Vein wall thickness and severity of pulmonary involvement due to sars n-cov2 virus infection.

BACKGROUND: An observational study involving patients recovered from COVID-19 was conducted in order to evaluate the presence/absence of vein wall thickness increasing, according to the severity of pulmonary involvement quantified with a CT-scoring system. METHODS: The venous wall thickness (VWT) of 31 patients (23 males and 8 females) with COVID 19 previously admitted to Federico II University Hospital of Naples was evaluated through ultrasound measurement of the common femoral Vein 1 cm proximal to the saphenous-femoral junction and the popliteal Vein 1 cm distal to the confluence of gemellary veins. Measurements were taken with an automated tool to avoid human error. All patients were evaluated in the supine position. Patients were then stratified into two groups, VWT > 1 mm and VWT < 1 mm. Lung damage was assessed through thoracic High Resolution Computer Tomography and subsequently quantified using the scoring system set out by Chung et al. CEAP-C class was calculated for all patients. RESULTS: The mean value of COVID score in VWT > 1 mm group was 7.4 (S.D. 4.83), whilst the mean value of the COVID score in the VWT < 1 mm group was 3.82 (S.D 3.34). These findings were determined to be statistically significant in a two-tie Student-T test. The linear regression test between VWT and Covid score values demonstrated a direct relationship between the two variables. CONCLUSION: These results demonstrate a link between two different aspects of the pathological effects on the vessels during a SARS-COV 2 infection. As such a common primum movens can be hypothesized in both micro-thrombotic and inflammatory processes relating to COVID 19.

Surgical treatment in late-stage gastric cancer. A retrospective analysis of 26 cases.

BACKGROUND: Gastric cancer represents the fourth most common form of cancer and the second most common cause of death in the world. It is also one of the most common cancers leading to mortality in Italy. Therefore, this study aimed to determine the survival rate of patients with advanced gastric cancer and its affecting factors in our experience at AOU Federico II. METHODS: 26 patients with late-stage T4N2M0 and T4N2M1 gastric cancer that were diagnosed and registered during 2008 to 2018 in Federico II Surgical department, were studied. All patients were followed to the end of 2019. Kaplan-Meier method was used to draw survival curves and to determine the effective factors on the survival rate of surveyed patients. Moreover, Log-rank test was used to evaluate whether or not survival curves for different patients, related to residual tumor, are statistically equivalent (p<0.05). RESULTS: The mean age of the study population was 49±29, and most of them were males (57,8% (15 patients). After diagnosis, the survival rates for 1, 2, 3 and 4 years, were 26,9%, 11,5 %, 3,8%, 19,2 %; 11,5% of patients with residual tumors survived 6 months respectively. Overall average survival was of 20.61 sd 17.52 months with a median of 12. No statistical difference was detected in terms of survival among M0 and M1 sub-groups. CONCLUSION: Based on the findings of the present study, T4 gastric cancer has a poor prognosis. Survival rate was decreased over time after diagnosis. Tumoral stage at the time of diagnosis is the most important factor affecting the survival of surveyed patients. This shows that there is a crucial need to diagnose the gastric cancer in early stages. KEY WORDS: Advanced gastric cancer, Surgical techniques, Therapy.

Male breast cancer: an update.

PURPOSE: To summarize and compare the most recent data from the literature to clarify the management of male breast cancer. METHODS: A review article. RESULTS: Diagnosis and Treatment of Male Breast Cancer have been derivative for years. Nowadays MBC is a nosological entity in its own right with biological, molecular and clinical features that require a multidisciplinary approach and the involvement of specific skills. Multimodal treatment involves surgery, radiotherapy and chemotherapy. It is evident that the outcome of the MBC is worse than the female one. MBC is often diagnosed in advanced stages. Screening programs in the male population need to be strengthened to obtain an earlier diagnosis. It is necessary to know even more in depth the endocrine-metabolic and behavioral risk factors related to the neoplasm. Finally in the coming years it is reasonable to expect an improvement in multigenic tests: the sensitivity of these methods could predict the risk of recurrence even more precisely. This could lead to substantial changes in the choice and duration of treatment with results that could be surprising. KEY WORDS: Male breast cancer, Management, Review, Update.

Outpatient vascular clinic management in COVID-19 pandemic.

