Daniele Bissacco

Conservative Management in a Young Woman Affected by Isolated Left Subclavian Artery Dissection

Subclavian Artery Dissection (SAD) is a rare condition, generally due to arterial catheterization, blunt trauma or connective tissue disease. Spontaneous or minimally traumatic cases have also been reported. Clinical manifestations are usually chest and/or back pain, pulse loss and paresthesia, whereas nausea, dizziness and vomiting are present in case of involvement of the vertebral artery. We report an unusual case of a young woman presenting isolated left SAD after traffic accident, minimally symptomatic, and treated with medical therapy alone. A conservative management and a closed follow-up appear to be a safe approach in patients affected by uncomplicated SAD without other comorbidities.

Carotid Artery Stenosis: The Curse of Best Medical Therapy

Recent reports dedicated to critical issues, opinions, and controversies in carotid artery stenosis and particularly the letter by Moris et al entitled ‘‘Current Debates on the Treatment of Carotid Stenosis in Both Symptomatic and Asymptomatic Patients: A Reappraisal’’ have shown once again that in about 35 years from first randomized controlled trials regarding the efficacy of surgery in symptomatic carotid stenosis (SCS) and asymptomatic carotid stenosis (ACS), problems and disputes remain substantial and unresolved. In the letter, the authors describe how recent trials have not answered the most urgent question regarding the management of patients with SCS and ACS—a comparison of carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical therapy (BMT) for asymptomatic patients. Although several studies have tried to propose a solution to this dilemma, nobody has still solved this important issue. Interim results from the Asymptomatic Carotid Surgery Trial 2 demonstrate that between February 2008 and September 2012 (55 months) the number of randomized patients was 986, recruiting on average about 18 patients per month. At this rate, recruiters need another 223 months (18.5 years) to reach the goal of 5000 patients. Also, in this case, the results do not include a BMT arm analysis. The Stent-Protected Angioplasty in Asymptomatic Carotid Artery Stenosis versus Endarterectomy (SPACE-2) study started in 2009 aiming to compare BMT with CEA and CAS in patients with severe asymptomatic carotid stenosis. The aim of the study was to recruit about 3500 patients. Due to low recruitment, the trial committee decided in 2012 to change the protocol and to divide this 3-arm trial into 2 separate 2-arm clinical trials: CEA þ BMT versus BMT alone (SPACE-2A) and CAS þ BMT versus BMT alone (SPACE-2B). The sample size for the overall trial was 3272 patients (SPACE-2A: 1636 and SPACE-2B: 1636). Unfortunately, it is beforehand terminated with no interim results for several reasons, including poor recruitment rate and financial factors. A new analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial 2 (CREST-2) is currently recruiting participants with ACS having 70% stenosis, comparing either BMT alone versus BMT + CEA or BMT alone versus BMT + CAS. Estimated primary completion date will be in December 2020. No more trials are currently in progress regarding BMT versus CEA or CAS. Although there are several calls to improve the management of ACS and to verify the effectiveness of invasive therapeutic maneuvers, the scientific community is responding slowly and always partially. Do we need a new trial BMT versus CEA/ CAS? The answer is certainly yes! But, do we really want to know the results? Probably, nowadays there is too much resistance to changing our thoughts about ACS, and ‘‘unexpected’’ results may be frightening, especially in European countries where CEA is performed in the majority of cases in patients with ACS.

Unusual clinical presentation of primary aortoduodenal fistula

Primary aorto-enteric fistula (PAEF) develops between the native aorta and the gastro-intestinal tract, in the presence of an abdominal aortic aneurysm. It is a rare, life-threatening condition and appears to be less frequent than secondary aorto-enteric fistula, which is associated with previous aortic prosthetic reconstruction. When untreated, the overall mortality rate is almost 100%. Diagnosis may be challenging until the occurrence of a massive haemorrhage. In the presence of gross contamination, patients tend to a worse prognosis. Extra-anatomical bypass and repair of the enteric tract is the treatment of choice in case of gross contamination. In situ reconstruction is often reported in cases of mild bacterial contamination. Endovascular treatment has recently become a valid option in haemodynamically unstable patients, but a staged approach, with delayed surgical treatment, seems advisable.

