Cervical paragangliomas: single centre experience with 44 cases.

Paragangliomas (PGL) are rare lesions of the neuroendocrine system; in the neck, they usually affect the carotid glomus (carotid body tumours-CBT). This retrospective analysis reports our experience in management of these lesions in patients treated by surgical resection. Between 2000 and 2014, 33 patients were surgically treated at our institution, obtaining a series of 44 cervical PGLs. Tumour characteristics, family history, diagnostic procedures, surgical treatment, short- and long-term outcomes were reviewed. A female prevalence was found (76% of cases). Familial cases occurred in 9 patients (20%); 6 presented with bilateral lesions and 1 had multiple paragangliomas. Lymph node metastasis was not found in any patient. All lesions were classified into three groups according to the latero-lateral diameter. Complete resection of the PGL was performed in all patients. Mortality was null; transitory cranial nerve deficit occurred in 20% of cases with permanent palsy in 6.7%. No perioperative stroke/TIA were observed. Surgical resection of PGL should be considered as the only therapeutic option because it can ensure complete removal of the disease. Patients with bilateral lesions and positive family history should be referred for genetic analysis. Preoperative planning of the surgical procedure by integrated diagnostic imaging and a full mastery of vascular surgery techniques are mandatory to minimise the risk of the most common postoperative complications. Long-term follow-up is recommended, particularly in patients with familial disease or sporadic lesions treated in an advanced stage.

Recurrent varicose veins of the legs: a single centre experience.

AIM: The aim of our study is to report our experience on the surgery for recurrent varicose veins of the legs over the period 2007-2012. MATERIALS AND METHODS: A series of 480 consecutive surgical procedures for varicose veins of the legs was reviewed; among a total of 480 cases, 65 procedures were for recurrent varicose veins. Data collected included clinical characteristics, surgical techniques, cause of recurrence and surgical outcomes. We analyzed the causes of recurrences in order to determine factors that influence recurrence itself. RESULTS: Sixty-five procedures for recurrent varicose veins were analized. The main causes of recurrence were: persistence of collaterals at the saphenofemoral junction (27.7%), inadequate stripping of the long saphenous vein (18.5%), perforating veins insufficiency (66.1%), sapheno-femoral junction neovascolarisation (12.3%), inguinal or popliteal cavernoma (27.7%), recurrence after short saphenous venous surgery (4.5%). CONCLUSIONS: We concluded that, as is clear from our study, the main cause of recurrence is inadequate surgery. This can only be due to inadequate preoperative assessment (lack of rigorous clinical and US Doppler rigorous evaluation) and not correct surgical technique, as it may occur if the surgery is performed by a surgeon inexperienced in this type of surgery.

An evaluation on management of carotid body tumour (CBT). A twelve years experience.

Objectives. Carotid Body Tumor (CBT) is a rare lesion of the neuroendocrine system but it is the most common form of head and neck paraganglioma (PGL). Our objective is to discuss the optimal management of these lesions to provide the best outcome of patients treated by surgical resection. Patients and Methods. A retrospective evaluation was obtained by review of the records of 20 patients with 26 CBT treated at our institution between 2000 and 2012. Primary tumor characteristics, diagnostic protocols, surgical treatment, short and long-term outcomes were collected and analyzed. Results. A total of 26 CBTs resections were performed on 20 patients; the age range was 21-89 years. There was a female prevalence (14 women-80% and 6 men-20%). Familial cases occurred in 6 patients (30%); of these, 3 patients had bilateral lesions and 1 patient multiple paragangliomas. In all cases no lymph node metastasis was found. All lesions were grouped into three groups according to the latero-lateral diameter: Group I < 3 cm; Group II 3<>5cm; Group III >5cm. All patients were managed by surgical resection of the CBT. There were no operative deaths. Overall we found transitory neurological impairment in 15,3% and permanent neurological deficit in 7,6% of cases. No complications occurred in all resections of Group I tumors. In Group II only 1 resection was followed by dysphonia by recurrent nerve palsy (after vagal nerve en-bloc resection). In Group III only 1 resection was followed by permanent vagus nerve palsy. Conclusions. Surgical removal of the tumor is the only treatment that can ensure a complete eradication of the disease. Family screening is of great importance in patients with hereditary forms. Careful preoperative planning of surgical procedure by integrated diagnostic imaging and a full mastery of the surgical technique can minimize the risk of the most common postoperative complications. Lifelong follow-up is mandatory to make early diagnosis of recurrent disease.

Post-EVAR aortic neck elongation: is a real phenomenon or a conformational change during the cardiac cycle?

