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We report the case of a 75-year-old man submitted to traditional endovascular aortic repair (EVAR) for infrarenal abdominal aortic aneurysm. He presented a late type II endoleak 6 months after operation, initially without sac enlargement. One year later, a computed tomography scan control demonstrated a sac expansion >10 mm, also responsible for a secondary proximal type I endoleak. The patient was submitted to transarterial embolization of lumbar arteries through left internal iliac artery, followed by type I endoleak correction with a proximal cuff deployment. Intraoperative angiography revealed no signs of endoleak. Six months later, a sudden enlargement of the sac was detected, with evidence of type III endoleak, probably consequence of the lumbar arteries embolization, promptly corrected through an aortoaortic endograft. In conclusion, even if a conservative approach for type II endoleak without sac enlargement is proposed, sometimes a sudden sac enlargement could be responsible for catastrophic events in the absence of strict follow-up. The sac embolization during EVAR could reduce the incidence of type II endoleak during follow-up, with reoperation and hospital cost reduction.

Phantom limb pain (PLP) is a chronic condition experienced by about 80% of patients who have undergone amputation. In most patients, both the frequency and the intensity of pain attacks diminish with time, but severe pain persists in about 5-10%. Probably, factors in both the peripheral and central nervous system play a role in the occurrence and persistence of pain in the amputated lower limb. The classical treatment of PLP can be divided into pharmacologic, surgical, anesthetic, and psychological modalities. Spinal cord stimulation (SCS) does not represent a new method of treatment for this condition. However, the concomitant treatment of PLP and critical lower limb ischemia by using SCS therapy has not yet been described in the current literature. The aim of the present article is to highlight the possibility of apply SCS for the simultaneous treatment of PLP and critical lower limb ischemia on the contralateral lower limb after failure of medical therapy in a group of 3 patients, obtaining pain relief in both lower limbs, delaying an endovascular or surgical revascularization. After SCS implantation and test stimulation, the pain was reduced by 50% on both the right and the left side in all our patients. The main indications for permanent SCS therapy after 1 week of test stimulation were represented by transcutaneous oxygen (TcPO2) increase >75%, decrease of opioids analgesics use of at least 50% and a pain maintained to within 20-30/100 mm on visual analog scale.

Critical limb ischaemia (CLI) is the most advanced form of peripheral artery disease (PAD) and it is often associated with foot gangrene, which may lead to major amputation of lower limbs, and also with a higher risk of death due to fatal cardiovascular events. Matrix metalloproteinases (MMPs) seem to be involved in atherosclerosis, PAD and CLI. Aim of this study was to evaluate variations in MMP serum levels in patients affected by CLI, before and after lower limb surgical revascularisation through prosthetic or venous bypass. A total of 29 patients (7 females and 22 males, mean age 73·4 years, range 65-83 years) suffering from CLI and submitted to lower extremity bypass (LEB) in our Institution were recruited. Seven patients (group I) underwent LEB using synthetic polytetrafluoroethylene (PTFE) graft material and 22 patients (group II) underwent LEB using autogenous veins. Moreover, 30 healthy age-sex-matched subjects were also enrolled as controls (group III). We documented significantly higher serum MMPs levels (P < 0·01) in patients with CLI (groups I and II) with respect to control group (group III). Finally, five patients with CLI (17·2%) showed poor outcomes (major amputations or death), and enzyme-linked immunosorbent assay (ELISA) test showed very high levels of MMP-1 and MMP-8. MMP serum levels seem to be able to predict the clinical outcomes of patients with CLI.

Horseshoe kidney is a common urology anomaly, while its association with infrarenal abdominal aortic aneurysm represents a very rare condition. Surgical approach remains controversial however, we believe that the left retroperitoneal approach should be preferred in order to avoid isthmus resection with any subsequent renal infarction, urinary tract damage and to facilitate renal arteries reimplantation, when required. We present a case of voluminous infrarenal abdominal aortic aneurysm associated with horseshoe kidney, successfully treated through a left retroperitoneal approach on the retro-renal space.

