Original approach for thrombolytic therapy in patients with Ilio-femoral deep vein thrombosis : 2 years follow-up.

OBJECTIVE: The aim of the study was to discuss the results of catheter-directed thrombolysis and complementary procedures to treat acute iliofemoral deep vein thrombosis (DVT) evaluating the safety and effectivness of an easy access such as the Great Saphenous Vein. METHODS AND MATERIALS: A total of 22 consecutive patients with iliofemoral thrombosis and two patients with femoro-popliteal thrombosis on recent onset diagnosed with Ultrasound Doppler and contrast venography underwent intrathrombus drip infusion of urokinase while intravenous heparin was continued using saphenical access. Residual venous stenosis were treated in six patients by percutaneous balloon Angioplasty and stenting. All patients underwent routine venous duplex imaging at 30 days, 3 months, 6 months and every 6 months thereafter. RESULTS: Complete patency of thrombosed veins was restored in 22 patients (91 %) with prompt symptomatic relief. There were no major complications in the immediate outcomes. At follow-up, two patients reported a persistant slim iliac vein stenosis, two patients had post-thrombotic syndrome, and two patients showed Deep Vein Reflux. CONCLUSION: Local thrombolysis using saphenical access was a safe and effective approach for the treatment of acute iliofemoral deep vein thrombosis. It seems to be a valid, easy and safe alternative, reducing the risks of haematoma and venous lesions, which can be observed when using femoral, popliteal, and trans-jugular access.

Giant cardiac hydatid cyst in children: case report and review of the literature.

Cardiac echinococcus is a rare affliction of the heart caused by the tapeworm Echinococcus granulosus. Primary echinococcosis of the heart represents 0.5-2% of all hydatid disease cases in endemic regions. It evolves slowly, explaining its rarity in children. We report the case of a 11-year-old child affected by a giant cardiac cyst of the left ventricle (LV). The patient underwent cardiac surgery and medical treatment. A retrospective review of the current literature was realized. We found 18 cases: the mean age was 11-years old. Nine cysts were localized in the LV, four in the interventricular septum, three in the right ventricle, and two in the right atrium. All underwent surgery except six patients. Routine echocardiographic screening may be useful in endemic regions where infestation is common. Cardiac echinococcus should be diagnosed in the early and uncomplicated stages and be removed surgically even in asymptomatic patients.

Successful embolization of a suprascapular artery aneurysm.

A 45-year-old woman was referred to our service because 9 months earlier she had developed a pulsating mass on the right supraclavicular fossa and torticollis. Ultrasounds and computed tomographic arteriography showed the presence of a subclavian collateral artery aneurysm with a diameter of 21 mm. On selective arteriography, an aneurysm of a suprascapular artery arising directly from the right subclavian artery was reported. The presence of thoracic outlet syndrome was excluded. The aneurysm was successfully treated with ethylene-vinyl alcohol polymer, a liquid embolic agent. The patient was discharged on postoperative day 1 in good general condition. After 12 months, control ultrasounds confirmed the complete thrombosis of the aneurysm sac.

Critical limb ischemia in a young man: saddle embolism or unusual presentation of thromboangiitis obliterans?

Thromboangiitis obliterans (TAO), also known as Buerger's disease, is a rare cause of peripheral arterial disease in western countries. Tobacco smoking is strongly correlated to the pathogenesis of this inflammatory vascular disease. We report the case of a 32-year-old tobacco and cannabis consumer presenting with right critical limb ischemia. Computerized tomography angiography revealed a bilateral tibioperoneal arterial occlusion and an aortoiliac saddle embolus. The patient was treated with intravenous heparin, transcatheter thrombolysis, and selective Fogarty embolectomy. Instrumental and laboratory examinations revealed that patient's most likely diagnosis was TAO. Arterial embolism is uncommon in Buerger's disease but should be always excluded in these patients.

Postpartum deep vein thrombosis and pulmonary embolism in twin pregnancy: undertaking of clinical symptoms leading to massive complications.

BACKGROUND: Deep Vein Thrombosis (DVT) is an important cause of morbidity and is the first cause of maternal death after delivery in Western Nations. The risk of venous thromboembolism is present throughout the pregnancy and is maximal during postpartum, especially after twin delivery. Many of the signs and symptoms of DVT overlap those of a normal pregnancy causing difficulty for diagnosis. CASE REPORT: We report the case of a 33 year-old woman transferred to our Department one week after caesarean section for twin delivery. She presented with severe abdominal pain, fever, abdominal distension and shortness of breath. She had no personal or family history of thromboembolism. Computerized Tomography Scan revealed right ovarian vein thrombosis, left renal vein thrombosis extending up to the Inferior Vena Cava and pulmonary embolism with bilateral pleural effusion. Caval filter was positioned and anticoagulation therapy associated with antibiotics was instituted. Pancreatitis showed up two days after and was promptly treated. Three months after discharge the caval filter was removed and oral anticoagulation was stopped. During a 12-months follow-up, she remained stable and symptom free. RESULTS: Ovarian vein thrombosis is rare but recognition of signs and symptoms is fundamental to start adequate therapy and avoid potential serious sequelae. The risk for maternal postpartum ovarian vein thrombosis is increased by caesarean section delivery of twins. Such patients should be closely monitored. We illustrated how an underestimated condition can lead to massive complications.

