Simultaneous Laparoscopic Cholecystectomy and Endovascular Infrarenal Aortic Aneurysm Repair.

Background/Aim: With the increasing use of endovascular aneurysm repair (EVAR) and the availability of laparoscopic cholecystectomy (LC) for treating abdominal aortic aneurysms (AAA) and cholelithiasis, respectively, the association between these elective treatments is not yet well-defined. Thus, this study aimed to evaluate the results of elective and simultaneous EVAR and LC. Methods: Thirteen patients (mean age, 72 years) with concomitant large and asymptomatic AAA and asymptomatic cholelithiasis underwent simultaneous EVAR and LC. Results: Post-operative mortality was absent, and the morbidity rate was 7%. The mean total duration of the procedure was 142 min. The mean duration of fluoroscopy was 19 min, and the mean radiation dose was 65 mGy. The mean amount of iodinated contrast injected was 49 mL. The timing of oral fluid intake was 28 h (range, 24-48 h) and that of the oral low-fat diet was 53 h (range, 48-72 h). No patient presented with an aortic graft infection during the entire follow-up period (mean duration, 41 months). The mean length of post-operative hospital stay was 6 days (range, 5-8 days). Late survival was 85%, and the exclusion of AAA was 100%. Conclusion: Simultaneous EVAR and LC can be performed safely, allowing effective and durable treatment under both AAA and cholelithiasis conditions.

Results of resection of carotid body tumors with and without lymphnodes' dissection.

BACKGROUND: Carotid body tumor (CBT) is a slow-growing tumor arising from the carotid body, a chemoceptor organ lying behind the carotid artery bifurcation. Although rarely, metastases can occur distally through the hematogenous route and through the lymphatic route.to the cervical lymphnodes. The purpose of this study was to assess whether lymphnodes' resection should systematically be associated with the primary resection of a CBT. METHODS: A retrospective analysis of 82 patients, 52 women of a mean age of 42 years undergoing resection of 88 CBT from 1994 to 2019. CBT were divided into 2 groups. Tumors in group A (n = 23, 26%) were treated by resection of the mass followed by a selective latero-cervical lymphadenectomy; tumors in group B (n = 65, 74%) underwent isolated resection of the mass. The study's primary endpoints were postoperative stroke/mortality rate, disease-specific survival and rate of local and distant recurrence of the disease. RESULTS: Postoperative stroke-mortality rate was nil. One patient in group A (4.3%) presented a minor weakness of the contralateral arm, completely regressive within 12 h. One patient in group B (1.5%) died of liver and lung metastases 51 months after operation, no patient died of recurrent disease in group A (p = .62). No nodal recurrence was observed in group A, whereas one patient in group B (1.5%) presented nodal recurrence 39 months after primary tumor resection (p = .58) CONCLUSION: Selective lymphadenectomy associated with CBT resection does not increase the overall long-term survival and cannot be considered mandatory. It may help to better define the stage of the disease and to plan eventual adjuvant treatments.

Intravascular Ultrasound-Assisted Endovascular Exclusion of Penetrating Aortic Ulcers.

BACKGROUND: Penetrating aortic ulcer (PAU) is an atherosclerotic lesion penetrating the elastic lamina and extending into the media of the aorta. It may evolve into intramural hematoma, focal dissection, pseudoaneurysm, and eventually rupture. The purpose of this study was to evaluate the effectiveness of a totally intravascular ultrasound (IVUS)-assisted endovascular exclusion of PAU. METHODS: Thirteen consecutive patients (median age 66 years) underwent IVUS-assisted endovascular exclusion of PAU. The primary end points were fluoroscopy time, radiation dose, and occurrence of type I primary endoleak. Secondary end points were postoperative mortality and morbidity, arterial access complications, postoperative length of stay in the hospital, and occurrence of type II endoleaks. RESULTS: The median fluoroscopy time was 4 min (4-5). The median radiation dose was 4.2 mGy (3.9-4.5). A proximal and distal landing zone of at least 2 cm could be obtained in all the patients. No patient presented a type I endoleak. No postoperative mortality, no morbidity, or arterial access complication was observed. The median length of postoperative stay in the hospital was 2 days (2-3). The median length of follow-up was 25 months (9.2-38.7). One late type II endoleak was observed (7.7%), because of reflux from the intercostal arteries, without the need for additional treatment. CONCLUSIONS: IVUS-assisted endovascular treatment of PAU allows durable exclusion of PAU with a short fluoroscopy time and no need for injection of contrast media. Further series are needed to confirm the results of this preliminary study.

