Infrarenal endograft clamping in late open conversions after endovascular abdominal aneurysm repair.

OBJECTIVE: The aim of this study was to report the technical aspects and outcomes of late open conversion (LOC) after endovascular aneurysm repair (EVAR) in a single center by using exclusively infrarenal clamping of the endograft as an alternative to suprarenal or supraceliac aortic clamping. METHODS: A retrospective analysis of EVAR requiring late explantation (>30 days) from January 1996 to October 2016 was performed. Patients' demographics, type of endograft, duration of implantation, reason for removal, extent of stent graft removal, type of reconstruction, 30-day mortality, postoperative complications, and long-term survival were obtained for analysis. RESULTS: During the study period, 28 patients required LOC. The mean age at conversion was 75.11 ± 6.65 years; 26 of 28 (92.86%) were male. Grafts were excised after a median of 41.4 months (range, 5.97-112.67 months), with 21 of 28 explantations (75%) performed electively. Multiple types of EVAR devices have been explanted; suprarenal fixation was present in 75% of the cases. The indication for LOC was the presence of an endoleak in 27 cases (20 type I, 4 type II associated with aneurysm growth, 3 type III, and 3 endotensions; in 3 cases, multiple types of endoleak were present) and graft thrombosis in 1 case. All patients underwent a transperitoneal approach with infrarenal clamping. No patient required revascularization of visceral or renal vessels. Complete removal of the stent graft was performed in 8 of 28 cases, partial removal in the remaining 20 cases (with conservation of the proximal portion in 16 of 20 cases). Technical success was 100%. Overall 30-day mortality was 7.14% (2/28). The 30-day mortality was 9.5% in elective patients and 0% in the urgent setting; this difference was not statistically significant (P = .56). Postoperative kidney injury rate was 7.7% (2/26). Mean follow-up was 47.37 ± 55.67 months (range, 0.23-175.07 months). The estimated 5-year survival rate was 78%. No aneurysm-related death or additional procedure occurred during follow-up. CONCLUSIONS: LOC after EVAR using infrarenal clamping of the endograft is a feasible and effective technique, with satisfactory postoperative mortality and morbidity. This method allows simplification of the surgical technique and may avoid renal and visceral complications related to suprarenal or supraceliac clamping.

Surgical management of isolated superficial femoral artery degenerative aneurysms.

OBJECTIVE: To investigate the mode of presentation, diagnosis, association with other aneurysms, operative management, and outcomes of superficial femoral artery (SFA) aneurysms. METHODS: Records of all patients who underwent surgery for isolated, true SFA aneurysms (not due to infection, vasculitis, or tissue disorders) from 2002 to 2012 in two European centers were retrospectively analyzed. Demographic (sex, age), clinical (cardiovascular risk factors, location of the aneurysm, symptoms, presentation, emergency setting), surgical and radiological data (diameter, surgical technique, runoff vessels patency, presence of aneurysms elsewhere) were obtained for analysis. Follow-up was undertaken with clinical and ultrasound examinations at 1 month, 3 months, 6 months, 12 months, and yearly thereafter. The patency of the graft and the status of the anastomoses and inflow and outflow vessels were assessed. Main end points were represented by 30 days and long-term mortality and amputation-free survival. RESULTS: A total of 27 cases of SFA aneurysm were analyzed. Mean age at operation was 78 years ± 8.5. At presentation, SFA aneurysms were often symptomatic (rupture was present in 7/27 cases and acute distal ischemia in 6/27 cases), large (mean diameter, 54 mm ± 33.1 mm), bilateral (38% of the cases), and associated with aneurysms elsewhere (84%). Sixteen patients underwent resection of the aneurysm and polytetrafluoroethylene interposition graft, seven patients exclusion of the aneurysm with a femoropopliteal bypass (autogenous bypass in five cases, prosthetic in two), three patients simple ligation, and one patient underwent primary amputation. Mean follow-up was 41.47 months (range, 0.43-128.67 months). Early (<30 days) mortality and amputation rate were 4% and 7%, respectively. Estimated 5-year survival, limb salvage, and graft patency rates were 62%, 88%, and 85%, respectively. CONCLUSIONS: Degenerative aneurysms of the SFA display peculiar characteristics (in terms of clinical onset, diagnostic timing, and clinical behavior) so that they differ from other peripheral aneurysms. In fact, they often grow to reach a considerable diameter before medical attention is sought, presenting with rupture or ischemia at diagnosis. SFA aneurysms preferentially affect elderly men and are often associated with aneurysms elsewhere. However, despite their rarity, the treatment is usually feasible, and long-term outcomes are good.

Endovascular stent grafting of a posterior tibial artery pseudoaneurysm secondary to penetrating trauma: case report and review of the literature.

