Ombretta Martinelli

Carotid body tumors: radioguided surgical approach

BackgroundCarotid body tumours (CBTs) are very rare lesions which should be treated as soon as possible even when benign since small tumour size permits easier removal and lower incidence of perioperative complications and recurrence. Malignant forms are rare and they can be identified by lymph node invasion and metastases in distant locations. The need of reliable and effective diagnostic modalities for both primary CBTs and its metastases or recurrence is evident.The present study reviews our experience and attempt to define the role of colour coded ultrasound (CCU) and Somatostatin receptor scintigraphy (SRS) with Indium-111-DTPA-pentetretide (Octreoscan®) using both planar and single photon emission tomography (SPECT) technique in the diagnosis and follow-up of these uncommon lesions within a multidisciplinary approach.MethodsFrom 1997 to 2008, 12 patients suffering from 16 CBTs (4 bilateral) were investigated by CCU and SRS-SPECT before and after surgery. All tumours were grouped according to Shamblins classification in order to assess the technical difficulties and morbidity of surgical resection on the ground of their size and relationship with the carotid arteries. Intraoperative radiocaptation by Octreoscan®) was also carried out in all cases to evaluate the radicality of surgery. All perioperative scans were evaluated by the same nuclear medicine physician.ResultsPreoperatively CCU showed CBTs (four were not palpable) with a sensitivity of 100%. Radioisotope imaging identified the CBTs as chemodectomas in 15 cases while no radioisotopic uptake was detected in 1 vagus nerve neurinoma. No evidence of metastasis or multicentricity were seen by total body radioisotopic scans. Combined data from CCU and SRS-SPECT allowed to determine tumour size in order to select 7 larger tumours which were submitted to selective preoperative embolization.Intraoperatively Octreoscan demonstrated microscopic tumour leftovers promptly removed in 1 case and an unresectable remnant at the base of the skull in another case.During follow-up CCI and radioisotope scans showed no recurrence in 14 cases and a slightly enlargement of the intracranial residual as detected during surgery in 1 patient.ConclusionCCU may allow an early and noninvasive detection of CBTs and hence safer operations. The combined use of CCU and SRS-SPECT provide useful data to identify those tumours and to evaluate their extent and carotid arteries infiltration. Radioisotope imaging is a sensitive modality to detect metastases and lymph node involvement that are markers of CBT malignancy. After surgery CCU and SRS-SPECT can be accurate modalities for surveillance for an early detection of CBTs recurrence.

Outcomes in the emergency endovascular repair of blunt thoracic aortic injuries.

Thoracic aorta blunt injury (BAI) is a highly lethal lesion. A large number of victims die before obtaining emergency care. Thoracic endovascular aneurysm repair (TEVAR) is a less invasive method compared with open surgery and may change protocols for BAI treatment. This retrospective study was developed to evaluate the potential issues about thoracic endografting in the management of these patients. Twenty-seven patients with a BAI underwent aortic stent grafting. Intervention was preceded by the treatment of more urgent associated lesions in nine cases. In-hospital mortality was 7.4%. No paraplegia or ischemic complications developed because of the coverage of the left subclavian artery. In one case (3.2%), a type I endoleak was detected, proximal endograft infolding in two cases (7.4%) and endograft distal migration in further two cases were detected during follow-up (6-110 months). Thoracic endovascular aneurysm repair of BAI showed encouraging results in terms of perioperative mortality and morbidity. Concerns still remain about the potential mid- and long-term complications in younger patients.

Mid- and Long-Term Results of Endovascular Treatment in Thoracic Aorta Blunt Trauma

Study Aim. Evaluation of results in blunt injury of the thoracic aorta (BAI) endovascular treatment. Materials and Methods. Sixteen patients were treated for BAI. Thirteen patients had associated polytrauma, 4 of these had a serious hypotensive status and 4 had an hemothorax. In the remaining 3, two had a post-traumatic false aneurysm of the isthmus and 1 had a segmental dissection. In those 13 patients a periaortic hematoma was associated to hemothorax in 4. All patients were submitted to an endovascular treatment, in two cases the subclavian artery ostium was intentionally covered. Results. One patient died for disseminated intravascular coagulation. No paraplegia was recorded. No ischemic complications were observed. A type I endoleak was treated by an adjunctive cuff. During the followup (1–9 years) 3 patients were lost. A good patency and no endoleaks were observed in all cases. One infolding and 1 migration of the endografts were corrected by an adjunctive cuff. Conclusion. The medium and long term results of the endovascular treatment of BAI are encouraging with a low incidence rate of mortality and complications. More suitable endo-suite and endografts could be a crucial point for the further improvement of these results.

