Giulio Tommasino

A Complex Thoracoabdominal Aneurysm in a Loeys-Dietz Patient: An Open, Hybrid, Anatomic Repair

We report the successful treatment of a life-threatening thoracoabdominal aneurysm in a young patient affected by type I Loeys-Dietz syndrome. To overcome anatomic and surgical difficulties, we used an original strategy and a specially designed surgical tool. The clinical and technical aspects of this approach are presented.

Successful use of a military haemostatic agent in patients undergoing extracorporeal circulatory assistance and delayed sternal closure

We report the successful control of bleeding in two patients who underwent post-cardiotomy extracorporeal circulatory support (ECMO) and then developed life-threatening bleeding due to severe coagulopathy. After the failure of conventional techniques, bleeding control was achieved using Celox Gauze (MedTrade Products Ltd, Cheshire, UK) packed on the sternal edges and pericardial cavity.

JAG Tearing Technique with Radiofrequency Guide Wire for Aortic Fenestration in Thoracic Endovascular Aneurysm Repair

An innovative approach, the JAG tearing technique, was performed during thoracic endovascular aneurysm repair in a patient with previous surgical replacement of the ascending aorta with a residual uncomplicated type B aortic dissection who developed an aneurysm of the descending thoracic aorta with its lumen divided in two parts by an intimal flap. The proximal landing zone was suitable to place a thoracic stent graft. The distal landing zone was created by cutting the intimal flap in the distal third of the descending thoracic aorta with a radiofrequency guide wire and intravascular ultrasound catheter.

Trans-pericardal Color Doppler Ultra Sound to Assess Blood Flow in the Visceral Branches during Type A Dissection Procedures Complicated with Mesenteric Malperfusion

Aortic dissection is a complex disease associated with high mortality and morbidity. Among the different possible clinical presentations, type A aortic dissection complicated at the onset by mesenteric malperfusion is characterized by poor outcome compared with patients not presenting such complication. We report the case of a patient with acute type A aortic dissection presenting with mesenteric malperfusion, in whom trans-pericardial color Doppler ultrasound (CDUS) examination was used to assess intraoperative and postoperative blood flow in the mesenteric artery. Trans-pericardial CDUS is demonstrated as a fast and simple diagnostic method with a good matching compared with contrast-enhanced computed tomography scan imaging, if correctly approached. We believe that this technique could be an important adjunctive tool for the intraoperative and perioperative management and decision-making in all patients with type A dissection presenting with mesenteric ischemia.

Surgical retroperitoneoscopic and transperitoneoscopic access in varicocelectomy: Duplex scan results in pediatric population

OBJECTIVE This is a retrospective study to compare duplex scan results of laparoscopic Palomos technique through retroperitoneal and transperitoneal approach for varicocelectomy in children. We statistically analyzed recurrence, testicular volume growth and complications. PATIENTS AND METHODS Surgical intervention was performed utilizing transperitoneoscopic (group A) or retroperitoneoscopic access (group B). Duplex scan control was performed after 12 months (T1), after 2 years (T2) and the last one at 18 years old in most patients. Statistical analysis was performed using the t-test for parametric data. Differences in proportions were evaluated using χ2 or Fishers exact test. RESULTS We treated 120 children (age range 10-17 years) who presented an asymptomatic IV grade of reflux, Coolsaet 1, associated with a left testicular hypotrophy in 36.6% of the cases (44 patients). No post-operative complications were verified. Duplex scan exam showed an increase of left testicular growth in both groups, with complete hypotrophy disappear in patients in both groups after 24 months. Hydrocele, diagnosed clinically and confirmed with duplex scan, was the most frequent post-operative complication (22/120 cases; 18.3%). CONCLUSIONS This study showed the importance of duplex scan at all steps of this vascular pathology in children, and that there is no significantly difference in results between the two surgical techniques except for hydrocele in transperitoneoscopic access.

Intimal re-layering technique for type A acute aortic dissection—reconstructing the intimal layer continuity to induce remodeling of the false channel

