Multimodal Neurophysiological Monitoring Reduces Shunt Incidence during Carotid Endarterectomy.

BACKGROUND: The use of shunt during carotid surgery is controversial. Different experiences are found in literature with transcranial Doppler (TCD), electroencephalogram (EEG), stump pressure (SP), and somatosensorial evoked potentials (SSEP). METHODS: We realized a retrospective analysis of patients treated with carotid endarterectomy in our unit in the last 2 years. We use several cerebral monitoring: until 2017 we preferred SP + TCD, and, if not available, EEG. Since 2017 we introduced EEG with SSEP, always in association with SP. We analyzed those 2 groups of patients: before and after introduction of EEG with SSEP. RESULTS: From January 2016 to December 2018 we performed 156 carotid revascularizations. In the first group of 93 patients treated under combined SP + TCD (or EEG), we observed 1 stroke (1.1%) and 2 transient ischemic attacks (TIAs) (2.1%); we selectively used a shunt in 21 cases (22.5%). In the second group, 63 patients had an SP + EEG with SSEP monitoring; we observed 1 stroke (1.5%) and 2 TIAs (3.1%), a shunt was necessary in 12 cases (12.9%). CONCLUSIONS: In our experience, EEG with SSEP represents an effective parameter to indicate shunt positioning, as we were able to reduce its use, with the same incidence of stroke and TIA.

The Debatable Choice of Iliac Inflow Source for Redo Femoropopliteal and Infrapopliteal Bypass.

BACKGROUND: Redo area region operation is associated with a significant morbidity such as neurovascular injury, infection, and lymphorrhea. The traditional management of occluded femoropopliteal grafts often includes redissection of a scarred groin to obtain adequate inflow via the common femoral artery. These procedures are more technically demanding and require more expertise and judgment than the primary operation. We describe a case of using the ipsilateral iliac branch prosthesis of aortobifemoral bypass as inflow for iliac-peroneal bypass, avoiding the previous groin incisions, to minimize the local complications related to a redo groin dissection and to decrease the operative time required to obtain an adequate inflow source. CASE REPORT: An 86-year-old man was referred to our hospital with severe pain in the right lower extremity one day before the present admission. He underwent aortobifemoral bypass for Leriché syndrome, in our department, 10 years before the present admission. Eight and 9 years later, a femoral popliteal suprageniculate bypass and jump to deep femoral artery bypass (when femoropopliteal bypass was occluded) were performed with 6-mm polytetrafluoroethylene grafts, both in some other institution. The patient's right foot was colder than the left, and he had some difficulty with movement. Absence of signal Doppler continous wave at right tibial vessels was recorded (category IIA of Rutherford classification for acute limb ischemia). Computed tomography (CT) confirmed the following duplex ultrasound (US) findings: occlusion of the femoral graft and popliteal artery below the knee and preocclusive stenosis of deep femoral artery with patency of aortobifemoral bypass and peroneal artery. Taking into consideration the multiple groin scars and the occlusion of superficial femoral and popliteal arteries and preocclusive lesion of deep femoral artery, we decided to perform a sequential composite and extra anatomical bypass from the right iliac prosthesis to the peroneal artery, with graft tunnellization through the lateral groin subfascial layer. The proximal component of the graft was made with a 6-mm Dacron prosthesis routed through a suprasartorial tunnel from iliac prosthesis to the proximal great saphenous vein. Proximal anastomosis was performed in a conventional side-to-end fashion. A tunnel was created between the abdominal flank incision and the median prosthesis-vein anastomosis of the bypass under inguinal ligament laterally with respect to femoral vessels, in lateral to median route, avoiding groin scars. The vein segment was orientated in a nonreversed format, with a LeMaitre Valvulotome to secure antegrade flow. The intermediate anastomosis was performed in an end-to-end way, whereas the distal anastomosis was carried out between the vein and peroneal artery in a conventional end-to-side fashion. Immediate intraoperative and postoperative assessments of graft patency were carried out with angiography and hand-held Doppler examination, respectively. Duplex US scan was used for graft surveillance at regular intervals up to 12 months after surgery. The patient recovered at 12 months postoperatively, and the CT imaging demonstrated the good patency of the entire graft. CONCLUSION: We believe that the external iliac artery (or prosthesis such as in our case) inflow should be considered selectively rather than preferentially, mostly in the subset of patients selected for reoperative distal bypass.

FemoSeal® Device Use for Femoral Artery Closure by Different Techniques.

