Surgical therapy of aorto-iliac aneurysm in a patient with congenital solitary pelvic kidney (CSPK): case report and literature review.

We report a case of a man with an Aorto-Iliac aneurysm and a congenital solitary pelvic kidney (CSPK). The maximum diameter of the aneurysm was 58 mm and the pelvic kidney was perfused by a single renal artery originating from the aortic bifurcation. A computed tomography scan was used for pre-operative planning and the patient underwent aorto-iliac aneurysm replacement with a Dacron graft. The renal artery was reimplanted on the Dacron right limb with a 'Carrel patch'. Several strategies were adopted to prevent renal ischemia such as sequential aortic cross clamping, selective cold perfusion of renal artery and a temporary Pruitt-Inahara shunt. The post-operative course was characterized by a transient increase in serum creatinine that did not require treatments and the patient was discharged after seven days. Congenital anomalies such as CSPK represent a challenge for the surgeon; however, the adoption of different intraoperative available strategies allowed to reduce possible complications.

Open surgical conversion for Type II endoleak following hybrid treatment of a giant aneurysm of aberrant right subclavian artery.

Type II endoleak following hybrid treatment of aneurysms of aberrant subclavian arteries (AARSA) and requiring reintervention is rare. A retroesophageal AARSA with a 70 mm diameter was treated with left and right carotid to subclavian bypasses and thoracic endografting to exclude its ostium. The distal neck was embolized with a vascular plug. At 22 months postoperatively, an angio-computed tomography (CT) scan performed for worsening of dysphagia showed the presence of a Type II endoleak from bronchial arteries with significant sac enlargement. An open surgical repair with thoracotomy, aneurysmorraphy and ligature of the feeding vessels was successfully performed.

Comparison of early and midterm results of open and endovascular treatment of popliteal artery aneurysms.

BACKGROUND: Aim of this study was to retrospectively compare perioperative (<30 days) and 2-year results of open and endovascular management of popliteal artery aneurysms (PAAs) in a single-center experience. METHODS: From January 2005 to December 2010, 64 PAAs in 59 consecutive patients were operated on at our institution; in 43 cases, open repair was performed (group 1), whereas the remaining 21 cases had an endovascular procedure (group 2). Data from all the interventions were prospectively collected in a dedicated database, which included main preoperative, intraoperative, and postoperative parameters. Early results in terms of mortality, graft thrombosis, and amputation rates were analyzed and compared by χ(2) text or Fisher exact text. The surveillance program consisted of clinical and ultrasonographic examinations at 1, 6, and 12 months and yearly thereafter. Follow-up results (survival, primary and secondary patency, limb salvage) were analyzed by Kaplan-Meier curves, and differences in the two groups were assessed by log-rank test. RESULTS: There were no differences between the two groups in terms of sex, age, risk factors for atherosclerosis, and comorbidities; PAAs were symptomatic in 48% of cases in group 1 and in 29% in group 2 (P = 0.1). Fifteen patients with mild-to-moderate acute ischemia due to PAA thrombosis underwent preoperative intra-arterial thrombolysis, 13 in group 1 and 2 in group 2. In open surgery group, nine cases were treated with aneurysmectomy and prosthetic graft interposition, and in seven cases, the aneurysm was opened and a prosthetic graft was placed inside the aneurysm. In 27 cases, ligation of the aneurysm with bypass grafting (21 prosthetic grafts and 6 autologous veins) was carried out. In group 2, 20 patients had endoprosthesis placement, whereas in the remaining patient, a multilayer nitinol stent was used. There was one perioperative death in a patient of group 2 who underwent concomitant endovascular aneurysm repair and PAA endografting. Cumulative 30-day death and amputation rate was 4.5% in group 1 and 4.7% in group 2 (P = 0.9). Follow-up was available in 61 interventions (96%) with a mean follow-up period of 22.5 months (range: 1-60). Estimated primary patency rates at 24 months were 78.1% in group 1 and 59.4% in group 2 (P = 0.1). Freedom from reintervention rates at 24 months were 79% in group 1 and 61.5% in group 2 (P = 0.2); estimated 24-month secondary patency rates were 81.6% in group 1 and 78.4% in group 2 (P = 0.9), and freedom from amputation rates were 92.7% and 95%, respectively (P = 0.7). CONCLUSIONS: Endovascular treatment of PAAs provided, in our initial experience, satisfactory perioperative and 1-year results, not significantly different from those obtained with prosthetic open repair in patients with similar clinical and anatomical status. There is, however, a trend toward poorer primary patency rates among patients endovascularly treated, who also seem to require more frequently a reintervention.

