Early Carotid Occlusion After Endarterectomy in a Patient With a Mutation for MTHFR A1298C Polymorphism.

INTRODUCTION: Significant carotid stenosis is a well-documented risk factor for ischemic stroke. Carotid endarterectomy (CEA) and carotid artery stenting are effective procedures for the prevention of stroke in patients with this disease. However, the occurrence of restenosis could contribute to an increase in the risk of ischemic stroke. CASE REPORT: A 79-year-old woman was admitted to the Neurosurgical Department to undergo a CEA because of a progressive stenosis. At the 3-month radiologic follow-up, the examinations showed a carotid restenosis. She was immediately started on a double-antiplatelet therapy. Blood samples revealed high levels of homocysteine and genetic tests showed a homozygous mutation for methylene tetrahydrofolate reductase A1298C polymorphism. Folic acid associated with pyridoxine was added to the treatment. Radiologic follow-ups showed no changes in the stenosis degree. CONCLUSIONS: Even if the association between homocysteine and carotid restenosis after CEA is unclear, an initial screening before the surgical procedure could be useful to promptly treat this condition and probably reduce the risk of this complication. In the case of homozygous mutation, the selection of patients and the appropriate therapy could reduce the risk of carotid restenosis.

Endovascular therapy for chronic mesenteric ischemia.

PURPOSE: The purpose of this article is to report on the effectiveness and durability of endovascular therapy for obstructive disease of the superior mesenteric artery and celiac trunk. PATIENTS AND METHODS: Our retrospective study population included nine patients (five women, four men; mean age 64 years, range 34-83 years) with 15 lesions. The indication for endovascular therapy was chronic mesenteric ischemia. The technical and clinical success rates and the incidence of complications were determined. Follow-up parameters included maintained patency and sustained clinical benefit. RESULTS: Ten vessels were treated. The primary technical and clinical success rates were both 100% with no perioperative mortality. Major complications occurred in two patients (pseudoaneurysms). During a mean follow-up of 31 +/- 18 months (range 3-60 months), thrombosis occurred in two patients at 1 and 3 months after the procedures, respectively. Thrombosis was successfully treated by catheter-directed intraarterial thrombolysis followed by percutaneous transluminal angioplasty (PTA) (n = 1) or stenting (n = 1). At 2 and 5 years, the primary patency rate was 78%, whereas survival was estimated to be 85% and 68% at 2 and 5 years, respectively. At this follow-up, all patients had obtained relief of symptoms. CONCLUSIONS: Our experience suggests that endovascular treatment for chronic mesenteric arterial obstructive disease is feasible, with a low incidence of complications and acceptable midterm results.

Endovascular treatment for mobile thrombus of the thoracic aorta.

Detection levels of mobile thrombus of the thoracic aorta have greatly increased after any embolic event. Although the indication for treatment remains controversial, there is a growing interest about the etiopathogenesis of this rare entity and to define proper diagnostic and therapeutic approaches. We present a case of mobile thrombus of the thoracic aorta causing recurrent peripheral emboli managed with endovascular stent graft.

Endovascular treatment for traumatic injuries of the peripheral arteries following blunt trauma.

OBJECTIVES: The continued advances in imaging and stent/stent-graft technology have considerably expanded the indications for endovascular approach also in vascular trauma. We report our institutional experience with endovascular treatment of peripheral arterial injuries after blunt trauma. METHODS: Between January 2000 and June 2006 out of a series of 81 patients, 10 male patients (mean age of 50+/-14 years) with peripheral arterial injuries were managed endovascularly. At admission, haemorrhagic shock was present in three patients. Artery location involved common femoral (n=2), subclavian (n=2), axillary (n=2), external iliac (n=2), superficial femoral (n=1), and popliteal (n=1). Type of lesion was as follows: pseudoaneurysm (n=4), dissection (n=4), expanding haematoma (n=1), and arterio-venous fistula (n=1). Follow-up program included visit and duplex-ultrasonography, X-rays and/or spiral-computed tomography at 6-month interval during the first year, and yearly thereafter. RESULTS: The lesion was excluded in all cases. All patients survived. Major complications did not occur. Mean hospitalisation was 13 days. Limb-salvage was 100%. Follow-up ranged from 3 to 60 months (mean 16); a late occlusion of a popliteal stent-graft was managed with another endovascular procedure. CONCLUSION: In our experience, endovascular treatment of vascular injuries after blunt trauma was feasible and effective.

