Case report of an endovascular repair of a residual type A dissection using a not CE not FDA-approved Najuta thoracic stent graft system

This report describes an endovascular repair of a residual type A dissection using a medical device that is not marked by european conformity (CE) or Food and Drug Administration (FDA).The patient underwent ascending aortic surgery for acute type A dissection. The 2-year angio-computed tomography demonstrated patency of the residual false lumen with evolution into a 6 cm aneurysm, the extension of the dissection from the aortic arch to the aortic bifurcation with thrombosis of the right common iliac artery. There was no CE- or FDA-marked medical device indicated for this case or any other acceptable therapeutic alternative.We used the Najuta thoracic stent graft and successfully handled the pathology in a multiple-phase treatment.Technology is evolving with specific grafts for the ascending and fenestrated grafts for the aortic arch. In this single case the Najuta endograft, in spite of the periprocedural problems, was a valid therapeutic option.

Endovascular treatment of extracranial vertebral artery aneurysm and aberrant right subclavian artery aneurysm

We report an endovascular approach that used to treat a symptomatic extracranial vertebral artery aneurysm associated to an asymptomatic aberrant right subclavian artery aneurysm. A 54-year-old man presented with neck pain, vertigo and loss of balance. The computed tomography (CT) scan demonstrated a left extracranial vertebral artery aneurysm that compressed and eroded the C5 vertebra associated to an aberrant right subclavian artery aneurysm. Endovascular exclusion of the vertebral aneurysm using a covered stent and a hybrid treatment of the aberrant subclavian artery aneurysm were performed. The 13th month follow-up CT scan confirmed the stent-grafts and supra-aortic vessels patency. The endovascular treatment represents a good option for these complex pathologies with excellent immediate results, reduces the complication rate and the hospital stay if compared to open repair. Long-term follow-up is necessary. To our knowledge this is a unique case in the literature.

Percutaneous endovascular aneurysm repair with the ultra-low profile Ovation Abdominal Stent-Graft System

AIM

Aim of the study was to report our single-center experience of the ultra-low profile OvationTM Abdominal Stent-Graft System with totally percutaneous endovascular aneurysm repair (PEVAR).

METHODS

Between December 2010 and March 2013 we electively treated 35 patients (male: 89%, mean age: 73±7 years) with abdominal aortic aneurysm (AAA) using bilateral PEVAR with the OvationTM endograft. Most (77%) cases were characterized by challenging femoral artery anatomy. Patients returned for follow-up visits at 1, 3, 6 months and annually thereafter.

RESULTS

Technical success was 97.1%. One type Ia endoleak was identified on final angiography, which was treated with an extension cuff. No groin complications were observed, including lymphocele, hematoma, pseudoaneurysm, dehiscence, or wound infection. Mean follow-up was 10 months (range 1-24 months). No death was registered. One type Ia endoleak was identified at the 12-month follow-up, which resolved with placement of a Palmaz balloon-expandible stent. No type II, III, or IV endoleaks were identified. No migration, AAA enlargement, AAA rupture, or conversion to open surgery was reported. Two patients (5.7%) developed monolateral iliac limb occlusion at 58 and 72 days of follow-up, respectively. In one case a limb kinking was observed and treated with iliac kissing stent. The other limb occlusion was due to external iliac artery severe stenosis and was treated with thrombolysis and iliac artery stenting.

CONCLUSION

PEVAR with the OvationTM endograft is feasible and safe in patients with unfavorable anatomy.

A NOTES approach for thoracic surgery: transgastric thoracoscopy via a diaphragmatic incision in a survival porcine model

AIM

Recently the NOTES approach has been extended to mediastinum by a transesophageal access and to the thorax by a transvescical endoscopic approach. The aim of this study was to assess the feasibility and the safety of transgastric endoscopic approach to the thoracic cavity, with lung biopsy, in a survival porcine model.

METHODS

The study was performed on four 20-30 kg female pigs (Sus scrofus domesticus). Following gastric wall incision, the muscular pars of the left diaphragmatic dome was incised along with the parietal pleura and the endoscope advanced into the thoracic cavity. In all animals, a thoracoscopy was performed as well as peripheral lung biopsy. At the end of the operation the endoscope was withdrawn from the thoracic cavity after pleural sac decompression and the diaphragmatic incision closed by endoscopic clips under maximal expansion of lungs. The gastric incision was finally closed by endoscopic clips. Chest-tube placement was not utilized. Animals were sacrificed by day 15 postoperatively.

