Mario Gruppo

Common femoral artery endarterectomy for occlusive disease: An 8-year single-center prospective study

BACKGROUND Only a few operative or interventional studies have addressed the issue of isolated arterial occlusive disease at the femoral bifurcation, the early and late results reportedly being favorable in the former, controversial in the latter. The purpose of this study was to analyze the peri-operative (30-day) and long-term outcomes of isolated surgical endarterectomy in patients with occlusive disease at the common femoral artery (CFA), providing a baseline for comparison with emerging endovascular procedures. METHODS Over an 8-year period, all consecutive patients referred to our institution for claudication, rest pain, nonhealing ulcer(s), or minor tissue loss, with imaging findings of CFA occlusive disease (isolated or with additional infrainguinal lesions in the ipsilateral limb) amenable to endarterectomy of the CFA (isolated or combined with a profundoplasty or with the endarterectomy of the superficial or deep femoral artery first tract, not >1 cm long) were enrolled in the study. We excluded all patients with major tissue loss for which a contemporary infrainguinal revascularization was performed because treating the inflow disease alone would not be sufficient to heal the ischemic wound(s) owing to the presence of concomitant femoral and/or distal lesions, inadequate collateralization, or poor runoff. Descriptive demographic data, risk factors, clinical manifestations, and operative details were recorded. Primary patency (PP), assisted PP (APP), and limb salvage (LS) rates, freedom from additional proximal or distal revascularization in the ipsilateral limb, and survival were assessed using Kaplan-Meier life tables. Univariate and multivariate analyses were performed to identify which factors could influence CFA segment patency or other parameters. RESULTS In all, 117 patients were enrolled and underwent 121 CFA endarterectomies, 60.3% for claudication and 39.7% for critical limb ischemia (CLI); 30 patients were excluded because they underwent a contemporary infrainguinal revascularization. All procedures were performed with patients under regional anesthesia and took an average operating time of 1.3 +/- 0.7 hours. There were no perioperative deaths or major complications, but 8 (6.6%) local complications. A complete follow-up (mean 4.2 years) was obtained in 111 patients (115 limbs). The 7-year PP, APP, and LS rates were 96%, 100%, and 100%, respectively; the 7-year rates of freedom from further revascularization and survival were 79% and 80%, respectively. CONCLUSION Operative endarterectomy in patients with claudication or CLI for occlusive CFA disease proved safe, effective, and durable, and should provide a baseline for comparison with endovascular treatment. Proponents of endovascular procedures as a routine alternative treatment option should bear this in mind.

Aerobic Exercise and Pharmacological Treatments Counteract Cachexia by Modulating Autophagy in Colon Cancer

Recent studies have correlated physical activity with a better prognosis in cachectic patients, although the underlying mechanisms are not yet understood. In order to identify the pathways involved in the physical activity-mediated rescue of skeletal muscle mass and function, we investigated the effects of voluntary exercise on cachexia in colon carcinoma (C26)-bearing mice. Voluntary exercise prevented loss of muscle mass and function, ultimately increasing survival of C26-bearing mice. We found that the autophagic flux is overloaded in skeletal muscle of both colon carcinoma murine models and patients, but not in running C26-bearing mice, thus suggesting that exercise may release the autophagic flux and ultimately rescue muscle homeostasis. Treatment of C26-bearing mice with either AICAR or rapamycin, two drugs that trigger the autophagic flux, also rescued muscle mass and prevented atrogene induction. Similar effects were reproduced on myotubes in vitro, which displayed atrophy following exposure to C26-conditioned medium, a phenomenon that was rescued by AICAR or rapamycin treatment and relies on autophagosome-lysosome fusion (inhibited by chloroquine). Since AICAR, rapamycin and exercise equally affect the autophagic system and counteract cachexia, we believe autophagy-triggering drugs may be exploited to treat cachexia in conditions in which exercise cannot be prescribed.

Infrapopliteal arterial revascularization for critical limb ischemia: Is the peroneal artery at the distal third a suitable outflow vessel?

