Vascular Tumors of the Neck in Adults: 10-Year Experience in a Tertiary Center.

INTRODUCTION: The diagnosis and management of vascular lesions of the neck is a challenging task that requires a multidisciplinary approach. This retrospective study assesses the single center experience of vascular tumors of the neck. MATERIALS AND METHODS: Patients diagnosed with a vascular tumor and/or a mass in close proximity to the carotid artery were identified from our records over a 10-year period. The demographic characteristics, clinical features, surgical approach, and outcomes were reviewed. RESULTS: Surgical excision of 17 vascular lesions were performed in 16 patients with a mean age of 51.56 ± 17.35 years at the time of operation. Intra- and/or postoperative clinical and histological assessment revealed unilateral glomus caroticum (N = 11), glomus vagale (N = 2), bilateral glomus caroticum (N = 1), cavernous hemangioma (N = 1), and carotid sheath tumor (N = 1). In three patients, internal carotid artery, common carotid artery and vagal nerve were sacrificed to facilitate complete tumor excision. During the follow-up period, no tumor recurrences were observed, and the morbidity and mortality were minimal. CONCLUSION: Preoperative evaluation concerning the size, extent, and anatomical relationships of the tumor thoroughly should be investigated. Multidisciplinary approach involving vascular surgery, otolaryngology, and radiology is preferred to treat these patients for better outcomes. Preoperative embolization in selected cases may decrease estimated blood loss and operative time.

Endovascular Repair of Iliac Artery Aneurysms: A Single Center Experience in 10-Years.

OBJECTIVES: Isolated iliac artery aneurysms (IAAs) are rare, but nonetheless life-threatening when ruptured. The endovascular approach has taken over open repairs in time. The reported data is constituted of a retrospective series. We reviewed our 10-year-long experience with elective endovascular treatment of iliac aneurysms. METHODS: Data regarding 22 patients with 24 IAAs treated with endovascular stent grafting between 2005 and 2015 were reviewed. RESULTS: Twenty-two patients (aged 68.4 ± 9.6 years, range 50-82) with 24 unilateral or bilateral iliac aneurysms were treated. Twenty patients (91%) were male. Two patients with unilateral IAA had prior abdominal aortic aneurysm (AAA) surgical repair. The mean aneurysm diameter was 4.8 ± 2.1 (3.8 to 7.1) mm. Procedural success rate was 100%, only one patient with an iliovenous fistula had periprocedural type II endoleak. Internal iliac artery coil occlusion was applied in 16 of 24 procedures (66%). Thirty-day mortality included one patient (4%). CONCLUSION: Endovascular repair is the preferred approach for isolated IAAs. Because of the retrospective nature of data sets, larger cohorts are necessary for better definition of morbidity and mortality rates.

Midterm results with drug-coated balloons for SFA lesions in patients with CLI: comparison with conventional bypass surgery.

BACKGROUND: Endovascular treatment of symptomatic peripheral artery disease has gained widespread acceptance. The efficacy and safety of drug-coated balloon (DCB) angioplasty in the setting of critical limb ischemia in comparison to conventional surgery has not been demonstrated. We have compared our results with DCB angioplasty to conventional bypass surgery in patients with critical limb ischemia (CLI). METHODS: A total of 187 patients with CLI treated over a 6-year period between 2006 and 2012 by a single operative team constituted the study population. Between 2006 and 2009, all patients underwent conventional surgery. Between 2009 and 2012, the investigators adopted endovascular approach with the use of IN.PACT Admiral (Medtronic Inc., Santa Rosa, CA, USA). Data collection was achieved prospectively. RESULTS: A total 210 procedures (100 surgery, 110 endovascular) were performed over a 6-year period. A 72% of all bypasses were performed using saphenous vein grafts with above-the-knee bypass as the technique of choice in 80% of the cases. 6-mm DCB was used in 41% of the patients. Procedural success rates (98% vs. 99%, NS) as well as clinical success rates (99% vs. 99%, P=NS) and operative mortality (3.7% vs. 2%, NS) was similar in both groups. Primary patency for DCB vs. bypass groups 91.8% vs. 88.9%, respectively (P=0.31) at 12 months and 82.7% vs. 82.8% at 24 months, respectively (P=0.28). Freedom from clinically-driven target lesion revascularization at 12 months was similar in both groups (87.6% vs. 85%, P=0.33). Primary patency for DCB vs. bypass groups at 24 months was 82.7% vs. 82.8%, respectively (P=0.28). CONCLUSIONS: DCB angioplasty yields comparable results to surgery in the setting of critical ischemia. The efficacy and the safety of DCBs in more complex lesions is to be investigated with randomized trials.

Staged or Combined Approach for Carotid Endarterectomy in Patients Undergoing Coronary Artery Bypass Grafting: A 5-Year-Long Experience.

