Roberto Gattuso

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.

Persistent Type II Endoleak: Two Cases of Successful Sacotomy

Endovascular treatment of persistent type II endoleak may not resolve the complication. We report two cases of sacotomy performed to treat this problem: the first case was in an emergency setting for aneurismal sac rupture, and the second occurred in an elective surgery setting after several unsuccessful endovascular procedures. In both cases, sacotomy allowed us identify the bleeding sources without aortic cross-clamping and endograft explantation. By minimizing hemodynamic modifications and reducing operative time, this procedure can be carried out even in patients considered unfit for surgery. Sacotomy could be considered as an alternative in selected cases of persistent type II endoleak with aneurysm sac enlargement.

Aorto-iliac/femoral reconstructions in patients with vasculogenic impotence.

One hundred and forty-eight patients out of 386 undergoing aorto-iliac or aortofemoral bypass had preoperative impotence, 37 of these were diabetics. In all of them Doppler studies revealed a penile/brachial pressure index less than 0.6 and an abnormal waveform analysis. Nocturnal penile tumescence was investigated in 44 cases and found to be abnormal. Angiography showed unilateral or bilateral obstructive lesions of the hypogastric arteries in 80%, in addition to aortic, common and external iliac and femoral lesions. One hundred and thirty patients (87.8%) had straight aorto-iliac/femoral bypass grafts inserted without a direct attempt to revascularise the hypogastric arteries but 24 had distal anastomoses to the bifurcation of the common iliac artery. In the remaining 18 patients the hypogastric artery was reconstructed on one side by an additional bypass or reimplantation on the graft. In 22 of 106 patients (20.7%) undergoing aortofemoral bypass, 18 of 24 (75%) with the distal anastomosis to the iliac bifurcation, and 14 of the 18 (77.7%) with revascularisation of the hypogastric arteries, erectile function was regained. A good result was obtained in only five of the diabetic patients (13.5%). Our experience suggests that: (1) impotence, as indicated by non-invasive investigations, was vasculogenic in origin since patients with the most effective revascularisation of the hypogastric arteries had the best results; (2) when it is feasible, revascularisation of the hypogastric arteries should be carried out more often, during the aorto-iliac or aortofemoral reconstructions, particularly in younger impotent patients; (3) aorto-iliac revascularisation restores potency in only a few diabetic 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.

Type IB and type III endoleak 8 years after endovascular aneurysm repair.

An 86-year-old man was admitted to our hospital for abdominal pain and underwent an AneurRx bifurcated endograft (Medtronic AVE, Sunnyvale, Calif) implantation 8 years earlier for a 7-cm-diameter abdominal aortic aneurysm (AAA). His comorbidities were chronic atrial fibrillation, diabetes, dyslipidemia, chronic renal failure, hypertension, severe chronic obstructive pulmonary disease, and coronary artery disease. This patient also underwent an appendicectomy, inguinal hernioplasty, and cholecystectomy. An expandible abdominal mass was found during a clinical examination. Doppler ultrasound imaging and a computed tomography scan showed a severe increase of AAA diameter to 11 cm, associated with a type IB endoleak from the right leg displaced into the aneurysmal sac itself and to a type III endoleak due to detachment of the contralateral leg (A-C). Similar patients reported in the literature underwent open or endovascular treatment. Our patient was assessed by the anesthesiologist and cardiologist as being in American Society of Anesthesiologist class IV and therefore unfit for surgical repair, so an endovascular approach was planned. Through a left transaxillary access, a hydrophilic guidewire was introduced first into the endograft main body and its right leg and, thereafter, was captured by means of an Amplatz GooseNeck (EV3, Plymouth, Minn) introduced through the right common femoral artery. This was exchanged with a stiff guidewire, and a right aorto-uni-iliac Zenith Cook endograft (Cook Inc, Bloomington, Ind) was deployed. After surgical exposure of the left common femoral artery, an endovascular plug (Iliac Plug Cook Zip-20) was inserted in the ipsilateral common iliac artery. A femoro-femoral crossover bypass was completed with a 7-mm external-supported polytetrafluoroethylene graft (Vascutek Ltd, Inchinnan, Scotland). The procedure was performed with spinal anesthesia, the operating time was 135 minutes, and the contrast medium amount was 250 mL. The patient’s postoperative period was uneventful and he was discharged after 8 days, with no worsening of renal condition. A computed tomography scan at 6 months showed a good result of the procedure, with no endoleak and reduction of the AAA diameter (D).

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).

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.

A Peculiar Case of Type 1 Endoleak after Nellix Endovascular Aneurysm Sac Sealing: Clinical Presentation and Management

We report a case of type 1 endoleak with an outflow via a lumbar artery (LA) following Nellix endovascular aneurysm sealing (EVAS) to discuss the specific peculiarities and management of this complication. A 64-year-old man (acetylsalicylic acid 3) underwent Nellix EVAS for an asymptomatic infrarenal aortic aneurysm. The 6-month duplex scanning ultrasound and magnetic resonance imaging showed a type IA endoleak with an outflow via an LA combined with a stable aneurysmal sac size. The subsequent 9-month imaging controls showed no changes of the endoleak cavity, but there was a slight enlargement in proximal neck size associated with the distal migration of both Nellix grafts. Thus, catheter-directed embolization with detachable coils first of the LA origin and then of the endoleak cavity was carried out. Postoperative course was uneventful. The patient is endoleak free with stable sac size on 6-month computed tomography imaging investigations following the secondary intervention.

Composite Grafts for Critical Ischaemia

A total of 236 femoropopliteal below the knee and 64 femorotibial bypasses were carried out for critical ischaemia of the lower limbs using various prosthetic materials. These were evaluated in order to assess the patency of composite grafts (29 cases) compared with autogenous saphenous veins (189) and polytetrafluoroethylene (PTFE) (82). The composite graft was made by anastomosing a segment of autogenous vein in the distal position and joining it by an end-to-end oblique anastomosis to a PTFE prosthesis in the proximal position. These grafts were employed when an adequate autogenous vein could not be used for the entire length of the bypass. The graft-graft anastomosis was never placed near the knee-joint and if the PTFE segment had to cross the knee, it was always of the externally supported type. There were no early occlusions in the composite grafts. A total of 257 grafts were available for assessment at a mean of 4 years (range 6 months to 15 years). The patency for autologous saphenous vein was: 81.2% (121/142 femoropopliteal and 13/23 femorotibial). The patency for PTFE was 67.1% (41/58 femoropopliteal and 4/9 femorotibial) and for composite grafts was 76% (10/11 femoropopliteal and 9/14 femorotibial). There was no significant difference in patency between the autologous saphenous vein and the composite grafts, both in the femoropopliteal and femorotibial positions. Both were significantly better than PTFE grafts. Composite grafts are the best alternative when an autologous saphenous vein is not available.