Endovascular treatment of anastomotic pseudoaneurysms after aorto-iliac surgical reconstruction.

PURPOSE: To assess the effectiveness of endovascular treatment of anastomotic pseudoaneurysms (APAs) following aorto-iliac surgical reconstruction. MATERIALS: We retrospectively evaluated 21 men who, between July 2000 and March 2006, were observed with 30 APAs, 13 to the proximal anastomosis and 17 to the distal anastomosis. The patients had had previous aorto-iliac reconstructive surgery with a bypass due to aneurysm (15/21) or obstructive disease (6/21). The following devices were used: 12 bifurcated endoprostheses, 2 aorto-monoiliac, 4 aortic extenders, 1 stent-graft leg, and 2 covered stents. Follow-up was performed with CT angiography at 1, 3, and 6 months after the procedure and yearly thereafter. RESULTS: Immediate technical success was 100%. No periprocedural complications occurred. Four patients died during follow-up from causes not related to APA, and 1 (treated for prosthetic-enteric fistula) from sepsis 3 months after the procedure. During a mean follow-up of 19.7 months (range 1-72 months), 2 of 21 occlusions of stent-graft legs occurred 3 and 24 months after the procedure (treated with thrombolysis and percutaneous transluminal angioplasty and femorofemoral bypass, respectively) and 1 type I endoleak. Primary clinical success rate was 81% and secondary clinical success was 91%. CONCLUSION: Endovascular treatment is a valid alternative to open surgery and can be proposed as the treatment of choice for APAs, especially in patients who are a high surgical risk. Further studies with larger series and longer follow-up are necessary to confirm the long-term effectiveness of this approach.

Endovascular repair of abdominal infrarenal penetrating aortic ulcers: a prospective observational study.

OBJECTIVE: Penetrating atherosclerotic ulcer generally occurs in elderly patients with systemic atherosclerosis, predominantly in the descending thoracic aorta, and it is uncommon in the infrarenal aorta. We reviewed our experience of endovascular treatment of penetrating aortic ulcer in the infrarenal aorta. METHODS: In the last 4 years, out of 348 patients who underwent abdominal aortic procedures, a total of 13 patients (12 men and 1 woman) were found to have an abdominal penetrating aortic ulcer, corresponding to an incidence of 3.7%. Mean age was 73+/-7 years. All patients had hypertension. Three lesions were discovered incidentally and 10 were symptomatic. All patients underwent endovascular treatment in the operating room. Follow-up included CT-A control at 1, 4 and 12 months after the intervention, and yearly thereafter. RESULTS: Primary technical success was 100%. No postoperative death was observed. Mean operative time was 100+/-29 min. Mean blood loss was 168+/-133 ml. No patient required intensive care unit stay. We observed one major complication (transient ischemic attack). Mean hospital stay was 4+/-1 days. During a mean follow-up period of 26 months no endoleak, aneurysm evolution or stent graft failure was recognized in any patient. One patient died 24 months after the intervention after a stroke. CONCLUSIONS: In our experience, endovascular or repair of infrarenal aortic ulcer appears feasible, and midterm results satisfactory.

Penetrating ulcers of the thoracic aorta: results from a single-centre experience.

