CEA versus CAS: short-term and mid-term results.

AIM: Ischemic stroke represents a major health problem and it is an important cause of long-term disability. The aim of this study was to compare short-term and mid-term results of carotid endarterectomy and stenting. METHODS: During a three-year period, we enrolled 300 patients with carotid stenosis that fit with Stroke Prevention and Educational Awareness Diffusion (SPREAD) guidelines and we performed 150 carotid endarterectomy operations (CEA) and 150 carotid artery stenting procedures (CAS) with distal protection devices. All patients underwent preoperative and postoperative: neurological examination, ultrasound imaging, magnetic resonance imaging (MRI) and cognitive tests; moreover all patients were submitted to preoperative, intraoperative and postoperative Transcranial Doppler (TCD) monitoring, in order to detect microembolic signals (MES). RESULTS: Mortality was zero; two patients developed myocardial infarction in the CEA group during follow-up. The main post-operative results after endarterectomy versus CAS were respectively: neurological deficit: 1.3% vs. 3.3%, embolic lesions at postoperative MRI: 4% vs. 34% and worsening of cognitive tests: 4% vs. 25.3%. CONCLUSION: CEA seems to be the treatment of choice for carotid stenosis, due to its low rate of mortality and morbidity, especially in asymptomatic patients; CAS should be carried out only in particular subgroup of cases, such as: restenosis, previous neck surgery or radian therapy, anatomical high bifurcation or extended lesions. Ongoing multicenter randomized trials may give a definitive answer to this matter.

Tibioperoneal true aneurysm: case report and literature review.

BACKGROUND: The true aneurysms of the infrapopliteal arteries are an unusual pathology with low incidence in the general population. They appear in the literature only as isolated case reports. True aneurysms of the infrapopliteal arteries represent a surgical problem, especially when a bifurcation is involved and when the distal vessels are affected by occlusive disease. CASE REPORT: A 67 year old man with an aneurysm which involved the tibioperoneal trunk and the origin of peroneal and posterior tibial arteries was surgical treated. At three months follow up, a duplex ultrasonography (DUS) control showed the bypass patency and the total exclusion of the aneurismal sac. DISCUSSION: Although the aneurysms of the infrapopliteal arteries are very uncommon and often asymptomatic, their associated vascular lesions and/or ischemic complications can lead to high risk of limb loss. When the aneurysm is large and/or symptomatic, the surgical treatment becomes mandatory. A conservative treatment and DUS follow up could be reserved to elderly patients and when the aneurysm is small and asymptomatic.

Transcarotideal access for endovascular repair of descending thoracic aortic aneurysm with intentional coverage of celiac artery.

Endovascular treatment of thoracic and thoraco-abdominal aortic aneurysm with celiac artery ostium coverage, seems to be safe according to the literature. We present a case in which the endograft deployement was achieved through a right common carotid artery access because four years before the patient was submitted to an axillo-bifemoral bypass with aortic graft removal and aortic stump ligature for infection. After endovascular repair the patient suffered from spinal cord ischemia, acute pancreatitis and spleen infarction. Probably, the new pancreatic event has been triggered by temporary visceral ischemia, acting on a pancreas damaged by a previous acute hemorrhagic pancreatitis.

Embolism to the brain during carotid stenting and surgery.