INTRODUCTION: The recent Sars-CoV2 pandemic has dramatically slowed patients' access to our clinic for vascular pathology when the contagion curve peaked. The need to restore the assistance activity has led us to adopt new individual prophylaxis and hygiene measures. METHODS: Doctors and staff must wear dedicated clothes. Mask and gloves are mandatory for patients. A visit is scheduled every 60 minutes to allow the sanitation of the rooms. The day before the visit patients are contacted by telephone for the Covid-19 risk triage. In the presence of symptoms the visit is postponed. In the presence of other risk factors a IgG/IgM Rapid Test for Covid-19 is performed on admission to the clinic. In the presence of fever, if an extraordinary rapid test cannot be performed, the visit must be postponed. Rapid test positive patients cannot be visited: they are placed in solitary confinement at their home waiting for a nasopharyngeal swab for Covid-19. When the rapid test is positive, immediate room sanitation also occurs. The rooms dedicated to the outpatient clinic as well as medical and not medical instruments are disinfected. CONCLUSION: The one adopted can be a useful management model for any type of care activity in order to guarantee the safety of patients and all the staff. KEY WORDS: COVID-19, Management, vascular, Outpatient clinic.

Surgical crossectomy and saphenic trunk sclerotherapy. Preliminary results of a combined approach to the treatment of saphenous vein varices.

AIM: Here our proposal of a new approach to the incontinent saphenous-femoral junction (SFJ) based on the combination of surgery and sclerotherapy for treatment of incontinent varices. It is a two-step procedure with a surgical ligation and transection of SFJ followed by a sclerosis of saphenous trunk and extra-fascial tributaries. MATERIALS AND METHODS: From January to December 2017, 95 patients (63 females and 32 males) with a mean age of 56.43 ± 6.07 years for a total of 121 limbs were treated with the SHSC approach. Under local anesthesia, after surgical selective hemodynamic crossectomy and a retrograde cannulation of the saphenous trunk by means of 8-10 ch nelaton-like catheter, 0.5-1% polydocanol foam, obtained with Tessari's technique, is injected into the vein. During injection, the catheter must be progressively withdrawn, so that the entire vein comes in contact with the foam. RESULTS: 121 limbs have been treated with the above technique. A complete obliteration of the saphenous trunk was observed after 116 (95.86%) treatments in the immediate postoperative time. With regard to collateral veins sclerosis, 99 (81.81%) complete obliterations were observed. 28 (23.14%) collateral varices had to be refined by sclerotherapy. DISCUSSION: SHSC associates the execution of a selective hemodynamic crossectomy with an intraoperative foam sclerotherapy for the treatment of the saphenous trunk and collateral varicose veins. SHSC, compared to classical US-guided foam sclerotherapy seems to be safer, with fewer risks of pulmonary and / or cerebral embolic complications. SHSC prevents blood wash out which could destabilize the consolidation of the saphenous trunk sclerosis. CONCLUSIONS: SHSC can be considered an effective treatment of varicose veins, simple to perform, minimally invasive and well tolerated KEY WORDS: Crossectomy, Saphenous vein, Sclerotherapy, SFJ.

Percutaneous treatment with radiofrequency ablation of varicose veins recurring after vein stripping surgery A preliminary study.

AIM: The aim of our study was to evaluate the efficacy of a new treatment of recurrent varicose vein after stripping of the great saphenous vein with rigid radiofrequency needles. MATERIAL OF STUDY: 37 patients enrolled (11 males and 26 females). 10 patients had recurrent varicose veins for the presence of residual reflux in the Saphenous-Femoral Junction (SFJ) stump, whilst 21 patients for the presence of a single or multiple re-chanalized and refluxing perforator veins, and 6 had mixed rechanalization due to perforator veins and refluxing saphenous stump. All patients have been treated by percutaneous ultrasound-guided obliteration with radiofrequency needles. Treatment efficacy have been assessed by US evaluation, and/or the appearance of recurrent varicose veins and classified as REVAS questionnaire. Follow up has been carried out at 30, 60, 180 days and 1 year after treatment. RESULTS: A complete obliteration of the perforator(s) stump(s) was observed in 12 procedures immediately after the treatment, and confirmed at 30 and 60 days. In 1 case (7.69 %) obliteration was not complete at 60 days. After 1 year of follow-up 3 perforators (23.07%) showed an incomplete or failed obliteration. A complete obliteration of the treated SFJ was observed in 27 cases at the end of the procedure and confirmed after 60 days of follow-up patients (Fig. 4). In 2 cases (6.89%), obliteration was non complete at 60 days. After 1 year of follow up 5 treated SFJ (17.24%) stumps showed an incomplete or a failed obliteration. DISCUSSION: Results show a reduction of the number of limbs affected by ulcer, skin pigmentation and stasis eczema, demonstrating correction of haemodynamic overload to be effective. CONCLUSIONS: This treatment is a new and effective solution to the problem of post-stripping recurrent varicose veins. KEY WORDS: Perforator veins, Radiofrequency, Recurrent post-stripping varicose veins, Saphenofemoral stump.