OBJECTIVES: To report our mid-term results of stent-graft (SG) placement for the treatment of penetrating thoracic aortic ulcers. METHODS: In the last 30 months, 11 patients (9 men; mean age 73 years; range 55 to 81) were treated for 12 penetrating thoracic aortic ulcers using SGs. Five patients were symptomatic: 2 had ruptured ulcers and 2 cases were complicated with dissection. Mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 10. Three patients had concomitant endovascular repair for an infrarenal abdominal aortic aneurysm (AAA). Follow-up included periodic computed tomography angiography (CT-A) scans at 1, 4, and 12 months after the intervention, and yearly thereafter. RESULTS: Primary technical success was achieved in 100% of patients; no conversion was required. In-hospital mortality did not occur. Paraplegia was not observed. Mean follow-up was 15 months (range 2 to 36). One patient died of respiratory failure 2 months after the intervention. Radiologic follow-up did not detect endoleaks. Survival was 90% at 1 and 3 years. CONCLUSIONS: Our experience confirms the feasibility of SG treatment for elective and urgent repair of penetrating aortic ulcers. Our current attitude is to treat all the ulcers of the descending aorta using an endovascular technique, since SG treatment represents a good treatment option, as the morbidity and mortality are low.

Splenic artery aneurysms: postembolization syndrome and surgical complications.

BACKGROUND: This study assessed the endovascular embolization of splenic artery aneurysms and false aneurysms with special consideration given to postoperative complications. METHODS: Fifteen patients (11 women; mean age, 56 y; range, 39-80 y) with splenic artery aneurysm (n = 13) or false aneurysm (n = 2) were treated with coil embolization. The lesion was asymptomatic in 9 patients, symptomatic in 5 patients, and ruptured in 1 patient. The mean aneurysm diameter was 33 +/- 23 mm (range, 15-80 mm). Postoperative follow-up evaluation included a clinical visit and spiral computed tomography at 1, 4, and 12 months, and yearly thereafter. RESULTS: Endovascular treatment was possible in 14 patients (93%) (1 failure: neck cannulation). Perioperative mortality was not observed. Morbidity included postembolization syndrome in 5 patients (30%). Neither pancreatitis nor spleen abscess occurred. The mean follow-up period was 36 months (range, 3-60 mo). During follow-up evaluation we detected 1 sac reperfusion that was sealed successfully with additional coils. Surgical conversion or open repair were never required. CONCLUSIONS: At our institute, endovascular treatment represents the first-line treatment for splenic artery aneurysms. Postembolization syndrome and infarcts are common events but generally resolve without sequelae.

Stent-graft repair of peroneal arteriovenous fistula.

Arteriovenous fistulas (AVFs) are infrequently seen in the civilian health-care system; traditionally, these lesions have been treated with ligation, or direct surgical repair with concomitant revascularization. We describe a rare case of a peroneal AVF treated with a stent-graft.

Endovascular versus open repair of ruptured abdominal aortic aneurysms.

Although major improvement has occurred to make elective repair of abdominal aortic aneurysms a safe procedure, the incidence of ruptured abdominal aortic aneurysms and mortality rates are still disappointing. Endovascular abdominal aortic aneurysm repair has produced quantum changes in aneurysm treatment. The successful application of the endovascular approach for the treatment of abdominal aortic aneurysms in the elective setting has prompted a strong interest regarding its possible use in dealing with the long-standing challenge of a ruptured abdominal aortic aneurysm. Since the first report, several centers have reported results and a wide spectrum of opinion regarding its application, with special consideration to logistical and practical barriers for appropriate utilization. The purpose of this article is to review all the available literature on the endovascular repair of ruptured abdominal aortic aneurysms and to analyze the most recent trends in their management, with special consideration given to comparing results of conventional and endovascular approaches.

Complications after endovascular stent-grafting of thoracic aortic diseases.

