thrombotic residue, enabling the possible embolization of the pulmonary district using a caval filter. The combined medical and surgical approach reduces the long-term incidence of PTS. Temporary caval filters are also available. In short, a modern approach to the clinical problem of DVT now takes the form of early diagnosis and combined thrombolysis-surgery, which appears to be the most appropriate choice, ensuring the best form of venous functional recovery. However, this requires hospitalization in specialist units and multidisciplinary skills (hematological, medical, radiological and surgical) to ensure the best results.

[Intestinal carcinoid. A propos of a case]. / Il carcinoide intestinale. A proposito di un caso.

In this paper the authors report a case of carcinoid neoplasm in a rare localization like sigmoid colon. They describe the clinical and biological aspects of this kind of tumors, with particular regard to the tumor site and its biochemical products. A rational and prompt clinical approach to this neoplasm is considered important for the good chance of long survivals, achievable in the case of early diagnosis.