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The contribution which Prof. Edmondo Malan gave to the world of surgery is matched only by the number of disciples that are working every day in his memory. Yet, the heritage of the Master is not limited to mere surgical teaching. Because of his willpower, many surgical departments have been inaugurated, many teaching schools have been founded, the boundaries of general surgery and many specialties have been crossed; in his memory, vascular research went far beyond expectations, reaching a level of excellence he could have only dreamed of. His heirs, once more, have perpetuated his lessons in surgery, keeping alive the true spirit of medicine, which is our foundation: the art of teaching and learning, as a never-ending process. Professor Edmondo Malan is not vanished. His name is not buried in history books. He is constantly alive, every day, a vivid presence in every surgical skill that reminds the audacity and the dedication of a man, not only a doctor, focused on caring and healing, from the bottom of his heart

Contains fulltext : 81133.pdf (Publisher’s version ) (Closed access) BACKGROUND: Case and single center reports have documented the feasibility and suggested the effectiveness of endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs), but the role and value of such treatment remain controversial. OBJECTIVE: To clarify these we examined a collected experience with use of EVAR for RAAA treatment from 49 centers. METHODS: Data were obtained by questionnaires from these centers, updated from 13 centers committed to EVAR treatment whenever possible and included treatment details from a single center and information on 1037 patients treated by EVAR and 763 patients treated by open repair (OR). RESULTS: Overall 30-day mortality after EVAR in 1037 patients was 21.2%. Centers performing EVAR for RAAAs whenever possible did so in 28% to 79% (mean 49.1%) of their patients, had a 30-day mortality of 19.7% (range: 0%-32%) for 680 EVAR patients and 36.3% (range: 8%-53%) for 763 OR patients (P < 0.0001). Supraceliac aortic balloon control was obtained in 19.1% +/- 12.0% (+/-SD) of 680 EVAR patients. Abdominal compartment syndrome was treated by some form of decompression in 12.2% +/- 8.3% (+/-SD) of these EVAR patients. CONCLUSION: These results indicate that EVAR has a lower procedural mortality at 30 days than OR in at least some patients and that EVAR is better than OR for treating RAAA patients provided they have favorable anatomy; adequate skills, facilities, and protocols are available; and optimal strategies, techniques, and adjuncts are employed.