BACKGROUND: Optimal surgical approach for patients with hemodynamically significant carotid and coronary disease remains controversial. We analyzed our 5-year experience and compared early and long-term outcome following staged and combined carotid and coronary artery bypass. METHODS: 312 consecutive patients undergoing carotid endarterectomy and coronary artery bypass between 2008 and 2013 were prospectively enrolled in the study. Patients were scheduled for a staged (carotid endarterectomy followed by coronary artery bypass within 1 week) procedure (Group S) unless they were unstable in terms of cardiac status (were deemed to a combined procedure; Group C). All patient data including demographics, risk factors, immediate perioperative events, 30-day, and long-term outcome were prospectively recorded and then analyzed. Groups S and C were compared for pre- and perioperative data as well as immediate, 30-day, and long-term survival. A P value less than .05 was considered significant. Survival analysis was made using Kaplan-Meier method and log-rank test. RESULTS: Group S included 204 patients and Group C included 108 patients. Preoperative demographics and clinical data were similar in the two groups except that preoperative cerebrovascular events were more common in Group C (31.7% versus 22.22%, P = .036) and bilateral carotid disease was more common in Group S. The EuroSCORE was higher in Group C (2.91 versus 2.65, P = .013). Carotid surgery techniques were similar; intraluminal shunting was more frequent in group C than group S (33.33% versus 9.88%, P = .001). Additional cardiac procedures in addition to coronary surgery was predominant in Group C. 30-day neurological adverse event rates, ICU, and hospital stay were significantly higher in Group C. The 30-day mortality was also sigficantly higher in Group C (1.96% versus 4.62%, P = .001). CONCLUSION: Staged and combined surgical approaches yield comparable outcomes. A staged approach may provide a more favorable neurological outcome with significantly reduced need for intraluminal shunting. Long-term outcome is, however, similar.

Midterm Results Following Percutaneous Rotational Thrombectomy for Acute Thrombotic Occlusions of Prosthetic Arteriovenous Access Grafts.

Patent vascular access is critical for patients on regular hemodialysis. Prosthetic grafts are good alternatives when the superficial venous system is of poor quality. However, thrombosis is one of the main drawbacks of synthetic grafts, with reports of 59% to 90% patency rates for 1 year. In cases of thrombotic occlusion of prosthetic arteriovenous fistula grafts, percutaneous mechanical thrombectomy has recently gained clinical popularity as a potential alternative to surgical thrombectomy or pharmacologic thrombolysis. We reviewed our preliminary results from 30 percutaneous rotational thrombectomies performed in a total of 22 patients in the setting of acute dialysis-access prosthetic graft occlusion of the upper extremity. Among the 30 cases of acute occlusion of the arteriovenous graft, immediate success with angiographic flow restoration was observed in all patients except for 2 patients (both females; 6%), with de novo occlusion where reocclusion occurred within 12 hours despite apparent immediate angiographic patency. The mean duration between the initial presentation with acute arteriovenous graft occlusion and the thrombectomy procedure was 27.4 ± 12.4 hours. The mean duration of graft patency was 10.45 ± 0.6 months. A total of 75% of the arteriovenous grafts were patent at the end of 12 months of follow-up. Female gender, diabetes mellitus, and diagnosis to intervention interval were reviewed for midterm graft failure, and the presence of diabetes mellitus yielded significance (P < 0.05). Percutaneous techniques play important roles in the treatment of failed or failing arteriovenous fistulae and grafts. Ongoing analysis of outcomes of both percutaneous and surgical intervention is necessary to continue to identify optimum treatment algorithms.

Debranching solutions in endografting for complex thoracic aortic dissections.

BACKGROUND: Conventional surgical repair of thoracic aortic dissections is a challenge due to mortality and morbidity risks. OBJECTIVES: We analyzed our experience in hybrid aortic arch repair for complex dissections of the aortic arch. METHODS: Between 2009 and 2013, 18 patients (the mean age of 67 ± 8 years-old) underwent hybrid aortic arch repair. The procedural strategy was determined on the individual patient. RESULTS: Thirteen patients had type I repair using trifurcation and another patient with bifurcation graft. Two patients had type II repair with replacement of the ascending aorta. Two patients received extra-anatomic bypass grafting to left carotid artery allowing covering of zone 1. Stent graft deployment rate was 100%. No patients experienced stroke. One patient with total debranching of the aortic arch following an acute dissection of the proximal arch expired 3 months after TEVAR due to heart failure. There were no early to midterm endoleaks. The median follow-up was 20 ± 8 months with patency rate of 100%. CONCLUSION: Various debranching solutions for different complex scenarios of the aortic arch serve as less invasive procedures than conventional open surgery enabling safe and effective treatment of this highly selected subgroup of patients with complex aortic pathologies.