Management of AAA and late Type II EL in a patient with concomitant renal cell carcinoma. Report of a case and review of the literature.

PURPOSE: Detection of cancer in patients with AAA complicates the treatment of both diseases. AAA associated with RN are rare, with an incidence of 0.1-3% representing a challenge in defining the surgical timing and approach. We discuss the rational for the treatment in patients with concomitant patologies. CASE REPORT: A 65 years-old man was diagnosed with both AAA and Renal Cell Carcinoma. The patient underwent first EVAR followed by renal embolization and Radical Nefrectomy. Three months later a Type II Endoleak was diagnosed and treated successfully. At 1 year follow-up the patient is disease free with complete exclusion of aneurysm sac. CONCLUSION: AAA can be successfully repaired in patients with renal neoplasm with great results, either simultaneously or in two stages. EVAR is a good alternative for such complex patients.

[Stenting versus carotid endarterectomy for carotid stenosis. A single center experience]. / Stenting Carotideo e Endoarterectomia Carotidea Esperienza di un singolo Centro.

AIM: The objective was to compare Carotid Endarterectomy (CEA) with Carotid Artery Stenting (CAS) in terms of efficacy and safety in patients with symptomatic and asymptomatic extracranial carotid stenosis. MATERIALS: This study enrolled 285 patients with symptomatic and asymptomatic carotid stenosis that underwent either to CAS or CEA. The primary end-points were death, stroke and myocardial infarction. The secondary end-points were restenosis and nerve injury. The Data emerged from the follow-up at 1,3,6,12,24 months that provided for clinical and EcocolorDoppler monitoring. A separate analyse was performed evaluating the prediction of the Ultrasonographic appearance of the atheroma on the symptomatic nature of the lesion. RESULTS: The percentage of neurological symptomatology in the periprocedural period was higher in CAS than in CEA group (9% vs 3%). We didn't report any case of periprocedural death. The results from the follow-up are: myocardial infarction 5% CAS vs 7% CEA; stroke 5% CAS vs 4% CEA; restenosis 3% CAS vs 6% CEA; nerve injury 0% CAS vs 1% CEA; mortality 0% CAS vs 1% CEA. DISCUSSION: CEA is the gold standard for treatment of significant carotid stenosis, although endovascular technique is emerging as a less invasive alternative. CAS has presented a less frequence of myocardial infarction, nerve injury and long-term mortality, but it showed an higher percentage of neurological events both in short and long-term. This last aspect is correlated with the plaque structure. Ultrasonographic study of the atheroma has become a defining moment in the choice of the therapeutic strategy.

Radiotherapy-related axillary arteriopathy.

Treatment of breast cancer involves surgery, then perhaps radiation, hormonal or chemotherapy. Radiation-induced arterial injury is a well-known entity that represents a rare cause of arterial occlusion. We present the case of a 76-year old woman who complained of a severe intermittent claudication of the right upper limb. Twenty years before, she underwent a right-sided radical mastectomy followed by intense radiation therapy for several weeks. The patient was found to suffer of a radiotherapy-related axillary artery thrombosis and was successfully treated by angioplasty and stenting.

Abdominal aortic occlusion of young adults.

The occlusion of the infrarenal aorta is a rare event, which is potentially life threatening. We present the case of a heavy smoking, 35-year-old woman who was referred to the emergency department of our hospital because of sudden abdominal pain and urinary incontinence. She also complained of a two-year history of bilateral intermittent claudication. A computerized tomography revealed the thrombosis of the abdominal aorta and of both iliac arteries. Treatment consists of an aortoiliac thromboendarterectomy (AITE). For young patients with atheromatous occlusive disease of the infrarenal aorta, AITE is an attractive alternative to bypass grafting.

Cystic adventitial disease of the popliteal artery.

Cystic adventitial disease (CAD) is a rare condition caused by a cystic abnormality of the adventitia. It is most commonly found in young or middle-aged adults without significant risk factors for peripheral arterial disease. The disease usually affects the popliteal artery and can present with intermittent claudication. We present a case of CAD of the popliteal artery in a 65-year-old man and describe its treatment. For symptomatic patients, treatment of choice remains surgical resection of the cyst through a posterior approach.

Acute thrombosis of external iliac artery secondary to endofibrosis.

Iliac endofibrosis is a rare condition caused by chronic wall stress and a subsequent progressive fibrosis that usually affects the external iliac artery. It can present with intermittent claudication and is most commonly found in young athletes without significant risk factors for peripheral arterial disease. We present a case of acute thrombosis of the external iliac artery secondary to endofibrosis in a 38-year-old cyclist and describe the treatment options. For symptomatic patients and in case of long arterial occlusion, the treatment of choice is the surgical resection with autologous vein interposition.