BACKGROUND: To update our experience with thoracic aortic stent-graft treatment over a 5-year period, with special consideration for the occurrence and management of complications. METHODS: From December 2000 to June 2006, 52 patients with thoracic aortic pathologies underwent endovascular repair; there were 43 males (83%) and 9 females, mean age 63 +/- 19 years (range 17-87). Fourteen patients (27%) were treated for degenerative thoracic aortic aneurysm, 12 patients (24%) for penetrating aortic ulcer, 8 patients (15%) for blunt traumatic injury, 7 patients (13%) for acute type B dissection, 6 patients (11%) for a type B dissecting aneurysm; 5 patients (10%) with thoraco-abdominal aortic aneurysms were excluded from the analyses. Fifteen patients (32%) underwent emergency treatment. Overall, mean EuroSCORE was 9 +/- 3 (median 15, range 3-19). All procedures were performed in the theatre under general anesthesia. All complications occurring during hospitalisation were recorded. Follow-up protocol featured CT-A, and chest X-rays 1, 4 and 12 months after intervention, and annually thereafter. RESULTS: Primary technical success was achieved in all patients; procedures never aborted because of access difficulty. Conversion to standard open repair was never required. Mean duration of the procedure was 119 +/- 75 minutes (median 90, range 45-285). Mean blood loss was 254 mL (range 50-1200 mL). The mean length of the aorta covered by the SGs was 192 +/- 21 mm (range 100-360). The LSA was over-stented in 17 cases (17/47, 36%). Overall 30-day operative mortality was 6.4% (3/47). Major complications included pneumonia (n = 9), cerebrovascular accidents (n = 4), arrhythmia (n = 4), acute renal failure (n = 3), and colic ischemia (n = 1). Overall, endoleak rate was 14%. CONCLUSION: Although this report is a retrospective and not comparative analysis of thoracic aortic repair, the combined minor and major morbidity rate was lower than previous reported to results of either electively and emergency performed conventional repair.

Surgical treatment of malignant involvement of the inferior vena cava.

BACKGROUND: Resection and replacement of the inferior vena cava to remove malignant disease is a formidable procedure. The purpose of this review is to describe our experience with regard to patient selection, operative technique, and early and late outcome. METHODS: The authors retrospectively reviewed a 12-year series of 11 patients; there were 10 males, with a mean age 57 +/- 13 years (range 27-72) who underwent caval thrombectomy and/or resection for primary (n = 9) or recurrent (n = 2) vena cava tumours. Tumour location and type, clinical presentation, the segment of vena cava treated, graft patency, and tumour recurrence and survival data were collected. Late follow-up data were available for all patients. Graft patency was determined before hospital discharge and in follow-up by CT scan or ultrasonography. More than 80% of patients had symptoms from their caval involvement. The most common pathologic diagnosis was renal cell carcinoma (n = 6), and hepatocarcinoma (n = 2). In all but 2 patients, inferior vena cava surgical treatment was associated with multivisceral resection, including extended nephrectomy (n = 5), resection of neoplastic mass (n = 3), major hepatic resection (n = 2), and adrenal gland resection (n = 1). Prosthetic repair was performed in 5 patients (45%). RESULTS: There were no early deaths. Major complications occurred in 1 patient (9%). Mean length of stay was 16 days. Late graft thrombosis or infection did not occur. The mean follow-up was 22.7 months (range 6-60). There have been no other late graft-related complications. All late deaths were caused by the progression of malignant disease and the actuarial survival rate was 100% at 1 year. Mean survival was 31 months (median 15). CONCLUSION: Aggressive surgical management may offer the only chance for cure or palliation for patients with primary or secondary caval tumours. Our experience confirms that vena cava surgery for tumours may be performed safely with low graft-related morbidity and good patency in carefully selected patients.

New trends in prosthesis infection in cardiovascular surgery.

BACKGROUND: Adult cardiovascular surgery entails, in many cases, the use of some kind of prosthesis. Among the potential complications, prosthetic device infection is one of the most devastating in incidence, as well as in prognosis and damage to surrounding tissues. RESULTS: The most common bacterial agents in vascular and cardiac prosthetic device infections are Staphylococcus aureus and S. epidermidis among gram-positive bacteria and Escherichia coli, Proteus mirabilis, and Pseudomonas aeruginosa among gram-negative bacteria. CONCLUSION: The alternative modalities of treatment for prosthetic device infection encompass partial or total explantation of the prosthesis and its replacement with an infection-resistant graft (e.g., homologous tissue, autologous tissue, or synthetic prosthesis bonded with antibiotics).