Treatment of a Juxtarenal Aneurysm with a Parallel Graft in the Left Renal Artery and Polymer-Based Technology to Seal the Entire Aneurysmal Sac

BACKGROUND Presenting the treatment of a juxtarenal aneurysm using a Nellix device combined with a chimney stent in a renal artery. CASE REPORT A 72-year-old woman was diagnosed with a 5.5-cm bilobed juxtarenal aneurysm. She underwent successful aneurysm repair with the Nellix system combined with a chimney stent in the left renal artery. Angio computed tomography control showed complete sealing of the aneurysm sac and patent chimney stent. CONCLUSIONS Endovascular aneurysm sealing combined with chimney may be a valid way to treat juxtarenal aneurysms, and the conformable polymer-filled endobags may provide a durable seal around the chimney-graft preventing gutter formation.

Preliminary results of endovascular aneurysm sealing from the multicenter Italian Research on Nellix Endoprosthesis (IRENE) study

Objective: Because of advances in technology and experience of the operator, endovascular aneurysm repair (EVAR) has supplanted open repair to treat abdominal aortic aneurysm (AAA). The low 30‐day mortality and morbidity of EVAR make the endovascular approach particularly suitable for patients at high surgical risk. However, endoleak or endograft migration requiring secondary intervention or open surgical conversion is a limitation of EVAR. The Nellix system (Endologix, Inc, Irvine, Calif) has been designed to seal the entire AAA to overcome these limitations with EVAR. We report the results of a retrospective, multicenter study with endovascular aneurysm sealing (EVAS) aimed to assess technical success, procedure‐related mortality, complications, and reinterventions. Methods: This study included patients selected for elective treatment with the Nellix device per the endovascular repair protocol at 16 Italian vascular centers. All patients were enrolled in a postoperative surveillance imaging program including duplex ultrasound investigations, computed tomography, and magnetic resonance controls following local standards of care. Results: From 2013 to 2015, there were 335 patients (age, 75.5 ± 7.4 years; 316 men) who underwent elective EVAS. In 295 cases (88.0%), EVAS was performed under standard instructions for use of the Nellix system. Preoperative aneurysm diameter was 55.5 ± 9.4 mm (range, 46‐65 mm). The inferior mesenteric artery and lumbar arteries emerging from the AAA were patent in 61.8% and 81.3% of cases, respectively. Chimney grafts were electively carried out in eight cases (2.4%). One (0.3%) intraprocedural type IB endoleak was observed and promptly corrected. Device deployment was successful in all patients, with no perioperative mortality. Early (≤30 days) complications included 1 (0.3%) type IA endoleak, 2 (0.6%) type II endoleaks (0.6%), 2 (0.6%) stent occlusions (0.6%), 3 (0.9%) distal embolizations, and 2 (0.2%) femoral artery dissections. Six (2.9%) patients underwent reinterventions. At 1‐year follow‐up, complications included 3 (1.1%) type II endoleaks, 4 (1.4%) type IA endoleaks, 1 (0.3%) type IB endoleak, 2 (0.7%) distal stent migrations, 5 (1.8%) distal embolizations, and 1 (0.3%) stent occlusion. Twelve patients (3.7%) underwent reinterventions, including four (1.4%) surgical conversions due to aortoduodenal fistula (1), endograft infection (1), and type IA endoleak that was unsuccessfully treated percutaneously (2). Two AAA‐related deaths occurred. Freedom from aneurysm‐related reintervention was 98.3% at 1‐month and 94.7% at 12‐month follow‐up. Conclusions: The preliminary results of this real‐world multicenter study showed that EVAS with Nellix for the management of AAAs appears feasible. This device platform is associated with acceptable procedure‐related mortality and low overall complication and reintervention rates. Definitive conclusions on the value of this novel device await long‐term follow‐up data.

Radioguided Surgical Resection of Carotid Body Tumors

Aim: We present our experience about surgical resection of Carotid body tumor (CBT) and to define the role of colour coded ultrasound (CCU) and of somatostatin receptor scintigraphy (SRS) with Indium-111-DTPA-pentreotide (Octreoscan) using both planar and single photon emission tomography (SPECT) technique. Methods: Twenty-three patients suffering from 27 CBTs were treated from 1997 to 2014. Preoperative investigations included CCU and SRS-SPECT. All tumours were grouped according to Shamblins classification. Intraoperative radiocaptation by Octreoscan was also carried out in all cases to evaluate the radicality of surgery. Results: Preoperatively CCU showed CBTs with sensitivity 100%. Radioisotope imaging identified the CBTs as carotid body tumors in 25 cases while no radio isotopic uptake was detected in 2 cervical vagal schwannoma. Combined data from CCU and SPECT allowed determining tumour size in order to select 12 larger tumours. Intraoperative Octreoscan demonstrated microscopic tumour leftovers promptly removed in 2 cases and an unrespectable remnant at the base of skull in another case. During follow-up (6 months-10 years, mean 3.9 years) CCU and radioisotope scans showed no recurrence in 25 cases, a slightly enlargement of that intracranial residual as detected during surgery in 1 patients and a little recurrence in another one case. Conclusion: CCU may allow an early and noninvasive detection of CBTs and hence safer operations. The combined use of CCU and SPECT provide useful data to identify that tumour and to evaluate their extent and carotid arteries infiltration. Radioisotope imaging is a sensitive modality to detect metastases and lymph node involvement that are markers of CBT malignancy. Mid and long terms results in terms of recurrence and carotid repairs patency seems very encouraging with this approach. After surgery CCU and SPECT seem to be accurate modalities for surveillance for an early detection of CBTs recurrence.