The association of an axillary artery aneurysm and an abdominal aortic aneurysm is extremely rare. In this study, we describe this association in a 69 year-old-man. We measured this patient’s metalloproteinases (MMPs) and Neutrophil Gelatinase - Associated Lipocalin (NGAL) levels over a three years period before the abdominal aortic aneurysm rupture. We speculate that high serium levels of MMPs and NGAL may have a prognostic role and may predict aneurysm rupture in patients with an uncommon association of arterial aneurysms.

The different histopathology of atherosclerotic plaques may modify carotid stiffness. In this work we evaluated if a correlation exists between stiffness, type of plaques, inflammatory and apoptotic molecules and Osteoprotegerin (OPG) expression. 19 patients were divided in two groups depending on type of plaque (Mixed and Fibrocalcific) established through Doppler-ultrasound. Among inflammatory molecules we considered p-JNK ,p-ERK and NLRP3 levels by Western Blotting analysis whereas among apoptotic molecules we evaluated TNFα and TNFαIIR, FAS and FAS-L, Bcl-2, Casp8, ASK1, OPG and HMGB1 levels by Real Time PCR. We observed increased OPG protein levels in mixed plaques compared with fibrocalcific ones according to expectations, because those plaques start to calcificate, as well as increased levels of all markers of inflammation and apoptosis, confirming a predictive role of these molecules relative to plaque composition. Stiffness and the Augmentation Index does not result affected to plaque composition but may depend on reduced size of patients recruited.

Takayasu arteritis is a form of large vessel granulomatous vasculitis affecting often young or middle-aged women, especially of Asian descent. It mainly affects the aorta and its branches. Primary malignancies, such as leiomyosarcoma of the aorta are extremely rare. This report discusses the exceptional and concomitant association of Takayasu arteritis and aortic leiomyosarcoma in a 55-year-old male. The patient suffered from systemic signs and symptoms related to arteritis together with claudication of left upper limb due to left artery subclavian stenosis. After instrumental evaluation, an infiltrating neoplasm at the level of abdominal aortic wall was detected and the patient underwent en bloc excision of the mass together with abdominal aorta and subsequent aortoaortic by pass reconstruction. Histologic findings showed an arterial leiomyosarcoma combined with elements of arterial inflammation. Patients completed therapeutic scheme with chemotherapy (doxorubicin and isosfamide) and radiotherapy for the cancer condition, as well as medical treatment (prednisone and adalimumab) for Takayasu arteritis. After 12 months, the patient showed no cancer recurrence and complete normalization of inflammatory indexes and symptoms of Takayasu arteritis.

We describe a technique for Shamblin II-III carotid body tumor (CBT) resection to reduce bleeding and neurologic complications during surgery. The technique was based on the fact that CBTs are supplied almost exclusively from the external carotid artery. Therefore, we carefully isolated the origin of the external carotid artery and its distal branches outside the tumor and temporarily clamped all of these vessels after heparin administration. This allowed a safe and bloodless resection as the tumor was dissected from the internal carotid artery in the usual subadventitial plane. The internal carotid artery was never clamped, and respect of peripheral nerves was warranted in the clean and bloodless field. From 2007 to 2010, we treated 11 patients with a CBT: six had a Shamblin II and five had a Shamblin III lesion. Neither perioperative neurologic events nor recurrences occurred after a mean follow-up of 42 months.