Obiettivo; In letteratura è riportato che solo il 50% dei pazienti con aneurisma toracico rotto raggiunge l’Ospedale ancora in vita, ed il 75% di questi muore nelle 24 ore successive. L’elevata percentuale di mortalità e paraplegia, in seguito a trattamento chirurgico di un aneurisma dell’aorta toracico rotto, limita di molto tale procedura. Il trattamento endovascolare offre un’alternativa meno invasiva alla chirurgia tradizionale, in quanto evita la toracotomia, la terapia anticoagulante e il clampaggio aortico. In questo lavoro riportiamo la nostra iniziale esperienza riguardante il trattamento endovascolare in urgenza dell’aneurisma dell’aorta toracico rotto. Metodi: La nostra esperienza è iniziata nel maggio 2004, da allora abbiamo trattato 11 pazienti con rottura franca di aneurisma dell’aorta toracica (10 aneurismi toracici rotti ed un caso di aneurisma dissecante rotto). I pazienti trattati presentavano un’età media di 76.2 anni (min. 69, max 88), 10 maschi ed una femmina. Tutti i casi, tranne uno, si sono presentati in Pronto Soccorso in condizioni emodinamicamente stabili (PA>70mmHg) e sono stati sottoposti ad un esame Angio TC dell’aorta toracica, addominale e degli assi iliaco femorali. Le condizioni cliniche e la valutazione strumentale hanno evidenziato la possibilità di un trattamento endovascolare. In un solo caso, presentandosi in shock emorragico, la diagnosi e la fattibilità endovascolare è stata fatta direttamente in sala operatoria, dopo un accurato studio angiografico e con IVUS (Intavascular Ultrasound). Risultati: Tutti i pazienti sono stati trattati entro 12 ore dall’arrivo in Ospedale e tutte le procedure sono state eseguite in sala operatoria e in anestesia generale. Le endoprotesi utilizzate sono state in 9 casi Endofit/Endomed, in un caso Talent/Medtronic ed in un altro Zenith/Cook, con un accesso femorale chirurgico ed uno percutaneo. Solo in un caso è stato necessario coprire l’arteria succlavia sinistra, mentre in un altro caso è stato necessario coprire l’origine dell’arteria succlavia e della carotide comune sinistra previo bypass carotido-carotideo. Il successo tecnico è stato del 100%, in due casi la presenza di on endoleak di tipo 1° ha reso necessario l’utilizzo di cuffs prossimali. La mortalità post-operatoria è stata del 54,5% (6/11), in tutti i casi si trattava di pazienti molto compromessi dal punto di vista cardiologico e respiratorio. Conclusioni: I risultati della nostra limitata esperienza e della letteratura evidenziano una percentuale di complicanze post-operatorie, in termini di mortalità, accettabile. Nella nostra esperienza la percentuale di successo, in termini d’esclusione dell’aneurisma, è stata del 100% e la maggior parte delle complicanze post-operatorie si è verificata in pazienti con preesistenti patologie cardiorespiratorie. Il trattamento endovascolare degli aneurismi rotti dell’aorta toracica sembra essere, dai dati della letteratura, abbastanza promettente. La presenza di un team endovascolare preparato e sempre reperibile e la disponibilità di apparecchiature e di materiale protesico a disposizione sono assolutamente necessarie per l’ottimizzazione dei risultati. Objective; In literature it is reported that only 50% of patients with ruptured thoracic aneurysm reaches the hospital alive, and 75% of these die within 24 hours. The high percentage of mortality and paraplegia after surgical treatment of a ruptured thoracic aortic aneurysm, limits indications to this procedure. Endovascular treatment offers a less invasive alternative to traditional surgery, as it avoids thoracotomy, anticoagulant therapy and aortic clamping. In this paper we report our initial experience regarding the endovascular treatment in emergency of broken thoracic aortic aneurysm. Methods: Our experience began in May 2004, since then we have treated 11 patients with frank rupture of the thoracic aortic aneurysm (10 aneurysms and a case of dissecting aneurysm). These patients had a mean age of 76.2 years (min. 69, max 88), 10 males and one female. All cases except one, were presented to the emergency department under hemodynamically stable (BP> 70 mm Hg) and were subjected to CT angiography of the thoracic aorta, abdominal aorta and iliac femoral axis. The clinical and instrumental evaluation have shown the possibility of endovascular treatment. In one case, presenting in hemorrhagic shock, the endovascular feasibility was made in the operating theater, after a careful study with angiography and IVUS (Intavascular Ultrasound). Results: All patients were treated within 12 hours of arrival in hospital and all procedures were performed in the operating room under general anesthesia. The endoprostheses used were in 9 cases Endofit / Endomed, in a case Talent / Medtronic and in another Zenith / Cook, with a surgical femoral access and percutaneous one. Only in one case it was necessary to cover the left subclavian artery, while in another case it was necessary to cover the origin of the subclavian artery and left common carotid artery after carotid-carotid bypass. The technical success was 100%, in two cases the presence of endoleaks on type 1 has necessitated the use of proximal cuffs. The post-operative mortality was 54.5% (6/11), in all cases the patients were very compromise in cardiac and respiratory systems. Conclusions: The results of our limited experience and related literature show an acceptable percentage of postoperative complications, in terms of mortality. In our experience, the success rate in terms of exclusion of the aneurysm, was 100% and the majority of post-operative complications occurred in patients with preexisting cardiopulmonary disease. Endovascular treatment of ruptured aneurysms of the thoracic aorta appears to be, from the literature, quite promising. The presence of an endovascular team prepared and always available and the availability of equipment and prosthetic materials are absolutely necessary for best results.

Emergency Surgical Conversion for Rupture of Abdominal Aortic Aneurysms after EVAR - The rare observations of rupture of abdominal aortic aneurysm (AAA), which had been excluded by endograft, are becoming more frequent, because of the spreading use of endovascular aneurysms exclusion (EVAR). Clinical presentation of AAA rupture after EVAR could be misleading, because of the possible plugging by the endograft and delayed haemorrhage, as in the presented clinical case. Some particular surgical techniques can assist the procedure of open repair, such as supra-renal clamping, which can be accomplished by aortic balloon, and arterial reconstruction, sewing a new vascular graft on the proximal and distal segments of the endograft, cut and left in situ, thus avoiding damage to the native arteries and facilitating surgical fixation.