The effects of Crenotherapy and exercise in peripheral arterial occlusive disease. A comparison with simple exercise training.

BACKGROUND: Conservative therapies for patients affected by Peripheral Arterial Occlusive Disease (PAOD) aim first to correct the risk factors and to slow down the disease progression. Among these, exercise has positive effects on blood flow, muscle metabolism and well demonstrated systemic effects. These include reduction of chronic inflammation markers, improvement of walking mechanics and heart function. Controlled physical training increases the ability to perform the daily activities improving life expectancy of these patients. The aim of this study is to evaluate the effects and the effectiveness of physical training performed in thermal water compared to traditional treadmill walking exercise. METHODS: 98 patients affected by IIb stage PAOD, according to Leriche-Fontaine classification, were enrolled. Patients were randomized into two groups: the first arm carried out an intensive training program under medical supervision (group A); the second one carried out a rehabilitative exercise associated with crenotherapy (group B). The following parameters were detected: Ankle-Brachial pressure index (ABI), actual claudication distance (ACD), maximum walking distance (MWD), flow mediated dilatation (FMD) and the intima-media thickness (IMT). All patients underwent Doppler echocardiography and complete biochemical assay. RESULTS: In both groups, there was a statistically significant improvement of lipidaemia compared to baseline. When compared with each other, the two groups did not show statistically significant differences. There were no significant differences between the two groups regarding echocardiographic findings. Vascular reactivity study showed a statistically significant improvement of FMD after 3 months of exercise in both groups. In crenotherapy group (B) FMD values were significantly higher than the treadmill ones (A). In both groups a statistically significant improvement in ACD was observed CONCLUSIONS: Our experience shows that crenotherapy has similar effects compared to traditional physical training in the treatment of PAOD, being equally well tolerated and safe; it gives an advantage over conventional physical training in terms of ACD and MWD improvement, although not statistically significant, and it is extremely welcome to patients compared to traditional physical training. KEY WORDS: Arterioscleroses, Intermittent Claudicatio, Peripheral Arterial Diseasen, Physical Exercise, Rehabilitation.

The use of transillumination as a rational approach to sclerotherapy and endovascular laser ablation of varices. Results in the use of an original instrument.

AIM: To explain the mode of using and the obtained results during EVLA procedures and sclerotherapies with support of Visioven®, a laser transillumination instrument. MATERIALS AND METHODS: 205 patients suffering from Chronic Venous Insufficiency - CEAP-C stage 1-2 enrolled (103 females and 102 males) and divided into two groups. A Group: patients candidate for sclerotherapy; B Group: patients to be subjected to endovascular laser ablation (EVLA). In both groups patients were divided into two sub-groups on the basis of the use of Visioven® or not during the procedure. The analyzed outcome variables were the total number of cannulations necessary to treat a whole limb, and the total procedure time. RESULTS: There is a statistically significant difference between the sub-groups in which Visioven® was used and the ones in which the procedure has been performed without using of any tools. Both in the sclerotherapy group than in the EVLA one, there is not a statistically significant difference for the time required to complete the procedures carried out with Visioven® compared with the ones performed without the use of any transillumination. DISCUSSION: Complete closure of the vein was highlighted. Total number of cannulations in sclerotherapy and EVLA procedures was reduced, as a consequence of a "smart" and "targeted" treatment achieved with Visioven® CONCLUSION: The VISIOVEN® system leads to have a more rational approach to sclerotherapy or Laser Ablation of teleangectasias and reticular veins as we can immediately verify the effectiveness of the treatment and adapting it to the desired effects. KEY WORDS: Chronic Vein Insufficiency, EVLA, EVLT, Laser, Varicose vein.

A new strategy in sclerotherapy of varicose veins.