Recently, we demonstrated the involvement of interleukin (IL)-23 in peripheral arterial disease (PAD). IL-23 is mainly involved in the generation of a new subset of effector T cells (Th17) that could be characterised by the ability to produce a unique set of inflammatory cytokines, such as IL-17A, IL-17F, IL-6 and tumour necrosis factor-a, that play an important role in vascular inflammation. We showed that serum levels of this cytokine are higher in three times in connection with surgical treatment (T0: 24 h before, T1: 24 h after, T2: five days after) in patients with lower extremity PAD stage IV compared to controls. Afterwards, we retrospectively analysed whether IL23 has a univocal behaviour in PAD patients or is influenced by its initial values. Therefore, we divided the 29 patients of the previous study into two subgroups: group A (14 patients) with IL-23 levels at T0 8 pg/ml. The cut-off value was established following the controls mean value (8.08 8.62 pg/ml). Data were presented as mean standard deviation (SD). Differences between two paired groups were analysed by the Wilcoxon test and between more than two paired groups by Friedman test. Relationship between variables was evaluated with the ANOVA linear regression which identified the dependent variable in IL-23 and the independent variables in parameters such as age, sex, allergy, smoking, diabetes, hypertension, ischemic heart disease, autoimmune diseases, chronic renal failure and dialysis and use of drugs. Statistical significance was set at p< 0.05. IL-23 serum levels in group A at three times (T01⁄4 3.65 2.23 pg/ml; T11⁄4 6.05 2.5 pg/ml; T21⁄4 8.22 2.77 pg/ml) (Figure 1) showed a statistically significant progressive increase (p< 0.0001) that we did not find in group B (T01⁄4 27.20 26.14 pg/ml; T11⁄4 25.49 30.37 pg/ml; T21⁄4 21.44 21.49 pg/ml; p1⁄4 0.627) (Figure 2). Specifically in group A, both between T0-T1 and T1-T2, the IL-23 serum levels increased in 13 of 14 patients (p1⁄4 0.001 and p1⁄4 0.003, respectively). In group B, both between T0-T1 and T1-T2, the IL-23 serum levels increased in seven of 15 patients (p1⁄4 0.650 and p1⁄4 0.496, respectively). Using ANOVA linear regression, we did not find a relationship between IL-23 serum levels and parameters such as age, sex, allergy, smoking, diabetes, hypertension, ischemic heart disease, autoimmune diseases, chronic renal failure and dialysis. It was also evaluated whether the use of drugs could influence IL-23 serum levels. The linear regression showed no relationship. In another study, Jiang et al. reported increased serum IL-23 levels in patients with Behcet disease after cataract surgery; the cytokine levels did not consistently change in a control group of uncomplicated cataract patients after surgery. The authors hypothesised an underlying inflammation and immune hypersensitivity reaction in patients with Behcet disease that is provoked by the cataract trauma. Our study shows that the increasing IL-23 levels after surgery is influenced by initial levels of this

Endovascular aortic repair (EVAR) has been shown to be a valid and minimally invasive alternative to open abdominal aortic aneurysm repair. A major shortcoming for EVAR is the need to submit patients to regular follow-up to detect potential complications such as endoleak, limb occlusion, aneurysm expansion, aneurysm rupture, infection, structural failure, and migration. In this case report, we describe an uncommon case of late type III endoleak due to complete detachment of the stent-graft main body segment from its suprarenal uncovered fixation stent. It was treated with a custom-made Relay(®) NBS Plus (Bolton Medical, Barcelona, Spain) thoracic stent graft which also provided extra suprarenal fixation of the thoracic stent graft in the proximal neck. The postoperative period was uneventful and a computed tomography scan 1 year later revealed proper positioning of the stent graft and no signs of endoleak. The successful strategy chosen to correct this complication was at the same time original and infrequent, and also avoided potential complications related to open surgical repair and general anesthesia.