Endovascular treatment of posttraumatic pseudoaneurysms has become a viable less-invasive option when compared with open repair. In this study, we present a case of a posttraumatic pseudoaneurysm of the posterior tibial artery in a 34-year-old man treated with endovascular stent grafting. An extensive review of the literature has been performed.

Elective palliative resection of incurable stage IV colorectal cancer: who really benefits from it?

PURPOSE: Despite the encouraging results of chemotherapy in patients affected by incurable colorectal cancer (CRC), surgical resection of a primitive tumor is still a common approach worldwide. The identification of prognostic factors related to short survival (<6 months) may allow excluding from resective surgery those who may not benefit from it. METHODS: A retrospective analysis was performed of 15 variables in a population of 71 patients undergoing nonemergency palliative primary resections of incurable CRC, including patients' demographics and clinical/histopathological characteristics of the tumor. RESULTS: No variables were related to perioperative mortality (8.5% overall). A multivariate analysis revealed that older age (≥80 years) and metastasis to more than 25% of the lymph nodes were associated with survival (4 and 6 months, respectively). Mucoid adenocarcinoma therefore tends to be associated with the prognosis (P = 0.070). CONCLUSIONS: An elderly age tends to be a contraindication to an elective primary tumor resection in patients affected by incurable CRC. Massive lymph node involvement and mucoid adenocarcinoma should also be considered before planning major colonic surgery.

Extracranial Internal Carotid Artery Aneurysms: case report of a saccular wide-necked aneurysm and review of the literature.

PURPOSE: To describe a case of atherosclerotic Extracranial internal Carotid Artery Aneurysm (ECAA) with an unique "diverticulum-like" morphological structure, surgically treated and to review the experiences of major referral centers. CASE REPORT: A 76-year-old woman presented with persistent dysphagia and transient hypophonia caused by a growing pulsatiling mass of the neck; duplex ultrasonography and angio-CT scan demonstrated a wide-necked, saccular aneurysm at the origin of the right Internal Carotid Artery (ICA). A total aneurysmectomy with patch angioplasty of the aneurysm of the neck on the carotid wall was successfully performed. No perioperative complications were encountered; at one year follow-up the patient was asymptomatic without any neurological complication and with carotid patency. CONCLUSIONS: Open surgery remains the gold standard for the treatment of extracranial internal carotid artery aneurysms in terms of patency and reduced risk of adverse complications; endovascular procedures may, in selected cases, provide a valuable additional tool in the armoury of the physician.

Carotid endarterectomy with mini-invasive access in locoregional anaesthesia.

AIM: To assess the validity of a carotid endarterectomy (CEA) with a mini-invasive access via a 3-7 cm cutaneous incision in locoregional anaesthesia as a viable alternative to the traditional access with a cutaneous incision longer than 7 cm. MATERIALS AND METHODS: We carried out a retrospective analysis of 76 consecutive patients (Group A) who had undergone carotid CEA in locoregional anaesthesia with cervical mini-access (3-7 cm incision), compared to a preceding series of 95 patients (Group B) who had undergone the same operation through a traditional access (incision > 7 cm). All patients in Group A were examined solely by means of duplex ultrasound scanning. RESULTS: No mortality occurred in Group A and the morbidity rate was as follows: 1.3% strokes, 2.6% minor neurological events and 6.5% transitory deficit of peripheral nerves. In Group B, the mortality rate was 1%, with the following morbidity rate: 2% strokes, 1% minor neurological events and 7.3% transitory deficit of peripheral nerves. Statistical analysis revealed the two groups as being compatible for age, sex, associated pathologies and type of surgery. No statistically significant differences emerged between the two series of patients with regards to neurological morbidity or operative mortality. CONCLUSIONS: In addition to being more aesthetically pleasing, mini-invasive access is a viable alternative to the traditional access for patients undergoing carotid CEA in locoregional anaesthesia.

Morphological Changes in the Carotid Artery Intima after Gastric Bypass for Morbid Obesity.