UNLABELLED: The aim of this study was to assess the prevalence and clinical relevance of microembolism in one hundred unselected patients submitted to 50 carotid endarterectomy (CEA) and 50 carotid stenting (CAS) procedures from January 2005 to January 2006 for hemodynamic lesions of the carotid bifurcation (> 70% stenosis). MATERIAL AND METHODS: High-resolution Colour-Flow Mapping (CFM), Transcranial Doppler (TCD), cerebral computed tomography (CT) or magnetic resonance (MR) and four psychometric tests (Mini mental state, Beck depression inventory, Zung anxiety inventory, SF-12) were carried out in the preoperative evaluation in all the patients. In the CEAs loco-regional anesthesia (100%), patch angioplasty (84%) and Pruitt- Inahara shunt (4%) were employed; in the CASs local anesthesia (100%), three different carotid stents (Precise-Cordis, Acculink-Guidant and Carotid Wallstent-Boston Scientific) and three temporary distal filter protection devices (Angioguard-Cordis, Accunet-Guidant, Filterwire-EZ- Boston Scientific), without pre-dilatation, were employed. TCD monitoring was used intra-operatively and 12 hours post-operatively to evaluate the presence and the number of microembolic events (ME's) and to investigate the efficiency of neuroprotective filter devices. The efficacy of the in situ opened filter was judged evaluating the decrease of mean blood velocity in ipsilateral middle cerebral artery and the reduction rate of microembolic events (number of microemboli detected during the entire procedure/number of microemboli detected during the filter positioning). Diffusion-weighted magnetic resonance imaging (DWI) of the brain was obtained within 24 to 48 hours after the procedures to detect new ischemic brain lesions. Psychometric tests were repeated at the discharge of the patient and after two months to evaluate cognitive faculties. RESULTS: During postoperative period (30 days) and follow-up, no procedure-related death and three regressive minor strokes occurred : 1 in CEA (2%) and 2 in CASs (4%) ; a cranial nerve lesion occurred in CEA (2%). TCD monitoring showed ME's (a mean of five events) in 37 CEAs (74%) and in 50 CASs (100%) (a mean of 60 ME's). In five patients submitted to CAS repeated microemboli occurred during one hour postoperative TCD control (10%). A 10-30% decrease of mean blood velocity basal value was recorded in the ipsilateral middle cerebral artery when the filter device was opened. A mean 70% reduction of ME's was obtained with a cerebral protection system deployed. Postoperative DWI detected new focal ischemic lesions in 24 patients [22 after CAS (44%) (a mean of 5 new ipsi and contra-lateral lesions) , and 2 after CEA (4%). Cognitive capability worsened in 20 patients [18 after CAS (36%) e 2 after CEA (4%)]. CONCLUSIONS: Mortality and morbidity rates of patients submitted to CAS are comparable to the results obtained by CEA. A great number of ME's are recorded by TCD during endovascular procedures, more than during open surgery. ME's due to CAS are reduced by filter protection devices, but the cognitive faculties in a great number of "asymptomatic" patients are decreased after CAS.

Classic and endovascular surgical management of isolated iliac artery aneurysms.

AIM: Isolated iliac artery aneurysm is a rare pathology that is often asymptomatic for long periods; this late diagnosis exposes patients to a high risk of death following aneurysm rupture. The aim of this study was to establish the most suitable diagnostic approach, the correct indications for treatment, and the most appropriate tactics and surgical technique. METHODS: Twenty-eight patients were observed over 13 years. Aneurysmal involvement was unilateral in 22 cases and bilateral in the remaining 6 patients. Preoperative diagnostic tests included eco-colour Doppler (ECD) and angio-CT in all cases, with angio-MR and angiography as more selective procedures. Seventeen patients underwent conventional open surgery with prosthetic replacement of the aneurysmatic tract, 7 patients were treated using endovascular exclusion, and lastly 4 were monitored over time. RESULTS: There was no perioperative mortality for either treatment. During the postoperative period following conventional open surgery, complications included one case of severe respiratory failure, one microembolism of the lower limb, and 2 periprosthetic hematoma. During the follow-up, we observed one pseudo-aneurysm, 3 cases of retrograde ejaculation and one patient with erectile dysfunction after traditional surgery; there was one minor endoleak after endovascular exclusion. CONCLUSIONS: Our experience suggests that ECD is a useful method for arriving at an early diagnosis, while angio-CT imaging is essential for a correct preoperative study. Aneurysms with a diameter equal or greater than 3 cm or that present annual increases in excess of 5 mm represent a correct indication for treatment. Conventional open surgery is the treatment of choice for young patients in good general conditions. Endovascular exclusion is indicated when the patient's clinical conditions contraindicate open surgery and the morphology of the aneurysmal arterial district allows the endoprosthesis to be safely implanted.

[Exposure of distal internal carotid artery through mandibular vertical ramus osteotomy]. / Accesso chirurgico all'arteria carotide interna distale medicante osteotomia mandiobolare verticale.

Exposure of the distal internal carotid artery at the level of the second cervical vertebra required manoeuvers such as division of digastric muscle or mandibular subluxation. These increase the exposure but may not provide adequate access and are associated with significant cranial nerves or temporal mandibular joint complications. Vertical Ramus Osteotomy (VRO) provided access of the internal carotid artery (ICA) up to the base of the skull, with low incidence of cranial nerve injury temporo-mandibular joint (TMJ) pain and no preincision preparation. We report two cases in which vertical division of the mandibular ramus provided access of the ICA up to the base of the skull. Preoperative Duplex Scan examination and in the second case the arteriography revealed ICA preocclusive stenosis within 1.5 cm of the skull base. VRO was performed trouhgh a standard neck incision and miniature titanium plates were used to reapproximate the mandible after vascular procedure. There were no death, cranial nerve injury, mandibular nonunion, malocclusion or TMJ pain. We found that VRO is useful when carotid artery pathology extends beyond the usual field of exposure, avoiding nerve injury or TMJ lesion and requires no additional pre-incision preparation.