Long-term results of polytetrafluoroethylene versus saphenous vein repair of degenerative carotid artery aneurysm.

OBJECTIVE: To compare the results of polytetrafluoroethylene (PTFE) and great saphenous vein (GSV) bypass after resection of a degenerative aneurysm of the carotid artery. METHODS: From January 1994 to November 2017, 37 patients (27 men) with a mean age of 58 years (range, 39-82 years) with a degenerative aneurysm of the carotid artery (median diameter, 28 mm; range, 19-42 mm), underwent resection of the aneurysm followed by a bypass with either a GSV (n = 10) or a PTFE prosthesis (n = 27). Although 31 patients were asymptomatic, 6 patients were symptomatic: transient ischemic attack (n = 4), minor stroke (n = 1), and compression of the hypoglossal nerve (n = 1). The preoperative workup included duplex ultrasound examination of the arteries to the head, and angiography or computed tomography angiography. All patients were operated under general anesthesia and six were intubated through the nose. Sixteen patients were monitored through transcutaneous oximetry. No shunt was used in this series. In 10 patients receiving a PTFE graft, the external carotid artery was implanted in the prosthesis. Mean follow-up was 16.9 ± 2 years (95% confidence interval, 14.5-19.3 years). Primary end points were the 30-day combined stroke/death rate, graft infection, late graft patency, and late stroke-free survival. Secondary end points were cranial nerve injury and length of postoperative hospital stay. RESULTS: Postoperative mortality was nil in both groups. One postoperative stroke was observed in the PTFE group, whereas none occurred in the GSV group (P = .84). No graft infection was observed in either group. At 10 years, survival in the GSV group was 80 ± 12%, and survival in the PTFE group was 76 ± 8% (log-rank [Mantel-Cox], P = .85). In the GSV group, graft patency at 7 and 10 years was 85 ± 13%. In the PTFE group B, graft patency was 100% (log-rank [Mantel-Cox], P = .12). No late stroke was observed. Two transient cranial nerve injuries were observed in the GSV group (20%) and two in the PTFE group (8%) (P = .97). Length of hospital stay was comparable in both groups (GSV group, 6 days; PTFE group, 5 days; P = .12). CONCLUSIONS: This study suggests that, after resection of a degenerative aneurysm of the carotid artery, bypass with a PTFE prosthesis gives comparable results to those obtained with the GSV. We recommend sparing the GSV and instead using a PTFE prosthesis in patients with a degenerative aneurysm of the carotid artery.

Laparoscopic lavage/drainage as a bridge treatment for perforated diverticulitis with purulent peritonitis associated with an abdominal aortic aneurysm A retrospective case-control study.

AIM: Laparoscopic lavage /drainage (LALA) or surgical resection are both methods of treatment for perforated diverticulitis with purulent peritonitis (Hinchey Stage III). In case of associated abdominal aortic aneurysm (AAA), laparoscopic lavage/drainage could be an interesting bridge option to treat sepsis before endovascular exclusion of the aneurysm and resection of the sigmoid. We performed LALA as a bridge treatment of peritonitis before elective, staged endovascular exclusion of the aneurysm (EE) and elective resection of the colon. MATERIAL AND METHODS: Seven patients presenting a perforated diverticulitis with purulent peritonitis (Hinchey III), associated with an uncomplicated AAA of a mean diameter of 6 cm, underwent LALA followed by staged EE and resection. They were retrospectively reviewed for a case-control study. The mean length of follow-up after completing all the procedures was 28 months. Primary endpoints were mortality and morbidity of each procedure, complications related to each procedure and to the untreated disease in the interval between each one of them, late outcome and complications related to each treatment method. As secondary endpoints, the mean length of surgery for resection, of stay in the hospital, of the interval between each procedure, and of time required for the treatment of both the diseases were considered. RESULTS: Postoperative mortality was absent. Morbidity consisted of a sigmoido-vescical fistula 18 days after resolution of peritonitis and sepsis, not hindering EE,and a delayed healing of the surgical wound for access to the common femoral artery (28.6%). No complications of untreated disease in the interval between each procedure were observed. No late complications of both diseases occurred. The mean interval between LALA and EE,and between EE and resection was, respectively, 19 days and 18 days. Both the diseases were treated within a mean delay of 37 days after LALA (range, 24-61 days). CONCLUSIONS: LALA, as a bridge treatment, before EE and resection, in patients presenting a perforated diverticulitis with purulent peritonitis, associated with an uncomplicated AAA, may be an effective treatment option. KEY WORDS: Perforated diverticulitis, Purulent peritonitis, Abdominal aortic aneurysm.