BACKGROUND: Common femoral artery is still the most frequently used site for vascular access, mostly for peripheral arterial interventions, and its puncture remains a significant source of patient's morbidity. Manual compression (MC) has been the gold standard for hemostasis after femoral catheterization until recently, but only in the last few years, vascular closure devices (VCDs) are replacing MC due to their rapid development. Nowadays, vascular surgeons (VSs) are also becoming familiar with VCDs. The purpose of this study was to investigate FemoSeal® arterial closure system use in terms of safety and efficacy in patients undergoing transfemoral peripheral procedure and evaluate the complication risk factors. METHODS: A retrospective analysis to compare 2 different specialists and technique with systematic implantation of FemoSeal® VCD was performed in a cohort of vascular patients treated by endovascular procedure with femoral artery access site over a 2-year period and sheaths ranged from 6F to 8F. All the patients were on antiplatelet therapy and received heparin during the procedure. The FemoSeal® was deployed in common femoral arteries. All patients were examined for access site complication by VS in both groups 20-24 hrs after VCD deployment and 1 and 6 weeks after the procedure with clinical visit and ultrasound duplex scan. Complications, as minor and major hematomas, pseudoaneurysm formation, vessel occlusion or dissection, and infection were recorded. RESULTS: During the study period, 130 FemoSeal® were deployed in 114 patients, 102 FemoSeal® in VS group, and 28 in interventionalist group. Mean age was 57 ± 24 years. There was no significant difference between the 2 groups in terms of comorbidities. Patient follow-up ranged from 1 to 15 months. All but 3 of the FemoSeal® devices were successfully deployed (all 3 cases in group 2). Mobilization time was 6 ± 4 hrs following interventions, and the discharge time ranged from 6 hrs to 7 days after procedure. Early discharge (within 6 hrs) was obtained in 23% of group 1 and in 0 cases of group 2 (P = 0.008). Delayed discharge was obtained in 74% of group 1 (67 pts) and in 70% of group 2 (18 pts) on postoperative day 1 (P = 0.47). Technical success was achieved in 99% of group 1 and in 93% of group 2 (P = 0.87). There were no perioperative deaths. There were no significant differences in terms of minor bleeding complications (P = 0.21) or infections or transfusion needing (P 0.06) in both groups. FemoSeal®-related complications occurred in 6 patients (1 in group 1 and 5 in group 2; P = 0.0017). All complications occurred following therapeutic intervention with 6F sheath introducer. Complication rate resulted significatively higher in group 2 in terms of pseudoaneurysm development (P < 0.0001) and transfusion needing (P = 0.03) in a subgroup analysis on peripheral arterial disease (Rutherford 3-5). Only chronic limb ischemia was found to be independent predictor of complications due to VCD use. CONCLUSIONS: Our data suggest that when simple guidelines are observed, the device is safe, effective, and easy to deploy and allows for early ambulation and discharge. However, appropriate randomized clinical trials could clarify the correct guideline to minimize the complication rates.

Effects of Chemotherapy in Patients with Concomitant Aortic Aneurysm and Malignant Disease.

BACKGROUND: The aim of the study is to present the results in a consecutive series of patients affected by aortic abdominal aneurysm and to underline the aneurysmal growth and evolution in oncological patients submitted to dedicated oncological medical therapy. METHODS: Between January 2010 and June 2016 we treated in our center 19 patients for coexisting aortic aneurysms (>3 cm) and malignancy. We observed patients undergoing oncological treatment and patients who did not undergo medical treatment. We studied computed tomography (CT) scan at the time when patients were addressed at our follow-up or treatment and we analyzed retrospectively prior CT scan at 6 and 12 months. RESULTS: Among those 19 patients, 7 patients were affected by colorectal cancer (36.8%), 6 by urinary tract cancer (31.6%), 4 by lymphoma (21%), and 2 by lung cancer (10.6%). In 8 patients who did not undergo oncological therapy, we did not observe any aortic growth; instead, in other 4 patients who underwent oncological medical therapy (3 abdominal aortic aneurysms and 1 thoracic aneurysm), we observed a mean sac growth of 2.9 cm in 6 months with 2 cases of aortic rupture treated in urgent fashion. The treatment was open surgery in 2 cases and endovascular in other cases. CONCLUSIONS: We observed that oncological drugs may play a role in aneurysm growth. Few case reports are found in the literature and more evidences are to be found. Those information may influence intention-to-treat small aneurysms in short life expectancy patients.