Cavoatrial junction stenting in vascular hemodialysis catheter malfunction.

In patients undergoing hemodialytic treatment via intravascular catheters, stenosis or occlusion of central veins is common. Despite an extensive characterization of Superior Vena Cava Syndrome (SVCS) no data is available about CavoAtrial Junction (CAJ) stenosis. We report the case of two patients with a story of multiple catheter failures due to thrombosis or infection. Computed tomography (CT) showed radiological signs of CAJ stenosis confirmed at the following venography. In absence of other feasible options to place a vascular access, the two underwent stenting with Gore Viabahn VBX balloon expandable endoprosthesis (W.L. Gore & Associates, Flagstaff, AZ, USA) of the CAJ stenosis. Completion venography showed complete resolution of the stenosis in both patients. No complications occurred during the procedures. At a mean follow-up of 878 ± 559 days no signs of in-stent restenosis or recoil were found. The present cases emphasize the feasibility and safety of CAJ stenting, underlining the importance of preserving CAJ and upper veins patency in hemodialysis access.

Modified upside-down technique with Gore tapered iliac limbs for isolated iliac artery aneurysms.

PURPOSE: To describe the off-label use of tapered iliac limbs for the treatment of isolated iliac aneurysms with proximal landing zone significantly larger than distal landing zone. TECHNIQUE: Inversion of a Gore Excluder tapered leg (W. L. Gore & Associates Inc, Flagstaff, Arizona) with a modified upside-down technique is described. The endoprosthesis, with the olive at the tip of the releasing system previously cut, is inserted in a tip-to-tip fashion into a 15 Fr introducer sheath. The graft is released inside the introducer. An 18 Fr introducer sheath is advanced up to the proximal sealing zone. Following the removal of the 18 Fr dilator, the 15 Fr introducer with the pre-released graft is inserted co-axially into the 18 Fr introducer. A pre-cut 15 Fr dilator is brought up to the endograft and used as a pusher. A pull-back maneuver of the co-axial system, countertractioning with the dilator maintained in position, allows the delivery of the endograft. CONCLUSION: This technique might offer a feasible option in case of endovascular exclusion of isolated iliac artery aneurysms with significant landing zone diameter mismatch. Extracorporeal inversion is time-saving and could be safer in terms of graft damage and infection.

Reproducing a decision-making network in a virtual visual discrimination task.

We reproduced a decision-making network model using the neural simulator software neural simulation tool (NEST), and we embedded the spiking neural network in a virtual robotic agent performing a simulated behavioral task. The present work builds upon the concept of replicability in neuroscience, preserving most of the computational properties in the initial model although employing a different software tool. The proposed implementation successfully obtains equivalent results from the original study, reproducing the salient features of the neural processes underlying a binary decision. Furthermore, the resulting network is able to control a robot performing an in silico visual discrimination task, the implementation of which is openly available on the EBRAINS infrastructure through the neuro robotics platform (NRP).

Early periaortic hematoma development after EVAR in the presence of severely calcified and modestly conical-shaped aortic neck: A potential trigger for sudden aneurysm progression toward rupture.

OBJECTIVE: The aim of this report is to present a singular case of early post-endovascular aneurysm repair abdominal aortic aneurysm rupture and discuss the possible etiopathogenic mechanism promoting the sudden aneurysm progression toward rupture.Methods/Results: An 84-year-old man was submitted to endovascular aneurysm repair via second-generation endograft (Cordis-Incraft Stent-graft) during which, the left occluded common iliac artery was recanalized via balloon-expandable covered-stent-graft (Atrium-Advanta-V12). The aneurysm presented a severely calcified and modestly conical-shaped aortic-neck. The post-operative course was complicated by a broncho pneumonic infiltrate and a CT scan performed two weeks postoperatively accidentally revealed a relatively small hematoma surrounding the aortic wall. No active bleeding, endoleak, or aneurysm increase in diameter was documented. Nevertheless, the patient remained closely monitored. Three days later, he suffered from abdominal aortic aneurysm rupture. A CT scan revealed an arterial wall tear at the neck level. Intra-operatively the reanalyzed common iliac artery was intact and a good endograft-sealing was confirmed. Following this event, small lumbar arteries suture saccotomy was performed. The patient eventually died of multiorgan failure one month later. CONCLUSIONS: The apparently "self-limiting" post-endovascular aneurysm repair CT-scan finding of periaortic hematoma may have represented a potential trigger for abdominal aortic aneurysm rupture. The possibility of developing undetected aortic lesions during endovascular aneurysm repair, specifically in the presence of potentially "at risk" anatomical conditions, should always be considered.