Introduzione e Scopo del Lavoro - Le osservazioni di rottura di aneurisma aortico, trattato in precedenza con endoprotesi, sono aumentate negli anni più recenti, per l’uso più frequente della metodica di esclusione endovascolare degli aneurismi (EVAR). Le differenze nella presentazione clinica e nell’approccio terapeutico devono essere conosciute e valutate nel trattamento di rotture dopo EVAR. Materiali e Metodi - Partendo dalla descrizione di un caso trattato, vengono considerati, alla luce dei dati riportati nella recente letteratura, i fattori di rischio, le caratteristiche cliniche e le tecniche chirurgiche particolari, da adottarsi nel trattamento di questa patologia di ormai meno raro riscontro. Discussione - Il trattamento degli aneurismi dell’aorta addominale mediante esclusione con endograft è andato progressivamente estendendosi negli ultimi anni. L’esclusione della sacca aneurismatica mediante stent graft ha il fine di impedire la progressiva dilatazione e rottura dell’aneurisma. Nonostante i miglioramenti nelle endoprotesi arteriose, con adattamento alla morfologia variabile dell’aneurisma e maggior fissazione dell’endograft, è riportata, su aneurismi trattati con EVAR, un’incidenza di rottura tardiva dell’1,5% per anno. Tra i vari fattori che causano tale rottura, risultano statisticamente significativi in primo luogo la presenza di endoleak di primo e terzo tipo, quindi la migrazione dell’endoprotesi e l’aumento nel diametro dell’aneurisma. A differenza della rottura di aneurisma aortico non trattato in precedenza, la rottura dopo EVAR può più facilmente tamponarsi, per la presenza dell’endograft e le pressioni più ridotte all’interno della sacca aneurismatica. La sintomatologia classica di ipotensione ed anemizzazione acuta può quindi mancare e può protrarsi la condizione di “fissurazione” dell’aneurisma, rendendo particolarmente subdolo il quadro clinico e quindi maggiormente pericolosa la rottura in due tempi. Conclusioni - La rottura di aneurisma aortico dopo EVAR è sempre meno rara. Il quadro clinico può essere ingannatore, per l’eventuale tamponamento e rottura in due tempi. Svariati accorgimenti di tecnica chirurgica facilitano il trattamento di questa patologia. Introduction and Aim of Work - The observations of rupture of aortic aneurysms, previously treated with endoprosthesis, have increased in recent years, for the most frequent use of endovascular exclusion of aneurysms (EVAR). The differences in clinical presentation and therapeutic approach must be recognized and evaluated in the treatment of ruptures after EVAR. Materials and Methods - Starting from the description of a clinical case, in the light of recent data reported in the literature, risk factors, clinical characteristics and surgical techniques are considered, which have to be considered in this increasing pathology. Discussion - The treatment of abdominal aortic aneurysms by exclusion with endograft has been gradually extending in recent years. The exclusion of the aneurysmal sac through the stent graft is intended to prevent progressive dilatation and aneurysm rupture. Despite the improvements in arterial endoprosthesis, with better adaptation to the morphology of the aneurysm and most valid fixation, recent articles report, about aneurysms treated with EVAR, an incidence of late rupture of 1, 5% per year. Among the various factors that cause such breakage, are statistically significant in the first place the presence of first and third type endoleak, then endoprosthesis migration and increase in the diameter of the aneurysm. In contrast to the rupture of aortic aneurysm not previously treated, the break after EVAR can evenctually stop by tamponade, for the presence endograft and smaller pressures inside the aneurysm sac. The classic symptoms of acute anemia and hypotension may lack misleading prompt diagnosis of the condition of "cracking" of the aneurysm, making it particularly insidious the clinical picture and therefore more dangerous a break down into two stages. Conclusions – Although rare, the rupture of aortic aneurysm after EVAR is increasing. The clinical picture can be deceptive, for the eventual plugging and breakage in two stages. Several expedients of surgical technique are useful tools to improve the handling of this pathology.