AIM: The aim of our study was to evaluate the efficacy of a new method of compression sclerotherapy of GSV and SSV. MATERIALS AND METHODS: 345 lower extremities with primary varicose veins, with a long reflux of the GSV (C2-6; Ep; As 2, 3; ± p; Pr), have been submitted to sclerotherapy applying the following method: injection of foam (Polidocanol 2%), or liquid sclerosant (iodate solution 4-6% or Polodocanol 3%) in the trunk of the GSV; echoguided compression of sapheno-femoral junction (performed using an inflatable device, the Safeguard); immediate eccentric positive compression on the trunk of the GSV; and short elastic bandage. RESULTS: The results have shown that applying this method of sclerotherapy the failure rate decreases, independently to physical form of sclerosing agent. CONCLUSIONS: The use of Safeguard® interrupts reflux to the lower veins, and these can so be well sclerosed and compressed with short elastic bandage. KEY WORDS: Long compression, Foam, Saphenous vein Sclerotherapy varicose veins.

Comparison of traditional surgery and laser treatment of incontinent great saphenous vein. Results of a meta-Analysis.

AIM: This paper aims to compare EVLA to traditional surgery, by evaluating the incidence of recurrences. MATERIAL OF STUDY: We performed a meta-analysis to challenge both surgical and LASER treatment, using, as clinical outcome, the presence or the absence of reflux. A systematic review of literature about the treatment of varicose veins was performed, searching in the following databases: PUBMED-MEDLINE, Cochrane Library. Search terms considered were: stripping, HL/S, surgery, LASER, EVL*, varicose vein, GSV, saphenous vein. Only RCTs based at least on sixmonths follow-up were considered eligible in the study. Methodological quality of the included studies was evaluated using Cochrane Collaboration Bias Risk Assessment Tool. Effects of the dichotomous variables taken in consideration were evaluated using pooled risk-ratios with 95% C.I. Articles were evaluated initially from abstracts; eligible papers were fulltext examined. RESULTS: We have considered 2 groups, A and B. A Group: 756 legs treated with conventional surgical procedure; B Group: 755 legs treated with EVLA technique. A Group showed 175 post-procedure recurrences, while B showed 97 recurrences. The average O.R. was 1.72; minimum O.R. was of .497 while the maximum was of 8.064. DISCUSSION: The obtained OR average value is 1.72 with a 95% C.I. of 0.94-3.12, which includes the value 1, contrary to the criteria for rejection of the null hypothesis. For this reason there is not a statistically significant difference between the results obtained by the two techniques. CONCLUSIONS: The endovascular laser ablation (EVLA) does not prove to be superior in terms of recurrence, to the surgical technique. However, it remains a viable treatment option in patients with impaired great saphenous vein, reducing postoperative pain and hospital stay. KEY WORDS: Laser therapy, Meta-analysis, Saphenous vein, Surgery, Venous insufficiency.

Role of the haemodynamic mapping in varicose vein surgery of lower limbs.

AIM: To demonstrate the importance of preoperative ultrasound haemodynamic mapping of venous system in surgery of varicose veins. MATERIALS AND METHODS: Doppler ultrasound evaluation of haemodynamic features of lower limb venous system according to Franceschi's subdivision. DISCUSSION: The importance of Doppler mapping in varicose veins surgery shows a similarity with the Plebographic classification of venous system developed by W. Hach. The study also reassesses the role of varicectomy in the surgery of varicose veins. CONCLUSIONS: Preoperative Doppler ultrasound mapping is essential to avoid accident and prevent recurrence of varicose veins. KEY WORDS: Doppler US, Surgery, Great Saphenous Vein, Varicose Veins, Stripping.

Prophylactic GSV surgery in elderly candidates for hip or knee arthroplasty.

Aging is one of the major risk factors for varicose veins. The same is for Knee and Hip Osteoarthritis. Most of the patients undergoing to Hip (THA) or Knee (TKA) arthroplasty are over sixteen. Varicose veins, excluding thrombophilia, are the most significant risk factors for VTE after THA and TKA. This study investigates on the usefulness of prophylactic treatment of GSV insufficiency in elderly patients undergoing to orthopedic surgery. A retrospective study enrolling 44 over-sixty five patients, undergoing to TKA or THA. 24 patients underwent to traditional surgery and 20 to EVLA. The presence of evident varicosities and/or a saphenic reflux lasting > 500 ms has been considered as operability criterion. Both in surgery and EVLA group has been performed the ablation of visible varicosities and only saphenic refluxing traits. RESULTS: 1 case of symptomatic DVT was recorded after arthroplasty. A statistically significant difference (p = 0.006) of recovery time between surgery and EVLA groups has been detected. There is not a statistically significant difference in long-term recurrence rate between surgery and EVLA. CONCLUSIONS: It is useful to program GSV surgery, before treat hip or knee. This study showed a 50% decrease in the incidence of postoperative DVT.