Transcriptional Regulation Factors of the Human Mitochondrial Aspartate/Glutamate Carrier Gene, Isoform 2 (SLC25A13): USF1 as Basal Factor and FOXA2 as Activator in Liver Cells.

Mitochondrial carriers catalyse the translocation of numerous metabolites across the inner mitochondrial membrane, playing a key role in different cell functions. For this reason, mitochondrial carrier gene expression needs tight regulation. The human SLC25A13 gene, encoding for the mitochondrial aspartate/glutamate carrier isoform 2 (AGC2), catalyses the electrogenic exchange of aspartate for glutamate plus a proton, thus taking part in many metabolic processes including the malate-aspartate shuttle. By the luciferase (LUC) activity of promoter deletion constructs we identified the putative promoter region, comprising the proximal promoter (-442 bp/-19 bp), as well as an enhancer region (-968 bp/-768 bp). Furthermore, with different approaches, such as in silico promoter analysis, gene silencing and chromatin immunoprecipitation, we identified two transcription factors responsible for SLC25A13 transcriptional regulation: FOXA2 and USF1. USF1 acts as a positive transcription factor which binds to the basal promoter thus ensuring SLC25A13 gene expression in a wide range of tissues. The role of FOXA2 is different, working as an activator in hepatic cells. As a tumour suppressor, FOXA2 could be responsible for SLC25A13 high expression levels in liver and its downregulation in hepatocellular carcinoma (HCC).

Insights into Structure-Activity Relationships of 3-Arylhydrazonoindolin-2-One Derivatives for Their Multitarget Activity on ß-Amyloid Aggregation and Neurotoxicity.

Despite the controversial outcomes of clinical trials executed so far, the prevention of ß-amyloid (Aß) deposition and neurotoxicity by small molecule inhibitors of Aß aggregation remains a target intensively pursued in the search of effective drugs for treating Alzheimer's disease (AD) and related neurodegeneration syndromes. As a continuation of previous studies, a series of new 3-(2-arylhydrazono)indolin-2-one derivatives was synthesized and assayed, investigating the effects of substitutions on both the indole core and arylhydrazone moiety. Compared with the reference compound 1, we disclosed equipotent derivatives bearing alkyl substituents at the indole nitrogen, and fairly tolerated bioisosteric replacements at the arylhydrazone moiety. For most of the investigated compounds, the inhibition of Aß40 aggregation (expressed as pIC50) was found to be correlated with lipophilicity, as assessed by a reversed-phase HPLC method, through a bilinear relationship. The N¹-cyclopropyl derivative 28 was tested in cell-based assays of Aß42 oligomer toxicity and oxidative stress induced by hydrogen peroxide, showing significant cytoprotective effects. This study confirmed the versatility of isatin in preparing multitarget small molecules affecting different biochemical pathways involved in AD.

Medial gastrocnemius vein aneurysm development after compressive trauma in the knee.

Objectives Venous aneurysms are uncommon. They can involve both superficial and deep venous systems. We hereby present a unique case of gastrocnemius venous aneurysm developed after compressive knee trauma. Report A large venous aneurysm in the left popliteal fossa was detected by chance in a 44-year-old woman one month after a compressive trauma to the posterior surface of the knee. Magnetic resonance-imaging of the same knee had documented normal venous anatomy one year earlier. The venous aneurysm involved the medial gastrocnemius vein near its confluence in the popliteal vein and was surgically resected. Histopathology evidenced a true venous aneurysm. The patient was discharged under oral anticoagulation for three months. At one year follow-up, neither complications nor new venous aneurysm development was detected. Conclusions An accurate evaluation of the venous system is always mandatory after limb traumas which may lead to post-traumatic venous pseudo-aneurysms, as well as more rarely, true venous aneurysms in the lower extremities.