BACKGROUND: Stent-graft migration is a late-term complication of endovascular abdominal aortic aneurysm repair (EVAR). A recent published study suggests that stent graft migration could be explained only by aortic neck elongation, mimicking the appearance of distal stent graft migration. Several studies about the use of dynamic CT Angiography (CTA) in the evaluation of aortic conformation changes during the cardiac cycle demonstrate that axial aortic pulsatility exists. No studies have been carried out to evaluate if a longitudinal aortic pulsatility also exists, that could justify the aortic neck elongation previously reported. AIM: To assess variations in length of proximal neck and infrarenal abdominal aorta in patients selected to undergo EVAR; to assess if longitudinal aortic pulsatility could modify EVAR planning. PATIENTS AND METHODS: 40 patients with Abdominal Aortic Aneurysm (AAA) underwent both static and dynamic ECG-gated 64-CTA (0.625 mm-slice-collimation; 1.25 mm-reconstruction increment). Manual measurements of aortic neck length and infrarenal abdominal aorta were performed on modified coronal images to determine dynamic conformational changes. RESULTS: Significant longitudinal pulsatility was demonstrated within aneurysm neck (19.1 ± 8.6%) and infrarenal abdominal aorta (6.6 ± 1.6%). When compared to dynamic measurements, the endograft previously selected according to static images in terms of fixation, would be potentially changed in 6/40 patients (15%) whereas 4/40 (10%) patients were not eligible for EVAR. CONCLUSIONS: Dynamic ECG-gated CTA may provide information regarding longitudinal pulsatile motion that could change the EVAR planning based on static imaging. Reported post-EVAR elongation of infrarenal aortic neck could be an unreal phenomenon only due to a conformational change during cardiac cycle.

Foot CT perfusion in patients with peripheral arterial occlusive disease (PAOD): a feasibility study.

PURPOSE: To prospectively assess the technical feasibility and reproducibility of quantitative foot perfusion multidetector-row computed tomography (MDCT) in patients with peripheral occlusive artery disease (PAOD) and to evaluate perfusion parameters changes after endovascular treatment. MATERIALS AND METHODS: Institutional review board approval and informed patient consent were obtained. 10 patients older than 65 years (mean 74.1 years, range 66-95 years) with PAOD and who were referred to our department for single-limb endovascular treatment were enrolled prospectively. All patients underwent foot CT perfusion examinations before and within 72 h after endovascular treatment. A 64-row CT lightspeed VCT scanner (GE Medical Systems) was used with acquisition of eight contiguous 5-mm reconstructed sections (60-s acquisition time; 40 mL Iomeprol 400 mgI/mL, @4 mL/s). Data were analyzed by two blinded readers using commercially available software to calculate perfusion parameters. Inter-observer and intra-observer agreement of perfusion CT analysis was assessed using Bland-Altman analyses and intra-class correlation coefficient (ICC). Changes in perfusion parameters after endovascular treatment were assessed using Wilcoxon's test. RESULTS: Good inter-observer and intra-observer agreement was obtained in all patients. Good agreement was obtained for perfusion parameters for the untreated foot and in repeated studies. By comparing perfusion parameters in the treated foot, a significantly shorter mean transit time (MTT) was obtained. CONCLUSIONS: Foot CT perfusion is a feasible and reproducible technique. A significant decrease of MTT between pre- and post-revascularization suggests improved flow in the below-the-knee arteries.

Aortic-neck dilation after endovascular abdominal aortic aneurysm repair (EVAR): can it be predicted?

PURPOSE: This study was performed to evaluate whether dynamic computed tomography (CT) can provide functional vessel information predicting outcomes of aortic neck in patients undergoing endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm (AAA). MATERIALS AND METHODS: Twenty patients with and 20 without AAA were enrolled. Electrocardiographically (ECG)-gated data sets were acquired with a 64-slice CT scanner. Axial pulsatility measurements were taken at three levels: 2 cm above the highest renal artery; immediately below the lowest renal artery; 1 cm below the lowest renal artery. Three independent readers performed the measurements. Systolic and diastolic blood pressures were measured in the brachial artery to calculate arterial-wall distensibility expressed as pressure strain elastic modulus (Ep). Cross-sectional area change, wall distensibility and Ep value were statistically compared. RESULTS: No significant differences were found in terms of Ep values in the suprarenal and juxtarenal level. In the AAA group, a significantly higher value was obtained at the infrarenal level. A subgroup of patients with AAA (45%) had a significantly higher Ep value at the infrarenal level. CONCLUSIONS: Dynamic CT provided insight into the abdominal aorta pathophysiology. Identifying patients with higher infrarenal distensibility could change selection of graft size to improve proximal fixation.

Carotid endarterectomy. Which diagnostic imaging technique is suitable for the indication and planning of surgery?

Based on data of recent literature, the most suitable preoperative diagnostic approach to cerebrovascular insufficiency, is evaluated. Correct indications for carotid endarterectomy in symptomatic and asymptomatic carotid stenoses are related to the degree of stenosis. This is also the most important predictive factor of stroke ipsilateral to the stenosis. Arteriography is being used selectively, while color Doppler US is the examination of first choice, combined with MR-angiography, cerebral CT and transcranial Doppler in most cases of carotid stenosis to be treated with surgery. An accurate and reliable preoperative diagnostic evaluation, together with an impeccable surgical procedure represents the indispensable prerequisite to maintain the mortality and complications within those strict limits that make a prophylactic intervention as carotid endarterectomy, advantagious to the patient.