Background Residual false channel is common after repair of type A acute aortic dissection (TAAAD). Starting from our recent series of TAAAD patients we carried out a retrospective analysis, regarding the failure of primary exclusion at the time of the initial operation. We classified the location of the principal entry tears perfusing the residual false channel. The proposed technique represents our attempt to correct the mechanism of false channel perfusion during primary repair. We describe a new technique designed to address some limitations of standard hemiarch aortic replacement. Its goal are: (I) to reinforce the intimal layer at the arch level; (II) to eliminate inter-luminal communications at the arch level using suture lines around the arch vessels; (III) to provide an elephant trunk configuration for further interventions. Methods Between August 2016 and January 2018, 11 patients underwent emergency surgery using this technique; 7 were men; the median age was 74 years. All patients were treated using systemic circulatory arrest under moderate hypothermia (26 °C) and selective cerebral perfusion. All patients had supra-coronary repair; 1 patient had aortic valve replacement + CABG. In the first two patients a manual suture around supra-aortic trunks was used; the subsequent seven patients were treated with a mechanical suture bladeless device. CT scan follow up was performed in all survivors with controls before discharge 3 months and 1 year after operation. Results No patient died in the operating room and no neurologic deficit was observed in this initial experience. One patient died in POD 5th for low cardiac output syndrome. Median ICU stay was 3 days (IQR, 2-6 days). Hospital mean length of stay was 15.2±8 days. Median cardiopulmonary bypass time was 130 min (IQR, 110-141 min); median arrest time for re-layering was 17 min (IQR, 16-20 min); median total arrest was 36 min (IQR, 29-39 min). Distal aortic anastomosis was performed in zone 0 in 4 patients, zone 1, with innominate replacement, in 5 patients, in zone 2, with branches to innominate and left common carotid arteries, in 2 patients. Median follow up (closing date 06/01/2018) was 443 days (IQR, 262-557 days); no late deaths occurred. No dehiscence at the level of stapler or manual sutures was observed. Proximal 1/3 of the thoracic aorta false channel was obliterated in all cases but one; in 3 cases complete exclusion of the false channel was obtained after operation. In one case stent graft completion was required. Conclusions This technique combines the advantages of arch replacement to the simplicity of anterior hemiarch repair. This study demonstrates the safety of the procedure and the possibility to induce aortic remodeling without complex arch replacement.

Emergency fast Bentall operation

We herein report an emergency technique of composite Bentall operation using a fast release valve. The technique was successfully performed in 2 emergency cases after failed supracoronary ascending aortic replacement in acute Type A aortic dissection. The speed and ease of execution are the main advantages of the procedure.

External jugular vein spontaneous aneurysm, diagnosis and treatment with video

True and false aneurysms of veins are very rare conditions and only few cases have been described in the literature. We present a case of a 56-year-old female with personal history of primary arterial hypertension and connective tissue disease. Ultrasound of the neck showed a saccular, compressible, hypoechoic structure that appeared to have a direct communication with the left external jugular vein lumen. The venous aneurysm was removed and the histopathology of the mass showed a grossly dilated vein, with continuous aspects of the entire 3 layer of the venous wall, classifying it as a venous aneurysm.

New endovascular strategy to overcome anatomical constraints when dealing with aortoiliac aneurysms

Involvement of the iliac arteries with an abdominal aortic aneurysm (AAA) is seen in 20% to 30% of AAA patients. Treatment options have been dramatically changed over the last 10 years. At first, the only endovascular option was embolization of the internal iliac artery (IIA) using coils or plugs to extend the iliac limbs of the aortic stent-graft past the IIA. In a significant number of patients, however, IIA embolization may cause chronic symptoms, such as buttock claudication and sexual dysfunction, whether transient or permanent. The most successful endovascular options to preserve IIA flow have been branched stent-grafts and the bell-bottom technique. Implantation of branched stentgrafts has been shown to be feasible and safe, with good long-term outcome, even if the device is significantly more expensive. The bell-bottom technique was developed to approach IIAs with diameters between 18 and 24 mm, which precludes its use in aneurysms with larger distal landing zones. In 2011, Lobato et al. described the sandwich technique for aortoiliac aneurysms, which included 5 steps: (1) bifurcated stentgraft main body insertion through an ipsilateral femoral approach and positioned such that the distal end of the iliac limb is 1 cm above the IIA origin; (2) catheterization of the ipsilateral IIA through a left brachial access; (3) placement of a covered self-expanding stent 2 cm inside the IIA with a 6-cm overlap into the iliac limb, followed by positioning of an iliac limb extension 1 cm below the covered stent’s proximal end; (4) modeling of the iliac limb stent-grafts using a latex balloon and dilation of the covered stent with an angioplasty balloon; and (5) deployment of the contralateral iliac limb. As performed by the authors, the sandwich technique was favorably accepted by other investigators, and midterm results seem promising. In our institution, we have used this technique in 12 patients to date (7 described in a previous article). Cannulating the IIA from the brachial artery and advancing an endograft from the upper extremity proved uncomplicated. Sealing the commissural angles was successful, as oversizing the limb grafts in relation to the diameter of the main graft produces a tight apposition of the components. The technique satisfactorily recanalized the IIA and was free from intraprocedural complications. Now with a mean follow-up of 20 months (range 6–47), we have seen no endoleak in any patient. The iliac aneurysm sac diameter has shrunk (range 1–15 mm) in