Davide Marinazzo

Surgical and endovascular treatment of extracranial carotid artery aneurysms: early and long-term results of a single center.

PURPOSE To evaluate early and long-term results of surgical and endovascular therapy of extracranial carotid artery aneurysms. PATIENTS AND METHODS A retrospective study was conducted of 26 aneurysms in 25 patients (19 men and 6 women) who underwent surgery between 1993 and 2010: 18 were atherosclerotic, 3 were from arteritis, 1 was a relapsing mycotic aneurysm from previous carotid surgery, and 4 were posttraumatic. A neurologic event was the presenting symptom in 10 cases (7 transient ischemic attacks, 3 strokes); 13 patients were asymptomatic and a cranial nerve dysfunction (hoarseness) was present in 2; fever was present in 1. A total of 15 aneurysms, located on the carotid bifurcation (CB), were resected and an end-to-end carotid anastomosis was performed. In 6 patients with CB aneurysms, a vein graft was applied in 5, and a polytetrafluoroethylene graft in the other. Aneurysmorrhaphy and a vein patch was the procedure in 2 patients with an aneurysm of the CB. One of these 2 patients had a relapsing mycotic pseudoaneurysm and was treated initially with a vein patch, subsequently with a vein graft, and lastly with a carotid artery ligation. Three common carotid artery aneurysms from arteritis were treated under local anesthesia through implantation of a Viabahn endoprosthesis. RESULTS A perioperative minor stroke occurred in 1 patient (3.8%) because of intentional ligation of the internal carotid artery from a relapsing mycotic aneurysm, already treated with a vein patch and subsequently with a vein bypass. No permanent cranial nerve injuries were recorded; transient cranial nerve injuries were observed in 2 patients. CONCLUSIONS Surgical treatment is feasible, with an acceptable rate of stroke and cranial nerve injuries, especially when the aneurysm is located on the common carotid artery and carotid bulb. Endovascular therapy is a fascinating option, with satisfactory early and long-term results, and should always be considered when treating aneurysms located in the distal internal carotid artery and when the patient is not a good candidate for open surgery.

Spinal cord, bowel, and buttock ischemia after endovascular aneurysm repair.

A 66-year-old man with multiple comorbidities presented with a juxtarenal perianastomotic aortic aneurysm 10 years after open abdominal aortic aneurysm repair. The aneurysmal disease also involved both iliac bifurcations, the right internal iliac artery, the left common femoral artery (CFA) up to its bifurcation, and the homolateral popliteal artery. We performed bilateral internal iliac artery coil embolization 1-month apart. Later, we performed aortouniiliac endografting extending to the right external iliac artery and placement of an endovascular plug in the left external iliac artery. A right CFA to left femoral bifurcation bypass graft was then constructed after ligation of the left CFA aneurysm. After recovering from anesthesia and despite sequential hypogastric embolization, the patient developed postoperative paraplegia, buttock ischemia, and ischemic colitis and died on postoperative day 5. The possible pathogenic mechanisms involved in the onset of these ischemic complications are discussed in this article.

Eight-year follow-up of endovascular repair of a brachiocephalic trunk aneurysm due to Takayasu's arteritis

Aneurysms of the brachiocephalic trunk are rare but their clinical outcomes are potentially devastating; they include rupture, cerebral or arm ischemia secondary to thromboembolism, and compression of the surrounding structures. Although open repair has proven successful, it is associated with significant morbidity and mortality rates. Endovascular treatment, if anatomically feasible, may offer a safer and less invasive approach to these lesions, especially in high-surgical-risk patients. We report the good long-term outcome of endovascular repair of a large innominate artery true aneurysm due to Takayasus arteritis. A stent graft was safely and successfully deployed to exclude the aneurysm; assessment by vascular imaging at 8-year follow-up demonstrated the efficacy of the procedure.

Leiomyosarcoma of the Inferior Vena Cava: Resection and Vascular Reconstruction Using a Dacron Graft and an Adam De Weese Clip—Three-Year Follow-Up

Leiomyosarcomas are rare malignant tumors that particularly affect women. In 2% of all cases, they involve the veins, and in 60% of the cases affecting veins, an involvement of the inferior vena cava (IVC) has been demonstrated. We report a case of IVC leiomyosarcoma operated by resection and reconstruction with a Dacron bypass and apposition of an Adams-DeWeese IVC filter. The latter procedure has never been reported before in association with a graft applied for this disease. Technical and clinical details are described.

Combined Use of High-sensitivity C-Reactive Protein and N-Terminal Pro-B-type Natriuretic Peptide for Risk Stratification of Vascular Surgery Patients