RESULTS

The gastroscope was easily introduced into the thoracic cavity that allowed to visualize the pleural cavity and to perform simple surgical procedures such as lung biopsies without complications. There were neither respiratory distress episodes nor surgical complications to report. No adverse event occurred during the survival period. The postmortem examination 15 days after surgery revealed a good closure of the diaphragmatic incision. At necropsy, the lung biopsies were completely healed. There were no signs of infection in both thoracic and peritoneal cavities. The length of follow-up and number of animals studied might have not been sufficient.

CONCLUSION

This study demonstrates the feasibility of transgastric thoracoscopy in porcine model. Long-term follow-up of much larger series will be necessary for provision of more reliable answers if this approach should be adopted in the future and eventually translated for humans with advantages for patients.

Temporal approach: a good way to provide cerebral protection for proximal carotid stenosis, the last chance for trackability in CAS

AIM

The aim of this study was to evaluate the usefulness of the temporal approach during coronary artery stenosis (CAS) to overcome tortuosity in case of difficult arch anatomy or tortuous common carotid artery, and to provide cerebral protection of proximal lesions of the supra-aortic trunks during stenting.

METHODS

The superficial temporal artery is exposed through a small incision right in front of the ear and is cannulated. A guidewire is used to descend in the external and common carotid artery and in the arch if needed. Between the end of March 2007 and May 2008 9 patients were treated with the temporal approach: in 5 cases of stenosis of the internal carotid artery with difficult arch anatomy to obtain a through and through guide from the temporal to the femoral artery, in 3 of the supra-aortic trunks to obtain cerebral protection during the procedure and in one case of tandem lesion of the left common and internal carotid artery.

RESULTS

The procedure was successful in all 9 cases and there were no complications.

CONCLUSIONS

The temporal approach proved to be feasible and at low risk; it represents a new possibility to increase the feasibility of carotid artery stenting in patients with difficult anatomy but, above all, it is a good way to obtain cerebral protection during endovascular treatment of proximal lesions of the supra-aortic vessels.

[Intravascular treatment of iliac aneurysms]

INTRODUCTION

We investigated the feasibility of the intravascular treatment of iliac aneurysms in patients at high perioperative risk.

MATERIAL AND METHODS

January, 1996, to December, 1997, seven iliac aneurysms in 5 patients were treated using endovascular procedures. The patients were 4 men and 1 woman whose mean age was 70 years (range: 61-74 years). Four of 7 aneurysms were in the common iliac artery (2 true aneurysms and 2 anastomotic aneurysms after aortoiliac bypass) and 3 were true internal iliac artery aneurysms. Preoperative CT and arteriography were performed in all cases to define the vascular morphology of the aneurysm, including its exact diameter and length. All procedures were performed in the operating room by a team of vascular radiologists and vascular surgeons, using a portable digital RX system (Philips BV29). The femoral approach was always used, which was percutaneous under local anesthesia in 4 cases and surgical under epidural anesthesia in the other 3 cases, according to the patient's general condition and to common femoral artery morphology. Six endovascular Passager grafts were positioned in the common iliac artery using over-the-wire techniques; platinum coil embolization of the aneurysmatic internal iliac artery had been performed in 2 cases. Coil embolization of the hypogastric artery aneurysm was the only treatment in 1 case. Bilateral aneurysms were treated separately, at intervals of no less than 3 months.

RESULTS

Immediate aneurysm exclusion was obtained in all cases, as confirmed at 2-20 months' follow-up in 6 cases. A displaced prosthesis needed reoperation in 1 case. No complications were observed during or early after the procedures, which were always well tolerated by the patients.

DISCUSSION

The endovascular treatment of iliac aneurysms is a relatively recent procedure and thus only short- and mid-run results are currently available, which appear satisfactory in 85% of the world's literature cases. Prosthesis displacement and intimal hyperplasia are reported as the main causes of failure. Lacking long-term results, we reserve this method to selected cases. Shorter hospitalization is another advantage.

CONCLUSIONS

This little invasive procedure appears suitable for high-risk patients and in the aneurysmatic complications metachronous to surgical bypass.