Comparison of contrast-enhanced ultrasound and computed tomography in classifying endoleaks after endovascular treatment of abdominal aorta aneurysms: preliminary experience.

The purpose of the study was to assess the effectiveness of contrast-enhanced ultrasonography (CEUS) in endoleak classification after endovascular treatment of an abdominal aortic aneurysm compared to computed tomography angiography (CTA). From May 2001 to April 2003, 10 patients with endoleaks already detected by CTA underwent CEUS with Sonovue to confirm the CTA classification or to reclassify the endoleak. In three conflicting cases, the patients were also studied with conventional angiography. CEUS confirmed the CTA classification in seven cases (type II endoleaks). Two CTA type III endoleaks were classified as type II using CEUS and one CTA type II endoleak was classified as type I by CEUS. Regarding the cases with discordant classification, conventional angiography confirmed the ultrasound classification. Additionally, CEUS documented the origin of type II endoleaks in all cases. After CEUS reclassification of endoleaks, a significant change in patient management occurred in three cases. CEUS allows a better attribution of the origin of the endoleak, as it shows the flow in real time. CEUS is more specific than CTA in endoleak classification and gives more accurate information in therapeutic planning.

Emergency endovascular stent-graft treatment for acute thoracic aortic syndromes.

OBJECTIVE: We report the results of our ongoing experience of urgent and emergency stent-graft implantation in acute thoracic aortic syndromes. METHODS AND RESULTS: In the last 5-years, 19 patients were treated for acute thoracic aortic syndromes. Traumatic rupture was diagnosed in 7 patients, complicated acute type B dissection was present in 5 patients, penetrating ulcer in 4, and symptomatic thoracic aortic aneurysm in 3 patients. There were 17 male patients with a mean age of 54 +/-26 years (range 18-87 ; median 63). Patients were treated in the theatre suite under general anesthesia. Stent-graft placement was technically successful in all patients. The early postoperative mortality was 10.5 %. Neurological events or upper arm ischemia due to overstenting of the left subclavian artery were not observed. Average intensive care unit and hospital stay were 18 and 21 days, respectively. Major complications occurred in 6 patients. Follow-up ranged between 3 and 60 months (mean 25) and included clinical examinations and serial CT-angiography at 1, 4 and 12 months, and every year thereafter. Only one type II endoleak was detected and treated by coil embolization of the left subclavian artery. CONCLUSIONS: Our experience suggests emergency stent-graft repair in patients with acute thoracic aortic syndromes is a less-invasive attractive alternative, showing encouraging early and mid-term results.

Endovascular treatment of femoropopliteal aneurysms: a five-year experience.

PURPOSE: To assess the effectiveness of endovascular treatment of femoropopliteal aneurysms (FPAs). METHODS: In the last 5 years, we have treated 17 FPAs (diameter 21-75 cm, mean 38.4 cm; length 27-100 cm, mean 72.5 cm) in 15 patients (age 57-80 years, mean 70.9 years). The diagnosis was obtained by color Doppler ultrasound (CDU) and the procedure was planned by CT angiography (CTA) and preprocedural angiography. Eight FPAs were excluded with only one stent-graft; in 8 patients, two stent-grafts were positioned; and in 1 patient, three stent-grafts were used. In 14 cases we used a Wallgraft endoprosthesis, in 2 cases a Hemobahn, and in 1 case an Excluder contralateral leg. The patients were followed up with CDU and occasionally with CTA. RESULTS: Immediate technical success was obtained in 17 of 17 cases (100%). One patient died during the first year. During a mean follow-up of 26.9 months (range 3-60 months) we observed 6 of 16 (38%) stent-graft occlusions (3 of which were recanalized with locoregional thrombolysis and 3 with mechanical thrombectomy). Two stent-grafts were patent at 12 and 24 months. Four patients experienced subsequent occlusions and recanalizations until corrected by surgical bypass (1 at 14 months, 2 at 18 months, and 1 at 36 months). Therefore the primary patency was 63% and assisted patency was 73%. CONCLUSION: The endovascular approach is a minimally invasive treatment option for FPAs. Moreover endovascular stent-grafting does not necessarily preclude conventional surgical repair, but it can delay it. Longer follow-up will be needed to determine the long-term patency rate.