Endovascular Exclusion of Abdominal Aortic Aneurysms and Simultaneous Resection of Colorectal Cancer.

BACKGROUND: No consensus exists on the optimal strategy for treatment of abdominal aortic aneurysm (AAA) associated with colorectal cancer (CRC). The purpose of this study was to evaluate the results of endovascular treatment of AAA with simultaneous resection of CRC. METHODS: Twenty-two consecutive patients presenting with AAA associated with a CRC were treated by endovascular AAA exclusion and simultaneous CRC resection. Median diameter of the aneurysm was 6.5 cm (range, 4.8-8 cm). Two patients (9%) had grade I cancer, 5 patients (23%) grade II, 13 patients (59%) grade III, and 2 patients (9%) grade IV. The 2 surgical procedures were performed under the same general anesthesia. Aneurysm exclusion was achieved using an infrarenal aorto-bi-iliac endoprosthesis (13 patients) and using an aorto-bi-iliac endoprosthesis with suprarenal fixation (9 patients), with 1 patient receiving bilateral renal chimney stent implantation. In all cases, vascularization of the hypogastric arteries was preserved. After AAA exclusion, colic resection was carried out by laparotomy with right colectomy (7 patients) and anterior rectocolic resection (15 patients). In all patients, AAA exclusion was controlled by a computed tomographic angioscan (CTA) at 1 month and duplex ultrasound every 6 months, and at some later stage, it was through inclusion of CTA as part of oncology surveillance. The mean duration of follow-up was 42 months (10-120 months). The primary endpoint was composite and regrouped any death occurring during the first 30 days after procedures, any type I endoleak, any aortic reintervention, and any AAA-related mortality. RESULTS: No patient died during the first 30 postoperative days, and no patient was lost to follow-up. No aortic endoprosthesis infection and no type I endoleak were observed. Five endoleaks arising from the lumbar arteries (n = 4) or from the inferior mesenteric artery (n = 1) were identified. As they were not associated with an increase of the AAA diameter >5 mm, they were not treated. 1 colic anastomotic leak and 2 incisional abscesses were successfully cured by local care only. Nine patients (41%) died of cancer evolution during the follow-up period. CONCLUSIONS: In this series, treatment of AAA and CRC during the same operative session yields results comparable to those observed when surgery is performed in 2 distinct operative sessions. Synchronous treatment reduced waiting time of colic resection. It may also shorten total hospitalization duration, although this last hypothesis is not supported by comparison with a control group.

Results of subclavian to carotid artery bypass for occlusive disease of the common carotid artery: A retrospective cohort study.

BACKGROUND: Optimal treatment of significant atherosclerosis of the common carotid artery (CCA) is not well-defined. The purpose of this study was to evaluate the long-term results of prosthetic subclavian to carotid bypass for occlusive disease of the CCA. MATERIAL AND METHODS: From January 1994 to December 2015, 45 patients, mean age 67 years, underwent an ipsilateral subclavian to carotid bypass for occlusive disease of the CCA. Thirty-eight patients (84%) presented with neurologic symptoms, including transitory ischemic attacks in 29 cases and minor strokes in 9 cases. The graft material consisted of a 7 mm polytetrafluoroethylene conduit, and the distal anastomosis was done on the carotid bulb in 21 patients, on the internal carotid artery in 19 cases, and on the distal CCA in 5 cases. Median length of follow-up was 58 months. Study endpoints were the combined postoperative stroke/mortality rate, graft infection, overall late survival, freedom from ipsilateral stroke, and graft patency. RESULTS: Postoperative stroke/mortality rate was 2%. No graft infection was observed throughout follow-up. At 60 months, overall survival, freedom from stroke, and graft patency were 71% (standard error [SE] = 0.07), 98% (SE = 0.02), and 95.5% (SE = 0.06), respectively. CONCLUSIONS: Subclavian to carotid bypass allows very good patency rates and excellent protection from postoperative and late stroke, remaining a benchmark for any other treatment method.