Carotid Stenting and Transcranial Doppler Monitoring: Indications for Carotid Stenosis Treatment

Background: Recently, angioplasty and stenting of carotid arteries (CAS) have taken the place of surgery. The aim of our study is to assess the role of transcranial Doppler (TCD) monitoring during CAS to address the embolic complications during the stages of the procedure, with or without embolic cerebral protection devices. Methods: A total of 152 patients were submitted to carotid stenting. All patients were submitted to carotid arteries Duplex scanning. Results: Neurological complications are related to TCD detection of corpuscolate signals in rapid succession. Even if no reduction of the overall incidence rate of microembolic signals (MES) was observed, a decrease in the number of corpuscolate emboli were recorded when a cerebral protection was working. Conclusions: According to our study, even in selected patients on the basis of preoperative diagnostic criteria, CAS is burdened by a nonnegligible risk of subclinical embolic ischemic events detected at TCD and confirmed by diffusion-weighted magnetic resonance imaging (DW-MRI).

Localization of lipopolysaccharide from Escherichia Coli into human atherosclerotic plaque

Experimental studies showed that gut-derived lipopolysaccharide (LPS) is pro-atherogenic, however, its relationship with human atherosclerosis is still to be defined. We investigate if gut-derived LPS from Escherichia Coli localizes in human carotid plaque and its potential role as pro-inflammatory molecule in the atherosclerotic lesion. LPS from Escherichia Coli and Toll-like receptor 4 (TLR4) were studied in specimens from carotid and thyroid arteries of 10 patients undergoing endarterectomy and 15 controls matched for demographic and clinical characteristics. Blood LPS were significantly higher in patients compared to controls. Immunochemistry analysis revealed positivity for antibodies against LPS and TLR4 coincidentally with positivity for CD68 only in the atherosclerotic plaque of carotid arteries but not in thyroid arteries; the positivity for LPS and TLR4 was greater in the area with activated macrophages. LPS concentration similar to that detected in atherosclerotic plaque resulted in a dose-dependent TLR4-mediated Nox2 up-regulation by human monocytes. These data provide the first evidence that LPS from Escherichia Coli localizes in human plaque and may contribute to atherosclerotic damage via TLR4-mediated oxidative stress.

Renal Stenting for Kidney Salvage in the Management of Renal Artery Atherosclerotic Stenosis

We studied the usefulness of preoperative resistance index to select patients who will benefit most from renal stenting. Sixty-two patients underwent renal stenting. All had chronic renal insufficiency with serum creatinine values ranging from 1.5 to 2.5 mg/dL and blood urea nitrogen between 80 and 107 mg/dL. All treated renal artery stenosis were >70%. Reduction in blood pressure in the early stages was observed in 39 (62.9%) patients; 31 (79.4%) patients returned to preoperative values within 12 months. A progressive reduction in creatinine values and blood urea nitrogen was reached in 43 (69.4%) patients, 12 (19.4%) patients remained unchanged, and the remaining 7 (11.2%) patients worsened. The best improvement in renal function was obtained in patients with a resistance index of ≤0.75 A preoperative resistance index up to 0.75 could be used as an indicator to predict which candidates will have improved renal function after stenting.

Extra-anatomic graft infection in the aortofemoral area

Infection of extra-anatomic vascular prosthesis in the aortofemoral area is repor ted episodically in the literature so that its f requency is still uncertain, though in axillopopliteal grafts it was found to be 3.6%. 1 It is considered to be a benign disease with a good possibility of conservative t reatment or segmental resection. 2 In our experience over 15 years we had the impression that this was not always so, and that differences existed in incidence, severity, evolution, ways of t reatment and final outcome between cases operated upon for obstructive arterial disease and those treated by extra-anatomic bypass for the management of an infected aortic graft. Therefore we studied retrospectively a series of 213 consecutive patients in w h o m 225 grafts were implanted, analysing indications, t reatment and outcome.