A "sneaky" symptom of aortic dissection. Brief literature review, physiopathology and diagnostic tools management.

Aortic diseases cover a large spectrum of conditions, such as aortic aneurysm and acute aortic syndromes (i.e., dissections, intramural hematoma, penetrating atherosclerotic ulcer, traumatic aortic injuries, and pseudoaneurysms), genetic diseases (e.g., Marfan syndrome) and congenital abnormalities, such as coarctation of the aorta. These conditions may have an acute presentation; thus, if the acute aortic syndrome is the first sign of the disease, the prognosis is extremely poor. Prompt diagnosis and timely therapy are therefore mandatory. In this paper, we discuss a deceptive symptom of painless aortic dissection and its physiopathology. Furthermore, we briefly review the literature and discuss the management of diagnostic tools.

Ultrasound-guided serratus anterior plane block combined with parasternal block in subcutaneous implantable cardioverter defibrillator implantation: Results of a pilot study.

BACKGROUND: The standard approach to subcutaneous defibrillator (S-ICD) implantation often requires general anesthesia or anesthesiologist-delivered deep sedation. Ultrasound-guided serratus anterior plane block (SAPB) combined with parasternal block (PSB) has been proposed in order to provide anesthesia/analgesia and to reduce the need for sedation during S-ICD implantation. In this pilot study, we compared the double-block approach (SAPB + PSB) with the single-block approach (SAPB only) and with the standard approach involving local anesthesia and sedation. METHODS: We prospectively enrolled 22 patients undergoing S-ICD implantation: in 10, the single-block approach was adopted; in 12, the double-block approach. As a control group, we retrospectively enrolled 14 consecutive patients who had undergone S-ICD implantation under standard local anesthesia and sedation in the previous 6 months. Intra- and postprocedural data, including patient-reported pain intensity, were collected and compared in the three study groups. RESULTS: The double-block approach was associated with a shorter procedure duration than the single-block and standard approaches (63.3 ± 7.9 vs 70.1 ± 6.8 vs 76.9 ± 7.8 min; P < .05) and with a lower dose of local an aesthetic for infiltration (18.9 ± 1.7 vs 27.5 ± 4.6 vs 44.6 ± 4.0 cc; P < .001). Both the double- and single-block approaches were associated with lower pain intensity at the device pocket and the lateral tunneling site (P < .05). The double-block approach proved superior to the other two approaches in controlling intraoperative pain at the parasternal tunneling site (P < .05). CONCLUSIONS: In our study, SAPB combined with PSB was superior to SAPB alone and to the standard approach in controlling intraoperative pain during S-ICD implantation. In addition, this approach resulted in shorter procedure durations.

[Subcutaneous defibrillator implantation with ultrasound-guided serratus block using the two-incision technique: our experience]. / Impianto di defibrillatore sottocutaneo con tecnica del blocco del muscolo serrato eco-guidato a due incisioni: nostra esperienza.

BACKGROUND: The aim of this study was to report our experience with subcutaneous defibrillator (S-ICD) implantation. METHODS: At our hospital, 7 procedures of S-ICD implantation were performed; 4 of these with ultrasound-guided serratus anterior plane block (SAPB) and 3 with usual local anesthesia followed by sedation. RESULTS: Surgical operations were not burdened with peri- and postprocedural complications, with only one event of limited hematoma of the thoracic wall. Ultrasound-guided serratus anterior plane block was associated with better pain control during the procedure and the postoperative period. The disconnection between latissimus dorsi and serratus obtained by serratus anterior plane block contributed to make the creation of the pocket easier. The technique used is with two incisions. CONCLUSIONS: In our experience, S-ICD implantation with the technique of the serratus anterior plane block is safe and effective, and significantly facilitated pain control during the procedure and postoperatively.

Partial splenic embolization in patients with idiopathic portal hypertension.