Combined Surgery for cardiac and carotid disease: management and results of a rational approach.

OBJECTIVES: The aim of the present study was to apply a rational plan for simultaneous cardiac and carotid surgery in high-risk patients. MATERIALS AND METHODS: A consecutive series of 89 patients with coexisting severe cardiac and carotid disease were operated on during a 5-year period with routinary carotid shunting, moderate hypothermia and balanced anaesthesia. The combined surgical procedures were coronary artery by-pass grafts (CABG) + carotid endarterectomy (CEA) in 81 patients, CABG + CEA + aortic valve replacement (AVR) in four patients, and four cases of CEA + AVR. RESSULTS: Two deaths (2%), three acute myocardial infarctions (3%) and one (1%) major stroke occurred in five patients during the perioperative (30 days) period for a combined rate of death and/or disabling stroke of 3%. There were five reversible neurological deficits. Carotid and aortic mean clamping times were 9 and 60 min respectively. Patients were discharged after a mean length of stay in Intensive Care Unit (ICU) of 131 h and 7 days of hospitalisation post-ICU. CONCLUSIONS: Based on our results, combined interventions of CEA and CABG can be performed with an acceptable morbidity and mortality when severe carotid stenosis is associated with advanced, symptomatic cardiac disease. The management of these patients needs careful and appropriate pre-intra and post-operative assessment and timing aimed to reduce the ischaemic injuries, both cardiac and cerebral, especially during CBP time.

Neuropsychologic effects of carotid endarterectomy.

This study assessed neuropsychologic changes after internal carotid endarterectomy using a design that limited the confounding effects of surgical and anesthesiological stress. Twenty-eight patients (mean age = 65.9 years, SD = 8.4, range 45-79), underwent extensive neuropsychological assessment before and on the seventh day after carotid endarterectomy for symptomatic carotid stenosis greater than 75%. A similarly assessed control group of 30 patients underwent elective orthopaedic surgery. A third cognitive assessment was performed 4 months postoperatively on a subgroup of the study patients. No significant cognitive change occurred in the control group. The study patients showed significant improvement in verbal memory, constructive abilities, verbal attainment, and visual attention; a trend towards further improvement of verbal functions was evident at the late postoperative assessment. No side-specific cognitive change was observed. In conclusion, carotid endarterectomy performed for currently accepted indications significantly improves several cognitive functions.

Femoral neuropathy from iliac muscle hematoma complicating anticoagulant therapy: a surgical emergency. Report of a case.

A case of femoral neuropathy from iliac muscle hematoma occurring during heparin administration, successfully treated by early surgical decompression is reported. Following the evaluation of anatomy, possible pathogenesis and CT scanning findings, the role of early diagnosis is emphasized in the assessment of prognosis and for successful operative decompression.

[Left inferior vena cava and aneurysm of the abdominal aorta]. / Veine cave inférieure gauche et anévrysme de l'aorte abdominale.

A case of isolated left-sided inferior vena cava, without situs inversus, in a patient with abdominal aortic aneurysm is reported. On the basis of a review of literature, the authors recall the incidence and the embryology of this anomaly, and analyze its surgical implications, with particular reference to abdominal aortic surgery.

[Surgical treatment of thromboses of the inferior vena cava]. / Le traitement chirurgical des thromboses de la veine cave inférieure.

Results of surgical treatment in 22 patients with inferior vena cava thrombosis from extension of femoro-iliac thrombosis are reviewed. Indications for the different types of operation and their technical modalities (thrombectomy through a femoral approach or by cavotomy, caval blockade by clip or Mobin Uddin's umbrella alone or combined with thrombectomy, arteriovenous fistula) are discussed in relation to the various pathological and clinical pictures observed.

[Hepaticoportal arteriovenous fistula: a case report, discussion of physiopathological and clinical problems, and review of the published literature (author's transl)]. / A propos d'un cas de fistule artério-veineuse hépatico-portale. Problèmes de physiopathologie et clinique et revue de la littérature.

A patient developed an arteriovenous aneurysm between the gastroduodenal and middle colon arteries and the main mesentericoportal vein, following gastroduodenal resection. This case is described, and patients with arteriovenous fistulae in the portal region reported in the published literature (179 cases) are reviewed. Etiological, pathological, and clinical aspects in relation to surgical treatment and according to the type and location of the lesion, are also discussed. Emphasis is placed on a study of physiopathological problems, and the effects provoked by these fistulae on portal vein hemodynamics, arterial hemodynamic function, and on the general circulation are analyzed in greater detail.