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Ancient Schwannoma is a type of peripheral neurogenic tumor formed by the Schwann cells presenting mainly as a benign and asymptomatic lesion. The neurilemmoma tumor appears in different sites and, in cases of cervical location, can mimic a carotid body tumor. Herein we describe a clinical case of a 51-year-old woman with latero-cervical swelling. A contrast-enhanced computed tomography scan revealed a classical wineglass image mimicking a carotid body tumor. During surgery the tumor appeared connected to the cervical sympathetic trunk without carotid involvement. The histological exam confirmed the nature of the mass which consisted of an ancient schwannoma. A subsequent systematic review of the literature on ancient schwannoma incidence and treatment confirms it being a benign and rare lesion primarily treatable with open surgery. KEY WORDS: Ancient Schwannoma, Carotid body tumor, Carotid artery, Vascular surgery.

We describe a case of a 44 year-old man with a subcutaneous swelling in the left popliteal fossa. The patient complained pain posteriorly to the left knee since several months and presented with a saccular aneurysm of the left popliteal vein (PVA) with reflux clearly evidenced at duplex ultrasound scan (DUS), but in absence of thrombus inside and without clinical signs of embolism. The patient was treated surgically by aneurysmectomy with lateral venorrhaphy according to Aldridge technique and a duplex ultrasound scan after six months revealed a complete patency of the left popliteal vein. According to literature evidences and our center experience, the surgical treatment of the popliteal vein aneurysm represents the gold standard in order to prevent the possible complications like development of thrombus inside the aneurysmatic vein and the consequent embolic risk and it is recommended in all case of a symptomatic saccular type of whatever diameter, and in fusiform type >20 mm, with or without thrombus., Key Words: Complications, Popliteal vein aneurysm, Vascular Surgery.

Unlabelled: In the management of severe carotid artery stenosis particular importance must be given to the evaluation of the risk of perioperative cerebral ischemic events. Our study analysed the possible relationship between the pre-operative middle cerebral artery Gosling Index, calculated after transcranial Doppler (TCD), and intra-operative stump pressure (SP), in order to identify patients with higher risk of ischemic accidents. Moreover, we studied pre- and post- operative Gosling Index values in association with possible events during follow-up. In a one-year time lapse 47 patients underwent either carotid endoarterectomy (CEA) or carotid artery stenting (CAS) with proximal embolic protection system. All patients were subject to pre- and post-operative TCD with calculation of the Gosling Index and intra-operative SP. We observed that higher pre-operative Gosling Index values are associated with lower intra-operative SP values, elements that represent a higher risk for cerebro-vascular ischemic accidents; this result is particularly evident when observing the diabetic sub-population. An increase in ischemic events did not present statistically significant differences when observing the populations treated with CEA or CAS. TCD and SP are valid and simple exams that can help identify precociously patients with a higher risk of cerebro-vascular accidents related to surgical or endovascular treatment., Key Words: Carotid artery stenosis, Carotid endarterectomy, Endovascular treatment.

Unlabelled: A 60 year old patient presenting chronic mesenteric Ischemia (CMI) was managed with superior mesenteric artery (SMA) stenting as bridge therapy to conventional open surgery. At 5 months follow-up, the SMA stent occluded. During this bridge period the patient gained his general condition and the body mass index (BMI) increased from 18 to 22. The patient was managed subsequently with iliac-SMA bypass in C-loop configuration. At 6 months follow-up the bypass is patent, the patient has no CMI symptoms and his BMI is 25. The endovascular approach did not preclude a subsequent conventional open surgery and it can be safely employed as bridge therapy. An improved patient clinical condition, also during a limited bridge period, can improve the conventional open surgery outcomes., Key Words: Body Mass Index(BMI), Mesenteric artery, Mesenteric ischemia.

Introduction: Severe dialysis-associated steal syndrome (DASS) is an uncommon and severe complication after arteriovenous fistula (AVF) creation that can lead to finger gangrene and amputation. As the number of patients on hemodialysis increases in western countries the number of patients at risk for DASS will continue to rise., Methods: We retrospectively reviewed all patients who underwent a surgical intervention for the management of DASS with finger gangrene from January 2004 to July 2013. Demographic data, pre-operative work-up, procedure details and outcomes were collected. A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles. Cross-references from these articles were also used., Results: A total of nine patients were identified. Mean age was 53 years, 67% were women. All patients presented with finger tissue loss or gangrene. Surgical procedures included AVF closure/ligation (5), distal artery ligation (DRAL) (2), distal revascularization with interval ligation (DRIL) (1), banding (1). All patients had improvement of symptoms during follow-up. No major amputation occurred., Conclusions: Surgical interventions to correct DASS in patients with finger gangrene are mandatory while conservative management is not recommended. The decision for which type of procedure is made individually, according to clinical symptoms, technical findings, and patients' general state of health.