BACKGROUND We sought to assess whether high-sensitivity C-reactive protein (hs-CRP) and pro-B-type natriuretic peptide (NT-proBNP) improve risk prediction when added to an established predictive tool and develop a point-based risk score. METHODS Four hundred eleven vascular surgery patients were enrolled. The primary outcome was a composite of death, acute coronary syndromes, pulmonary edema within 30 days of surgery, and postoperative troponin-I elevation. The risk score was developed from a logistic regression model by using an integer-based scoring system. RESULTS The rate of the primary outcome was 18%. Adding both hs-CRP and NT-proBNP to the Revised Cardiac Risk Index led to an increase in C statistic from 0.670 to 0.774. The net reclassification improvement was 0.210 (P = 0.004) and the integrated discrimination improvement was 0.112 (P = 0.0001). In the multivariable regression analysis used to develop the risk score, insulin therapy for diabetes (odds ratio [OR]: 2.8; P = 0.003), open surgery (OR: 1.95; P = 0.027), fibrinogen >377 mg/dL (OR: 2.83; P = 0.001), hs-CRP >3.2 mg/L (OR: 3.85; P < 0.0001), and NT-proBNP >221 ng/L (OR: 4.05; P < 0.0001) were associated with the primary outcome. There was no statistical evidence of overfit. The C index was 0.82 and the Hosmer-Lemeshow statistic was 1.61 (P = 0.0447). The observed and predicted rates of the primary outcome across quartiles of risk score were highly correlated. CONCLUSIONS Hs-CRP and NT-proBNP substantially improve risk prediction when added to an established predictive tool. The biochemical marker-based risk score may be useful for accurately risk-stratifying vascular surgery patients; nonetheless, further validation studies on external datasets are needed before it can be used in clinical practice.

Aortic Aneurysms in Takayasu Arteritis

Takayasu arteritis is a non-atherosclerotic chronic inflammatory vascular disease of unknown etiology that affects the aorta, proximal parts of its major branches and the pulmonary arteries. The disease may cause stenosis, occlusions and sometimes aneurysm formation in the aorta and/or the affected arteries. As the use of arteriography gradually became a more widespread and the procedure was more generally available, more details of the disease and its manifestation began to be described. From the historical perspective, Mikito Takayasu is credited with having been the first to describe the disease in 1908, when he presented a case of a 21-year old woman with a peculiar optic fundus abnormality, characterized by arteriovenous anastomosis around the papilla (fig. 1). He made no mention of whether or not radial pulses were absent or diminished. Two other ophthalmologists, Onishi and Kagoshima, also described patients very similar to the one described by Takayasu, adding that their patients had no radial pulses. This is why nowadays, the disease is called Takayasu-Onishi aorto-arteritis. Probably the first description of the disease we now call Takayasu arteritis was actually done by Giovan Battista Morgagni in 1771. Patients with pulseless disease or aortic syndrome were also described by Adams in 1827, Devy in 1839 and William Broadbent in 1875. In 1856, the English surgeon William Savory described pathological and clinical examination findings in a patient who died of pulseless disease and aortic arch syndrome. In this 22-year old woman, autopsy revealed obliteration of left internal carotid artery, together with bilateral subclavian artery occlusion. Histological descriptions of Takayasu arteritis were reported by Beneke in 1925 and Harbitz in 1926.

Endovascular Treatment of Multiple Aneurysms Complicating Cogan Syndrome

To report the use of endografts to manage multiple aneurysms due to Cogan syndrome (CS). A 38-year-old woman with descending thoracic aorta and right common carotid artery aneurysms due to CS was treated with endovascular grafts. After 4 years, angio computed tomography scan demonstrated complete exclusion of the aneurysms with no signs of endoleak, whereas echo color Doppler showed patency of the carotid graft, no signs of restenosis, no progression of the disease in the landing zones, and complete aneurysm exclusion. Endovascular repair seems to have favorable long-term outcomes and should be considered a viable alternative to surgery in unfit for open surgery patients, even if they are young, and when the aneurysm size and location would pose a higher risk of perioperative and postoperative complications after an open surgical procedure.

Carotid stenting versus endarterectomy in the same patient: A “direct” comparison

The aim of this study was to evaluate outcomes and feasibility of carotid artery stenting versus carotid endarterectomy, both procedures performed in the same patient. Forty-five subjects (33 males, 70 ± 7 years) underwent carotid endarterectomy or carotid artery stenting, the counter procedure on the contralateral carotid performed after a variable period. We evaluated the post-procedural percentage of carotid stenosis at 30, 180 days and one-year follow-up, and the occurrence of acute myocardial infarction, New York Heart Association class progression, stroke, death, cardiovascular death, angina, transient ischemic attack and renal failure. Carotid artery stenting treatment reduced the degree of re-stenosis after 180 days equally to carotid endarterectomy procedure (difference: 0.033%, P = 0.285). No statistically significant differences were observed according to the occurrence of acute myocardial infarction and New York Heart Association class progression, revealing odds ratio (OR) equal to 0.182 (P = 0.361) for acute myocardial infarction and 0.303 (P = 0.434) for New York Heart Association class progression. Carotid endarterectomy confirms its efficacy in carotid revascularization, but carotid artery stenting constitutes a good alternative when the procedures are selected based on patient-specific risk factors.

Management of a large hepatic artery aneurysm

We present a rare case of a giant hepatic artery aneurysm in a 61-year-old man that was successfully treated by aneurysmectomy with prosthesis bypass grafting. Because the gastroduodenal artery was occluded, an adequate collateral circulation was not ensured after simple ligation, so a direct arterial flow to the liver was restored to avoid the risk of significant liver or biliary tract ischemia. A computed tomography scan at 1 month showed occlusion of the bypass. The patient remained asymptomatic, despite the supposed lack of adequate collateral circulation. The unpredictable blood supply to the liver is discussed.