Primary Stenting of Right-Sided Subclavian Artery Stenosis Presenting as Subclavian Steal Syndrome: Report of 3 Cases and Literature Review.

BACKGROUND: Right-sided subclavian artery stenosis (SAS) is a rare cerebrovascular disease involving the upper extremities. Considering an endovascular approach for its management requires increased endovascular and catheterization skills when compared with the left side, due to the close approximation of the right subclavian artery origin, vertebral, and common carotid arteries. METHODS: Three patients suffering from proximal right-sided SAS were treated in our center through primary stenting. Percutaneous transfemoral and transbrachial approaches were used for vascular access, whereas in 2 cases an additional carotid protection device was deployed intraoperatively. RESULTS: Technical success was met in all 3 cases, with no intraoperative or postoperative complications being observed. All patients resumed ambulation and were uneventfully discharged the next day with dual antiplatelet medication. No recurrent stenosis was reported in duplex ultrasound scan during 6-month follow-up, with all patients reporting resolution of their symptoms. DISCUSSION: Subclavian artery stenosis is an uncommon vascular disease, showing a 4-fold left, rather than right-sided predisposition. Although a low-grade stenosis is usually asymptomatic and may remain unobserved, a severe stenosis may cause retrograde blood flow in the ipsilateral vertebral artery, leading to a medical condition with various clinical symptoms, known as subclavian steal syndrome. A number of open surgical techniques exist for management of subclavian artery stenosis, although a paradigm shift in the 21st century has led to the introduction of minimally invasive techniques for its treatment, with available modalities including angioplasty, stenting, and the kissing stent technique.

Neuroendocrine carcinoma as a rare cause of jejunal intussusception in an adult. Management and literature review.

Intussusception of the small bowel is an uncommon condition, with the majority of cases being observed during infancy. A number of points are responsible, with benign and malignant lesions of the small intestine being the most common. Herein, we present the case of a 75-year-old male patient with vague abdominal pain and black stool during defecation, who underwent surgery due to jejunal intussusception. Pathology report demonstrated a neuroendocrine carcinoma as the underlying cause for his condition, with no additional metastases during the initial diagnosis. Although a conservative approach for management of intussusception is viable, the possibility of gastric outlet obstruction and the presence of malignancy as the primary point usually lead to urgent surgery. In the case of malignancy, adjuvant chemotherapy or additional symptomatic therapy with close follow-up may be required depending on tumor's grade and aggressiveness.

Laparoscopic repair of an excessive Morgagni hernia in an adult presenting as upside-down stomach.

INTRODUCTION: Morgagni hernia is defined as the intrathoracic protrusion of abdominal viscera through a defect in the anterior diaphragm. It represents an uncommon type of diaphragmatic congenital hernia. CASE PRESENTATION: A 68-year-old female patient was admitted in our department due to progressive epigastric discomfort for the past four months. A preoperative diagnosis of a paraesophageal hernia was set through computer tomography, with gastric portions and parts of small bowel protruding inside the thoracic cavity. Intraoperatively, an excessive diaphragmatic defect was detected in the anterior side of the diaphragm. Reduction of the hernia's contents inside the abdominal cavity was achieved through laparoscopy, with the additional fixation of an intraperitoneal non-absorbable mesh for reinforcement of the diaphragmatic wall. Patient was discharged uneventfully on the 4th postoperative day. DISCUSSION: Morgagni hernias refer to a rare type of diaphragmatic congenital hernias, usually identified during childhood, leaving only a small number of cases observed in the adult population. Its diagnosis can pose a challenge due to the non-specific and usually asymptomatic presentation. An early surgical management is advised due to an increased number of potentially lethal complications, such as gastric incarceration and obstruction. Treatment consist of open surgical techniques through a trans-thoracic or a trans-abdominal approach, although a paradigm shift in the 21st century considers minimal invasive laparoscopic surgery the treatment of choice. CONCLUSSION: A high index of clinical suspicion is required for diagnosis of Morgagni hernias, while prompt management is advised. Laparoscopy is considered the best approach in the hands of an experienced surgeon.