Early and long-term comparison of endovascular treatment of iliac artery occlusions and stenosis.

OBJECTIVES: This study evaluated early and long-term results of endovascular treatment of iliac artery occlusions and compared these outcomes with those in patients treated for stenotic lesions. METHODS: During a 10-year period ending in January 2010, 223 endovascular procedures to treat aortoiliac occlusive disease (PAD) were performed. All patients were prospectively enrolled in a dedicated database. The intervention was performed for iliac occlusion in 109 patients (group 1) and for iliac stenosis in 114 (group 2). Early results were analyzed and compared by χ² and Fisher exact tests. Follow-up consisted of clinical examination and duplex scanning at discharge, ≤ 3 months, at 6 and 12 months, and yearly thereafter. Follow-up results were analyzed with Kaplan-Meier curves and compared with the log-rank test. RESULTS: The two groups had similar risk factors for atherosclerosis and comorbidities. Critical limb ischemia was more common in group 1 (20.5%) than in group 2 (8.5%; P = .01). Intraoperative technical details were similar, except for a higher percentage of brachial and contralateral femoral access and more frequent use of nitinol stents in group 1. Two immediate technical failures occurred, one in both groups, requiring immediate conversion to surgical bypass. Four intraoperative iliac ruptures occurred, two in each group; all were successfully treated with covered stents. An additional 10 immediate complications occurred (8 in group 1; 2 in group 2), one of which required conversion to open surgical bypass. The cumulative rate of perioperative complications was 9% in group 1 and 3.5% in group 2 (P = .08). Primary patency at 30 days was 97.3% and 98.7%, respectively. Mean duration of follow-up was 28.4 months; 203 patients (91%) had a regular postoperative follow-up visit. At 60 months, primary patency in group 1 vs group 2 was 82.4% vs 77.7% (P = .9), assisted primary patency was 90.6% vs 85.5% (P = .4), and estimated secondary patency was 93.1% vs 92.8% (P = .3). The cumulative rate of reintervention during follow-up (excluding reinterventions performed in the perioperative period) was 2.5% in group 1 and 12.5% in group 2 at 60 months (P = .09). Univariate analysis in group 1 failed to find any of the examined risk factors significantly affected long-term primary patency rates. CONCLUSIONS: In our experience, endovascular treatment of iliac occlusions provides excellent early and long-term results, similar to those obtained in the treatment of stenotic lesions.

Early and long-term results of carotid endarterectomy in diabetic patients.