Hybrid treatment of tandem, common carotid/innominate artery and ipsilateral carotid bifurcation stenoses by simultaneous, retrograde proximal stenting and eversion carotid endarterectomy: Preliminary results of a case series.

BACKGROUND: Tandem stenoses of the internal carotid artery (ICA) and proximal, ipsilateral common carotid artery (CCA) or innominate artery can be treated with a hybrid approach, combining conventional carotid endarterectomy (CEA) and retrograde stenting of the proximal stenosis, through surgical exposure of the carotid bifurcation. The purpose of this study was to evaluate the results of combining eversion CEA with retrograde CCA/innominate artery stenting. MATERIAL AND METHODS: From January 2015 to July 2017, 7 patients, 6 men of a mean age of 72 years (range 59-83 years) underwent simultaneous, retrograde stenting of the proximal CCA/innominate artery and an eversion CEA of the ipsilateral ICA, through surgical exposure of the carotid bifurcation, for severe tandem stenoses. The proximal stenosis involved the left proximal CCA in 4 patients, the proximal innominate artery in 2 patients and the right CCA in one patient. The procedure was performed under general anesthesia in a conventional operating room equipped with a mobile C-arm. A covered, balloon expandable stent was deployed over the proximal stenosis via a 6-F sheath directly introduced into the proximal CCA through the obliquely transected carotid bulb. After removing the sheath, debris were flushed through the carotid bulb and eversion CEA completed the procedure. Study endpoints were: postoperative stroke/mortality rate, cardiac mortality and morbidity, peripheral nerve injury, cervical hematoma, overall late survival, freedom from ipsilateral stroke and patency of arterial reconstruction. RESULTS: No postoperative mortality or neurologic morbidity was observed in any patient. Cervical hematomas and peripheral nerve injuries were likewise absent. At a mean follow-up of 18 months, all the patients were alive, free from neurologic events of new onset and free from restenosis. CONCLUSION: Combined proximal stenting and eversion CEA for tandem lesions seems a valid treatment, with the advantages of eversion CEA over other techniques of carotid bifurcation revascularization.

True aneurysm of the proximal occipital artery: Case report.

INTRODUCTION: True aneurysms of the proximal occipital artery are rare, may cause neurological symptoms due to compression of the hypoglossal nerve and their resection may be technically demanding. PRESENTATION OF CASE: The case of an aneurysm of the proximal occipital artery causing discomfort and tongue deviation by compression on the hypoglossal nerve is reported. Postoperative course after resection was followed by complete regression of symptoms. CONCLUSION: Surgical resection, as standard treatment of aneurysms of the occipital artery, with the eventual technical adjunct of intubation by the nose is effective in durably relieving symptoms and preventing aneurysm-related complication.

Results of Infrageniculate Bypasses Using the Profunda Femoris Artery as Inflow Source.