Pseudoaneurysm of the descending genicular artery after arthroscopic meniscectomy: report of a case

Vascular injuries in the arthroscopic meniscectomy of the knee are uncommon. A case of pseudoaneurysm of the descending genicular artery in a 39-year-old man, after medial arthroscopic meniscectomy, is reported. The pseudoaneurysm was simple to diagnose with computed tomographic scan and angiography, and treatment was successful surgical resection.

Adventitial cyst of the popliteal artery. Report of a case

A case of cystic degeneration of the popliteal artery in a 58-year-old male is reported. Symptoms consisted of a claudication of abrupt onset and the correct diagnostic clue was initially given by magnetic resonance of the knee and confirmed by angiography. Treatment consisted of surgical removal of the cyst and saphenous vein angioplasty of the popliteal artery, with good anatomic and functional result at one year follow-up. Diagnostic tools and treatment of the condition are briefly discussed.

Treatment of peripheral arteriopathies with a new low weight heparin. Results of a double blind, controlled study

Forty out-patients, 28 males and 12 females (mean age: 50.75 +/- 5.28); range: 39 to 67) suffering from peripheral arteriopathies of the lower limbs, were admitted to the study. The treatment, assigned at random in a balanced way, was performed with an LMWH or with placebo (one vial by s.c. route/day, for a mean duration of 6 months). During the therapy we observed a gradual symptomatology, claudicatio intermittens and Winsor index improvement in patients treated with the active drug, in comparison with evident stationarity in patients treated with placebo. The haemocoagulative balance control, performed through the determination of Activated Partial Thromboplastin Time, of Xa factor inhibition and of plasminogen, confirmed the poor influence of the treatment with LMWH both on haemostatic function and on a possible increment in haemorrhagic risk. Systemic and local (at the injection site) tolerability were good in particular as to haematoma frequency.

[Diverticula of the cecum. Our experience]

On the basis of their experience in right colonic emergencies, the Authors report two cases of diverticular disease presenting with acute abdomen. Pointing out the difficulty of a correct pre- and intraoperative diagnosis, different surgical procedures are analysed.

[Peritoneal oxygenation-dialysis as a temporary treatment of intestinal infarction]

The interval preceding the growth of irreversible lesions in an abdominal apoplexy is variable (3-48 hours). It may be used to improve the ischaemic viscus oxygenation, also compensating possible metabolic imbalances. 16 rabbits were used for research, in which apoplexy by the ligature of the arteria mesenterica superior was induced. Dialysis-oxygenation peritoneal treatment was carried out for 8 rabbits, the results of which were evaluated on the basis of the intestine macroscopic morphologic aspect; on the basis of the hematic phosphates values and in enteral biopsy. The oxygenation-dialysis produced a rapid improvement in enteral hue and in enteral motility, an important increase of PO2 and a reduction of hematic phosphates compared with the control group. Histologic examination did not show any significant variation. The attempt to increase general oxygenation by supplying PO2 via the peritoneum, was partly successful (10-15%). The aim of oxygenation the ischaemic enteral zone was successful. This due to elimination of CO2 and toxic products using dialysis. This simple method seems to be effective but further tests on swine would be necessary for clinical applications.

Large aneurysm of the superior mesenteric artery

This report describes a rare case involving a large aneurysm of the superior mesenteric artery (S.M.A.) in a 53-year-old female. Diagnosis was made by X-ray and echography and confirmed by CT-scan and arteriography showing the lesion to be atherosclerotic in origin with several thrombi on the wall of the artery. Resection of the aneurysm and venous reconstruction was performed. Recovery was uneventful. Angiography one month later demonstrated patency of the bypass. At six months the patient is presently asymptomatic.

[Healthy carriers of positive staphypococcal coagulase and the prevention of food poisonings in aircraft catering]

The most scrupulous respect should be paid to rules of hygiene in aircraft catering. In addition, human beings are the most dangerous vectors of food poisoning and infection. Enterotoxic staphylococci are responsible for about 75% of such cases. A year-long check was therefore made on the staff of a firm engaged in intercontinental aircraft catering. A total of 1.135 bacteriological examinations were carried out on biological specimens from the oropharyngeal cavity. 9.42% of those engaged in various food preparation processes were identified as healthy carriers of coagulase-positive staphylococcus and cleared. Comparison between the seasonal and monthly incidence figures fokr healthy carriers showed that December and January are the most dangerous months in the northern hemisphere and at European latitudes, with an average of 15% of positives. Equally dangerous is the winter season, in which diseases of the "cold" type are generally endemic.