Continued sac perfusion of popliteal artery aneurysms after ligation and bypass. Relevance of duplex ultrasound surveillance and treatment.

AIM: Conventional management of popliteal artery aneurysms (PAA) through a medial approach may be lon term ineffective. We report our long term rate of continued sac perfusion after ligation and bypass, combined to duplex ultrasound (DUS) surveillance protocol. PATIENTS AND METHODS: Follow-up data of 24 PAA (mean diameter 37.5 ± 8.8 mm) treated by ligation and bypass with eventual adjunctive procedures (direct sac embolization or resection) were collected. The endpoints of the study were the long term rate of continued sac perfusion and the freedom from any reintervention. RESULTS: Twentyfour PAA were treated in 20 patients. Long term follow-up was complete for 19 graft (79.1%). During a median follow-up of 71.2 months (4-168), persistent sac flow was found in 5 legs (26.3%), 4 to 36 months after surgery, without enlargement or rupture. The cumulative Kaplan-Meier survival free from PAA reperfusion at 1, 3, and 6 years was 91.5%, 77.5%, and 71.5%, respectively. Basing on DUS surveillance, late additional procedures were required in 5 patients (25%), to treat sac reperfusion or preserve graft patency. The cumulative Kaplan-Meier survival free from any reintervention at 1, 3, and 6 years was 91.5%, 72.8%, and 67%, respectively. CONCLUSIONS: Conventional management of PAA through a medial approach may be associated to progressive sac expansion. The DUS surveillance protocol remains strongly recommended to detect sac perfusion and suggest the timing of reintervention before rupture occurs. Adjunctive intraoperative procedures could improve the long term results, but further studies on large series are needed. KEY WORDS: Acrylic glue, Duplex ultrasound study, Femoropopliteal bypass, Popliteal artery aneurysm, Ultrasoundguided embolization.

Surgical approach to the suprarenal abdominal aorta.

AIM: The surgical approach to the pararenal aorta can be performed through a midline laparotomy or retroperitoneal approach. The current paper reports the techniques for the suprarenal aortic approach, through the review of technical literature on this topic. METHODS: Forty-six out of 82 technical papers regarding the surgical approach to the suprarenal aorta were reviewed, focusing on relevant technical details, such as the position of patient, type of incision, aortic approach and anatomical limitations. RESULTS: The left retroperitoneal abdominal approach offers numerous advantages, mainly observing some modifications of the original technique (9th intercostal space incision, short radial frenotomy, section of the inferior mesenteric artery). The traditional transperitoneal access, through a midline or bilateral subcostal incision with retroperitoneal medial visceral rotation, is best indicated when an unrestricted approach to the right iliac arteries is needed, but it can be more challenging in patients with "hostile abdomen", for which a retroperitoneal route is probably more appropriate. A more aggressive surgical approach through a 7th-9th space thoracolaparotomy, combined with semicircunferential frenotomy, should be strongly recommended to provide a safe suprarenal aortic aneurysm repair in high risk patients, who often require adjunctive procedures, such as selective visceral perfusion and left heart bypass. CONCLUSIONS: Many technical options can be used to approach the suprarenal aorta, but none can be "radicalized". The surgical strategy must be individualized according to the anatomo-clinical characteristics of the patient and aneurysm morphology as well. KEY WORDS: Abdominal aorta, Aortic aneurysm, Surgical approach.

The influence of aneurysm size on early outcome of abdominal aortic aneurysm repair in female patients.

AIM: The purpose of this study was to examine the influence of aneurysm size on early outcome in women undergoing abdominal aortic aneurysm (AAA) repair, with suggestion of lowered threshold for intervention. PATIENTS AND METHODS: Retrospective cohort study on the early outcome of 25 females undergoing elective endovascular (EVAR) and open AAA repair, compared to 340 males from 2005 to 2017. The study was focused on 30-days mortality (primary endpoint) and incidence of non fatal major adverse events - MAE (secondary endpoint) of two subgroups of women: AAA diameter <50 mm (n.14, group F1), AAA diameter ≥ 50mm (n.11, group F2). RESULTS: The incidence of the primary endpoint at 30 days was 4% in females, and 1.1% in males, respectively (p=ns). Similarly, females showed a higher rate of MAE compared to males (16% vs 9.4%, p=ns). Women who underwent surgery with small aneurysms (F1 group) had an early outcome similar to men (30-day death 0% vs 1.1%, p=ns; MAE 7.1% vs 9.4%, p=ns) and significantly better than women with larger aneurysms (30-day death 0% vs 9%, p=ns; MAE 7.1% vs 27.2, p=ns). CONCLUSIONS: Although poorly significant from a statistical point of view, the present report seems to confirm that the AAA diameter is a relevant marker of disease severity in women, assuming that repair at smaller size may be associated with less comorbidity and better outcome. KEY WORDS: Abdominal aortic aneurysm, Abdominal aortic aneurys open repair, Endovascular aortic aneurysm repair, Female gender.

