True Giant Ruptured Superficial Femoral Artery Aneurysm in Nonagenarian Female Patient: A Case Report and Review of the Literature.

Atherosclerotic superficial femoral artery (SFA) true aneurysm is rare and often associated with other aortic or peripheral aneurysms, usually discovered when it reaches a considerable diameter or becomes symptomatic. We present the case of a 92-year-old woman admitted in the emergency department with a huge ruptured SFA aneurysm. The patient underwent successful aneurysmectomy, followed by bypass grafting. Degenerative SFA aneurysms differ from other peripheral aneurysms, being usually larger and symptomatic at presentation, occurring in old people, and representing life-threatening situations. The commonest symptom is rupture.

Symptomatic aneurysm of a perforating peroneal artery after a blunt trauma.

A 48-year-old woman was referred to us for a pulsatile and painful mass on the right leg after a trauma occurred 2 months earlier. The duplex scan revealed the presence of an aneurysm of the perforating peroneal artery. The patient underwent an endovascular coil embolization of the aneurysm. The duplex-scan follow-up showed the patency of the peroneal vessel and the complete aneurysm thrombosis. The patient was discharged in good condition without pain. In literature, only four cases of aneurysm of perforating peroneal artery aneurysm, all with a clear traumatic etiology, are reported. In this case, the endovascular treatment was safe and effective.

Acute management of aortoesophageal fistula and tracheoesophageal fistula treated by thoracic endovascular aortic repair and esophageal endoprosthesis: a case misdiagnosed as esophageal cancer.

Aortoesophageal fistula is rare but fatal if untreated. Open thoracic surgery is associated with high operative mortality and morbidity. We report a case of a 77-year-old man who, treated with thoracic endovascular aortic repair (TEVAR) for descending thoracic aneurysm in another center, after an acute episode of hematemesis and melena was referred to our center. The total body computed tomography scan showed the presence of reperfusion of the descending thoracic aneurysm sac (8.8 cm in diameter) in the proximal and distal TEVAR landing zone (endoleak type I) without clear signs of fistulous tract with the esophageal lumen. The patient underwent new TEVAR inside previous implantation with proximal landing very close to left subclavian artery and distal landing just above celiac trunk. For the presence of a tracheoesophageal fistula, an esophageal endoprosthesis was implanted few days later, and a jejunostomy was performed. At 30 days, patient was in good general condition, but he died at 3 months' follow-up. Aortoesophageal fistula is a rare and usually fatal condition; early recognition and TEVAR treatment prevent immediate exsanguination in patients, but after deployment of the endograft, most patients are at risk for infectious complications. Cessation of bleeding and restoration of circulation is of paramount urgency, but infectious diseases and esophageal repair remain open problems.

Endovascular treatment of a symptomatic mycotic aneurysm of the peroneal artery.

A 69-year-old man was referred to our facility owing to the sudden onset of a compression-like pain in the right leg, without limb-threatening acute ischemia. The duplex scan examination, followed by a selective leg angiography, showed the presence of a peroneal artery aneurysm. A diagnosis of mycotic aneurysm was made on the basis of the patient's clinical condition, positive blood cultures, and the unusual location of the lesion. Endovascular repair was performed by using a coil embolization and covered stent release. The patient was discharged in good general condition with complete pain relief. In previously published data, only four cases of peroneal artery aneurysm with a mycotic etiology have been reported. In this case, the endovascular treatment was safe and resolutive.

Management and urgent repair of ruptured visceral artery aneurysms.

Five patients were treated for ruptured visceral artery aneurysms during the last 9 years, including two splenic and three pancreaticoduodenal aneurysms. The average size of aneurysm was 2.6 cm (range: 1.5-5 cm). All patients underwent open surgical treatment. There was one operative death. After a mean follow-up of 46.6 months, there were no cases of mortality or secondary complications. The authors conclude that operative treatment of ruptured visceral artery aneurysms is durable.

Free-floating thrombus in the internal carotid artery: diagnosis and treatment of 16 cases in a single center.

BACKGROUND: Free-floating thrombus in the internal carotid artery (FFT-ICA) is a rare condition and its real incidence is unknown. The most common etiology is a complication of an atherosclerotic plaque, but several medical conditions can be responsible. The purpose of this study was to retrospectively analyze our experience with carotid endarterectomy in the management of FFT-ICA and also to analyze the patient outcome. METHODS: A retrospective review was performed of all patients admitted during the past 9 years with a diagnosis of FFT-ICA. Patient demographics, clinical manifestations, diagnostic modalities, surgical indications, operative details, postoperative courses, and follow-up information were recorded from the hospital database. RESULTS: Between January 2000 and December 2008, in our Unit, 2,572 carotid endarterectomies were performed for carotid artery disease. A total of 16 patients (16 of 2,572; 0.62%) were treated for an FFT-ICA. In all, 87.5% (14 of 16) of patients had neurological symptoms. All patients underwent a duplex scan. In 75% (12 of 16) of cases, additional diagnostic tests were performed: digital subtraction angiography (DSA), magnetic resonance angiography, or computed tomographic scan. Duplex scan and DSA detected the FFT-ICA in 62.5% and 100% of cases, respectively. Computed tomographic scan and magnetic resonance angiography failed to provide a diagnosis in majority of the patients (33.4% and 66.7%, respectively). The presence of FFT-ICA was confirmed intraoperatively in all cases. The cumulative stroke rate after surgery was 6.3% (one of 16). Of the total number of patients discharged, 68.75% showed an improvement of neurological symptoms, 12.5% were asymptomatic, 12.5% had no changes in symptoms, and 6.25% of cases worsened. At 30-day follow-up, the survival rate was 93.7% and 75% of patients showed an improvement of neurological symptoms, 12.5% were asymptomatic, and 6.25% died. In all, 6.25% of patients were lost to follow-up. CONCLUSION: Patients with FFT-ICA are usually symptomatic and present with an acute emergency. DSA remains the gold standard diagnostic test in FFT-ICA detection. We cannot assert that early surgery is superior to temporary anticoagulation and/or delayed intervention because of the absence of a comparison group. However, our retrospective results suggest that prompt intervention seems to be a safe alternative in FFT-ICA treatment.