Factors Affecting Long-Term Results of Above-Knee Femoropopliteal Bypass: A Single-Center Contemporary Study.

INTRODUCTION: The aim of this study was to assess whether individual patients' or bypass characteristics may influence long-term results of prosthetic above-knee femoropopliteal bypasses in patients with claudication in today's endovascular era. METHODS: Seventy-one consecutivee Expanded Polytetrafluoroethylene (e-PTFE) bypasses were considered. All patients presented a debilitating claudication. Patency of grafts was achieved by Kaplan-Meier method. The association between individual patients' or graft characteristics and primary patency (PP) or secondary patency (SP) was assessed via Cox regression models. RESULTS: An immediate technical success was achieved in all cases. No patient was lost during follow-up (8-90 months, median = 34 months). The median PP was 48 months. Occlusion occurred in 32 bypasses (45%). Eight (25%) of these were treated conservatively. Fifty-two bypasses (73%) were still patent at the end of follow-up, and 13 (25%) of these had been submitted to one or more surgical revisions. There were 2 graft infections. Of 17 (25%) patients with occluded graft at the end of follow-up, 2 (2.8%) had significant aggravation followed by limb loss. The PP was directly influenced by undetected minor distal anastomosis technical defects (hazard ratio [HR] = 5.89, P value = .000002), popliteal artery size (HR = 0.62, P value = 0.007), and distal anastomosis angle ≥40° (HR = 5.55, P value = .003). The SP was associated strictly to technical defects (HR = 11.08, P value = .000007). Multivariable analyses confirmed the influence of technical defects (HR = 6.42, P value = .000003) and anastomosis angle (HR = 1.05, P value = .009) on PP and that of technical defects on SP (HR = 10.84, P value = .00003). A significantly shorter SP was also observed after a previous failed endovascular treatment on the superficial femoral artery (HR = 3.73, P value = .02). CONCLUSION: An adequate arterial size, an ideal anastomotic angle, and the absence of minor, technical defects have a major role in prosthetic above-knee femoropopliteal bypass long-term outcome. A previous, failed endovascular procedure on the superficial femoral artery could markedly alter the natural history of patients with claudication because this approach seems to have a detrimental effect on long-term outcome of grafts needing surgical revisions.

A Prospective Nonrandomized Study on Carotid Surgery Performed under General Anesthesia without Intraoperative Cerebral Monitoring.

BACKGROUND: The purpose of this study was to assess our experience of carotid surgery habitually performed under general anesthesia without intraoperative intracerebral monitoring, and following a pre-established perioperative protocol, which includes extensive use of an intraoperative shunt (IOS). METHODS: This study included 311 consecutive carotid operations performed over 32 months. This patient cohort represents 14% of our total experience in carotid surgery (2219 operations, major stroke/mortality rate: 1.4%). The IOS was inserted routinely in the presence of intraoperative blood pressure instability during cross-clamping and when the predictable clamping time might have exceeded 20 minutes. A moderate and stable hypertension was maintained throughout surgery without IOS. RESULTS: Overall, 120 (38.6%) endarterectomies were performed with primary closure, 73 (23.5%) with eversion technique, 113 (36.3%) with patch angioplasty, and 5 (1.6%) with other techniques. Out of 113 patch angioplasties, 111 (98.2%) were performed with an IOS. This was utilized in only 3 cases of direct carotid reconstructions or other carotid endarterectomy techniques (1.5%). Overall, the IOS placement rate was 36.7%. Postoperatively, 2 major strokes (.64%), 2 minor strokes (.64%), 4 hyperperfusion syndromes (1.3%), and no mortality were recorded. No cases of cross-clamp ischemia/shunt-related perioperative strokes were observed. CONCLUSIONS: The low perioperative stroke rate reported in this prospective study proves the advantages of wide use of IOS during carotid surgery. This coupled with a large experience in carotid surgery and close monitoring and support of blood pressure, are the major determinants of these results that demonstrate the low risk of shunt-related complications for surgeons who regularly utilize an IOS.

Robotic Total Gastrectomy With Intracorporeal Robot-Sewn Anastomosis: A Novel Approach Adopting the Double-Loop Reconstruction Method.