BACKGROUND: Carotid intima-media thickness (C-IMT) can be considered as an early marker of atherosclerosis, thus representing a reliable cardiovascular risk predictor. Bariatric surgery decreases the burden of cardiovascular disease in obese patients through complex mechanisms, of which weight loss is merely the most evident epiphenomenon. The aim of this study is to evaluate C-IMT variations in patients undergoing Roux-en-Y gastric bypass (RYGB) and possible correlations with biometric parameters and cardiovascular risk factors. METHODS: Thirty patients undergoing RYGB for morbid obesity were enrolled for carotid artery B-mode ultrasound evaluation before surgery and at 1-, 3-, 6-, and 12-month follow-up; C-IMT was recorded at three levels (bulb, common, and internal carotid). At each one of the follow-ups, biometric and serohematic parameters were also collected. RESULTS: The 22 patients who completed the follow-up and were included in the study showed significant C-IMT reduction at all three levels at 12-month follow-up (p < 0.001). Along with a significant BMI reduction and diabetes/hypertension remission, we found a considerable decrease in total cholesterol (219 vs 164 mg/dl; p < 0.001) and uric acid (5.6 vs 4.5 mg/dl; p < 0.01) and a significant increase in HDL cholesterol (43.9vs59.2 mg/dl; p < 0.001). The data imply that the mean 10-year cardiovascular risk score drops by nearly 50 % (5.7 ± 5.6 vs. 2.9 ± 2.7 %, p < 0.001) according to Framingham cardiovascular risk stratification. CONCLUSIONS: RYGB is associated with significant decrease in C-IMT at 1 year. Pathophysiologic processes underlying such a variation, probably involving lipid and urate metabolism and their correlation with cardiovascular risk reduction should be confirmed by long-term prospective trials.

Early increases in cardiac troponin levels after major vascular surgery is associated with an increased frequency of delayed cardiac complications.

OBJECTIVE: To evaluate changes in cardiac troponin-I levels after major vascular surgery and their association with early and late postoperative cardiac complications. DESIGN: Prospective, observational investigation. SETTING: University teaching hospital. PATIENTS: 75 consecutive patients undergoing major vascular surgery. INTERVENTIONS: All patients received a standard sevoflurane-fentanyl anesthesia during the procedure. Blood levels of creatine kinase with MB subtype and cardiac troponin-I were assessed before surgery and then everyday for the first 3 days after surgery. At the same time, 12-lead electrocardiography was also performed, and occurrence of any cardiac adverse event was recorded. Patients were then followed up for 1 month after surgery. MEASUREMENT AND MAIN RESULTS: Troponin-I levels increased in 25 patients (33%) during the first 3 days after surgery; 9 of these patients (12%) had myocardial infarction. At univariate analysis, uncontrolled hypertension was the only risk factor for perioperative infarction (odds ratio, 16; (95% confidence interval, 3-74); however, multivariate logistic regression analysis failed to show statistically significant associations. Increases in troponin-I had a 100% sensitivity and 75% specificity in detecting myocardial ischemia with a 36% positive and 100% negative predictive values. Severe cardiac complication 1 month after surgery was reported in 5 patients (6.6%). The increase of cardiac troponin-I levels during the first 3 postoperative days was associated with an increased frequency of major cardiac complication at 1-month follow-up (P = 0.003), with a 100% sensitivity, 71% specificity, and 100% negative predictive value. CONCLUSIONS: Myocardial infarction after major noncardiac vascular surgery occurs in up to 12% of cases. Perioperative monitoring of troponin-I plasma levels may help to identify patients at increased risk for cardiac morbidity not only early after surgery but also during the first postoperative month.

Superior Mesenteric Artery Aneurysm Caused by Aortic Valve Endocarditis: The Case Report and Review of the Literature.

Infectious aneurysms of the superior mesenteric artery are a rare but life-threatening condition due to the risk of visceral ischemia, sepsis, or hemorrhage. In this study, we report the case of a superior mesenteric artery aneurysm (SMAA) secondary to a bioprosthetic valve endocarditis, successfully managed with aneurysm resection and saphenous vein interposition graft. We performed an extensive PubMed-based rewiew of the literature of the last 10 years on SMAA, which include the detection of 38 articles quoting 41 SMAAs. The case histories were divided in 2 groups: 18 cases belonged to nonmycotic group A and 23 cases were included in mycotic group B. In group A, 44.4% of patients were treated surgically, whereas in group B, 90.5%. The 2 study groups significantly differed (P = .01) in terms of surgical treatment. The surgical approach still remains the first choice of treatment in mycotic aneurysm.

Mini-invasive aortic surgery: a 2 year experience.

The aim of this study was to evaluate a less invasive technique for the exposure of the infrarenal aorta and its impact on the treatment of patients with abdominal aortic aneurysms (AAA). Fortyfour patients with AAA we re prospectively selected f o r minilaparotomy a ortic exposure and repair using asmall periumbilical midline incision, intra-abdominal nondisplaced retraction of the small bowel and conventional hand-sewn vascular anastomosis. Perioperative comparisons with a contemporary group of AAA patients treated with long, open midline incision and extracavitary small bowel retraction were made. There were no significant differences between the minilaparotomy and open surgical control group concerning operating room time, intraoperative and perioperative morbidity or mortality. Significant differences were shown between the two groups regarding intensive care unit stay; the return to a general diet and the length of hospitalization. Minilaparotomy exposure is safe and effective for the treatment of infrarenal AAA. This technique maintains quality outcome while reducing postoperative ileus, hospital stay and resource utilization.