Delayed carotid wallstent shortening.

INTRODUCTION: Carotid angioplasty and stenting (CAS) has been demonstrated to be safe and an acceptable alternative to surgery. Stent malpositioning can occur during the maneuvers of delivering; technical errors can lead to proximal or distal slipping of the stent that needs the placement of additional pieces. PRESENTATION OF CASE: We describe the case of a postoperative dislocation of a carotid stent that happened 1 year after placement. After the first ultrasound control confirmed the correct position of the Stent the following one, executed 9 months later, showed a severe restenosis due to a proximal dislocation of the stent. The problem was solved with the positioning of a further one more distally. DISCUSSION: We observe the possibility of Carotid Wallstent shortening during the implant due to an incorrect placement or sizing, but a delayed displacement is a rare complication that, we highlight, can occur after CAS and that needs to be considered at the moment of the preoperative planning. CONCLUSION: After CAS a closed ultrasound follow up is advisable for a long time in order to detect unexpected complications.

Unusual treatment of abdominal aortic aneurysm: Aortic stenting with covered stent.

INTRODUCTION: It is now becoming increasingly difficult to accept that some patients are not suitable for surgery due to high surgical risk. The continuous technological progress, in the endovascular field in particular, are urging surgeons to put the limit even more forth. PRESENTATION OF CASE: We are going to describe an endovascular option used to treat an infrarenal aortic aneurysm where the diameter of the iliac vessels couldn't allow the use of any device available on the market. Three covered AdvantaV12 stents were placed in series in the aorta to build the endoprosthesis body and two Bard Fluency 8mm×60mm were then placed in a "kissing way" into the common iliac arteries like legs. DISCUSSION: Continuous technological progress, particularly in the endovascular field, is driving surgeons to push the limits even further. Nevertheless, some things still seem not to be possible, but in comparison to traditional surgery where all is well demonstrated and documented, the endovascular approach is still a young discipline and allows us to try to find new solutions. CONCLUSION: We can therefore assert that in exceptional circumstances, an aortic endoprosthesis can be built inside the aortic lumen using covered stents.

Celiac artery compression syndrome: successful laparoscopic treatment-a case report.

Several authors believe the crus of the diaphragm or the arcuate ligament is largely implicated in the etiology of the celiac artery compression syndrome (CACS). An unusual case of CACS successfully treated with laparoscopic decompression is reported. While under general anesthesia, the patient underwent laparoscopic division of the hypertrophic median arcuate ligament and dissection free of the celiac trunk. Postoperative angiography demonstrated improved flow in the celiac artery. The patient was discharged on the second postoperative day. At 6 months, Doppler ultrasound scanning and magnetic resonance angiography revealed good patency of the celiac trunk. The patient reported complete resolution of symptoms and increased weight. A laparoscopic approach allows the surgeon to sufficiently dissect the celiac axis. An excellent clinical result at short-term follow-up was attained. This is the second reported experience with this new procedure and the first successfully performed with only four port sites.

Emergency stenting to treat neurological complications occurring after carotid endarterectomy.

OBJECTIVES: The purpose of this study was to assess the efficacy of emergency stent implantation for the treatment of perioperative stroke after carotid endarterectomy (CEA). BACKGROUND: Carotid endarterectomy has been proven safe and effective in reducing the risk of stroke in symptomatic and asymptomatic patients with >60% carotid artery stenosis. However, perioperative stroke has been reported in 1.5% to 9% of CEA cases. The management of such a complication is challenging. Recently, percutaneous transluminal carotid angioplasty with stent deployment has emerged as a valuable and alternative strategy for the treatment of carotid artery disease. METHODS: Between April 1998 and February 2000, 18 of the 995 patients (1.8%) who had CEA in our institution experienced perioperative major or minor neurological complications. Of these, 13 patients underwent emergency carotid angiogram and eventual stent implantation, whereas the remaining five had surgery re-exploration. RESULTS: Carotid angiogram was performed within 20+/-10 min and revealed vessel flow-limiting dissection (five cases) or thrombosis (eight cases). Percutaneous transluminal carotid angioplasty with direct stenting (self-expandable stent) was performed in all 13 cases. Angiographic success was 100%. Complete remission of neurological symptoms occurred in 11 of the 13 patients treated by stent implantation and in one of the five patients treated by surgical re-exploration (p = 0.024). CONCLUSIONS: Stent implantation seems to be a safe and effective strategy in the treatment of perioperative stroke complicating CEA, especially when carotid dissection represents the main anatomic problem.

Fresh and cryopreserved arterial homografts in the treatment of prosthetic graft infections: experience of the Italian Collaborative Vascular Homograft Group.