BACKGROUND: When the common femoral artery is not accessible for infrainguinal bypass grafting, the profunda femoris artery (PFA) can be a valuable alternative inflow source for distal arterial revascularization. The purpose of this retrospective study was to evaluate the results of infrageniculate bypass grafting via the PFA as inflow source for critical limb ischemia. METHODS: Between 1994 and 2016, 68 patients, 51 men of a mean age of 74 years, underwent an infrageniculate arterial bypass grafting for critical limb ischemia, using the PFA as inflow site. PFA was exposed at the Scarpa's triangle in 38 patients (56%) and at its medio-crural segment in 30 patients (44%). The distal anastomosis was performed on the infragenicular popliteal artery in 33 patients (48%), the peroneal artery in 14 patients (20%), the tibioperoneal trunk in 8 patients (12%), the posterior tibial artery in 8 patients (12%), and the dorsalis pedis artery in 5 patients (8%). The graft material consisted of a reversed great saphenous vein (GSV) in 62 patients (91%) and a 6-mm polytetrafluoroethylene graft in 6 patients (9%). The median duration of follow-up was 51 months (range, 6-72 months). As main results, postoperative mortality and morbidity, overall late patients' survival, primary grafts' patency, and limb salvage rate were considered. RESULTS: Operative mortality and morbidity were 3% and 4%, respectively. Overall patients' survival, primary patency and limb salvage rate, at 36 and 60 months were, respectively, 62% and 53%, 66% and 59%, and 92% and 77%. CONCLUSIONS: The PFA, both exposed at the Scarpa's triangle and at mid-thigh, is an excellent inflow source for infrageniculate revascularizations. It should remain an important part of the technical armamentarium of vascular surgeons, even in the endovascular era.

A computational evaluation of sedentary lifestyle effects on carotid hemodynamics and atherosclerotic events incidence.

PURPOSE: Hemodynamics has a key role in atheropathogenesis. Indeed, atherosclerotic phenomena occur in vessels characterized by complex geometry and flow pattern, like the carotid bifurcation. Moreover, lifestyle is a significant risk factor. The aim of this study is to evaluate the hemodynamic effects due to two sedentary lifestyles - sitting and standing positions - in the carotid bifurcation in order to identify the worst condition and to investigate the atherosclerosis incidence. METHODS: The computational fluid dynamics (CFD) was chosen to carry out the analysis, in which in vivo non-invasive measurements were used as boundary conditions. Furthermore, to compare the two conditions, one patient-specific 3D model of a carotid bifurcation was reconstructed starting from computer tomography. Different mechanical indicators, correlated with atherosclerosis incidence, were calculated in addition to flow pattern and pressure distribution: the time average wall shear stress (TAWSS), the oscillatory shear index (OSI) and the relative residence time (RRT). RESULTS: The results showed that the bulb and the external carotid artery emergence are the most probable regions in which atherosclerotic events could happen. Indeed, low velocity and WSS values, high OSI and, as a consequence, areas with chaotic-swirling flow, with stasis (high RRT), occur. Moreover, the sitting position is the worst condition: considering a cardiac cycle, TAWSS is less than 17.2% and OSI and RRT are greater than 17.5% and 21.2%, respectively. CONCLUSIONS: This study suggests that if a person spends much time in the sitting position, a high risk of plaque formation and, consequently, of stenosis could happen.

Infrarenal aorta as the donor site for bypasses to the superior mesenteric artery for chronic mesenteric ischemia: A prospective clinical series of 24 patients.

BACKGROUND: Treatment of symptomatic, chronic mesenteric ischemia is indicated to relieve symptoms and prevent acute ischemia and death. Current therapeutic options include endovascular and open surgery. The purpose of this prospective study was to evaluate the results of bypasses to the superior mesenteric artery arising from the infrarenal aorta or infrarenal aortic grafts. METHODS: From January 1999 to December 2016, 24 consecutive patients with a mean age of 61 years underwent a prosthetic bypass to the superior mesenteric artery. Nine patients (37%) presented with an associated clinically important stenosis of the celiac artery and 10 (42%) of the inferior mesenteric artery. Five patients (21%) received preoperative parenteral nutrition. Four patients (17%) underwent dual antiplatelet treatment. The donor site was the infrarenal aorta in 19 patients (79%) and an infrarenal, Dacron graft was used in 5 (21%). The origin of the bypass was from the distal infrarenal aorta or Dacron graft in 19 patients (79%) and from the proximal infrarenal aorta in 5 patients (21%). The graft material consisted of 7 mm polytetrafluoroethylene in 19 cases (79%) and 7 mm Dacron in 5 cases (21%). A concomitant bypass to the inferior mesenteric artery was performed in 4 patients (17%). The primary end points were postoperative mortality, morbidity, graft infection, late survival, primary patency, and symptom-free rate. The secondary end point was postoperative hemorrhagic complications. RESULTS: No postoperative mortality occurred. Postoperative morbidity included a prolonged postoperative ileus in 4 patients (17%), transitory postoperative increases in serum creatinine concentrations in 3 patients (12%), and myocardial ischemia in 2 patients (8%). No postoperative hemorrhagic complications or graft infection were observed. Overall, the cumulative survival rate was 77% at 60 months. The overall late-patency rate and freedom from recurrence of symptoms were both 87% at 60 months. CONCLUSION: Infrarenal aorta and infrarenal aortic grafts are an excellent source for the revascularization of the superior mesenteric artery. Bypasses to the superior mesenteric artery from the infrarenal aorta, either isolated or associated with adjunctive bypass to the inferior mesenteric artery, yield results that are comparable with those obtained with complete digestive artery revascularization using other donor sources.