Debranching Solutions in Endografting for Complex Thoracic Aortic Dissections / Soluções de Desramificação em Endoprótese para Dissecções Complexas da Aorta Torácica

Background: Conventional surgical repair of thoracic aortic dissections is a challenge due to mortality and morbidity risks. Objectives: We analyzed our experience in hybrid aortic arch repair for complex dissections of the aortic arch. Methods: Between 2009 and 2013, 18 patients (the mean age of 67 ± 8 years-old) underwent hybrid aortic arch repair. The procedural strategy was determined on the individual patient. Results: Thirteen patients had type I repair using trifurcation and another patient with bifurcation graft. Two patients had type II repair with replacement of the ascending aorta. Two patients received extra-anatomic bypass grafting to left carotid artery allowing covering of zone 1. Stent graft deployment rate was 100%. No patients experienced stroke. One patient with total debranching of the aortic arch following an acute dissection of the proximal arch expired 3 months after TEVAR due to heart failure. There were no early to midterm endoleaks. The median follow-up was 20 ± 8 months with patency rate of 100%. Conclusion: Various debranching solutions for different complex scenarios of the aortic arch serve as less invasive procedures than conventional open surgery enabling safe and effective treatment of this highly selected subgroup of patients with complex aortic pathologies. .

Fundamentos: O reparo cirúrgico convencional de dissecção da aorta torácica é um desafio devido aos riscos de mortalidade e morbidade. Objetivos: Analisamos nossa experiência no reparo híbrido do arco aórtico em dissecções complexas do arco aórtico. Métodos: Entre os anos de 2009 e 2013, 18 pacientes (idade média de 67 ± 8 anos de idade) foram submetidos ao reparo híbrido do arco aórtico. A estratégia de procedimento foi determinada individualmente para cada paciente. Resultados: Treze pacientes fizeram o reparo tipo I utilizando enxerto trifurcado; outro paciente utilizou um enxerto bifurcado. Dois pacientes fizeram o reparo tipo II com substituição da aorta ascendente. Dois pacientes receberam desvios extra-anatômicos de enxertia pela artéria carótida esquerda, permitindo a cobertura da zona 1. A taxa de implantação do stent foi de 100%. Nenhum paciente apresentou acidente vascular cerebral. Um paciente com desramificação total do arco aórtico após dissecção aguda do arco proximal faleceu 3 meses depois de realizar o reparo endovascular da aorta torácica (TEVAR), por insuficiência cardíaca. Não houve endoleak precoce ou a médio prazo. A média de acompanhamento foi de 20 ± 8 meses, com taxa de patência de 100%. Conclusão: Diversas soluções de desramificação, utilizadas em diferentes cenários complexos do arco aórtico, são procedimentos menos invasivos que a cirurgia aberta convencional e permitem o tratamento seguro e eficaz deste subgrupo, altamente selecionado de pacientes com patologias complexas da aorta. .

Extracardiac off-pump fontan completion for single ventricle with dextrocardia.

Extracardiac off-pump is reported to result in better early hemodynamics and shorter mechanical ventilation periods. We present a case report of extracardiac off-pump Fontan in a 5-year-old girl with single ventricle and dextrocardia.

Midterm results with endovascular approach to abdominal aortic pathologies in Behçet's disease.

BACKGROUND: Vascular involvement in Behcet's disease is rare, but may be at the forefront of the clinical picture with possible life-threatening scenarios. We reviewed our preliminary results with endovascular treatment of abdominal aortic pathologies in Behçet's disease. METHODS: Data regarding seven patients with abdominal aortic pathologies (aneurysm, pseudoaneurysm, and aortoenteric fistula) and Behçet's disease were treated with endovascular stent-grafting between 2002 and 2006. RESULTS: Seven patients (aged, 39.1 ± 9; range, 27-52 years) with a mean aortic diameter of 58.4 ± 6.3 mm received endovascular stent-grafts, two patients being in emergency settings. Two patients were in active disease state. Four tube-shaped, two aorto-bi-iliac, and one aorto-uni-iliac stents were implanted. One patient expired on day 28 with multiorgan failure after emergency stent-grafting owing to enlarging periprosthetic hematoma following open surgery for ruptured aneurysm. Another patient was declined for endovascular therapy owing to hypoplastic aortoiliac vasculature. CONCLUSION: Endovascular approach provides a reasonable alternative to open repair for the treatment of abdominal aortic aneurysms in select cases; however, in emergency settings, endovascular repair may well have an important, but limited, role in select patients with aortoenteric fistulae, it may yet require a surgical intervention.

Single-stage correction, with extensive pulmonary arterial reconstruction, of a pulmonary arterial sling associated with tetralogy of Fallot.