Following the experience of cardiac surgeons with homografts in the treatment of infective aortic valve endocarditis, cardiovascular surgeons have investigated in situ revascularization by means of homografts in the management of vascular prosthetic graft infections. Preliminary results are encouraging, but their late fate in long-term follow-up and the influence of preservation techniques are still under investigation. This article reports the experience of the Italian Collaborative Vascular Homograft Group, with the use of fresh and cryopreserved arterial homografts for the treatment of prosthetic graft infections. Between March 1994 and December 1996, 44 patients with prosthetic graft infection were treated with homografts (13 preserved at 4 degrees C, 31 cryopreserved). The mean age of the patients was 65 years. Emergency surgical procedures were performed in eight patients (18%). Sepsis was diagnosed in 11 patients, aortoenteric fistula in 13, and false aneurysms in 10. Staphylococcus was the main cause of infection. The types of vascular reconstruction with homograft were: 32 aortobifemoral, 3 aortoaortic, 2 iliofemoral, 4 peripheral, and 3 axillobifemoral. Human lymphocyte antigen (HLA) and antibody (ABO) blood group system compatibility between donors and recipients was not respected. The mean duration of follow-up was 15 months (range 1-33). Clinical and duplex scanning evaluations were routinely performed. Computed tomography (CT) or magnetic resonance (MR) scanning or arteriography were performed on the basis of duplex scanning results. There were six deaths during the early postoperative period (30 days) with a mortality rate of 13.6%. During the follow-up there were five late deaths with a mortality rate of 11.4%. Eight patients had graft occlusion. Three cases were successfully treated with thrombectomy. Two cases were successfully treated with femoropopliteal bypass with autologous vein. In three cases leg amputation was necessary. The results of fresh and cryopreserved homograft were compared. No significative differences of early postoperative mortality, late mortality, homograft related mortality, and graft occlusion were observed. We have evaluated the actuarial survival of the patients and the actuarial patency of the homografts on the aortoiliac reconstructions. Twelve months after the surgery the actuarial survival of the patients was 73% and the actuarial patency of the homografts was 56%. In our preliminary experience, we have not observed any significant difference in terms of clinical outcome by using fresh rather than cryopreserved homografts. In the near future it will be our policy to employ only cryopreserved homografts. Moreover, we will extend vessel harvesting to nonheart-beating donors, thus maximizing retrieval. The aforementioned solutions will supply the best graft availability to obtain dimensional and ABO compatibility between donors and recipients.

Is endoscopy useful for early diagnosis of ischaemic colitis after aortic surgery? Results of a prospective trial.

BACKGROUND: Ischaemic colitis is an infrequent, but potentially fatal, complication of abdominal aortic surgery. Its presentation is often underestimated on account of a paucity of symptoms, thus the real incidence of ischaemic colitis may be higher. AIM: To determine the prognostic value and sensitivity of endoscopy, early postoperative endoscopic findings were evaluated. METHODS: Over a period of three years a prospective study was undertaken in a consecutive series of 105 patients (mean age 68.9 years, range 51-85) undergoing routine rectosigmoidoscopy within 72 hours of aortic reconstructive surgery. RESULTS: Colonic ischaemia was found in 12 patients (11.4%); five had endoscopic evidence of mild ischaemic colitis, ulcerations were identified in five and diffuse superficial necrosis in two. Seven of the 12 patients were symptomatic. Laparotomy was never deemed necessary and all patients were successfully treated with a conservative regimen. There were no deaths. Elective reconstruction or urgent procedure did not correlate with the development of colonic ischaemia, nor did duration of aortic cross-clamp time, patency of the inferior mesenteric artery and its possible ligation or reimplantation or patency of the hypogastric arteries. CONCLUSIONS: Rectosigmoidoscopy is effective for early diagnosis of ischaemic colitis. Early endoscopy should be routinely performed only for patients in whom impaired blood flow is suspected on the basis of the intraoperative objective assessment of the colon and in presence of symptoms.

[Role of totally implantable systems for long-term vascular access in the treatment of the neoplastic patient]. / Ruolo dei sistemi totalmente impiantabili per accesso vascolare a lungo termine nel trattamento del paziente neoplastico.