PURPOSE: To evaluate results of carotid endarterectomy (CEA) in diabetic patients in a large single-center experience. METHODS: Over a 13-year period ending in December 2008, 4305 consecutive CEAs in 3573 patients were performed. All patients were prospectively enrolled in a dedicated database. Interventions were performed in diabetic patients in 883 cases (20.5%; group 1) and in nondiabetics in the remaining 3422 (79.5%; group 2). Early results in terms of 30-day stroke and death rates were analyzed and compared. Follow-up results were analyzed with Kaplan-Meier curves and compared with log-rank test. RESULTS: Diabetic patients were more likely to be females and to have coronary artery disease, peripheral arterial disease, hyperlipemia, and arterial hypertension than nondiabetics. There were no differences between the two groups in terms of preoperative clinical status or degree of carotid stenosis. Interventions were performed under general anesthesia with somatosensory-evoked potentials (SEPs) monitoring in 67% of the patients in both groups, while the remaining interventions were performed under clinical monitoring. Shunt insertion (14% and 11%, respectively) and patch closure rates (79% and 76%, respectively) were similar between the two groups. There were no differences between the two groups in terms of neurological outcomes, while the mortality rate was higher in group 1 than in group 2 (P = .002; odds ratio [OR], 3.5; 95% confidence interval [CI], 1.5-8.3); combined 30-day stroke and death rate was significantly higher in group 1 (2%) than in group 2 (0.9%; P = .006; 95% CI, 1.2-3.9; OR, 2.2). At univariate analysis, perioperative risk of stroke and death in diabetic patients was significantly higher in patients undergoing intervention with SEP cerebral monitoring (95% CI, 0.9-39.9; OR, 5.9; P = .01), and this was also confirmed by multivariate analysis (95% CI, 1.1-23.1; OR, 8.3; P = .04). The same analysis in nondiabetics demonstrated that again the need for general anesthesia significantly increased perioperative risk, but this was not significant at multivariate analysis. Follow-up was available in 96% of patients, with a mean duration of 40 months (range, 1-166 months). There were no differences between the two groups in terms of estimated 7-year survival (87.3% and 88.8%, respectively; 95% CI, 0.57-1.08; OR, 0.8) and stroke-free survival (86.8% and 88.1%, respectively; 95% CI, 0.59-1.07; OR, 0.8). Diabetic patients had decreased severe (>70%) restenosis-free survival rates at 7 years than nondiabetics (77.4% and 82.2%, respectively; 95% CI, 0.6-1; OR, 0.8; P = .05). Univariate analysis demonstrated again that the use of instrumental cerebral monitoring significantly decreased stroke-free survival in diabetics (P = .01; log rank, 10.1), and this was also confirmed by multivariate analysis (95% CI, 1.7-17.7; OR, 5.4; P = .005). CONCLUSIONS: In our experience, the presence of diabetes mellitus increases three-fold the risk of perioperative death after CEA, while there are no differences with nondiabetics in terms of perioperative stroke. However, the rate of stroke and death at 30 days still remains below the recommended standards. During follow-up, this difference becomes negligible, and results are fairly similar to those obtained in nondiabetics. Particular attention should be paid to patients undergoing intervention under general anesthesia, who seem to represent a subgroup of diabetics at higher perioperative risk, suggesting neurologic monitoring should be used when possible.

Combined carotid and cardiac surgery: improving the results.

BACKGROUND: Aim of this study was to analyze our experience in the last 5 years of combined carotid and cardiac surgery. METHODS: During a 5-year period (January 2002-December 2006), 111 patients underwent combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) (group 1), while 1,446 patients underwent isolated CEA (group 2). Perioperative outcomes in the two groups were compared using chi(2) and Fisher's exact tests to analyze neurological deficits, cardiac events, and death at 30 days. Results during follow-up were analyzed using Kaplan-Meier survival curves, and both groups were compared using the log-rank test. RESULTS: Immediate postoperative neurological deficits occurred more frequently in group 1 patients (2.5 vs. 0.4%, p = 0.002), with a higher incidence of transient ischemic attacks in group 1; however, there was no difference in the incidence of stroke (1% group 1 vs. 0.6% group 2, p = n.s.). Mortality rate was increased in the combined surgery group (3.5 vs. 0.5%, p < 0.001). Combined stroke/myocardial infarction/death rate at 30 days was 6.3% in group 1 compared with 1.4% in group 2, p = 0.001. Perioperative stroke/myocardial infarction/death rate was much improved in the 55% (61/111) of patients undergoing CABG off-pump (3.3 vs. 10%, p = 0.001). Mean follow-up was 18.7 months (range, 1-60). Survival at 24 months was significantly higher in patients of group 2 compared with group 1 (99.4 vs. 91.3% respectively, p < 0.001). At 24 months, there was no significant difference between the two groups in the risk of developing ipsilateral or contralateral neurologic events (3.1% group 1 vs. 1.7% group 2). CONCLUSION: In our experience, combined CEA and cardiac surgery carries a higher risk of perioperative mortality than patients undergoing isolated CEA. Whenever possible, CEA combined with off-pump CABG seems to be the therapeutic strategy of choice.

