Massimiliano Allegritti

Retrograde popliteal access in the supine patient for recanalization of the superficial femoral artery: initial results.

Purpose To report an initial experience of superficial femoral artery (SFA) recanalization performed with a dual femoral-popliteal approach in the supine patient. Methods From May 2008 to April 2010, 26 patients (16 men; mean age 68±6.3 years) with intermittent claudication and chronic SFA occlusion (mean length 97.4±3.8 mm, range 35–220) underwent percutaneous recanalization from a retrograde popliteal access. The common femoral artery was punctured with an antegrade (n=9) or retrograde contralateral (n=17) approach, then with the patient still supine and the knee gently flexed and medially rotated, the popliteal artery was punctured using an 18-G needle under ultrasound (10, 38.4%) or fluoroscopic (16, 61.5%) guidance with a roadmap technique. Once the SFA was recanalized, the procedure was completed with angioplasty and stenting from the femoral approach. At the end of the procedure, hemostasis at the popliteal access was obtained with manual compression (5–10 minutes). Results Technical success (puncture of the popliteal artery and SFA recanalization) was achieved in all cases. In the majority of patients (24, 91.6%), endoluminal recanalization was possible from the popliteal access; SFA recanalization in the other 2 cases was obtained through the subintimal space. Two small hematomas were found in the popliteal region, but no pseudoaneurysm or arteriovenous fistulas were seen on duplex examinations during a mean 12.5-month follow-up (range 6–28). Twenty (76.9%) SFAs were patent; in-stent restenosis occurred in the remaining 6 (23%). Primary patency was 80.7% at 6 months and 76.9% at 1 year. No stent fracture was observed. Conclusion The retrograde popliteal approach with the patient in the supine position can be considered a “first choice” method for safe and effective SFA recanalization, especially in occlusions located at the distal and mid portion SFA.

Minimally invasive treatment of gastric leak after sleeve gastrectomy

PurposeObesity is a leading problem in Western countries, and laparoscopic sleeve gastrectomy (SG) is the most commonly used procedure for the surgical management of morbid obesity. SG is recognised as one of the safest and most effective bariatric procedures but it is limited by a rate of gastric leaks (GL) ranging from 1.4% to 20%. No international consensus exists about the treatment of GL. This paper reports our experience with the noninvasive management of GL.Materials and methodsFrom July 2004 to December 2010, 16 patients with GL after SG were referred to our unit. All patients underwent contrast radiography (Gastrografin) and computed tomography (CT) examination. On the basis of the radiographic findings, patients were divided into those eligible for drainage and those not eligible.ResultsTwelve patients (75%) were eligible for percutaneous drainage. Of these, seven patients (44%) were successfully treated with percutaneous drainage alone, whereas five patients (31%) required placement of a covered stent due to incomplete resolution of the collection. After 1009.8±456.7 days of follow-up, one patient died from a cardiovascular event and two patients required a bilio-pancreatic-digestive bypass (BPD-BP). Twelve patients (75%) were in an excellent state of health with significant reduction of their body mass index (BMI).ConclusionsOur experience confirms the value of an algorithm based on patient eligibility for percutaneous drainage in the treatment of GL. The patient’s general condition and in particular the presence of sepsis supports the value of this approach in preference to the conventional surgical approach.RiassuntoObiettivoL’obesità è uno dei problemi emergenti dei paesi industrializzati e la sleeve gastrectomy (SG) è una dei presidi più utilizzati per la cura dell’obesità patologica. La SG è riconosciuta come una delle più sicure tecniche chirurgiche bariatriche, ma è gravata in percentuale variabile dall’1,4% al 20% da fistola gastrica (GL). Non esiste un consensus internazionale sul trattamento del GL dopo SG. Riportiamo la nostra esperienza nel trattamento minimamente invasivo del GL dopo SG.Materiali e metodiDa giugno 2004 a gennaio 2010, 16 pazienti con GL post SL sono stati trattati dal nostro team. Tutti i pazienti sono stati sottoposti a transito con mezzo di contrasto per os (Gastrografin) e tomografia computerizzata (CT). In base all’aspetto radiografico i pazienti sono stati suddivisi in passibili di drenaggio e non passibili di drenaggio.RisultatiDodici pazienti (75%) sono stati passibili di drenaggio. Di questi in 7 (44%) pazienti il drenaggio percutaneo è stato l’unico presidio terapeutico; 5 pazienti (31%) hanno richiesto stents per la mancata risoluzione del GL. Dopo 1009,8±456,7 giorni di follow-up: 1 paziente è morto per evento cardiovascolare e 2 pazienti sono stati sottoposti a bypass bilio-pancreatico-digestivo. 12 pazienti (75%) presentano un ottimo stato di salute con riduzione dell’indice di massa corporea (BMI).ConclusioniLa nostra esperienza conferma l’utilizzo di un algoritmo basato sulla fattibilità del drenaggio percutaneo per la cura del GL. La presenza di sepsi corrobora questo approccio rispetto al tradizionale trattamento chirurgico.

Endovascular repair for acute mesenteric ischemia: case report

Methods We present a case of a 75-year-old patient with acute occlusive mesenteric ischemia that was successfully treated with endovascular intervention. Angiography revealed high-grade stenosis of the proximal tract of the SMA. Immediate option for endovascular therapy was made, and a MARIS self-expandable 6x40 mm stent was positioned. The patient was discharged 2 days after with full recovery from the symptoms.

Case report: Percutaneous treatment of multiple honeycomb-like liver hydatid cysts (type III CE2, according to WHO classification).

Percutaneous treatment has been developing as a reliable and effective alternative to surgery in the treatment of liver hydatid cysts. However, percutaneous treatment is strongly recommended only for some types of hydatid cysts (types I and II). We report a patient with type III (CE2, according to the WHO classification) multiple liver hydatid cysts treated with the PAIR (puncture–aspiration–injection–reaspiration) technique. The patient developed a secondary biliary fistula, which ultimately healed.

Malformazioni artero-venose

Per malformazioni vascolari si intendono le anomalie congenite dello sviluppo embrionale delle strutture vascolari. A differenza degli emangiomi, neoplasie vascolari benigne, le malformazioni vascolari non sono caratterizzate da un’aumentata proliferazione cellulare; sono sempre presenti sin dalla nascita, seppur diagnosticate tardivamente in relazione alla loro manifestazione clinica, e non regrediscono spontaneamente (Tabella 15.1).