Pemetrexed and Carboplatin are two well-known chemioterapic agents used for the treatment of many tumors, especially for lung cancer and mesothelioma. Peripheral ischemic events related to Pemetrexed and Carboplatin are rarely reported. We herein report a case of lower limb acute ischemia related to combined treatment of Pemetrexed and Carboplatin. A 68-year-old woman was given the chemiotherapic treatment with combination of Pemetrexed and Carboplatin after pleural resection for a malignant pleural mesothelioma. Immediately after the second cycle of treatment, the patient experienced sudden acute left lower limb ischemia. Symptoms resolved after an intra-operative thrombolytic and spasmolytic therapy.

Aim: Pseudoaneurysm (PA) at the anastomosis site in kidney transplantation is a rare but serious complication that usually requires graft nephrectomy. Literature reports are sporadic and usually focused on limb rather than graft salvage. In this paper we focus on this last point., Material of Study: 6 patients presenting large PA at the anastomosis between iliac and graft artery were identified in our series. The diagnosis was performed with US, AngioTC scan and angiography. Blood cultures and labeled leukocyte scintigraphy were also performed. All patients underwent open surgery., Results: Transplant nephrectomy was needed in all cases except one, in which it was possible to perform a graft replanting on hypogastric artery. Our perioperative mortality and morbidity rate was recorded., Discussion: Etiology of PA is multifactorial, however an association with chronic rejection or infection must be also considered. Our mortality and morbidity rates are in accordance to literature. In our experience we observed only large PA so to require an open surgery but this approach has allowed the rescue of graft functioning just in a single case. Endovascular procedures are linked to higher rate of graft salvage than surgery but they can be used just in selected cases., Conclusions: Our experience and literature review led us to believe that the rate of graft salvage in patients with large PA at anastomosis site could be improved only by a planned therapeutic program that includes surgical and endovascular approach, taking the advantages of both technique and overcoming their limits.

Introduction: Abdominal aortic pseudoaneurysms are a rare but serious complication of aortic surgery. Treatment with traditional open surgery is associated with a high rate of perioperative mortality and morbidity. Endovascular treatment is less invasive and guarantees lower mortality and morbidity rates. The aim of this study was to evaluate the role of short-, medium- and long-term endovascular treatment of these pseudoaneurysms., Materials and Methods: Over the past 10 years, 14 patients with abdominal aortic aneurysms, which developed after prior aortic surgery, underwent endovascular treatment involving implantation of an endoprosthesis at our institutions. Exclusion criteria were emergency treatment and suspicion of an infected prosthesis. A Cheatham-platinum covered stent mounted on a balloon catheter was implanted in one patient and self-expandable stent-graft in the other 13. No fenestrated or custom-made prostheses were used., Results: The procedure had a 100% technical success rate. There was no postoperative mortality. Two type I endoleaks, observed at aortography at the end of the procedure, were not seen on the CT scan taken one month later. Three patients (21.4%) had major perioperative complications which consisted of early occlusion of a branch of the endoprosthesis, (treated with a femoro-femoral crossover bypass graft), a transient ischemic attack, and jaundice. The long-term mortality rate, at an average follow-up of 37.4 months, was 21.4%. None of the deaths was related to the procedure., Conclusions: Endovascular treatment of patients who develop anastomotic pseudoaneurysm after surgery of the abdominal aorta is safe and effective both in the short and long term. In our opinion it is the treatment of choice for this category of patients.