Human brucellosis is a disease of protean manifestations, and has been implicated in complications and focal disease in many human organ systems. However, little is collectively known about the background, the course, the clinical characteristics, the diagnostic issues raised, and the short- and long-term therapeutic approaches in patients with aortic involvement as a complication of brucellosis. With the aim to glean from the literature useful information to better understand and manage this complication, a computerized search without language restriction was conducted using PubMed and SCOPUS. An article was considered eligible for inclusion in the systematic review if it reported data on patients with involvement of the aorta due to a Brucella infection. The epidemiologic and clinical characteristics of 44 cases of brucellar aortic involvement found through the systematic review of the literature were analyzed together with those of two new cases that we treated in the recent past. This complication involved the ascending thoracic aorta in 18 cases (in 16 of them as a consequence of brucellar endocarditis), and the descending thoracic aorta or the abdominal aorta in the remaining 30 cases. In the latter it was associated with spondylodiscitis of the lumbar spine in 13 cases. History of or symptoms indicative of brucellosis were not universally present. Brucellar aortic involvement represents a possibly underdiagnosed and underreported complication with major morbidity and mortality potential. Experience with novel invasive therapeutic approaches remains limited. Early suspicion through detailed history and diagnosis, aided by advances in aortic imaging, would allow for better planning of therapeutic interventions

Objectives To clarify whether interleukin (IL)-23 is involved in peripheral arterial disease (PAD). Design and methods We evaluated IL-23 serum levels, in 29 patients suffering from lower extremity PAD and in 30 healthy subjects. Results IL-23 serum levels were higher during the three times (T0, T1 and T2) compared to the control group, although only statistically significant for T0 and T2: T0 (15.83 ± 22.08 vs. 8.08 ± 8.62 pg ml, p = 0.026), T1 (16.10 ± 23.71 vs. 8.08 ± 8.62 pg/ml, p = 0.101), T2 (15.06 ± 16.72 vs. 8.08 ± 8.62 pg/ml, p = 0.005). Conclusion For the first time, our data gives us reason to believe there is an involvement of IL-23 in PAD.

In 80% of the patients presenting with deep-venous thrombosis (DVT), a risk factor can be identified. An absent or hypoplastic infrarenal vena cava is a rare risk factor for DVT in young adults. In these cases, the prevalence of congenital anomalies of the inferior vena cava (IVC) is estimated at 0.5% of the general population, up to 5% in young people. The association with coagulopathy increases the risk of DVT. We report a case of a young man who presented with a massive caval and iliofemoral-popliteal thrombosis in presence of the agenesis of retrohepatic inferior vena cava and atresia of the left renal vein. Open thrombectomy and caval reconstruction with a polytetrafluoroethylene graft were performed. Surgical option with vein reconstruction was preferred to prevent new episodes of thrombosis and the risk of acute renal failure.

We describe a technique for rescue surgery of autologous arterovenous fistula (AVF), using Bovine Mesenteric Vein (BMV), which may be used in patients with autologous AVF malfunction caused by steno-occlusion on the arterial side or by fibrosis of the first portion of the vein. To preserve the autologous AVF, we replaced the diseased portion of the artery, or the first centimeters of the vein, by a segment of BMV, with the aim of saving the patency and functionality of the access. We used this technique in 16 cases. All patients underwent hemodialysis treatment immediately after the procedure. Infection or aneurismal dilatation of the graft in implanted BMV was never observed.

Context: Foot ulcer is the principal cause of hospitalization for patients with diabetes. Polydeoxyribonucleotide (PDRN), an adenosine A2A receptor agonist, improves wound healing in diabetic mice. Objective: The aim of this study was to evaluate the effect of PDRN on chronic ulcer healing in patients with diabetes. Design and Setting: This randomized, double-blind, placebo-controlled trial, involved two medical centers in Italy. Intervention: Patients with diabetes showing hard-to-heal ulcers (Wagner grade 1 or 2) were randomly assigned to receive placebo (n = 106) or PDRN (n = 110). The treatments (PDRN and placebo) were performed 3 days a week for 8 weeks by intramuscular and perilesional route. Main Outcome Measures: The primary outcome was complete ulcer healing. Secondary outcomes were the days needed to complete wound closure and the reepithelialization of wound surface (as percentage of the original area). Results: After 8 weeks, 91 placebo and 101 PDRN subjects completed the study. Complete heali...