Alternative hybrid reconstruction for bilateral common and internal iliac artery aneurysms associated with external iliac artery occlusion.

PURPOSE: To describe an alternative reconstruction for bilateral common (CIA) and internal (IIA) iliac artery aneurysms associated with external iliac artery (EIA) occlusion in a patient unfit for open surgery. CASE REPORT: A high-risk 81-year-old man presented with contained rupture of a left CIA aneurysm in the presence of bilateral CIA and IIA aneurysms associated with complete occlusion of the left EIA and normal patency of both common femoral arteries. In an emergent procedure, the left EIA was recanalized subintimally, and the right IIA was embolized with a 14-mm Amplatzer Plug. The main body of a standard Excluder endograft was deployed just distal to the origin of the left renal artery, and the ipsilateral leg was extended into the proximal right EIA. On the contralateral side, a short 10-mm-diameter limb was inserted through a 12-F sheath and deployed in the CIA, proximal to the iliac bifurcation. Via a percutaneous left brachial artery access, 3 covered stents (9x59 mm, 10x59 mm, 10x59 mm) were deployed from the distal IIA to the endograft contralateral limb. A right-to-left femorofemoral crossover bypass graft concluded the operation. The patient was discharged on the 5th postoperative day without complications; follow-up imaging at 6 months showed patency of the stent-graft and crossover bypass, with complete exclusion of the aneurysms and no evidence of endoleak. CONCLUSION: This case demonstrates an effective solution for complex aortoiliac lesions using commercially available devices, underlining how an accurate knowledge of alternative endovascular techniques and materials is crucial in the management of complex cases.

Carotid endarterectomy in female patients.

OBJECTIVES: To evaluate early and late results of carotid endarterectomy (CEA) in female patients in a large single center experience. METHODS: Over a 12-year period ending in December 2007, 4009 consecutive primary and secondary CEAs in 3324 patients were performed at our institution. All patients were prospectively enrolled in a dedicated database containing pre-, intra-, and postoperative parameters. Patients were female in 1200 cases (1020 patients; Group 1) and male in the remaining 2809 (2304 patients, Group 2). Early results in terms of intraoperative neurological events and 30-day stroke and death rates were analyzed and compared. Follow-up results were analyzed with Kaplan Meier curves and compared with log-rank test. RESULTS: Patients of Group 1 were more likely to have hyperlipemia, diabetes, and hypertension; patients of Group 2 were more likely to be smokers and to have concomitant coronary artery disease (CAD) and peripheral arterial disease (PAD). There were no differences in terms of clinical status or degree of stenosis. Patients of Group 2 had a significantly higher percentage of contralateral carotid artery occlusion than patients in Group 1 (6.9% and 3.9%, respectively; P < .001). Thirty-day stroke and death rates were similar in the two groups (1.2% for both groups). Univariate analysis demonstrated the presence of CAD, PAD, diabetes, and contralateral carotid artery occlusion to significantly affect 30-day stroke and death rate in female patients. At multivariate analysis, only diabetes (odds ratio [OR] 3.6, 95% confidence interval [CI] 0.1-0.9; P = .05) and contralateral occlusion (OR 7.4, 95% CI 0.03-0.6; P = .006) were independently associated with an increased perioperative risk of stroke and death. Median duration of follow-up was 27 months (range, 1-144 months). There were no overall differences between the two groups in terms of survival, freedom from ipsilateral stroke, freedom from any neurological symptom, and incidence of severe (>70%) restenosis. In contrast to male patients, univariate and multivariate analysis demonstrated that female patients with diabetes or contralateral occlusion had an increased risk of developing ipsilateral neurological events during follow-up. CONCLUSIONS: Female sex per se does not represent an adjunctive risk factor during CEA, with early and long term results comparable to those obtained in male patients. However, in our study we found subgroups of female patients at higher surgical risk, requiring careful intra- and postoperative management.