Wounds Difficult to Heal: An Effective Treatment Strategy.

OBJECTIVE: Treatment of wounds difficult to heal concerns 50% of the elderly population in Italy and is therefore a relevant social burden. The present study shows how the treatment with autologous leuco-platelets reduces the healing time of wounds improving the functional recovery. PATIENTS AND METHODS: Patients (n=100) with ulcers of the legs were divided in two groups: 1) 50 patients treated with conventional therapies; 2) 50 patients treated with autologous leuco-platelet concentrate (LPC) and hyaluronic acid (HIAFF, Hyalofill-F® ) as a scaffold. RESULTS: After 2 months, a 49% reduction in wound area was observed in the second group and in about 65% wound reduction was achieved in 15 days (4 LPC dressings). In contrast, patients treated by conventional therapies, showed a longer healing time and a greater percentage of failures. Morphometric analysis of biopsy samples obtained from the edge as well as from the bottom of the lesions obtained from the LPC group, detected an abundant presence of neoformed capillaries, characterized by a cubic, "reactive endothelium", close to the site of LPC infiltration. CONCLUSION: These results suggest that healing was promoted not only by limiting bacterial infections but also by the release of chemotactic and proangiogenic factors from leukocytes and platelets, improving the neoformation of capillaries.

Surgical treatment of spontaneous common carotid dissection: a case report.

BACKGROUND: Cervical carotid dissection is more common in extracranical vessel: internal carotid artery dissection (ICAD) is typical, vertebral artery dissection is uncommon, common carotid artery dissection (CCAD) is rare and even a more rare cause of ischemic stroke. Cervical artery dissections account up to 20-25% of ischemic strokes in young patients. Isolated and spontaneous common carotid artery dissection without aortic damage is unique. Indeed in the Literature 8 cases were identified. MRI and CTA were the most commonly used for diagnosis and follow-up. CASE REPORT: A 67-year-old came to our observation reporting burning pain in the right latero-cervical region in supine position, irradiated in the temporal region and recurrent episodes of migraine with aura (scintillating scotoma), in the last 3 months. The last Doppler Ultrasound control, performed after the onset of symptoms, showed an highlighted dissection wall with double lumen at the origin of the bulb and the internal carotid artery on the right. Aortic arch arteriography confirmed the diagnosis. The patient underwent surgery (longitudinal arteriotomy, removing four miointimal flaps, fastening the distal common carotid artery with 3 Kunlin's points). RESULTS: Any neurological or vascular problems after surgery were noticed. DISCUSSION AND COMMENTS: The pathogenesis can be related to a combination of an intrinsic weakness in the arterial wall and an external trigger. The diagnosis of CAD is made with MRI (78.0%), conventional angiography (31.1%), CTA (14.7%), and ultrasound (11.3%). CONCLUSION: No evidence-based guidelines exists for treatment of CCAD. In our patient surgical CEA treatment was the optimal solution.

Actin is a target of T-cell reactivity in patients with advanced carotid atherosclerotic plaques.

Atherosclerosis is a chronic inflammatory disease of the arterial wall associated with autoimmune reactions. In a previous study, we observed the presence of actin-specific antibodies in sera from patients with carotid atherosclerosis. To extend our previous results we evaluated the possible role of actin as antigenic target of cell-mediated immune reactions in carotid atherosclerosis. Peripheral blood mononuclear cells (PBMC) from 17 patients and 16 healthy subjects were tested by cell proliferation assay and by ELISA for cytokine production. Actin induced a proliferative response in 47% of patients' PBMC samples, with SI ranging from 2.6 to 21.1, and in none of the healthy subjects' samples (patients versus healthy subjects, P = 0.02). The presence of diabetes in patients was significantly associated with proliferative response to actin (P = 0.04). IFN- γ and TNF- α concentrations were higher in PBMC from patients than in those from healthy subjects and in PBMC proliferating to actin than in nonproliferating ones. Our data demonstrate for the first time a role of actin as a target autoantigen of cellular immune reactions in patients with carotid atherosclerosis. The preferential proinflammatory Th1 activation suggests that actin could contribute to endothelial dysfunction, tissue damage, and systemic inflammation in carotid atherosclerosis.