Gastric cancer constitutes a major health problem. Robotic surgery has been progressively developed in this field. Although the feasibility of robotic procedures has been demonstrated, there are unresolved aspects being debated, including the reproducibility of intracorporeal in place of extracorporeal anastomosis.Difficulties of traditional laparoscopy have been described and there are well-known advantages of robotic systems, but few articles in literature describe a full robotic execution of the reconstructive phase while others do not give a thorough explanation how this phase was run.A new reconstructive approach, not yet described in literature, was recently adopted at our Center.Robotic total gastrectomy with D2 lymphadenectomy and a so-called "double-loop" reconstruction method with intracorporeal robot-sewn anastomosis (Parisi's technique) was performed in all reported cases.Preoperative, intraoperative, and postoperative data were collected and a technical note was documented.All tumors were located at the upper third of the stomach, and no conversions or intraoperative complications occurred. Histopathological analysis showed R0 resection obtained in all specimens. Hospital stay was regular in all patients and discharge was recommended starting from the 4th postoperative day. No major postoperative complications or reoperations occurred.Reconstruction of the digestive tract after total gastrectomy is one of the main areas of surgical research in the treatment of gastric cancer and in the field of minimally invasive surgery.The double-loop method is a valid simplification of the traditional technique of construction of the Roux-limb that could increase the feasibility and safety in performing a full hand-sewn intracorporeal reconstruction and it appears to fit the characteristics of the robotic system thus obtaining excellent postoperative clinical outcomes.

Multiple Pancreatoduodenal Artery Arcade Aneurysms Associated with Celiac Axis Root Segmental Stenosis Presenting as Aneurysm Rupture.

A 57-year-old woman was admitted to our unit suffering from hemorrhagic shock and upper abdominal pain. An enhanced computerized tomography (CT) scan evidenced a large retroperitoneal hematoma due to visceral arteries aneurysm rupture and a significant celiac axis root segmental stenosis due to median arcuate ligament compression. A selective splanchnic arteries angiography showed 3 saccular pancreaticoduodenal artery arcade aneurysm (PDAAs), 2 in the inferior posterior pancreaticoduodenal artery, and 1 smaller in the superior anterior pancreaticoduodenal artery. The largest aneurysm showed evident rupture signs. Both inferior PDAAs were successfully treated via endovascular coil embolization. The celiac trunk stenosis and small inferior PDAA did not require treatment. A CT scan control at 1-year follow-up did not reveal any new PDAAs. In cases of celiac artery trunk (CAT) steno-occlusive lesions, multiple aneurysms can develop in the pancreaticoduodenal arcade. PDAAs should be treated because of high rupture risk, regardless of diameter. Although endovascular treatment via coil embolization represents the treatment of choice nowadays, a simultaneous treatment of the associated CAT lesions is still debated. However, in cases of aneurysm embolization alone, one cannot exclude that other PDAAs might develop in these patients in the future. Close monitoring and accurate long-term follow-up is highly recommended in these cases.

Robotic pylorus-preserving pancreaticoduodenectomy: Technical considerations.

Laparoscopy has revolutionized the way of thinking abdominal surgery, however, to date there are still limitations making it difficult to apply this technique to some types of surgical procedures considered technically demanding even when performed by open surgery, such as the pancreaticoduodenectomy. This technical note provides a complete description of the surgical procedure performed for the execution of a robotic pancreaticoduodenectomy through the use of the "Da Vinci Si" robotic system. Robotic systems represent a real evolution in minimally invasive surgery. We wish to emphasize this concept, highlighting the application of this technology to complex procedures in digestive surgery.

Myocarditis in athlete and myocardial bridge: An innocent bystander?

Myocarditis is a bacterial or viral inflammatory disease, often unnoticed or misdiagnosed. Athletes with myocarditis must stop practicing their activity since International medical Literature described some cases of sudden death. In the present report, we describe a case of an asymptomatic, apparently healthy, competitive athletes, who was diagnosed a myocarditis and as incidental finding a myocardial bridging. We focused the attention on the importance of anamnesis, electrocardiogram and athletes' entourage for the diagnosis of such insidious pathologies and we evaluated the follow up, focusing the attention on electrocardiogram changes as well as on restitution ad integrum and prognosis, especially for the athletes.