PURPOSE Though the peroneal artery (PA) often remains patent despite disease or occlusion of other infrapopliteal arteries, there is skepticism about using the terminal PA as the outflow tract in distal revascularizations for limb salvage, especially when a patent inframalleolar artery is available. We analyzed our experience of using the distal PA and inframalleolar or pedal branches arteries as outflow tracts in revascularizations for critical limb ischemia. METHODS Over a decade, among 651 infrapopliteal arterial reconstructions performed in 597 patients, the PA was the outflow vessel in 214, its distal third being involved in 69 vein revascularizations (study group). During the same period, 187 vein bypass grafts were performed to 179 inframalleolar and 8 pedal branches arteries (control group). Patency, limb salvage and survival rates were assessed using Kaplan-Meier life-table analysis. Complete follow-up (range, 0.1-10.2 years; mean, 5.8 years) was obtained in 245 (95.7%) patients (66 were in the study group). RESULTS The distal PA was chosen as the target vessel: (1) because the proximal, mid-PA was occluded or severely diseased and no other adequate inframalleolar or pedal branches arteries were identified preoperatively (n = 30; 43.5%); (2) because an alternative inframalleolar target vessel was present but severely diseased (n = 9; 13%); (3) because of the length limitations of the available vein (n = 12; 17.4%; or (4) because of the presence of invasive infection or necrosis overlying the dorsalis pedis or posterior tibial arteries (n = 18; 26.1%). The study group was significantly younger than the control group (68 +/- 7 years vs 70 +/- 6 years, P = .039), and included significantly more patients with diabetes mellitus (65.2% vs 50.2%, P = .033) and insulin dependence (52.2% vs 37.9%, P = .041), dialysis-dependent chronic kidney disease (5.8% vs 1.1%, P = .047), and history of smoking (75.3% vs 58.2%, P = .012). None of the patients died in the perioperative period. Although the overall need for minor amputation was statistically higher in the PA group (78.2% vs 63.1%, P = .022), especially as concerns partial calcanectomy (8.7% vs 2.1%, P = .026), the proportion of wounds completely healed during the follow-up and the mean time to wound healing were comparable in the two groups. Kaplan-Meier analysis showed comparable long-term patency, limb salvage, and survival rates in the two groups. CONCLUSIONS Revascularization to the distal third of the PA can achieve much the same outcome in terms of patency and limb salvage rates, wound healing rate and timing, as when other inframalleolar or pedal branches are used. The skepticism surrounding use of the terminal PA as an outflow vessel appears to be unwarranted.

Midline abdominal wall incisional hernia after aortic reconstructive surgery: A prospective study

BACKGROUND AND PURPOSE To evaluate rate of formation of midline abdominal wall incisional hernia (MAIH) after elective open repair of abdominal aortic aneurysm (AAA) and revascularization for aortoiliac occlusive disease (AOD). METHODS AAA and AOD patients operated electively via a primary midline abdominal incision at our institution over a decade were entered in this prospective study. Patients who had already undergone midline laparotomy or had an MAIH after previous celiotomy were excluded. Patients were examined for MAIH 6-monthly for 2 years, then yearly. RESULTS We included 1,065 patients who underwent aortic reconstructive surgery (412 with AAA and 653 with AOD). The follow-up (mean ± standard deviation) was 6.4 ± 3.8 years (range, 0.5-12.7). Wounds were closed with a suture length-to-wound length (SL:WL) ratio of at least 4:1 in 58% (239 of 653) of AAA patients and 66% (431 of 653) of AOD patients (P = .01). There were 124 (11.6%) MAIHs, with an incidence of 12.4% (51 of 412) in the AAA group and 11.2% (73 of 653) in the AOD group (P = .62), and 3 (0.4%) wound infections (all among the AOD patients), none of which resulted in MAIH. At multivariate analysis, a SL:WL ratio of <4:1 was the only independent predictor of MAIH in AAA (P = .004) and AOD patients (P < .001). CONCLUSION AAA and AOD patients had a similar incidence of MAIH, which seems related to the wound closure technique. A SL:WL ratio of at least 4:1 is recommended. Further clinical studies are required to determine possible technical and perioperative variables that may be modified to decrease the incidence of MAIH development after aortic reconstructive surgery.

The impact of gender on outcome after infrainguinal arterial reconstructions for peripheral occlusive disease