Prosthetic bypass for restenosis after endarterectomy or stenting of the carotid artery.

OBJECTIVE: The objective of this study was to evaluate the results of prosthetic carotid bypass (PCB) with polytetrafluoroethylene (PTFE) grafts as an alternative to carotid endarterectomy (CEA) in treatment of restenosis after CEA or carotid artery stenting (CAS). METHODS: From January 2000 to December 2014, 66 patients (57 men and 9 women; mean age, 71 years) presenting with recurrent carotid artery stenosis ≥70% (North American Symptomatic Carotid Endarterectomy Trial [NASCET] criteria) were enrolled in a prospective study in three centers. The study was approved by an Institutional Review Board. Informed consent was obtained from all patients. During the same period, a total of 4321 CEAs were completed in the three centers. In these 66 patients, the primary treatment of the initial carotid artery stenosis was CEA in 57 patients (86%) and CAS in nine patients (14%). The median delay between primary and redo revascularization was 32 months. Carotid restenosis was symptomatic in 38 patients (58%) with transient ischemic attack (n = 20) or stroke (n = 18). In this series, all patients received statins; 28 patients (42%) received dual antiplatelet therapy, and 38 patients (58%) received single antiplatelet therapy. All PCBs were performed under general anesthesia. No shunt was used in this series. Nasal intubation to improve distal control of the internal carotid artery was performed in 33 patients (50%), including those with intrastent restenosis. A PTFE graft of 6 or 7 mm in diameter was used in 6 and 60 patients, respectively. Distal anastomosis was end to end in 22 patients and end to side with a clip distal to the atherosclerotic lesions in 44 patients. Completion angiography was performed in all cases. The patients were discharged under statin and antiplatelet treatment. After discharge, all of the patients underwent clinical and Doppler ultrasound follow-up every 6 months. Median length of follow-up was 5 years. RESULTS: No patient died, sustained a stroke, or presented with a cervical hematoma during the postoperative period. One transient facial nerve palsy and two transient recurrent nerve palsies occurred. Two late strokes in relation to two PCB occlusions occurred at 2 years and 4 years; no other graft stenosis or infection was observed. At 5 years, overall actuarial survival was 81% ± 7%, and the actuarial stroke-free rate was 93% ± 2%. There were no fatal strokes. CONCLUSIONS: PCB with PTFE grafts is a safe and durable alternative to CEA in patients with carotid restenosis after CEA or CAS in situations in which CEA is deemed either hazardous or inadvisable.

Dual Antiplatelet Therapy Does Not Increase the Risk of Bleeding After Carotid Endarterectomy: Results of a Prospective Study.

BACKGROUND: The purpose of this study was to evaluate the risk of bleeding and other postoperative complications of carotid endarterectomy (CEA) in patients receiving dual antiplatelet therapy (DAPT). METHODS: From January 2005 to December 2015, 188 consecutive patients undergoing CEA and receiving DAPT (aspirin 100 mg + clopidogrel 75 mg) were enrolled in a prospective study. All of them underwent coronary artery stenting with drug-eluting stents during the 6 months preceding CEA. In the entire series, DAPT was continued until the evening before CEA and resumed on the evening of the operation. All patients received intraoperative heparinization (5,000 IU before carotid clamping), which was reversed in 5 patients. In addition, all of them were given 2,000 units of enoxaparin every 12 hr after the operation, beginning 6 hr after completion of the operation, and until discharge. All the patients presented with carotid artery stenosis >70% (North American Symptomatic Carotid Endarterectomy Trial [NASCET] criteria), which was symptomatic in 42 patients (transient ischemic attack, n = 32; minor stroke, n = 10) and asymptomatic in 146. The CEA technique was standard, with prosthetic patch closure in 109 cases (58%) and eversion in 79 (42%). The primary endpoints of the study were occurrence of a postoperative cervical hematoma requiring surgical hemostasis and occurrence of cranial nerve injuries. The secondary endpoint was the combined rate of postoperative mortality, stroke, and myocardial ischemia. RESULTS: No postoperative cervical hematoma requiring surgical evacuation occurred in this series. One hypoglossal nerve palsy, regressive within 2 weeks, was observed. Postoperative mortality and neurologic and cardiac morbidity were nil. CONCLUSIONS: CEA under DAPT yields results comparable with those obtained in patients receiving a single antiplatelet treatment. No hemorrhagic complications were observed in this prospective series.