Detection of small (≤ 2 cm) pancreatic adenocarcinoma and surrounding parenchyma: correlations between enhancement patterns at triphasic MDCT and histologic features.

BACKGROUND: The aim is to assess the time-density curves (TDCs) and correlate the histologic results for small (≤ 2 cm) PDA and surrounding parenchyma at triphasic Multidetector-row CT (MDCT). METHODS: Triphasic MDCT scans of 38 consecutive patients who underwent surgery for a small PDA were retrospectively reviewed. The TDCs were analyzed and compared with histologic examination of the PDA and pancreas upstream/downstream in all cases. Three enhancement patterns were identified: 1) enhancement peak during pancreatic parenchymal phase (PPP) followed by a rapid decline on portal venous phase (PVP) and delayed phase (DP) at 5 minutes (type 1 pattern: normal pancreas); 2) maximum enhancement in PVP that gradually decreases in DP (type 2 pattern: mild chronic pancreatitis or PDA with mild fibrous stroma); 3) progressive enhancement with maximum peak in DP (type 3 pattern: severe chronic pancreatitis or PDA with severe fibrous stroma). A p value less than 0.05 was considered statistically significant. Sensitivity was calculated for PDA detection and an attenuation difference with the surrounding tissue of at least 10 HU was considered. RESULTS: PDA showed type 2 pattern in 5/38 cases (13.2%) and type 3 pattern in 33/38 cases (86,8%). Pancreas upstream to the tumor had type 2 pattern in 20/38 cases (52,6%) and type 3 pattern in 18/38 cases (47,4%). Pancreas downstream to the tumor had type 1 pattern in 19/25 cases (76%) and type 2 pattern in 6/25 cases (24%). Attenuation difference between tumor and parenchyma upstream was higher of 10 UH on PPP in 31/38 patients (sensitivity = 81.6%), on PVP in 29/38 (sensitivity = 76.3%) and on DP in 17/38 (sensitivity = 44.7%). Attenuation difference between tumor and parenchyma downstream was higher of 10 UH on PPP in 25/25 patients (sensitivity = 100%), on PVP in 22/25 (sensitivity = 88%) and on DP in 20/25 (sensitivity = 80%). Small PDAs were isodense to the pancreas upstream to the tumor, and therefore unrecognizable, in 8 cases (8/38; 21%) at qualitative analysis and in 4 cases (4/38; 10,5%) at quantitative analysis. CONCLUSIONS: The quantitative analysis increases the sensitivity for detection of small PDA at triphasic MDCT.

Diffuse aneurysmal degeneration of the brachial artery after long-standing high-flow arteriovenous fistula closure for hemodialysis at elbow level.

While the possibility of development of a panarterial dilatation proximal to a long-standing high-flow posttraumatic arteriovenous fistula is well known, to the best of our knowledge, this event has never been described after vascular access for hemodialysis closure. We describe a man in whom a diffuse aneurysmal degeneration of the brachial artery has been highlighted 6 months after long-standing high-flow arteriovenous fistula closure. A 47-year-old man developed a painful pulsatile mass in the anterior distal third of his arm 6 months after long-standing high-flow arteriovenous fistula closure at the level of his elbow. A computed tomography scan revealed multiple "true" aneurysms of the brachial artery (BA) that appeared enlarged in toto. One of these aneurysms (near the BA bifurcation) presented with significant thrombus stratification. Surgery was recommended because of the major risk of peripheral embolization. Considering the anatomic characteristics of both the BA and aneurysm, no arterial substitution was performed and, after removal of the thrombus, the aneurysm diameter was reduced via direct arterial wall suture. The patient was discharged under oral anticoagulation. Aneurysmal degeneration of the donor artery after vascular access is relatively rare but represents a challenging problem. Operative or conservative management of these aneurysms should evaluate both the possible aneurysm-related complications and the feasibility of vascular reconstruction. In this context, the risk of additional donor artery and/or vascular reconstruction enlargement over time should also be considered.

An unusual ST-segment elevation: apical hypertrophic cardiomyopathy shows the ace up its sleeve.