Uncommon primary hydatid cyst occupying the adrenal gland space, treated with laparoscopic surgical approach in an old patient.

Hydatid disease (HD) is caused by Echinococcus Granulosus (EG), which is a larva endemic in many undeveloped areas. The most common target is the liver (59%-75%). The retroperitoneal space is considered as a rare localization. We report an uncommon case of HD located in the adrenal gland space. PRESENTATION OF CASE: This is a 78-year-old Moroccan woman, with right flank pain for eight months previously. She denied contact with dogs or sheep. Her physical examination was normal. There was no pathological alteration of laboratory exams. CT scan measuring 5 cm without clear signs for a sure diagnosis found a round lesion in the right adrenal gland. An abdominal MRI showed a round mass of 34 x 27 mm with fluid component without a clear plane of dissection from kidney and liver. A laparoscopic procedure was performed to obtain a histological diagnosis. We reached a conclusive diagnosis of Hydatid cyst of right adrenal gland space. Hydatid cysts often develop in the liver. The location in the adrenal bed is rare without clinical signs related to alteration of the gland's secretion. Hydatid cyst identification in the adrenal gland space is based on ultrasonography, CT or MRI scans. The differential diagnosis includes various benign and malignant lesions. Laparoscopic procedure is the best approach available to obtain a histological diagnosis and a curative treatment. The best treatment for HD is the pericystectomy. Laparoscopic surgery can guarantee a radical resection of these lesions when it performed by an expert surgeon.

Superficial epigastric vein sparing in the saphenous-femoral crossectomy or in the closures of the saphena magna.

AIM: Considerations based on years of experience, have led our school to spare the superior collateral vein: the superficial epigastric vein. MATERIAL OF STUDY: 1536 selective epigastric-sparing crossectomies performed with the support of Duplex US to detect the normal functioning of terminal saphenous-fermoral junction and femoral valves. RESULTS: The selective-haemodynamic sapheno-femoral junction ligation" (although this is not strictly done), saves from ligation (but only in the presence of functioning femoral and saphenous terminal valves) and division the termination of the superficial epigastric vein into the common femoral vein. DISCUSSION: Superficial epigastric vein is a descending draining vessel, assisted by gravity (unlike the inferior collaterals). In case of obesity or portal hypertension, the spared superficial epigastric vein could drain into the common femoral vein keeping its anatomical and haemodynamic functions. CONCLUSIONS: The resulting anterograde flow will provide some flow through the residual saphenous stump, preventing its thrombosis. KEY WORDS: Duplex US, Ligation, Saphenous vein.

Is surgery always the best treatment for severe carotid stenosis in the frail elderly?

OBJECTIVES: Presentation of a case of carotid stenosis in an elderly patient with multiple co-morbidities, and its management. METHODS: Pre-operative management of an elderly patient affected by carotid artery stenosis with cardiac, metabolic and renal comorbidities and a recent history of buccal squamous carcinoma. RESULTS: Pre-operative anestesiologic assessment showed an increased risk for the presence of heart failure, cardiogenic pulmonary hypertension, mild/moderate stage renal disease. CONCLUSION: The frail elderly represents a real challenge for the surgeon, because in choosing treatment other options must be taken into account both in view of local disease and of various systemic comorbidities.

Is the fibrotic parietal thickening a reliable parameter for diagnosing previous asymptomatic deep vein thrombosis?

AIM: Research of a starting point to debate about the possibility of identifying a unique sign of previous DVT. MATERIAL OF STUDY: A retrospective study involving 202 outpatients with venous insufficiency of the lower limbs (CEAP classes C 4/6), classified according to the affected venous district. Patients positive for deep vein thrombosis (DVT) were subjected to Compression Ultra Sound test (CUS test) with measurement of the wall thickness at the point of formation of the thrombus and at fixed points of common femoral and popliteal veins used also in the patients with negative history of DVT RESULTS: Among total group, only 19 patients (9.40%) had an history of DVT. No one of them had a superficial incontinence. The measurement of wall thickness in positive DVT history patients (group A) resulted in an average value of 1.10 mm (s.d=0.06), while the average value obtained in negative DVT history (group B) was 0.55 mm (s.d.= 0.20). However, in 13 patients wall thickness was > 1mm (mean: 1.04 mm). The difference between the averages of group A and B was statistically significant (p <0.05). DISCUSSION: In all positive DVT history patients and in 13 ones with negative history we found an increase in wall thickness, with a value > 1 mm. Can the wall thickening more than 1 mm be considered an indicator of previous DVT? Can it be considered a "marker" for thrombophilia status? CONCLUSIONS: The usefulness of a sign of previous DVT (even if asymptomatic), detected during a routine Doppler ultrasound check of lower limbs, could be a warning bell to investigate thrombophilia status. KEY WORDS: Chronic Venous Insufficiency, Duplex ultrasound, Hypercoagulability, Post-thrombotic Syndrome, Venous Thromboembolism.