From varices to venous ulceration: the story of chronic venous disease described by metalloproteinases.

Chronic venous disease (CVD) and its most frightening complication, chronic venous ulceration (CVU), represent an important socioeconomic burden in the western world. Metalloproteinases have been identified in the pathogenesis of several vascular diseases such as venous problems. The aim of this study was to evaluate a broad range of metalloproteinases, such as matrix metalloproteinases (MMPs), ADAMs (a disintegrin and metalloproteinases) and ADAMTSs (a disintegrin and metalloproteinases with thrombospondin motifs) and their inhibitors, tissue inhibitor of metalloproteinases (TIMPs) and a related protein, neutrophil gelatinase-associated lipocalin (NGAL), in patients with CVD in order to correlate their serum levels with each stage of the disease. We performed a multicenter open-label study that comprised the enrolment of 541 patients with CVD of clinical stages C1-C6, (178 males, 363 females; mean age 57·29, median age 53·72, age range 29-81); 29 subjects without CVD were included in this study (9 males and 20 females; mean age 54·44, median age 50, age range 28-84) as the control group. Enzyme-linked immunosorbent assay (ELISA) was performed for measuring serum levels of proteases and related proteins. The study found that the serum elevation of MMP-2, ADAMTS-1 and ADAMTS-7 appeared to be correlated with the initial stages of CVD, whereas the serum elevation of MMP-1, MMP-8, MMP-9, NGAL, ADAM-10, ADAM-17 and ADAMTS-4 was particularly involved in skin change complications. This study showed that each stage of CVD may be described by particular patterns of metalloproteinases, and this may have therapeutic implications in discovering new targets and new drugs for the treatment of CVD.

Fondaparinux for intra and perioperative anticoagulation in patients with heparin-induced thrombocytopenia candidates for peripheral vascular surgery: Report of 4 cases.

INTRODUCTION: Intra and perioperative anticoagulation in patients with heparin induced thrombocytopenia (HIT), candidates for peripheral vascular surgery remains a challenge, as the best alternative to heparin has not yet been established. We evaluated the off-label use of fondaparinux in four patients with HIT, undergoing peripheral vascular surgery procedures. PRESENTATION OF CASES: Four patients of whom 3 men of a mean age of 66 years, with proven heparin induced thrombocytopenia (HIT) underwent two axillo-femoral bypasses, one femoro-popliteal bypass and one resection of a splenic artery aneurysm under fondaparinux. No intra or perioperative bleeding or thrombosis of new onset was observed. DISCUSSION: In the absence of a valid alternative to heparin for intra and perioperative anticoagulation in HIT, several other anticoagulants can be used in an off-label setting. However, no general consensus exist on which should be the one of choice. In this small series fondaparinux appeared to be both safe and effective. CONCLUSIONS: These preliminary results seem to justify the off-label use of fondaparinux for intra and perioperative anticoagulation in patients with HIT, candidates for peripheral vascular surgery interventions.

Outcome of Resection and Chemotherapy versus Chemotherapy Alone for Retroperitoneal Recurrence of Testicular Cancer Involving the Inferior Vena Cava: A Retrospective Cohort Study of 22 Consecutive Patients.