ObjectivesThe purpose of this study was to evaluate the consequences on patient selection and on early and midterm results of the learning curve of a surgical team performing laparoscopy-assisted surgery in the treatment of severe aortoiliac occlusive disease (AIOD).Patients and methodBetween January 1998 and June 2003, 58 patients (53 men, 5 women; mean age, 59.5 years [range, 37-76 years]) were included in a prospective study and underwent a laparoscopy-assisted aortofemoral reconstruction with graft implantation through a 5-cm to 8-cm minilaparotomy. Fifty-one patients (88%) had claudication (category 2 or 3, Rutherford classification), and seven patients (12%) had tissue loss; at presentation they had TransAtlantic Inter-Society Consensus C (n = 24, 41.4 %) or D (n = 32, 55.2%) iliac lesions, and the last 2 patients (3.4%) had severe aortic lesions. Perioperative data for the first 29 patients, obtained during the first 34 months of the study (group 1), were compared with data for the last 29 patients, obtained during the last 32 months of the study (group 2). Follow-up consisted of clinical examination or duplex scanning, or both, at 1, 3, 6, and 12 months and yearly thereafter, and computed tomography before discharge and then every 2 years.ResultsOne intraoperative surgical conversion (1.7%) was necessary, and two other patients (3.4%) died in the immediate postoperative period. With experience, initial contraindications such as obesity or suprarenal artery aortic clamping were eliminated, making it possible to increase the percentage of patients included, from 53.7% during the first 34 months to 90.6% during the last 32 months (P = .003). The mean duration of the operative procedure decreased from 285 minutes in group 1 to 192 minutes in group 2 (P < .001), and the mean duration of aortic clamping decreased from 76.4 minutes in group 1 to 31.8 minutes in group 2 (P < .001). The number of early repeat interventions was reduced from three (10.3%) in group 1 to 2 (6.9%) in group 2 (P = NS), and the clinical recovery period decreased from 7 days to 4.5 days (P = .05). During a mean follow-up of 26.7 months (range, 1-66 months) there were 5 repeat surgeries (9%) to treat late graft occlusion, establishing midterm primary and secondary patency rates of 89.3% and 91%, respectively. No aortic false aneurysms were detected, and no major amputations were performed.ConclusionThese preliminary results assess the feasability and the safety of this minimally invasive video-assisted technique. A short period of postoperative recovery and good midterm patency rate are the two main benefits of this new surgical option.

The purpose of this study was to assess which modalities offered the best timing in the treatment of abdominal aortic aneurysms associated with other abdominal surgical diseases. From January 1984 to December 2002, 372 patients underwent surgery for abdominal aortic aneurysms, 350 men (94%) and 22 women (6%), mean age 72 years. Of these 10% were operated on urgently. The traditional open technique was used in 307 patients, and the endovascular method in the remaining 65 cases. In 40 patients (11%) we observed other associated abdominal diseases which were treated during the same operation in 34 cases (85%). We had three deaths in the 34 cases treated in the same operation (9%). In the remaining cases no perioperative mortality was registered. There were no cases of prosthesis infection. The mean hospital stay was 9 days. Simultaneous treatment appears, on the one hand, to carry an increased operative risk and increased mortality and, on the other, to present the advantage of having to perform only one surgical procedure. The advent of the endovascular method allows us to postpone the treatment of the associated disease without increasing the technical difficulty of the second operation.

Chez 80% des patients ayant une thrombose veineuse profonde (DVT), un facteur de risque peut etre identifie. Une veine cave sous-renale absente ou hypoplasique est un facteur de risque rare de DVT chez de jeunes adultes. Dans ces cas, la predominance des anomalies congenitales de la veine cave inferieure (IVC) est estimee a 0,5% de la population globale, jusqu'a 5% chez les jeunes. L'association avec une coagulopathie augmente le risque de DVT. Nous rapportons le cas d'un jeune homme qui s'est presente avec une thrombose cave et ilio-femoro-poplitee massive en presence d’une agenesie de la veine cave inferieure retrohepatique et une atresie de la veine renale gauche. Une thrombectomie ouverte avec reconstruction cave par une prothese en polytetrafluoroethylene ont ete faites. L'option chirurgicale avec reconstruction veineuse a ete preferee pour empecher de nouveaux episodes de thrombose et le risque d'insuffisance renale aigue.