Surgical treatment of visceral artery aneurysms: A 25-year experience.

OBJECTIVE: The aim of this study was to analyze our 25-year experience with surgical treatment of visceral artery aneurysms (VAAs), with particular attention paid to early and long-term results. MATERIALS AND METHODS: From January 1982 to September 2007, 55 patients (32 males, 58%, and 23 females, 42%) underwent surgical treatment of 59 VAAs. Only one patient was treated with an endovascular procedure. Mean patient age was 59.3 years (range, 36-78 years). The site of aneurysmal disease was splenic artery in 30 (50.8%) cases, renal artery in nine (15.2%) cases, common hepatic artery in seven (11.9%) cases, pancreaticoduodenal artery in four (6.8%) cases, celiac trunk in three (5.1%) cases, superior mesenteric artery in two (3.4%) cases, and gastroduodenal, inferior mesenteric, middle colic and right gastroepiploic in one (1.7%) case for each artery. Two (3.6%) patients had multiple VAAs. In five (9.1%) patients, an abdominal aortic aneurysm coexisted. Early results in terms of mortality and major complications were assessed. Follow-up consisted of clinical and ultrasound examinations at 1 and 12 months, and yearly thereafter. Long-term results in terms of survival and aneurysm-related complications were analyzed. RESULTS: In all but two cases, elective intervention in asymptomatic patients was performed. Two (3.6%) patients had a ruptured aneurysm (one pancreaticoduodenal artery and one middle colic artery). The one perioperative death was due to an acute pancreatitis in a patient operated on for a giant inflammatory splenic artery aneurysm, yielding a perioperative mortality rate of 1.8%. Two major complications (retroperitoneal hematoma and acute pancreatitis) were recorded. Mean duration of follow-up was 82.1 months (range, 0-324 months). Estimated 10-year survival rate was 79.5%. During follow-up two aneurysm-related complications occurred, with an estimated 10-year, aneurysm-related, complication-free survival rate of 75.2%. CONCLUSION: In the era of minimally invasive therapeutic approaches, elective open surgical treatment of visceral artery aneurysms is safe and effective, and offers satisfactory early and long-term results.

Lower limb revascularization with a new bioactive prosthetic graft: early and late results.

The aim of the study was to evaluate the immediate and long-term results of femoropopliteal bypasses performed with a new bioactive heparin-treated expanded polytetrafluoroethylene (ePTFE) graft in a single-center experience. From March 2002 to April 2006, 51 patients underwent lower limb revascularization with a new bioactive ePTFE prosthetic graft with covalent end-point attachment of heparin to the graft surface. Data concerning preoperative assessment, intraoperative strategy, drug administration, and follow-up surveillance program were prospectively collected in a dedicated database; early results were analyzed in terms of graft patency, amputation rate, and deaths. Follow-up consisted of clinical and duplex scan examination at 1, 6, and 12 months and yearly thereafter. Midterm results in terms of primary and secondary patency, limb salvage, and survival were analyzed. Patients were predominantly male (35 patients, 71%), with a mean age of 71 years (SD = 9.05). Indications for surgical revascularization were critical limb ischemia in 36 patients and severe intermittent claudication in 15 patients. Interventions were performed for occlusion of a native vessel in 35 cases, whereas 12 patients had late thrombosis of a femoropopliteal bypass; the remaining four patients were operated on for an occluded popliteal artery aneurysm. Intervention consisted of below-knee bypass in 34 patients, while the other 17 had an above-knee revascularization. No perioperative deaths occurred. Cumulative 30-day graft patency was 88%, with an amputation rate of 4% (two cases). Results were similar in above- and below-knee revascularizatons. Mean duration of follow-up was 18 months (SD = 7). Cumulative estimated 24-month survival and primary patency rates were 97% and 80.2%, respectively; the corresponding limb salvage rate was 85.7%. Long-term results did not significantly differ in above- and below-knee revascularizatons. In our experience, the use of a modified ePTFE graft with covalent end-point linkage of heparin molecules on the graft surface provides good early and midterm results, with low rates of graft thrombosis and amputation.