Anomalous origin and aneurysm of the suprascapular artery: the first case observed.

A 45-year-old woman was referred to our department having suddenly developed, 9 months earlier, a pulsating mass on the right supraclavicular fossa and torticollis. Colour Doppler sonography and computed tomographic angiography showed the presence of an aneurysm (21 mm in diameter) of the suprascapular artery that had an anomalous origin from the subclavian artery. Thoracic outlet syndrome was excluded. After selective arteriography, the aneurysm of the suprascapular artery was successfully treated with ethylene-vinyl alcohol polymer (Onyx, MicroTherapeutics, Irvine, California, USA), a liquid embolic agent. The patient was discharged on the first postoperative day in good condition. Control colour Doppler sonography at 1 year confirmed the complete thrombosis of the aneurysm sac.

Thoracic endograft positioning and carotid-subclavian bypass grafting in a patient with a saccular aneurysm at the aortic arch.

A 75-year-old man was referred to our hospital because of sudden thoracic pain. A saccular aneurysm of the aortic arch extending on the anterior surface of the aortic arch was found on computed tomographic arteriography. The patient was hemodynamically stable and he was programmed for a staged surgical and endovascular approach (hybrid approach). As a first stage and in order to prevent major cardiac complications due to the overstenting of the left subclavian artery (LSA) with the occlusion of the aortocoronary bypass, the patient underwent a polytetrafluoroethylene bypass graft (GORE-TEX, W.L. Gore & Associates, Flagstaff, AZ) between the LSA and the left carotid artery. Intraoperative arteriography revealed a good patency of the left carotid-subclavian bypass and of the left internal mammary bypass on the left anterior descending artery. As a second stage the endovascular procedure was accomplished 5 days later in the operating room. A Gore TAG stent graft (W.L. Gore & Associates) was deployed in the aortic arch 20 mm proximally to the aneurysmatic segment covering the ostium of the LSA. The postoperative course was uneventful and the patient was discharged on the fifth postoperative day in good general conditions. Hybrid procedures for treatment of aneurysms of the aortic arch or of the descending thoracic aorta are a promising alternative to open surgery especially in high-risk patients, with lower early morbidity and mortality rates. Long-term effectiveness remains to be fully elucidated.

Late occurrence of a large brachial artery aneurysm following closure of a hemodialysis arteriovenous fistula.

After the pioneer observations by Hunter more than two centuries ago, recent reports have expanded our knowledge about the occurrence and pathophysiology of arterial abnormalities associated with long-lasting hemodialysis arteriovenous fistula (AVF) after its closure. Observed abnormalities include arterial dilatation and aneurysm formation proximal to the site of the repaired AVF. We describe here a patient who developed, after long-lasting hemodialysis AVF, a pan-arterial dilatation with a large brachial artery aneurysm, which was successfully treated with a polytetrafluoroethylene bypass graft.

Embolization of isolated hypogastric artery aneurysm: a case report and a review of the literature.

A 75-year-old man with arterial hypertension, coronary artery disease, and myocardial infarction was referred to our service because of an asymptomatic hypogastric artery aneurysm (HAA) detected by a routine computed tomography (CT) scan. As shown on the angio-CT the maximum transverse diameter (m.t.d.) of the HAA was 47 mm. There were no symptoms of distal embolization or compression on the pelvic structures. We performed the successful complete thrombosis of the aneurysm using vascular plugs via a controlateral femoral approach. The control angiogram was satisfactory and there were no intraoperative complications. A CT-angiography done 4 months after the procedure showed no signs of refilling of the aneurysm sac. This case illustrates some possible advantages of vascular plugs in the treatment of isolated HAA.

Giant non Hodgkin lymphoma of Scarpa's triangle: a case report.

A 72-year-old lady was admitted to hospital with a large, bleeding mass on the right groin and an 8-month history of deep vein thrombosis of the left leg with pulmonary microembolisation treated medically. On clinical examination there was a solid, necrotising and bleeding right inguinal mass which extended 20 cm below the right inguinal ligament. A tissue biopsy, performed under local anaesthesia, revealed the presence of a non Hodgkin lymphoma with giant B-cells of follicular origin. An angio-CT scan of the pelvis and of the leg showed the compression of the 30 cm diameter tumour on the surrounding tissues. The mass appeared to be extra-compartmental and to have a non-homogeneous aspect with internal areas of necrosis and colliquation. Particular attention was devoted to the femoral vessels which were apparently not involved in the tumour mass. The patient was then operated on by a team of vascular and plastic-reconstructive surgeons. She underwent an operation consisting in an inguinal mass excision and skeletisation of the femoral vessels and nerve. The wound was then closed using both an abdominal and lateral flap from the hip. Postoperatively the patient made an uneventful recovery and was discharged from hospital on postoperative day 11. Follow-up at 3 months showed good healing of the wound and no signs of metastatic spread of the tumour.