Stent-graft treatment for isolated infrarenal aortic dissecting aneurysms.

OBJECTIVES: We report three cases of isolated infrarenal aortic dissecting aneurysms managed with stent-graft. MATERIALS AND METHODS: Three patients, two men and one woman, with a mean age at diagnosis of 69 years were identified. In all cases, chest CT-A did not reveal evidence of thoracic aortic dissection. The mean maximal aneurysm diameter was 6.7+/-1.5 cm (range: 5.5-8 cm). All patients underwent stent-graft repair. Follow-up computed tomographic (CT)-angiography examinations were scheduled 1, 4, and 12 months after the procedure. RESULTS: Stent-graft deployment was technically successful in all cases. Intraoperative mortality was not observed. All patients were adequately treated with a bifurcated device. Intensive care unit (ICU) stay was never required. Mean hospitalization was 4.6 days (range: 4-6 days). Mean follow-up was 18 months. No stent-graft-related complications were observed. CONCLUSIONS: Endovascular repair for isolated infrarenal abdominal aortic dissecting aneurysms is feasible and effective.

Endovascular treatment of isolated iliac artery aneurysms.

We report our experience of endovascular repair of isolated iliac artery aneurysms using commercially available stent grafts (SGs). Twenty-five patients (mean age 71 +/- 7 years) presented with 33 isolated iliac artery aneurysms (common iliac artery n = 29, external iliac artery n = 4). Five patients were symptomatic. Depending on the proximal iliac neck and the presence of unilateral or bilateral iliac artery aneurysms, the patient was treated by tube or bifurcated SG that was delivered percutaneously (n = 14) or through surgical exposure of one femoral artery (n = 12). In our follow-up control protocol, the patients are routinely scheduled after 1, 4, and 12 months and then annually after the intervention. Primary technical success with an instant exclusion of the aneurysm was achieved in all patients. The perioperative (<30 days) mortality rate was 0. Major complications did not occur. Mean hospitalization was 6 +/- 6 days (range 2-28, median 4). Four patients (16%) died during follow-up. At a mean follow-up of 32 months (range 3-72, median 36), we detected three type 1 endoleaks (14.3%) that were managed with additional SG; two stenoses at the distal extremity of the SGs, treated with mechanical thrombectomy; and additional stent. In the remaining patients (n = 17), computed tomography angiography confirmed the patency of the SG and the absence of device complication (e.g., endoleak, migration, breakage); shrinkage of the aneurysm was observed in 11 cases (52.4%). Overall, survival rates at 1, 4, and 5 years were 91.6%, 73.3%, and 58.6%, respectively; event-free rates at 1 and 3 years were 79.4% and 67.4%, respectively. In our experience, SG treatment for isolated iliac artery aneurysm proved to be a feasible and low-risk procedure with acceptable mid-term results. At our institute, it is the primary alternative to conventional surgical repair and is offered as first-line treatment.

Intravenous uterine leiomyomatosis with right heart extension: successful two-stage surgical removal.

Intravenous leiomyomatosis is an uncommon nonmalignant tumor which originates from the smooth muscle cells and is usually confined to the pelvic venous system. Rarely, intracaval and intracardiac extension has been described: the literature includes only 100 cases with cardiac involvement. We report a case of a young woman with intravenous leiomyomatosis originating from the uterus and extending into the right atrium, successfully treated through a two-stage surgical approach.