Introduction: Aneurysms of popliteal artery are the most frequently reported aneurysm after abdominal aorta. An unusual presentation is compression to adjacent structure., Case Presentation: A 67 years old caucasian man presenting deep vein thrombosis signs to the right leg including functional impotence was admitted in emergency setting to Vascular Surgery Unit. A pulsing mass was present in the popliteal cave at inspection. The computed tomography angiography demonstrated a 53.2 mm popliteal artery aneurysm causing an ab extrinseco compression of the popliteal vein and a dislocation of popliteal nerve. A surgical open reconstruction with a reinforced Dacron graft was performed via a posterior approach. Patient was discharged on the fourth postoperative day with no functional impotence. At three and six months Doppler ultrasound followup both popliteal arterial graft and popliteal vein were patent., Conclusion: An unusual presentation of a popliteal artery aneurysm can be a popliteal compartment syndrome, especially in large aneurysms. Deep popliteal vein compression and/or popliteal nerve dislocation signs can rarely represent the clinical symptoms. The popliteal artery aneurysm repair is generally required to avoid a distal embolization and rupture. Through a surgical open repair was possible to achieve both popliteal cave decompression and the popliteal artery aneurysm repair.

Introduction: Endovascular popliteal artery aneurysm repair has emerged recently as a feasible alternative to standard surgical repair. However, the evidence from the literature is still limited, with only case reports, case series and one small randomized trial. Currently, the available data suggests that stent-grafts should be used in patients at very high surgical risk. The purpose of this study is to present our surgical experience in popliteal artery aneurysm repair in an endovascular era., Materials and Methods: Data from 36 consecutive patients, who were admitted to our hospital from January 2000 to April 2010, was analyzed retrospectively. Twenty-six patients underwent surgical treatment through medial or posterior access. The posterior approach was used preferentially. The medial approach was adopted in patients with large aneurysms or aneurysms involving the superficial femoral artery., Results: Twelve patients (Group A; 46.1%) were operated on via medial access followed by femoropopliteal bypass. In the remaining fourteen patients (Group B; 53.9%) an interposition graft was performed via a posterior approach. The 30-day overall mortality rate was 3.8% (1/26). The 30-day amputation rate was 0% in both groups. The primary patency rate was 83.3% in Group A at 78.8-month average follow-up (range: 18-128 months) and was 100% in Group B at 46.3-month average follow-up (range: 5-121 months)., Conclusion: Notwithstanding the extensive use of stent-grafts worldwide, surgical repair remains the gold standard for the management of popliteal artery aneurysms. In our experience open repair using either a medial or posterior approach is associated with low mortality and morbidity rates.

Introduction: The Abdominal Compartment Syndrome (ACS) is a "condition in which increased tissue pressure in a confined anatomic space, causes decreased blood flow leading to ischaemia and organic dysfunction and may lead to permanent impairment of function"., Materials and Methods: Between June 2007 and June 2008 all patients recovered to our Institution for Abdominal Aortic Aneurysm (AAA) underwent intermittent intra-abdominal pressure monitoring using intra-vescical catheter. Pressure data were registered before abdominal incision, during intervention, at closure of abdominal wall and at 6, 12, 24 and 36 hours in post-operative course. Rise in Intra-Abdominal Pressure (IAP) more then 20 mmHg was considered for surgical decompression., Results: Twenty three cases of AAA were treated surgically Fourteen underwent elective repair and 9 emergency/urgency repair; in the emergency/urgency group, 8 were symptomatic without rupture signs and one case presented TC rupture signs. In the last case we registered preoperatively IAP more than 20 mmHg treated with only skin tension-free suture. No perioperative mortality was registered., Discussion: ACS have been increasingly recognized as causes of significant morbidity and mortality over the last years after AAA surgery. ACS was recently classified from the World Society of the Abdominal Compartment Syndrome (WSACS) as primary, secondary and recurrent. ACS was recognized as major prognostic factor after AAA repair. ACS incidence ranges from 4 to 12%. Even if ACS etiological bases are not well known, principal risk factor for ACS development after AAA repair are massive fluid resuscitation infusion and aortic clamping IAP values, and subsequent possibility of ACS development, are superior after ruptured AAA repair than elective repair. Also in our study, even if limited by small number of cases, we registered differences in IAP value during emergency/urgency repair and elective repair. Patients management with rising IAR or at risk of ACS development, should be mandatory decompressed for IAP higher than 20 mmHg or also with inferior values if in association to organ dysfunction. IAP measurement can be performed directly or indirectly and all these techniques have as objective IAP monitoring before its clinical manifestation in ACS., Conclusion: ACS can be considered a reliable predictive factor for aneurysm surgery outcome. Prevention of the ACS, with early recognition of rising IAP and urgent intervention to decompress the tense abdomen can lead to mortality reduction after aneurysm repair. The measurement of IAP is simple and non-invasive, and should be a routine component of physiological monitoring in patients following ruptured aneurysm repair in association with hypotensive hemostasis.