[Indications and short term results of subfascial endoscopic perforator surgery (SEPS)]. / Indicazioni e risultati preliminari dell'interruzione endoscopica sottofasciale delle vene perforanti (SEPS).

BACKGROUND: The aim of this study is to evaluate diagnostic methods, indications and surgical technique in SEPS procedure and to analyze short term results. METHODS: Eighteen patients affected by chronic venous insufficiency (CVI) have been analyzed. According to NAVS (North American Vascular Society) classification three patients were included in class 6 (C6), 3 (C5), 6 (C4), 2 (C3) and 4 (C2). From 2 to 5 selective subfascial endoscopic ligation of perforator veins, especially I and II Cockett perforator veins' were performed. In 7 cases, total stripping of the great (6) or less (1) saphenous vein was associated with SEPS procedure. After the operation, an elastic bandage of the lower limbs was performed and a medical treatment with LMVH was started. RESULTS: In 6 patients of the C2 and C3 groups, neither recurrence or pathological reflux were observed at clinical examination and at color duplex. In 12 patients of C4, C5 and C6 groups a reduction of the perimalleolar oedema was observed. In the last 3 patients, with leg ulceration, a resolution of the lesion in 2 cases, and a reduction in diameter in the last one, were observed. CONCLUSIONS: SEPS is particularly advised in those patients belonging to C5 and C6 groups, especially in presence of leg ulceration. This operations is suggested also in patients with CVI and incontinence of perforator veins detected by at color duplex. This diagnostic investigation seems to be adequate in the diagnosis of CVI and in the mapping of perforator veins of the leg.

[Elective and emergency surgical treatment of popliteal aneurysms. Indications and results]. / Trattamento chirurgico degli aneurismi poplitei in elezione e in urgenza. Indicazioni e risultati.

BACKGROUND: The aim of this paper is to evaluate the long term results related to surgical technique and to prosthetic material in planned and emergency conditions. METHODS: From January 1990 to December 1999, fourty-five patients with popliteal aneurysms were observed. Eighteen patients (40%) were asymptomatic; eleven (24.4%) suffered from claudicatio; six had an acute ischemia (13.3%) and four presented (8.9%) clinical signs of rest pain; in four cases (8.9%) symptoms were related to venous compression and to rupture in two (4.4%). Diagnosis was obtained by ultrasounds, angiography and CT-scan. All patients were operated on and in four cases (8.9%) the procedure involved both legs. The prosthetic material was reversed autologous saphenous vein (ASV) in 30 patients (61.2%), PTFE-EXS-TW in 16 (32.6%), homologous vein in one (2%), composite graft in one (2%), and a Dacron in the last one (2%). RESULTS: Six patients died for causes not related to the operation and eight bypasses (18.2%) became occluded. Amputation was needed in two patient, in relation to late bypass occlusion. In one cases an amputation was carried out for acute thrombosis of the contralateral aneurysm which was not treated for patients refusal. The long term patency rate was 81.8%. CONCLUSIONS: Popliteal aneurysms must be considered for reconstructive surgery, also when asymptomatic and with a diameter over 2 cm. The routinely use of the ASV improves the long-term patency rate. Best long term results are obtained in elective surgery.

[Popliteal trauma due to posterior dislocation of the knee]. / Lesioni traumatiche dell'arteria poplitea da lussazione posteriore del ginocchio.

Popliteal artery injuries have an incidence ranging between 5% and 19% of all traumatic arteria lesions. A high index of amputation, when associated with lesions of the infrapopliteal branches, and a 4-5% overall mortality are recorded in these conditions. Three patients with popliteal artery injury due to posterior knee dislocation were operated upon in our department during the last 12 months. In one case, the physical examination revealed a warm limb, with peripheral pulse; angiography showed a pseudoaneurysm of the popliteal artery with intimal dissection and partial thrombosis. In the last two cases an acute ischemia of the limb was present; in one case the angiographic study showed a complete transection of the artery, while in the second case an obstruction of popliteal artery. In all cases the dislocation was corrected and a the reconstruction carried out by inverted autologus saphenous vein with termino-terminal anastomosis. In all cases a good patency of the popliteal reconstruction was achieved with limb salvage. Prognosis of popliteal injuries is related to an early diagnosis and they should be suspected even in absence of overt signs of acute ischemia. Surgical timing cannot be the same in all cases. The need for a preliminary orthopedic phase with its modality must be established case by case, relating to the severity of ischemia, to the time elapsed between trauma and surgery, to the peculiarities of skeleton and joints lesions.