Tailored treatment of intestinal angiodysplasia in elderly.

BACKGROUND: Angiodysplasia of the gastrointestinal tract is an uncommon, but not rare, cause of bleeding and severe anemia in elderly. Different treatments exist for this kind of pathology. METHODS: The aim of this work was to study 40 patients treated for intestinal angiodysplasia with two different kind of endoscopic treatments: argon plasma coagulation (APC) and bipolar electrocoagulation (BEC). RESULTS: Age of patients was similar in both groups (76,2 ± 10.8 years vs 74,8 ± 8,7 years, P = 0,005). Angiodysplasia treated were located in small bowel, right colon, left colon, transverse colon and cecum. We analysed number of treatment, recurrence, hospital discharge, needs of blood transfusions before and after endoscopic treatment. Number of treatment was the same in both groups (1,2 ± 0,2 vs 1,1 ± 0,1, P < 0,001). We had more recurrence in patients treated with BEC (4/20 vs 2/20, P < 0,001). Hospital discharge was comparable in both groups (5,3 ± 3,1 days vs 5,4 ± 2,8 years, P < 0.001). CONCLUSIONS: Treatment of angiodysplasia in elderly is not easy. Different kinds of treatment could be adopted. APC and BEC are both safe and effective. The choice of a treatment should consider several factors: age, comorbidity, source of bleeding. In conclusion we think that treatment of bleeding for angiodysplasia in elder population should be a tailored treatment.

"Ductal adenocarcinoma in anular pancreas".

INTRODUCTION: The annular pancreas is a congenital anomaly in which pancreatic tissue partially or completely surrounds the second portion of the duodenum. Its often located above of papilla of Vater (85%), rarely below (15%). This pancreatic tissue is often easily dissociable to the duodenum but there is same cases where it the tissue is into the muscolaris wall of the duodenum. MATERIAL AND METHODS: We describe three case of annular pancreas hospitalized in our facility between January 2004 and January 2009. There were 2 male 65 and 69 years old respectively and 1 female of 60 years old, presented complaining of repeated episodes of mild epigastric pain. Laboratory tests (including tumor markers), a direct abdomen X-ray with enema, EGDS and total body CT scan were performed to study to better define the diagnosis. EUS showed the presence of tissue infiltrating the muscle layer all around the first part of duodenum. Biopsies performed found the presence of pancreatic tissue with focal areas of adenocarcinoma. Subtotal gastrectomy with Roux was performed. The histological examinations shows an annular pancreas of D1 with multiple focal area of adenocarcinoma. (T1aN0M0). RESULTS: We performed a follow up at 5 years. One patients died after 36 months for cardiovascular hit. Two patients, one male and one female, was 5-years disease-free. DISCUSSION: Annular pancreas is an uncommon congenital anomaly which usually presents itself in infants and newborn. Rarely it can present in late adult life with wide range of clinical severities thereby making its diagnosis difficult. Pre-operative diagnosis is often difficult. CT scan can illustrate the pancreatic tissue encircling the duodenum. ERCP and MRCP are useful in outlining the annular pancreatic duct. Surgery still remains necessary to confirm diagnosis and bypassing the obstructed segment.

Venous aneurysm complicating arteriovenous fistula access and matrix metalloproteinases.

INTRODUCTION: An arteriovenous fistula (AVF) for placed for hemodialysis may be burdened by one particular complication-the formation of a venous aneurysm. It has been shown that matrix metalloproteinases (MMPs) and neutrophil gelatinase-associated lipocalin (NGAL) could represent markers of disease in both venous and arterial vessels. MATERIALS AND METHODS: This case study reports a rare case of enormous venous aneurysm-correlated MMP and NGAL levels in a woman with an AVF. RESULTS: Significantly higher levels of plasma MMP-1, MMP-8, MMP-9, and NGAL were detected in this patient during aneurysmal evaluation before the surgery; these levels significantly decreased 1, 3 and 6 months after surgery. CONCLUSION: MMP and NGAL levels could represent a marker of aneurysmal disease, and their plasma evaluation could help physicians to stratify the risk of complications in patients with an AVF.