OBJECTIVE The role of gender on the outcome of infrainguinal arterial revascularization (IAR) for peripheral arterial occlusive disease remains uncertain. This study analyzed the outcome of IARs performed over 15 years, stratifying the results by sex. METHODS Details of consecutive patients undergoing primary IAR for peripheral arterial occlusive disease from 1995 to 2009 at our institution were prospectively stored in a vascular registry. Demographics, risk factors, indications for surgery, inflow sources, outflow target vessels, types of conduit, and adverse outcomes were analyzed. Postoperative surveillance included clinical examination supplemented with duplex scans and ankle-brachial index measurements in all patients at discharge, 30 days, 6 months, and every 6 months thereafter. End points of the study, ie, patency, limb salvage, and survival rates, were assessed using Kaplan-Meier life-table analysis. The χ(2) or Fisher exact, Student t, and log-rank tests were used to establish statistical significance. RESULTS Our sample consisted of 1459 IARs performed in 1333 patients, comprising 496 women (37.2%; 531 IARs), who were a mean 3 years older than the men (74 vs 71 years; P < .001) and had a higher incidence of diabetes mellitus (52% vs 46%; P = .03) and surgery for limb salvage (91% vs 87%; P = .02). An autogenous vein conduit (great or small saphenous, or both, spliced, arm, or composite veins) was used in 87% of the IARs. No deaths occurred perioperatively (30 days). The major and minor complication rates were comparable between men and women. At 10 years, the primary patency rate was 47% in women vs 49% in men (P = .67), the assisted primary patency rate was, respectively, 53% vs 50% (P = .69), the secondary patency rate was 61% vs 61% (P = .66), limb salvage rate was 93% vs 91% (P = .54), and survival rate was 43% vs 49% (P = .65). Stratifying by type of conduit revealed no differences in patency or limb salvage rates. CONCLUSIONS Despite an older age and more advanced stages of disease on presentation in women, IAR performed in women can achieve patency and limb salvage rates statistically no different from those recorded in their male counterparts, supporting the conviction that sex per se does not influence the outcome of lower extremity revascularization.

Predictors of neck bleeding after eversion carotid endarterectomy

OBJECTIVE The aim of this study was to identify predictors for neck bleeding after eversion carotid endarterectomy (eCEA). METHODS A prospectively compiled computerized database of all primary eCEAs performed at a tertiary referral center between September 1998 and December 2009 was analyzed. The end point was any neck bleeding after eCEA. End point predictors were identified by univariate analysis. RESULTS Of 1458 eCEAs performed by the same surgeon on 1294 patients under general anesthesia with continuous electroencephalographic monitoring and selective shunting, there were five major and three minor perioperative strokes (0.5%), and no deaths. Neck bleeding after eCEA occurred in 120 cases (8.2%), of which 69 (4.7%) needed re-exploration. Univariate analysis (odds ratio [95% confidence interval]) identified preoperative antiplatelet treatment with clopidogrel (1.77 [1.20-2.62], P = .004), particularly when continued to the day before CEA (3.84 [2.01-7.33], P < .001), and postoperative hypertension (9.44 [6.34-14.06], P < .001) as risk factors for neck bleeding in general and for neck bleeding requiring re-exploration (4.50 [1.85-10.89], P = .001; 15.27 [2.08-104.43], P = .006, and 2.44 [1.12-5.30], P = .02, respectively). An increased risk of neck bleeding in general was associated with clopidogrel plus acetylsalicylic acid (12.00 [2.59-56.78], P = .005), acetylsalicylic acid alone (4.37 [1.99-9.57], P < .001), and ticlopidine (2.49 [1.10-5.63], P = .02) only when they were continued to the day before CEA. No neck bleeding was associated with preoperative treatment with dipyridamole or warfarin, or no medication. No further complications occurred in the patients who underwent re-exploration. CONCLUSIONS The results of this single-center university hospital study show that neck bleeding after CEA is relatively common but is not associated with an increased risk of stroke or death. Preoperative treatment with clopidogrel, particularly when it is continued to the day before surgery, and postoperative arterial hypertension seem to be associated with a higher risk of neck bleeding after CEA, requiring re-exploration in most cases. Other antiplatelet agents appear to be associated with an increased risk of postoperative neck bleeding only if they are continued to the day before CEA. Larger studies are warranted to confirm our findings and prevent this feared surgical complication.

Extra-gastrointestinal stromal tumor of the pancreas: case report and review of the literature

Primary extra-gastrointestinal stromal tumor (EGISTs) arising in the pancreas is extremely rare: only 20 cases have previously been reported in the English literature from 2000 to 2013. We reported a case of EGIST of the pancreas in a 69-year-old woman who presented with abdominal pain and with a solid, heterogeneously enhancing neoplasm in the uncinate process of the pancreas, revealed preoperatively by an abdominal computed tomography scan. A diagnosis of neuroendocrine tumor was suggested. Positron emission tomography with 68Ga-DOTATOC did not show pathological accumulation of the tracer in the pancreas. The patient underwent enucleation, under ultrasonic guidance, of the pancreatic tumor that emerged to the surface of the pancreas. Histopathology and immunohistochemical examination confirmed the final diagnosis of EGIST of the pancreas (CD117+), with one mitosis per 50 high-power fields. Although rarely, GIST can involve the pancreas as a primary site, and this tumor should be considered in the differential diagnosis of pancreatic neoplasms.