Acute traumatic rupture of the descending thoracic aorta: endovascular treatment.

BACKGROUND: Acute traumatic rupture of the descending thoracic aorta is usually considered a surgical emergency; a conventional surgical approach carries high morbidity and mortality rates in the perioperative period. Endovascular surgery has recently been considered as providing a new therapeutic strategy for these patients. The aim of our study was to evaluate the feasibility along with early and midterm results of this procedure in our experience. METHODS: Among 59 thoracic stent-graft procedures performed between May 2001 and May 2005 in our Department, 11 male patients (mean age 48+/-7.3 years) underwent endovascular repair for acute traumatic rupture of the descending thoracic aorta caused by motor vehicle accidents. The feasibility of endovascular repair and the size of the endograft were assessed on the basis of urgent spiral computed axial tomography. In all cases, the lesion was limited to the isthmus. Follow-up was performed at discharge, at 3, 6, and 12 months, and yearly thereafter by clinical examination, chest x-ray, and computed axial tomography scan. RESULTS: Technical success was obtained in all patients, and no conversion to open repair was necessary. No intraoperative deaths or complications occurred, and no patient developed temporary or permanent neurologic deficits in the postoperative period. One patient died 22 days after the procedure from acute respiratory failure; cumulative 30-day mortality rate was 9.1%. The mean follow-up duration was 18.2+/-4.5 months. No death, endoleak, or reintervention occurred during follow-up. COMMENTS: The treatment of acute traumatic rupture of the descending thoracic aorta with stent graft is a feasible and safe technique; it provides low morbidity and mortality rates in the early postoperative period, and midterm results are encouraging. However, long-term studies are worthwhile to evaluate the effectiveness and the durability of this procedure.

Surgical management of popliteal artery aneurysms: which factors affect outcomes?