PURPOSE: To evaluate the effectiveness of partial splenic embolization (PSE) in patients with idiopathic portal hypertension (IPH) in reducing variceal bleeding episodes, splenomegaly and thrombocytopenia. MATERIALS AND METHODS: Six patients (2M, 4F, mean age 30.3 years) with IPH presenting with splenomegaly, thrombocytopenia and recurrent variceal bleeding were treated with PSE using gelatin sponge (four patients) or Contour particles (two patients) as embolization material. RESULTS: PSE was performed successfully in all cases; 3F coaxial microcatheters were necessary in two patients due to extreme splenic artery tortuosity. The average amount of devascularized parenchyma at CT 1 week after PSE was 71%. Splenomegaly and thrombocytopenia improved in all cases, with a mean platelet count increase of 120,000/mm(3) and an average 68% reduction of spleen volume at follow up. Variceal bleeding did not recur after PSE. Esophageal or gastroesophageal varices disappeared (one patient) or significantly reduced (five patients) at endoscopic controls. No significant complications were noted. The follow up was of at least 18 months in all patients; mean follow up was 28.2 months. CONCLUSION: In patients with IPH PSE can be effective in preventing variceal bleedings, in reducing spleen volume and in significantly increasing platelet count; therapeutic results were durable in our population.

Chemoembolization for hepatocellular carcinoma: effect of intraarterial lidocaine in peri- and post-procedural pain and hospitalization.

PURPOSE: To assess the efficacy of intraarterial lidocaine on peri- and post-procedural pain and on length of hospital stay in hepatocellular carcinoma (HCC) patients undergoing chemoembolization. MATERIALS AND METHODS: Twenty-eight patients (19M, 9F, age range 49-76) who underwent hepatic chemoembolization at our Institution between March 2000 and February 2002 were included in the study. Group A consisted of 14 patients who received intraarterial lidocaine immediately before and during chemoembolization, while in the 14 patients of group B lidocaine was substituted with saline solution. The doses of centrally acting narcotics (tramadol) administered periprocedurally and in the three days following the procedure were compared, as were the hospitalization times. Subjective pain was measured using the visual analogue scale. Chemoembolizations were performed with an emulsion of lipiodol, cisplatin and epirubicin followed by embolizing material (gelfoam of Contour particles) in order to achieve complete blood flow stop in the proper hepatic artery. RESULTS: No side effects were noted that could be due to systemic administration of lidocaine. All patients experienced some degree of post-embolization syndrome. Periprocedural, day 1 and day 2 post chemoembolization dosages of tramadol were significantly lower in group A with respect to group B patients. No group A patient required analgesia on day 3. No statistical difference was observed in time persistence of nausea and vomiting, fever and hospitalization time between the two patient groups. CONCLUSIONS: Intraarterial administration of lidocaine before and during chemoembolization is a safe and effective method for preventing or reducing peri- and post-procedural pain and dosage of narcotic analgesics in patients with HCC. Hospitalization times did not differ significantly between the two groups, probably because of the other components of post-embolization syndrome, such as fever, nausea and vomiting.

Upper thoracic sympathetic chain neurolysis under CT guidance. A two year follow-up in patients with palmar and axillary hyperhidrosis.

PURPOSE: To evaluate the efficacy, safety and middle-term results of upper thoracic sympathetic chain neurolysis performed under CT guidance in patients with palmar/axillary hyperhidrosis. MATERIALS AND METHODS: From April 1999 to July 2000 we performed 30 upper thoracic sympathetic chain neurolysis in 15 patients presenting with palmar/axillary hyperhidrosis (6 M, 9 F, mean age 29.5 years). Neurolysis was performed under CT guidance injecting 2-10 ml of a solution of phenol 8%, glycerine 20% and saline through 22 G needles placed in the paraspinal space at T3 level through a paraspinal extrapleural approach. At least one week was allowed between neurolysis of right and left thoracic sympathetic chain in the same patient. Procedures were performed on outpatient basis. Patients were followed up with interviews and/or physical examination every 6 months for 2 years. RESULTS: All patients experienced immediate cessation of symptoms. Three patients (20%) experienced one-sided recurrence of symptoms 5, 7 and 12 months respectively after the first neurolysis, which disappeared after a repeated procedure. Two (13%) patients showed a slight Horner's syndrome immediately after the procedure, which resolved in 1 and 2 months respectively. Two patients (13%) experienced pain in the arm on the same side of the neurolysis, which resolved in 1 week. Three (20%) patients experienced mild compensatory sweating. All patients declared they were satisfied with the outcome of the neurolysis when interviewed at 2 years follow up from the first procedure, with no recurrence of symptoms. CONCLUSIONS: Upper thoracic sympathetic chain neurolysis performed under CT guidance in patients with palmar/axillary hyperhidrosis is a safe procedure, with low rate of complications and good results at 2 years follow-up.