Leiomyosarcoma of the Pancreas with Liver Metastases as a Paradigm of Multimodality Treatment: Case Report and Review of the Literature

Primary leiomyosarcoma is a rare malignant neoplasm, although it is the most common primary pancreatic sarcoma [1]. It accounts for 0.1 % of malignant pancreatic neoplasms [2], and it seems to arise from smooth muscle cells of ducts or blood vessels within the pancreas [3] Pancreatic leiomyosarcoma is a highly aggressive neoplasm in which widespread metastases occur frequently and the liver is typically affected [4], so the prognosis is generally bad [5]. Radical resection of the primary lesion seems to offer the best possibility for cure [6]. We report a case of primary leiomyosarcoma of the pancreas with synchronous hepatic metastases occurring in a 54-year-old female who was treated with repeated surgical excision together with different chemotherapeutic regimens.

Infrapopliteal arterial reconstructions for limb salvage in patients aged ≥80 years according to preoperative ambulatory function and residential status

BACKGROUND Although numerous studies have addressed peripheral revascularizations for critical limb ischemia (CLI) in patients aged > or =80 years, few have focused exclusively on infrapopliteal arterial reconstructions. This study aimed to analyze early and long-term outcomes in very elderly patients who underwent surgical infrapopliteal revascularization for CLI according to their pre-operative ambulatory function and residential status. METHODS Over an 18-year period, all consecutive patients aged > or =80 years referred to our institution for CLI requiring primary infrapopliteal or inframalleolar arterial reconstruction were enrolled in the study. All procedures were completed by the same surgeon with patients under regional anesthesia. Patency, limb salvage, amputation-free survival, and cumulative survival rates were assessed by Kaplan-Meier analysis. The patients pre- and postoperative ambulatory function and residential status (at home vs in a nursing home) were also analyzed. The mean follow-up was 6.2 years (range, 0.1-11.5) and was obtained for 98% of patients. RESULTS In all, 197 patients (134 men; mean +/- SD age, 82.8 +/- 1.7 years) with 201 critically ischemic limbs were enrolled in the study. No deaths or fatal major complications occurred in the peri-operative period (first 30 days); the local complication rate was 6%. After 1 and 7 years, the primary patency rates were 88% and 68%, the limb salvage rates were 96% and 87%, the amputation-free survival rates were 88% and 39%, and the survival rates were 91% and 44%, respectively. At last follow-up or death, 80% of the patients were ambulatory and 20% were not; 80% lived at home and were independent, another 9% lived at home with assistance, and 76% of the sample lived at home and were ambulatory. CONCLUSION Infrapopliteal arterial revascularization in the very elderly with CLI proved safe, effective, and durable, confirming that age per se and concomitant comorbidities do not necessarily affect technical and clinical outcomes. Ambulatory function and independent living status are well preserved because, despite a relatively short life expectancy, the majority of very elderly revascularized CLI patients can be expected to spend their remaining years ambulatory and at home. In contrast, patients with poor ambulatory function or who required assistance pre-operatively were less likely to improve their status after limb revascularization despite a successful technical result.

Mesenteric-Portal Vein Resection during Pancreatectomy for Pancreatic Cancer

The aim of the present study was to determine the outcome of patients undergoing pancreatic resection with (VR+) or without (VR−) mesenteric-portal vein resection for pancreatic carcinoma. Between January 1998 and December 2012, 241 patients with pancreatic cancer underwent pancreatic resection: in 64 patients, surgery included venous resection for macroscopic invasion of mesenteric-portal vein axis. Morbidity and mortality did not differ between the two groups (VR+: 29% and 3%; VR−: 30% and 4.0%, resp.). Radical resection was achieved in 55/64 (78%) in the VR+ group and in 126/177 (71%) in the VR− group. Vascular invasion was histologically proven in 44 (69%) of the VR+ group. Survival curves were not statistically different between the two groups. Mean and median survival time were 26 and 15 months, respectively, in VR− versus 20 and 14 months, respectively, in VR+ group (p = 0.52). In the VR+ group, only histologically proven vascular invasion significantly impacted survival (p = 0.02), while, in the VR− group, R0 resection (p = 0.001) and tumors grading (p = 0.01) significantly influenced long-term survival. Vascular resection during pancreatectomy can be performed safely, with acceptable morbidity and mortality. Long-term survival was the same, with or without venous resection. Survival was worse for patients with histologically confirmed vascular infiltration.