OBJECTIVE: Popliteal artery aneurysm (PAA) is uncommon. The clinical presentation of PAA includes rupture, embolism, and thrombosis. In this article, we evaluate the results of our 20-year experience with surgical management of PAAs, analyzing the role of anatomic, clinical, and surgical factors that potentially affect early and long-term results. METHODS: From January 1984 to December 2004, 159 PAAs in 137 patients were operated on at our department. Data from all the patients were retrospectively collected in a database. PAAs were asymptomatic in 67 cases (42%); 5 (3%) PAAs were ruptured. In 51 cases (32%), PAA caused intermittent claudication. The remaining 36 limbs (23%) had threatening ischemia due in 30 cases to acute PAA thrombosis, in 4 cases to chronic PAA thrombosis, and in 2 cases to distal embolization. In selected patients with acute ischemia, preoperative intra-arterial thrombolysis with urokinase was performed. Early results in terms of mortality, graft thrombosis, and limb salvage were assessed. Follow-up consisted of clinical and ultrasonographic examinations at 1, 6, and 12 months and yearly thereafter. Long-term survival, patency, and limb salvage rates were analyzed. RESULTS: Forty cases were treated with aneurysmectomy and prosthetic graft interposition; in 39 cases, the aneurysm was opened, and a graft was placed inside the aneurysm. Four patients had aneurysmectomy with end-to-end anastomosis. In 73 cases, ligation of the aneurysm with bypass grafting (39 with a prosthetic graft and 34 with an autologous vein) was performed. The remaining three patients underwent endovascular exclusion of their PAAs. A medial approach was used in 97 patients (61%), and a posterior approach was used in 59 patients (37.1%). The outflow vessel was in most cases (93.7%) the below-knee popliteal artery. Thirty-day amputation and death rates were 4.4% (7/159 limbs) and 2.1% (3/137 patients), respectively. The amputation rate was significantly higher in symptomatic limbs than in asymptomatic ones (6.5% and 1.4%, respectively; P = .05). Eight limbs (5%) had an early graft thrombosis that required a reintervention. Follow-up was available in 116 patients (84.7%) and 138 limbs (86%) with a mean follow-up time of 40 months (range, 1-205 months). The cumulative estimated 60-month survival, limb salvage, and primary and secondary patency rates were 84.2%, 86.7%, 66.3%, and 83.6%, respectively. Asymptomatic limbs had significantly better results than symptomatic ones in terms of limb salvage (93.4% and 80.4%, respectively; P = .03; log-rank, 4.2) and primary patency (86.5% and 51.6%, respectively; P = .001; log-rank, 10.3). Among symptomatic patients, results were better in claudicant limbs than in acutely ischemic ones in terms of limb salvage (90.5% and 58.7%, respectively; P = .001; log-rank, 17.5). Univariate analysis showed the absence of symptoms, the presence of two or three tibial vessels, the use of a posterior approach, the kind of intervention, and the site of distal anastomosis to significantly affect long-term patency. Cox regression for factors affecting 60-month primary patency showed that clinical presentation, runoff status, and the site of distal anastomosis significantly influenced long-term results. CONCLUSIONS: Results of surgery on asymptomatic PAAs are good-significantly better than those for symptomatic ones. Elective surgical intervention should be performed in patients with a low surgical risk and a long life expectancy when the correct indication exists. In thrombosed aneurysms, intra-arterial thrombolysis may represent an alternative to emergent surgical management. Our data demonstrated that results are similarly good in claudicants, and this fact confirms that only acute ischemia due to PAA thrombosis represents a real surgical challenge. In selected patients with focal lesions, a posterior approach seems to offer better long-term results. The runoff status and the site of distal anastomosis affect long-term patency as well.

Does the high-risk patient for carotid endarterectomy really exist?

BACKGROUND: High surgical risk is advocated as a major criterion for carotid artery stenting. To date, definitely accepted criteria to identify "high-risk" patients for carotid endarterectomy (CEA) do not exist. The aim of this study was to analyze the statistical weight of each single previously described risk factor on early and late results after carotid surgery in our experience. METHODS: A retrospective review of 1,883 CEAs performed during a 6-year period in a single institution was performed. Early and late results in terms of mortality and neurologic events were recorded. Univariate and multivariate analysis for early and late risk of stroke and death were performed, considering the influence of age, sex, comorbidities, clinical symptoms, and anatomic features. RESULTS: The cumulative 30-day stroke and death rate was 1.3%. Univariate analysis and logistic regression did not show statistical significance for 30-day results in any of the considered variables. The three-year stroke-free survival was 94.5%, and it was significantly affected by chronic renal failure, respiratory insufficiency, and older age. CONCLUSIONS: Carotid endarterectomy is a safe procedure also in so-called high-risk subsets of patients. Severe comorbidities seem to affect only long-term survival.

Isolated inflammatory aneurysm of superior mesenteric artery: unexpected pathologic diagnosis.

A 78-year-old woman was admitted to our department because of the incidental finding during routine abdominal ultrasound examination of a large aneurysm of the superior mesenteric artery. Presence of the aneurysm was confirmed at computed tomography and digital subtraction angiography, but its inflammatory origin was not recognized. No other aneurysm localization was found. Macroscopic intraoperative findings suggested the inflammatory nature of the lesion, but only histopathologic examination was diagnostic. Aneurismorraphy with prosthetic in-line reconstruction was performed. This report presents the previously undescribed possibility of an isolated inflammatory aneurysm of the superior mesenteric artery.