Aortic rupture of acute aortic dissection type treated with thoracic endovascular aortic repair (TEVAR).

OBJECTIVE: Acute aortic dissection (AAD) is one of the most frequent aortic emergencies, which occurs to the vascular specialist. Endovascular reconstruction of the true lumen using minimally invasive stent grafting or stenting has become increasingly popular and widespread among institutions. The aim of this paper is to report a case series composed by twenty-eight patients, who underwent endovascular intervention for acute type B aortic dissections complicated by rupture using thoracic endovascular aortic repair (TEVAR). PATIENTS AND METHODS: All patients with type B-AAD were admitted to the surgical intensive care unit and initially managed with a standing protocol for medical management of AD and observed for evidence of visceral or extremity malperfusion. RESULTS: No major complications or adverse reactions occurred during the immediate postoperative period. Two patients died in the first three months of the study; both developed a cerebral ischemia. Three patients were lost at follow-up, the remaining twenty-three had a mean follow-up of 41.12±3.55 months (range: 36-58). CT scans were routinely performed at 3 months, 6 months, and yearly after the intervention for all patients. CONCLUSIONS: Endovascular repair is developing as a strong alternative to surgery and may eventually evolve as a superior method for definitive treatment for patients with appropriate indications, such as complicated dissections. AD rupture may be more common in arch stent-graft patients with an ascending aortic diameter >4 cm and with a multi-stents placement.

Treatment of facial vascular malformations with embolisation and surgical resection.

INTRODUCTION: Facial arteriovenous malformations (AVMs) are quite rare morbid conditions that clinically present themselves mainly as a massive bleeding or a significant aesthetic defect. Vascular malformations do not regress spontaneously; this is the reason why their resection is necessary. The successful treatment of these vascular anomalies is often compromised, since a high incidence of recurrence could be expected if the lesion is not managed properly. A multidisciplinary approach is needed for the assessment and treatment of these lesions. The therapeutic management involves a preoperative superselective embolisation, a surgical resection of the lesion within the following 24 hours and finally an aesthetic reconstruction. PATIENTS AND METHODS: The study was carried out on a total of 62 patients with facial AVMs; all the patients underwent surgical procedures from 2000 to 2010. RESULTS: The case series consisted of 8 patients with haemangiomas and 54 patients with AVMs; in 31 cases of the latter group the vascular malformations showed a low blood flow, whereas the remaining 23 cases had a high blood flow. The lips were the most common localization. All 54 patients with AVMs underwent a surgical resection. Among the 23 patients with facial high-blood flow AVM, 21.7% were classified as stage I Schobinger, 47.9% as stage II, and 30.4% as stage III. The treatment consisting of associated embolisation and resection was performed in 14 arteriovenous malformations (stage II, III) with high blood flow; 5 of them required a flap reconstruction. CONCLUSION: Recent advances in microsurgery and interventional angioradiology have improved the prognosis of treatment for these malformations. Combining embolisation and resection with aesthetic flap reconstruction represents the therapy of choice for facial arteriovenous malformations, as it prevents their recurrence.

[Abdominal "packing": indications and method]. / Il packing addominale: indicazioni e metodo.

Abdominal packing is a lifesaving technique for temporary control of severe injury and it is used in damage control surgery schedule. Technically bleeding from abdominal cavity can generally be achieved by applying pressure with several large abdominal packs. Its possible too applying packs in organ-specific techniques (early abdominal packing). A wide review of the literature has allowed to emphasize the most common problem of this technique, the adequacy of the particular indications, their evolution, timing, the results in general and particular which multiple critical situations and not always predictable when an intensive diagnostic and methodological approach is necessary in. The principal indications are when complex anatomic lesions are diagnosed with not ruleable hemorrhages, in presence of metabolic failure (hypothermia < 35 degrees C, acidosis > 7.2, coagulopathy PTT > 16 seconds: These three derangements become established quickly in the exsanguinating trauma patient and, once established, form a vicious circle which may be impossible to overcome. The results are encouraging and we can evaluate a median survival of the 70%, certainly superior to the obtainable survival with immediate surgical repair. Immediate failures are substantially due to bleeding, especially in "underpacking" case, and remote: these last can be premises, fundamentally septic and bound at the time of stay (above the 72 hours) and associated by the coexistence of lesions: in these situations is possible a MOF syndrome due to excessive intra-abdominal pressure (overpacking) or to an Abdominal Compartment Syndrome.

[Superior vena cava syndrome]. / Sindrome della vena cava superiore.

Superior vena cava syndrome is due to an intrinsic or extrinsic caval obstruction that evolves in acute or subacute way with distinctive clinical feature such as respiratory symptoms and venous stasis. Since 1998 we have treated three cases of spontaneous superior vena cava thrombosis in neoplastic patients who underwent several infusion of chemotherapy, respectively for a breast, uterine and rectum cancer. All patients was female, 52, 58 and 70 years old. The first two cases was treated with locoregional thrombolysis by infusing Urokinase 50,000 UI/h during 24 hours and Urokinase 50,000 UI/h during 12 h the third one. After that, we have positioned a 16/9 wallstent: in the first two cases directly into the superior vena cava, in the third case in the subclavian-anonyma truncus. We had in all cases the complete opening of the stent within the first 48 hours without complications, enabling us to reach a free caval diameter of about 2 cm with resolution of the clinical signs. In patients with high surgical risk, the caval wall-stent is the first choice to solve the vein recanalization.

[Deep venous thrombosis and neoplastic pathology: our experience in emergencies]. / Trombosi venose profonde e patologia neoplastica: nostro contributo in urgenza.

Deep vein thrombosis incidence is 1/1000 per year; it is associated with many risk factors which is considered as "thrombophilic states". Its pathogenesis is complex, caused by alterations of hemostasis system. Many studies have established the relation between cancer and subsequent venous thromboembolism, confirming the relationship of neoplastic cell interaction with coagulation system. Forty-seven patients admitted to the hospital from 1987 to 1996 with symptomatic clinically proved deep vein thrombosis were included in a retrospective study. Routine examination at the time of diagnosis of deep vein thrombosis revealed an occult cancer in 8 out of 47 patients; 9 out of 47 patients were admitted in hospital with vein thrombosis and known cancer. The aim of this study is to suggest the best, first treatment of vein thromboembolism in emergency to avoid the dangerous pulmonary embolism complication. The patients affected with deep vein thrombosis and cancer were elderly (over 70 years old, in mean); the neoplasia was of digestive system (8/17) in advanced metastatic stage there was cancer familiarity in 7 out of 47 patients. The high risk of pulmonary embolism associated to deep vein thrombosis suggests the importance of early starting the anticoagulant therapy and placing caval filter.

Spontaneous pseudocystogastrostomy as a cause of gastrointestinal bleeding. Management by selective embolization.

A case of pancreatic bleeding pseudocyst communicating with the stomach, developing after post-operative acute pancreatitis is reported. The successful treatment by selective embolization is described and alternative methods of management are reviewed.