Introduzione e Scopo del Lavoro - Le osservazioni di aneurismi dell’arteria splenica sono aumentate negli anni più recenti, per l’uso più frequente di metodiche diagnostiche quali Ecografia, Ecodoppler, Tomografia Computerizzata (TC) e Risonanza Magnetica (RM), ponendo quindi spesso il quesito sulla miglior condotta terapeutica da tenere nei confronti di questi. Materiali e Metodi - Partendo da alcune osservazioni personali, rivedendo quindi i dati riportati nella recente letteratura, i vantaggi e le complicanze delle diverse metodiche utilizzabili: chirurgia tradizionale “aperta”, embolizzazione, esclusione con stent graft, chirurgia laparoscopica, con o senza splenectomia associata, vogliamo definire quale sia l’indicazione terapeutica più opportuna. Discussione - Gli aneurismi dell’arteria splenica sono lesioni rare, con incidenze riportate dallo 0,1 al 10%, essi costituiscono la più frequente localizzazione degli aneurismi viscerali, terzo tipo d’arteria addominale colpita, dopo aorta ed iliache, in soggetti adulti, intorno ai 60 anni. Sono molto più frequenti nel sesso femminile, presentano associazione significativa con gravidanza, ipertensione arteriosa, ipertensione portale. Sono spesso di natura fibrodisplastica, anche se le alterazioni più frequentemente rilevate sono di natura arteriosclerotica e calcifica, la morfologia è tipicamente sacculare. Le possibili complicanze dell’aneurisma splenico sono il progressivo aumento di volume, la trombosi, l’embolizzazione ed ovviamente la rottura, con emorragie gravi e mortali, anche se la maggioranza dei casi diagnosticati sono di aneurismi asintomatici. L’indicazione terapeutica è al trattamento chirurgico, se la lesione supera i 2 centimetri di diametro, mostra tendenza evolutiva o presenta una sintomatologia. La chirurgia tradizionale prevede la legatura dell’arteria splenica, con o senza asportazione dell’aneurisma, o la sua ricostruzione. L’abbondante perfusione collaterale permette nella maggior parte dei casi la conservazione della milza, pur dopo interruzione dell’arteria, anche se la facilità di lacerazioni capsulari e parenchimali ne consiglia talora l’asportazione. Lo stretto rapporto con il pancreas, specie degli aneurismi più prossimali, impone un’attenta dissezione, o la scelta della semplice esclusione, onde evitare complicanze legate a pancreatite secondaria. Il trattamento endovascolare ideale prevede il posizionamento di stent ricoperti, con esclusione della sacca. La tortuosità dell’arteria e le abbondanti calcificazioni la rendono però sovente difficoltosa. La morfologia prevalentemente sacculare permette spesso un’embolizzazione mediante spirali, cianoacrilati od iniezioni di trombina, con trombosi dell’aneurisma. Complicanze da non sottovalutare, per tutte le procedure endovascolari, sono tuttavia la rottura, l’embolizzazione con infarti splenici, lo sviluppo di ascessi e la riabitazione dell’aneurisma. Le tecniche laparoscopiche consentono un approccio ad invasività ridotta, di poco superiore alle endovascolari. Le metodiche prevedono la semplice legatura o la resezione dell’aneurisma, seguita o meno da splenectomia. Vi sono anche reports isolati di ricostruzione laparoscopica. Conclusioni - L’aneurisma dell’arteria splenica è raro, perlopiù asintomatico, la rottura è d’altronde spesso mortale. Il trattamento è dunque indicato, attraverso chirurgia aperta, endovascolare o laparoscopica. Le diverse metodiche presentano vantaggi e limiti, la loro scelta dipenderà dunque dalla morfologia dell’arteria e dalle caratteristiche del singolo paziente.

Importance of Carotid Plaque characterization before Carotid Angioplasty and Stenting: the ICAROS study The procedure of endovascular angioplasty and stenting (CAS), from his introduction by Kerber, in 1980, after a long period of heated diatribes on the risk / benefit offered by it, but above all of extraordinary technological improvements, is now showing a valid therapeutic alternative to the traditional surgical carotid endarterectomy (CEA), in the treatment of prevention of cerebral ischaemia. The preliminary results of the Sapphire study, which randomized patients at high surgical risk, showed that in this particular group there is an advantage of CAS performed with cerebral protection, the incidence of peri-procedural major events (death, stroke or myocardial infarction) is 5.8% compared to 12.6% of the CEA. Apart from the technical expertise, particularly relevant in endovascular techniques, and the anatomic contraindications to CAS - vessels access eccessivametne stenotic or tortuous, the angle of the arch or the supra-aortic arteries and sub-occlusive stenoses - the literature increasingly shows the importance of carotid plaque morphology. Its careful assessment is now indispensable for a correct indication to angioplasty and stenting, in order to obtain the best therapeutic results.

L’ulcera penetrante dell’aorta (PAU) è lesione rara, localizzata prevalentemente nell’aorta toracica, il più spesso asintomatica e benigna, tendendo nella maggioranza dei casi alla stabilizzazione, od anche alla regressione. In alcuni casi però la PAU ha tendenza evolutiva, verso l’ematoma periaortico, lo pseudoaneurisma e la rottura dell’aorta, o la dissecazione, con imminente pericolo di vita (Sindrome Aortica Acuta). Il rilievo di una PAU alla TC od RM richiede dunque un attento controllo e, nel caso compaiano sintomatologia o segni d’evoluzione, deve essere urgentemente trattata, con sostituzione chirurgica, o, preferibilmente, con esclusione mediante endoprotesi. Penetrating Aortic Ulcers – Clinical Relevance and Therapeutic Indications _ Penetrating aortic ulcer (PAU) is a rare pathology, affecting more frequently the thoracic aorta. Mostly benign and asymptomatic, PAU frequently tends to stabilize or even regress. In some cases, on the contrary, it evolves into peri-aortic ematoma and aortic rupture or dissection, with absolute mortality (Acute Aortic Syndrome). A diagnosis of PAU at TC or RM requests therefore careful observation and repeated examinations. In case of symptomatology and evolution, PAU has to be treated in emergency, by means of surgical repair or, more likely, by endovascular exclusion.