Pulmonary arterial sling, rare in itself, is even rarer when associated with tetralogy of Fallot. Successful single-stage correction of this combination, with extensive pulmonary arterial reconstruction, has been reported only occasionally. We describe our experience with an 18 month-old girl, showing that extensive reconstruction of both the pulmonary arteries and the right ventricular outflow tract can permit single-stage correction in selected patients, resulting in favourable physiology and anatomy.

Isolated partial anomalous pulmonary venous connection of the left lung.

Isolated partial anomalous pulmonary venous connection (PAPVC) of the entire left lung is a rare congenital anomaly with incidental diagnosis and vague symptoms, if any, until late adulthood. If left untreated, PAPVC may result in severe right ventricular failure and pulmonary vascular disease. We present the case of a 34-year-old woman with isolated PAPVC of the entire left lung. The patient underwent operation with a side-to-side left atrio-vertical vein anastomosis while on cardiopulmonary bypass and under cardioplegic arrest. She was discharged without complications and with a gradient of 2 mm Hg across the anastomosis. Left-sided PAPVC can be repaired with minimal morbidity and mortality. Surgical correction is warranted when patients are symptomatic or show evidence of right-sided overload due to unpredictability of the natural course. Recent data demonstrate that both on-pump and off-pump surgical procedures produce excellent long-term outcomes when performed without persisting gradients.

Combined aortic and mitral valve replacement in a child with mucopolysaccharidosis type I: a case report.

Mucopolysaccaridosis syndromes are metabolic disorders that are inherited in an autosomal recessive pattern, and demonstrate cardiovascular involvement that, on rare occasions, results in surgery. The case is presented of a 12-year-old boy with symptoms and signs of congestive heart failure who was referred to the authors' department for severe mitral and aortic valvular stenosis. The patient was shown to have the somatic characteristics of mucopolysaccharidosis, while urinalysis indicated the presence of chondroitin sulfate B. Mitral and aortic valve replacements were carried out, using bileaflet mechanical valves with a standard median sternotomy and cardiopulmonary bypass. A bileaflet preservation technique was adopted during mitral valve replacement to provide better hemodynamics. Severe cardiac involvement in mucopolysaccharidosis requiring cardiac surgery in pediatrics has been rarely documented. A low-profile bileaflet mechanical valve, enabling a larger-sized valve insertion, is preferred in order to avoid patient-prosthesis mismatch during somatic growth of the patient.

Posterior pericardial ascending-to-descending aortic bypass through median sternotomy.

BACKGROUND AND AIM: Adult patients with complex forms of descending aortic disease remain a surgical challenge and have a high risk of postoperative mortality and morbidity. Surgical management may be complicated when there is an associated cardiac defect, necessitating repair, or a hostile anatomy exists. We present our experience with extra-anatomic bypass through posterior pericardial route at the same stage with intracardiac/ascending aortic aneurysm repair. METHODS: Patients that underwent one-stage surgery with posterior pericardial bypass between ascending and descending aorta during 2003-2007 were reviewed. Data from early and mid-term follow-up, including mortality, perioperative blood loss, graft-related complications, patency, and persistent hypertension, were noted. RESULTS: Six male patients with a mean age of 20.8 +/- 0.7 years were operated for coarctation of the aorta associated with additional pathologies (three cases of ascending aortic aneurysm-one with associated aortic valve insufficiency, one case of isolated aortic valve regurgitation, two cases of mitral valve regurgitation). No early or mid-term mortality was observed during follow-up of a mean of 21.6 +/- 10.0 months. No late graft-related complications or reoperations were observed with patent grafts. Systolic blood pressure decreased after surgery by an average of 43 mmHg. CONCLUSIONS: Coarctation of the aorta with concomitant cardiac lesions can be repaired simultaneously through sternotomy and posterior pericardial approach, when patients present in adulthood, to minimize morbidity and mortality.

Concomitant coronary and peripheral arterial disease: single-stage revascularization.

Acute presentation of critical peripheral arterial ischemia in an unstable cardiac patient is a challenge to the surgeon. Coexistence of two entities is usually managed with a staged approach; however, decision to treat which entity first may be difficult clinically. We present a 49-year-old man with acute infrarenal aortic occlusion and cardiac ischemia who was treated with single-stage ascending aorta-bifemoral bypass following saphenous vein grafting to left anterior descending artery. Concomitant coronary and peripheral vascular revascularization is a practical method with a high flow inflow source as ascending aorta. We believe that a single-stage approach may be performed in the unstable patient as presented in this report.

An alternative patch repair technique during valve replacement for native valve endocarditis.

A patient with native valve endocarditis and vegetation on anterior mitral leaflet underwent aortic valve replacement with preservation of aortic noncoronary leaflet as a patch over the inflamed intervalvular fibrous body. This technique may minimize prosthetic material use, which is the most important risk factor for reinfection.