Apical hypertrophic cardiomyopathy is part of the broad clinical and morphologic spectrum of hypertrophic cardiomyopathy. We report a patient with electrocardiographic abnormalities in whom acute coronary syndrome was excluded and apical hypertrophic cardiomyopathy was demonstrated by careful differential diagnosis.

Endovascular exclusion coupled with operative anterior leg compartment decompression in a case of postthromboembolectomy tibialis anterior false aneurysm.

The aim of this study was to present a case of iatrogenic thromboembolectomy-related tibialis anterior false aneurysm (FA) treated with endovascular FA exclusion and anterior leg compartment (ALC) operative decompression and to assess the current management options in posttraumatic leg vessel FAs. A 68-year-old man had a painful pulsating mass in the superior ALC 2 months after a thromboembolectomy was performed during popliteal aneurysm repair. He had been discharged under oral anticoagulation and had ALC manual massages for mild post-revascularization leg edema. Angio-CT showed tibialis anterior injury successfully treated with a covered stent graft, while a residual ALC hematoma was surgically evacuated. Endovascular treatment of tibialis anterior FAs using a covered stent graft is an excellent therapeutic option. After an endovascular procedure, caution must be taken to identify the need for early operative ALC decompression. Current leg vessel FA management should consider both the specific anatomic characteristics of the FA and the possibility of development of delayed compartment syndrome.

Multiple aneurysms of the radial artery in a woman with neurofibromatosis type 1 presenting as aneurysm rupture.

A 48-year-old woman with neurofibromatosis type 1 (NF1) experienced progressive forearm swelling coupled with impending compartment syndrome. Computed tomography angiography revealed a ruptured aneurysm of the proximal radial artery, multiple fusiform radial artery aneurysms, and a high independent ulnar artery origin. Compartment syndrome required prompt hematoma evacuation. Radial artery reconstruction, technically demanding due to vessel wall fragility, was deemed unnecessary because of satisfactory blood supply to the hand. Histologic findings indicated NF1-related vascular abnormalities also in the apparently normal radial artery as well as in a forearm vein, suggesting diffused vasculopathy. This case report is the first on ruptured radial artery aneurysm in NF1-related polianeurysmatic degeneration.

N-(Phenoxyalkyl)amides as MT(1) and MT(2) ligands: antioxidant properties and inhibition of Ca(2+)/CaM-dependent kinase II.

Recently a series of chiral N-(phenoxyalkyl)amides have been reported as potent MT(1) and MT(2) melatonergic ligands. Some of these compounds were selected and tested for their antioxidant properties by measuring their reducing effect against oxidation of 2',7'-dichlorodihydrofluorescein (DCFH) in the DCFH-diacetate (DCFH-DA) assay. Among the tested compounds, N-[2-(3-methoxyphenoxy)propyl]butanamide displayed potent antioxidant activity that was stereoselective, the (R)-enantiomer performing as the eutomer. This compound displayed strong cytoprotective activity against H(2)O(2)-induced cytotoxicity resulting slightly more active than melatonin, and performed as Ca(2+)/calmodulin-dependent kinase II (CaMKII) inhibitor, too.

Internal carotid artery dissection after inferior alveolar nerve block for third molar dental care presented as hypoglossal nerve palsy.

Cervicocephalic artery dissections occurring during dental care have exceptionally been reported. We describe a case of internal carotid artery dissection, presenting as hypoglossal nerve palsy, occurring immediately after difficult inferior alveolar nerve anesthetic block for third inferior molar dental care. Carotid dissection was successfully treated with anticoagulation therapy while hypoglossal nerve palsy recovered with carotid dissection shrinkage. The etiopathogenetic mechanisms of this singular form of internal carotid artery dissection are discussed. The possibility of internal carotid artery dissection development during oral or dental procedure, specifically in cases of possible trivial intraoperative internal carotid artery injury, severe local periodontal infection, or prolonged cervical hyperextension should be considered. Every possible prophylactic measure should be taken (eg, sedating the patient during oral or dental procedures, aggressive preoperative management of general and local periodontal chronic infections, avoiding prolonged perioperative neck hyperextention) to prevent this very rare but potentially life-threatening complication.