BACKGROUND/AIM: Optimal treatment strategy for retroperitoneal recurrence of testicular cancer involving the inferior vena cava (IVC) is uncertain. The purpose of this study was to validate the hypothesis that surgical resection, en-bloc with the involved segment of IVC and its subsequent reconstruction followed by chemotherapy, would yield better oncologic results than chemotherapy alone. PATIENTS AND METHODS: Two consecutive series of patients with retroperitoneal recurrence of testicular cancer involving the IVC, treated with surgical resection plus chemotherapy (group A, n=14) or chemotherapy alone (group B, n=8) were retrospectively reviewed. The mean duration of follow-up was was 65 months (range=8-184). Operative mortality and morbidity in group A, response to chemotherapy in group B, disease-specific survival and quality adjusted life-years (QALY) for both groups, were primary end-points of the study. RESULTS: Postoperative mortality and morbidity (group A) were, respectively, nil and 14%. In group B, two patients (25%) fully responded to chemotherapy and remained free from disease progression. Disease-specific survival at 3 and 5 years was 81% and 54% in group A and 36% in group B both at 3 and 5 years, respectively (p=0.02). QALY was 3.92 in group A and 0.77 for both 3 and 5 years in group B, respectively, (p=0.031). CONCLUSION: En bloc resection of retroperitoneal recurrence of testicular tumors invading the IVC, followed by chemotherapy, allows a better survival rate compared to chemotherapy alone.

Study on the efficacy of surgery of the superficial venous system and of compression therapy at early stages of chronic venous disease for the prevention of chronic venous ulceration.

The mainstay of treatment of chronic venous ulceration (CVU), as also suggested by current treatment guidelines for chronic venous disease (CVD), is represented by surgery and compression therapy for which there is strong evidence of their role in clinically relevant improvement in wound healing and also in the reduction of CVU recurrence, but no information is available as to whether or not these treatments provide effective protection from the onset of CVU. In our study, we have followed, for a median time of 13 years, a total of 3947 patients with CVD at classes C2-C3 of CEAP classification, treated with our treatment protocol (surgery and compression therapy) in order to track the natural history of these patients with regards to CVU development. We identified four groups of patients: 2354 patients (59·64%) (Group A) fully adherent to protocols; 848 patients (21·48%) (Group B) fully adherent to surgery and non-compliant to compression therapy; 432 patients (10·95%) (Group C) fully adherent to compression therapy and non-compliant to surgery; and 313 patients (7·93%) (Group D) non-compliant to either treatments. Regardless of compliance to treatments, the ulcer development rates were very similar between groups (range: 3·23-4.79%), with no statistical significance (P = 0·1522). Currents treatments used in the early stages of CVD appear to have no effects to progression to CVU. Additional longitudinal studies are required to confirm these findings.

Superiority of resection over enucleation for schwannomas of the cervical vagus nerve: A retrospective cohort study of 22 consecutive patients.

INTRODUCTION: Schwannoma of the cervical vagus nerve is rare. Treatment options include intracapsular enucleation and en bloc resection. The purpose of this study was to compare the outcomes of enucleation and resection in terms of postoperative mortality and morbidity, freedom from vocal cord palsy, freedom from local recurrence, quality-adjusted life-year (QALY) and vocal handicap index (VHI). METHODS: Twentytwo consecutive patients were divided into two groups. Patients in group A (n = 9) underwent intracapsular enucleation, whereas patients in Group B (n = 13) underwent en bloc resection. Main endpoints of the study were postoperative mortality and morbidity, freedom from vocal cord palsy, freedom from local recurrence and quality of life. The quality of life after surgery was assessed according to the quality-adjusted life-year (QALY) EQ-5D-5L methodology, and calculation of the voice handicap index (VHI). RESULTS: Postoperative mortality was nil. Morbidity included 1 wound dehiscence in group A and 2 transitory dysphagias in group B. Freedom from vocal cord palsy was 22% in group A and zero in group B (p = 0.15). Operation-specific local recurrence rate was 33% (3/9 patients) in group A and nil in group B (0/23 patients) (p = 0.05). QALYs was 0.55 in group A and 0.54 in group B (p = 1.0). VHI was 23.77 in group A and 26.15 in group B (p = 1.00). CONCLUSION: Resection is superior to enucleation in terms of freedom from local recurrence. Functional results are comparable for both techniques.