Objective In this study, we retrospectively evaluated our experience in minilaparotomy (MINI) and compared the results with conventional open repair (OPEN). Methods From January 2005 to December 2012, we surgically treated 234 consecutive patients with elective infrarenal abdominal aortic aneurysms, 195 men and 39 women, with a mean age of 74 years. Inclusion criteria for MINI were not ruptured abdominal aortic aneurysm, increased surgical risk, anatomical limits for endovascular repair, no previous surgical invasion of the abdominal cavity, and no requirement for concomitant abdominal surgical invasion. Surgical treatment was OPEN in 113 patients (48.3%) and MINI through an 8- to 14-cm incision in 121 patients (51.7%). Epidural anesthesia has been added in 26.5% and in 19.3% of the MINI and OPEN patients, respectively. Mortality, complications, aortic clamping time, operative time, need for postoperative morphine therapy, time to solid diet, and length of hospital stay were registered. Results The MINI has been performed in all patients selected, with 72 aortoaortic grafts and 49 aortobisiliac grafts. Early mortality was 1.6% versus 3.5% ( P > 0.5); 1-, 3-, and 5-year mortality were 7% versus 9%, 19% versus 22%, and 29% versus 34% ( P > 0.5); complications were 12.2% versus 26.6% ( P > 0.05); mean (SD) clamping time was 48 (12) versus 44 (14) minutes ( P > 0.5); mean (SD) operative time was 218.72 (41.95) versus 191.44 (21.73) minutes ( P > 0.025); mean (SD) estimated intraoperative blood loss was 425.64 (85.95) versus 385.30 (72.41) mL ( P > 0.1); mean (SD) morphine consumption in the group given epidural and the group not given epidural was 0 (2) and 2 (2) mg intravenously (IV) versus 2 (4) ( P < 0.5) and 4 (3) mg IV ( P > 0.1); mean (SD) ambulation was 2.1 (0.6) versus 4.1 (2.7) ( P < 0.5); mean (SD) time to solid diet was 2.1 (0.4) versus 3.5 (1.6) ( P < 0.5); and mean (SD) length of hospital stay was 4.9 (1.64) versus 7.35 (1.95) days ( P > 0.05), in the MINI and OPEN groups, respectively. Postoperative hernia at 3 years was 18% versus 23% in the MINI and OPEN groups ( P < 0.5), respectively. Conclusions The MINI gives the patients a significantly shorter period of recovery with the quality and safety of the OPEN. This experience suggested extending the indication to all surgical candidates without local limitations.

As reported in previous investigations, erythrocytes are the elements of peripheral blood most affected by free radical activity in the pathogenesis of cancer. In these studies, the level of sulphydrilic groups and reduced glutathione were assayed in the erythrocytes and plasma, while their successful scavenger activity against cell membrane oxidation and peroxidation has already been established. In subjects with cancer, the levels of -SH groups (p0.002) and reduced glutathione in both plasma and erythrocytes (p0.0001) were shown be a statistically significantly decreased compared to healthy controls. These differences were related to the defence of the hematic tissue against free radical activity. A similar pattern has also been reported when studying vitamin A and E content in the peripheral blood of cancer patients. The role of oxido-reduction phenomena in this disease is discussed, as well as the importance of reducing the oxido-peroxidation involvement of tissues and cell elements. The study of the GSH/GSSG ratio in order to determine the stage of the disease would be useful and might represent a systemic marker for cancerous lesions.