Spontaneous Rupture of Multiple Occipital Artery Aneurysms in a Patient With Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF-1) is an autosomal dominant genetic disorder, mainly characterized by skin and peripheral nervous system abnormalities. Uncommonly, NF-1 may be associated with peripheral or supra-aortic trunks artery aneurysms. We report a case of symptomatic multiple occipital artery aneurysms detected in a 53-year-old woman affected by sporadic NF-1. An endovascular approach was performed to exclude aneurysms and to stop laterocervical spontaneous hematoma.

Medical Therapy Before Carotid Endarterectomy: Changes Over a 13-Year Period and Comparison Between Asymptomatic and Symptomatic Patients

We evaluated the evolution of chronic medical therapy in patients admitted for carotid endarterectomy (CEA) over a 13-year period and to analyze the difference in medical treatment between symptomatic and asymptomatic patients. A retrospective study was conducted on patients treated between 2002 and 2015. The use of antiplatelets (acetylsalicylic acid [ASA], ticlopidine, and clopidogrel), oral anticoagulant therapy (OAT), statins and antihypertensives (angiotensin-converting enzyme inhibitors [ACE-I]/angiotensin receptor blockers [ARBs], β-blockers [BB]) administration was evaluated. During the study period, 852 CEAs were performed in 681 (79.9%) asymptomatic patients. Prescription rate increased significantly for ASA (+29.2%), clopidogrel (+10.3%), statins (+60.8%), ACE-I/ARBs (+31.1%), and BB (+19.3%; all P trend < .05). No significant modification was observed for ticlopidine and OAT (ticlopidine use was abandoned in the recent years, but this difference was not significant due to the small numbers). A lower medication intake was recorded for symptomatic patients when compared with asymptomatic patients, except for OAT and clopidogrel. Our analysis suggests that medical therapy has changed over the years for patients with carotid stenosis. Although this is a big step toward best medical therapy, preoperative drug therapy remains suboptimal in symptomatic patients.

Saphenous vein ablation with a new cyanoacrylate glue device: a systematic review on 1000 cases

Abstract Background: To review published evidence regarding an n-butyl-cyanoacrylate (NBCA) injection device for great (GSV) and small (SSV) saphenous vein incompetence in terms of occlusion rate, postoperative complications and quality of life improvement. Material and methods: International bibliographic databases (PubMed, EMBASE, Scopus) were searched to identify possible target articles. The only inclusion criterion was the use of the Variclose® system (Biolas, Ankara, Turkey) for superficial vein insufficiency. Exclusion criteria were case reports, review, meta-analysis, article with <6-month follow-up data, abstracts and congress presentations. PRISMA guidelines were used to lead articles selection. Results: Seven studies were included in the final data analysis. A total of 918 patients (1000 limbs) underwent an NBCA procedure for GSV (947 cases) or SSV (53 cases) incompetence. The average procedure duration was 11.7 min. The most common postoperative complications were postoperative pain (4.8%) and superficial vein thrombosis (2.1%). No deep vein thrombosis or pulmonary embolism cases were described. The occlusion rates at six, 12 and 30 months were 97.3%, 96.8% and 94.1%, respectively. Conclusion: NBCA injection with the Variclose device seems to be a feasible, effective and safe treatment in GSV incompetence. Long-term follow-up studies and randomized controlled trials are needed to achieve high-quality evidence.

Development and validation of a score to predict life expectancy after carotid endarterectomy in asymptomatic patients