OBJECTIVE: To assess retrospectively the effectiveness, the safety and the impact on the quality of life of the Subcutaneous Infusion Ports (SIPs) for prolonged venous access in the treatment of neoplastic patients. DESIGN: Retrospective analysis of a case series collected-during 30 months (April 1991-September 1993). SETTING: General Surgery Division and Radiochemotherapy Service. PARTICIPANTS: 35 patients (23 male, 12 female), aged between 27-80 years, received 37 SIPs. 2 patients received 2 SIPs. 34 patients were affected by neoplasm; 1 patient had short gut syndrome secondary to massive small bowel resection. INTERVENTIONS: The SIP was implanted in all patients in the operating room with the Seldinger technique ("catheter over wire"). The suclavian vein, through an infraclavicular approach, was the only site of venous access. One SIP was implanted in the hepatic artery. All neoplastic patients received chemotherapy. The patient with short gut syndrome had parenteral nutrition. An external infusion device (CADD-1, CADD-plus, Pharmacia) was used in 13 patients for the continuous infusion of either 5-Fluoro-Uracil (1000 mg/m2/die for 5 days, every 28 days) or 5-Fluoro-Deoxy-Uridine (0.15-0.30 mg/kg/die for 14 days, every 28 days). SIP management required the port "flush" with normal saline solution with heparin (100 U/ml) at least every 40 days, using Huber needle. All patients were treated as outpatients. MAIN OUTCOME MEASURES: All intraoperative and long-term complications, recorded in the charts of the patients, were reviewed. The rate of intraoperative complications was assessed over 37 procedures. Long-term complications were assessed over 28 patients (7 patients were excluded for lack of follow up data). Incidence of complications was analyzed over patient days, considering the cumulative permanence time of the SIP in a single patient. RESULTS: We recorded 4 intraoperative complications (10.8%). None of them required to stop the procedure and to delay the implant of the SIP. During the follow-up period (range 1-18 months) we had 1 major complication (pleural effusion secondary to TPN extravasation), that is 3.5% of the patients (1/8255 patient days), and 3 minor complications (10.7% of the patients; 1/2751.6 patient days). Patient tolerance was good in all cases. CONCLUSIONS: SIP is a safe and effective device for prolonged venous access. We stress the need of a wider use of this type of device for the management of neoplastic patients.

[Magnetic resonance: preoperative assessment of abdominal aortic aneurysms. Comparison with surgical findings in 80 cases]. / Risonanza magnetica: valutazione preoperatoria degli aneurismi dell'aorta addominale. Confronto con i reperti operatori in 80 casi.

This work was aimed at assessing Magnetic Resonance (MR) accuracy in the preoperative investigation of abdominal aortic aneurysms, with a view to suggesting MRI as the method of choice for surgical planning, replacing other relatively invasive investigation techniques like angiography and enhanced CT. In the last 3 years 80 patients with abdominal aortic aneurysms identified with US or CT were examined with 0.5-T MRI and underwent surgical repair within 15 days. Spin-echo (SE) T1-weighted axial, sagittal and coronal sequences were always performed. In 18 patients gradient-echo (GE) flow sequences were also acquired; SE T2-weighted sequences were used to study parietal thrombi in 10 patients and finally Gd-DTPA T1-weighted sequences were obtained in inflammatory aneurysms (3 patients). MR images were blindly evaluated by 2 radiologists. The following variables which are useful for surgical planning were considered for each patient: aneurysm extent, characteristics of parietal thrombi, dissections, fixurations, inflammation signs, involvement of renal arteries, vena cava, ureters, duodenum, the presence of retroaortic renal vein or of other anomalies or associated conditions. MR images were always compared with intraoperative findings, since surgery was considered as the gold standard. MR findings were in agreement with surgical findings in the evaluation of cranio-caudal aneurysm extent (78/80), parietal thrombus features (80/80), dissection (1/1) and fixuration signs (8/9), origin of renal arteries (80/80), inferior vena cava involvement (3/3), other anatomical anomalies or conditions (6/6). Inflammation signs were overestimated (14/8) as well as adhesion between aneurysm and duodenum (17/13). The presence of distal renal polar arteries was underestimated (2/4). In conclusion, MRI proves to be a highly sensitive method to demonstrate abdominal aortic aneurysms and is therefore suggested as the examination of choice before surgery.

[The surgical treatment of inflammatory aneurysms of the abdominal aorta. The usefulness of nuclear magnetic resonance (MR) in the preoperative diagnosis]. / Trattamento chirurgico degli aneurismi infiammatori dell'aorta addominale. Utilità della risonanza magnetica nucleare (RM) nella diagnostica preoperatoria.

Inflammatory abdominal aortic aneurysms (IAAA) represent a peculiar variant compared with the common atherosclerotic origin of aortic aneurysms. Between January 1988 and March 1992, 111 aneurysmectomies were performed at our institution: 98 elective and 13 emergency procedures. In 10 cases (all males, mean age 68.5) an IAAA was found. 8/10 of those patients operated upon electively were studied preoperatively with MRI. All the IAAA but one were correctly identified preoperatively. Identification of IAAA with MRI in these cases improved the surgical approach. In conclusion, patients with IAAA can be operated upon safely especially if a preoperative diagnosis is present. MRI greatly improves our ability to characterize non invasively IAAA.