Unheralded Lower limb threatening ischemia in a COVID-19 patient.

Acute thromboembolic events appear to be frequent in patients with SARS-CoV-2 infection. We report a case of an intubated patient, who developed a threatening lower limb ischemia. Intra-arterial fibrinolysis and intravenous heparin infusion did not lead to complete recanalization of the tibial arteries, which were successfully treated by surgical embolectomy.

Multistep and Multidisciplinary Management for Post-irradiated Carotid Blowout Syndrome in a Young Patient With Oropharyngeal Carcinoma: A Case Report.

BACKGROUND: Carotid blowout syndrome is a severe complication of head and neck cancer, associated with high mortality and morbidity. METHODS: We present a case of acute hemorrhage from the carotid artery of a 59-year-old man with a history of chemoradiotherapy for lingual base and oropharyngeal squamous cell carcinoma. The case was managed by a staged multidisciplinary approach of open arterial reconstruction, after initial endovascular hemorrhage control using stent graft. RESULTS: The patient was discharged to home with patent carotid artery, no sign of infection or bleeding, and autonomous ambulation. A CT/PET scan performed 6 months later confirmed healing and absence of tumor recurrence. CONCLUSIONS: A multidisciplinary approach involving vascular surgeons, ENT surgeons, plastic and maxillofacial surgeons is particularly appropriate in the management of carotid blowout syndrome to warrant a durable and effective repair of all the anatomical structures involved.

The different scenarios of urgent carotid revascularization for crescendo and single transient ischemic attack.

OBJECTIVE: Carotid stenosis with crescendo-transient-ischemic-attack (cTIA) requires a prompt intervention to reduce the stroke risk. Few data are reported in literature about cTIA suggesting a different perioperative risk compared with patients with single TIA (sTIA). This study aimed to compare the outcome of carotid endarterectomy (CEA) in patients with TIA (single/crescendo) and evaluate the outcome risk-factors. METHODS: Data from two tertiary hospitals for vascular treatment were analyzed from 2007 to 2016. All patients with TIA subjected to CEA were considered, comparing the 30-day postoperative stroke and stroke/death in patients with cTIA and sTIA, particularly in the urgent (≤48 h) setting. RESULTS: On a total of 3866 CEA, 888 (23%) were performed in symptomatic patients and 515 for TIA: 365 (71%) patients with sTIA and 150 (29%) with cTIA. When compared with sTIA, cTIA patients were younger and less frequently affected by coronary disease, dyslipidemia, and chronic pulmonary disease; however, contralateral carotid occlusion was more common (20% vs. 10%, P = .004; 56% vs. 46, P = .03; 16% vs. 7%, P = .01; >80 years 26% vs. 16%, P = .01 and 2% vs. 10%, P = .001; respectively). Postoperative stroke and stroke/death were significantly higher in cTIA compared with sTIA (5.3% vs. 1.6%, P = .02 and 6.0% vs. 2.2%, P = .03; respectively). Urgent CEA was performed in 58% ( n: 87) cTIA and in 11% ( n: 56) sTIA( P<.01). The urgent setting did not influence the stroke and stroke/death rate of CEA for sTIA (3.6% vs. 1.3%, P = .21 and 3.6% vs. 1.9%, P = .44, respectively), but was associated with lower rate of events in cTIA (1.1%vs. 11.1%, P = .01 and 2.3% vs. 11.1%, P = .03, respectively). This beneficial effect in patients with cTIA treated within 48-h was confirmed also by multivariate analysis (OR: 0.09, 95% CI: 0.76-0.01, P=.02). CONCLUSIONS: cTIA subjected to CEA have a higher stroke and stroke/death risk compared with patients with sTIA. The urgent setting seems to reduce the stroke/death rate cTIA; for sTIA with a stable neurological condition, the timing of CEA did not influence the outcome.

Is Near-Infrared Spectroscopy a Reliable Method to Evaluate Clamping Ischemia during Carotid Surgery?

Guidelines do not include cerebral oximetry among monitoring for carotid endarterectomy (CEA). The purpose of this study was to evaluate the reliability of near-infrared spectroscopy (NIRS) in the detection of clamping ischemia and in the prevention of clamping-related neurologic deficits using, as a cutoff for shunting, a 20% regional cerebral oxygen saturation (rSO(2)) decrease if persistent more than 4 minutes, otherwise a 25% rSO(2) decrease. Bilateral rSO(2) was monitored continuously in patients undergoing CEA under general anesthesia (GA). Data was recorded after clamping, declamping, during shunting and lowest values achieved. Preoperative neurologic, CT-scan, and vascular lesions were recorded. We reviewed 473 cases: 305 males (64.5%) mean age 73.3 ± 7.3. Three patients presented transient ischemic deficits at awakening, no perioperative stroke or death; 41 (8.7%) required shunting: 30 based on the initial rSO(2) value and 11 due to a decrease during surgery. Using the ROC curve analysis we found, for a >25% reduction from baseline value, a sensitivity of 100% and a specificity of 90.6%. Reliability, PPV, and NPV were 95.38%, 9%, and 100%, respectively. In conclusion, this study indicates the potential reliability of NIRS monitoring during CEA under GA, using a cutoff of 25% or a cutoff of 20% for prolonged hypoperfusion.

Renal anomalies in aortic surgery: contemporary results.

OBJECTIVE: The purpose of this study was to evaluate technical problems and results of surgical treatment of aortic disease associated with major renal anomalies. STUDY DESIGN: Renal anomalies observed during aortic procedures performed over a 19-year period were reviewed. Type of renal anomaly, diagnostic procedures, preoperative renal function, technique of vascular reconstruction, and management of the anomalous kidney were considered and correlated with peri-operative and long-term results. RESULTS: Eighteen patients (1.1%) with major renal abnormalities were found in our experience with more than 1650 aortic procedures. Of these, 10 involved horseshoe kidneys and 8 ectopic kidneys (3 pelvic, 3 lumbar, and 2 crossed ectopias). All elective cases were evaluated with computed tomography, urography, and angiography. Aortic reconstruction was performed in 17 patients for aortic aneurysm (1 urgent repair for rupture) and in 1 patient for obstructive disease. Surgical access was anterior transperitoneal in 16 patients and retroperitoneal/thoracoabdominal in 2. In 8 patients, reimplantation of 1 or both renal arteries was necessary. Division of the renal isthmus was necessary in 3 patients with horseshoe kidney. The perioperative mortality rate was 0%. Renal function was normal at discharge in all patients. At long-term follow-up (median, 5 years; range, 1 to 19 years) neither renal nor aortic complications were detected. In 15 of 17 patients, the aneurysm was confined to the abdominal aorta. CONCLUSION: Although infrequent, renal anomalies encountered during aortic surgery can be effectively treated with accurate diagnosis and preoperative planning.