Early carotid surgery in patients after acute ischemic stroke: is it safe? A retrospective analysis in a single center between early and delayed/deferred carotid surgery on 285 patients.

BACKGROUND: The early risk of stroke after transient ischemic attack (TIA)/stroke is of the order of 5-10% at 1 week and 10-20% at 3 months. Even if carotid endarterectomy (CEA) is the treatment of choice in symptomatic internal carotid artery stenosis, the timing of carotid intervention after acute stroke is not yet codified. The authors want to determinate whether early CEA is safely carried out in the first few hours (<48 hours) successive to the nondebilitating neurological event and whether the outcome (TIA/stroke/death) in these cases is comparable with the results of those treated by delayed/deferred surgery (range, 48 hours-24 weeks). METHODS: In 4 years, the authors performed 1,184 CEA (285 symptomatic). Five groups were formed from 285 symptomatic patients, according to interval between TIA/stroke onset and performance of CEA: G1, less than 48 hours; G2, 48 hours-2 weeks; G3, 2-4 weeks; G4, 4-8 weeks; G5, 8-24 weeks. Surgery was never performed on patients with disabling neurological deficit (modified Rankin Scale, 5) at the time of admittance, cerebral lesions greater than 3 cm at magnetic resonance/computed tomography scan, presence or suspect of parenchymal hemorrhage associated with ischemic damage, condition considered unfit for surgery (American Society of Anesthesiology classification grade V), and occlusion of the cerebral middle artery. Neurological and diagnostic examinations (duplex-scanning and computed tomography/magnetic resonance scan) were used in determining the selection for early CEA. RESULTS: Cumulative TIA/stroke/death rate after CEA was 3.8% (11/285) and at 30 days was 2.8% (8/285). The cumulative TIA rate after CEA and at 30 days was 0% (0/285). The cumulative stroke rate after CEA was 3.5% (10/285) and at 30 days was 2.4% (7/285). The cumulative death rate after CEA and at 30 days was 0.3% (1/285). Stroke rate after CEA in each group was: G1 4.2% (3/70); G2 3.2% (2/61); G3 0% (0/22); G4 3.4% (1/29); G5 3.8% (4/103). Any statistically significant difference between G1 and the other four groups was not detected with regard to postoperative stroke: G1 (4.2%) versus G2 (3.2%), p = 0.7641; G1 (4.2%) versus G3 (0%), p = 0.7648; G1 (4.2%) versus G4 (3.4%), p = 0.8473; G1 (4.2%) versus G5 (3.8%), p = 0.8952. No hemorrhagic stroke was detected after early CEA. The type of anesthesia and the use of a shunt didn't show any significant difference between the five groups. CONCLUSIONS: The analysis of these records suggests that early CEA in the acute post stroke phase, for patients clinically selected, does not result in greater complications than when performed delayed or deferred . Furthermore, the advantage of early CEA is the reduction of recurrent strokes, as untreated patients present a higher incidence of neurological events.

Carotid endarterectomy: comparison between general and local anesthesia. Revision of our experience with 428 consecutive cases.

BACKGROUND: This sequential retrospective monocentric study compares the results between general and local anesthesia for carotid endarterectomy (CEA). METHODS: Between November 2002 and October 2004, 428 CEAs were performed in our vascular unit. Two groups were formed: group GA (general anesthesia): 219 patients operated under general anesthesia; group LA (local anesthesia): 209 patients operated under local anesthesia. RESULTS: No mortality was found in both groups. After surgery, three strokes were detected in group GA and three in group LA (GA 1.36% vs. LA 1.43%, p = .9540); After CEA, there were three TIAs in GA group and none in LA group (GA 0.42% vs. LA 0%, p = .2634). CONCLUSION: The morbi-mortality was not influenced by the type of anesthesia used for carotid surgery. No statistical difference was detected in the perioperative neurological and cardiopulmonary complication rates between GA and LA.

Rupture of a true giant aneurysm of the posterior tibial artery: a huge size of 6 cm on diameter.

True aneurysms of tibial artery are rare occurrences and their rupture is really rare. We report the case of a 59-year-old man who, after an episode of bacterial endocarditis, presented a posterior tibial aneurysm formation evolved in rupture. To our knowledge, this is the first case of a true giant aneurysm rupture of the posterior tibial artery (diameter, 6 cm). The treatment consisted of aneurysmectomy and surgical arterial ligation. A follow-up of 24 months was performed with good results.

Mesothelioma and internal carotid artery occlusion: acute ischemic stroke and efficacy of emergency carotid thrombectomy.

We report the case of a 54-year-old man with acute stroke caused by left internal carotid artery (ICA) occlusion secondary to pleural mesothelioma, discovered later. The cranial computed tomography scan revealed a left hemisphere ischemic lesion. At neurological examination, the modified National Institutes of Health Stroke Scale (mNIHSS) score was 9. The carotid duplex scan (DS) showed a complete thrombotic occlusion of the left ICA. The patient underwent emergency carotid thrombectomy. The screening tests revealed thrombocytosis, hyperfibrinogenemia, increased C-reactive protein values, and multiple left pleural mesothelioma nodularity confirmed at the immunohistochemical investigation. After surgery, the patient's neurological symptoms improved, with an mNIHSS score of 3. At 30 and 120 days, the DS follow-up showed regular patency of the ICA.