Objective Recent improvement of best medical treatment for carotid stenosis has sparked a debate on the role of surgery—identification of patients who may benefit from carotid endarterectomy (CEA) is crucial to avoid overtreatment. An expected 5‐year postoperative survival is one of the main selection criteria. The aim of this study was the development of a score for predicting survival of asymptomatic patients after CEA. Methods Our score was derived from a retrospective analysis of 648 consecutive asymptomatic patients from a single hospital. External validation of the score was then performed on a second cohort of 334 asymptomatic patients from two different hospitals in the same area. Factors associated with reduced postoperative survival within the derivation cohort (DC) were identified and tested for statistical significance. Each selected factor was assigned a score proportional to its &bgr; coefficient: 1 point for chronic obstructive pulmonary disease, diabetes mellitus, coronary artery disease, and lack of statin treatment; 4 points for age 70 to 79 years and creatinine concentration ≥1.5 mg/dL; 8 points for age ≥80 years and dialysis. The DC was divided into four groups based on individual scores: group 1, 0 to 3 points; group 2, 4 to 7 points; group 3, 8 to 11 points; and group 4, ≥12 points. Group‐specific survival curves were calculated. The validation cohort (VC) was stratified according to the score. Survival of each of the four risk groups within the VC was compared with its analogue from the DC. Results Median follow‐up of the DC and VC was, respectively, 56 and 65 months. Intercohort comparison of 5‐year survival was 84.7% ± 1.7% vs 85.2% ± 2% (P = .41). Group‐specific 5‐year survival within the DC was 97% ± 1.5% (group 1), 88.4% ± 2.2% (group 2), 69.6% ± 4.7% (group 3), and 48.1% ± 13.5% (group 4; P < .0001). Five‐year survival within the VC was 95.5% ± 2% (group 1), 89.5% ± 2.7% (group 2), 65% ± 6.1% (group 3), and 44.8% ± 14.1% (group 4; P < .0001). Intercohort comparison of group‐specific survival curves showed close similarity throughout the groups. Conclusions Our score is a simple clinical tool that allows a quick and reliable prediction of survival in asymptomatic patients who are candidates for CEA. This selective approach is crucial to avoid unnecessary surgery on patients who are less likely to survive long enough to experience the benefits of this preventive procedure.

Recurrent varices after surgery: A clinical and color-doppler ultrasound scan analysis

BACKGROUND To evaluate clinical pictures, symptoms and etiology of recurrent varices after surgery (REVAS) through a clinical and color-Doppler-ultrasound scan (CDUS) analysis. METHODS During a three-year period, data about 9043 consecutive outpatients were collected. Among these, 160 patients (1.8%) were affected by REVAS. Data about risk factors, types of primary vein surgery, symptoms, clinical and CDUS characteristics were analyzed using the Clinical, Etiology, Anatomy and Pathophysiology (CEAP), Stonebridge and Perrin classifications in order to evaluate clinical and anatomical varices patterns. RESULTS Family history for chronic venous disease (90%), sedentary lifestyle (61.9%) and obesity (11.9%) were the most representative risk factors. REVAS symptoms were rather heterogeneous, although only 10% of cases was fully asymptomatic. CEAP classification showed a prevalence of C2 and C3 class (56.3% and 35% respectively). About half of inguinal REVAS was connected from a great saphenous vein residual stump (Stonebridge type 1). Lower limb perforating veins resulted associated to REVAS in 43.8% of cases. CONCLUSIONS REVAS remain a major and still unsolved problem in patients following varicose veins surgery. Their clinical pictures and symptoms are heterogeneous and require a watchful analysis in order to identify both etiology and natural history.

Aortic pseudoaneurysm after endarterectomy for small aorta syndrome

Highlights • Small Aorta Syndrome is a rare pathology that affects almost exclusively young and middle aged women.• In the past thromboendarterectomy with patch graft was one of the preferred treatment options.• Aortoiliac PA has been rarely observed after endarterectomy.• Endovascular treatment should be preferred considering morbidity and mortality of open surgery.• Open surgery was preferred because of small iliac diameters unsuitable for endovascular treatment.

Bovine Aortic Arch and Bilateral Retroesophageal Course of Common Carotid Arteries in a Symptomatic Patient.

Anatomical variations of carotid arteries may be related to their development (agenesis, aplasia, hypoplasia) or course (coiling, kinking, tortuosity). Partial or total aberrancies in carotid vessel anatomy rarely occur. We describe the case of a 95-year-old woman presented with sudden onset of confusion and disorientation together with upper limb clonus. Computed tomography (CT)-scan revealed a left frontal brain injury with a not conclusive carotid doppler ultrasound. CT angiography reported a bovine aortic arch with bilateral retroesophageal course of both common carotid arteries and left severe (>70%) internal carotid artery stenosis. The knowledge of anatomical variations of the course of carotid arteries is relevant for possible surgical or endovascular repair or in case of otolaryngology or intubation procedures.