Il trattamento chirurgico tradizionale degli aneurismi rotti dell’aorta addominale è tuttora gravato da un’alta mortalità post-operatoria. Le recenti metodiche endovascolari consentono l’esclusione rapida della sacca aneurismatica rotta e la rivascolarizzazione periferica, per mezzo di un’endoprotesi introdotta attraverso un accesso femorale. L’esclusione endovascolare degli aneurismi aortici rotti ha un decorso post-operatorio meno impegnativo per il paziente, con relativa diminuzione delle complicanze ad esso correlate. Per considerare la procedura è necessario che il paziente giunga in Pronto Soccorso in uno stato di relativa stabilità, onde poter effettuare un’Angio-TAC, confermare la diagnosi e studiare se la morfologia dell’aneurisma permetta di praticare con sicurezza la tecnica endovascolare. L’esperienza della nostra equipe e degli specialisti che ci affiancano all’Ospedale Bassini ci ha consentito di iniziare con successo questo trattamento degli aneurismi rotti, motivandone la sua prosecuzione e, se possibile la sua estensione. EMERGENCY ENDOVASCULAR TREATMENT of RUPTURED ABDOMINAL AORTIC ANEURYSMS A high post-operative mortality (50%) is still related to conventional surgical repair of ruptured AAA. Newer Endovascular Techniques allow fast exclusion of ruptured aneurismal sac by means of aorto-iliac endoprosthesis trough a femoral access. EVAR in ruptured AAA is associated with shorter post-operative recovery and less related complications. It is mandatory that patients with aortic rupture can reach the Hospital in stable conditions, in order to allow accurate selection of candidates for Endovascular Exclusion through Angio-CT. Multi-disciplinary team with experience in Endovascular procedures is essential. Our good initial outcome using this procedure stimulates to continue and, possibly, extend the application of EVAR in AAA rupture.

Endidovascular procedures have emerged as an attranative technique for the repair of abdominal arotic aneury, sms with an increasing popularity and diffusion. even if technology progresses are developing more and more efficient grafts and devices, at the ment is still not applicable to all patients.the most common reason for patient exclusion remain an proximal implantation site. 'endografts with suprarnal fixation were studied for solving the problem of the proximal neck but results seem to he not so encouraging. At the moment pararenal aortic aneury-sms. involving ostia of renal or visceral arteries, are usually excluded from endotutscidar treatment. the solution could be a custom-made graft for each single patient with fenestrations or branches for renal and visceral arteries. 1 he first clinical use of a fenestrated graft was by Park in 1996 and some groups are now studying different kinds of grafts, both in experimental and clinical studies, which are opening attractive new posibilities. At present results are only preliminary but this would be the first step towards the potential substitution of the entire aorta through oidova scular techniques. Copyright © 2004 GEM s.r.l.

Stroke is the third leading cause of death and the first, among cardiovascular diseases, most frequent cause of disability, demanding elevated social costs and needing huge resources to address assistance and rehabilitation. The prevention of stroke has consequently become of utmost importance in modern health care. Some 30 years after the introduction on large scale of carotid endarterectomy (CEA) for the prevention of neurological disturbances from carotid bifurcation plaques, and more than 10 years since the publication of international prospective randomized studies that seemed to finally allay doubts and uncertainties on the subject, transmitting for posterity the message that CEA is the gold standard for the prevention of stroke, some old problems concerning indication and appropriateness of CEA remain unsolved and some new ones have appeared preponderantly on the international scene. While there is a substantial consensus that CEA is effective in the prevention of stroke in symptomatic patients with haemodynamic carotid artery stenoses, Trials have concluded that the evidence of benefit of CEA in asymptomatic patients with a 70% or more carotid stenosis is questionable and in many cases minimal, compared with conservative medical treatment. These data conflict with the diffuse practice worldwide of CEA procedures performed on asymptomatic patients and also with the conclusion of other equally influential and authoritative publications. The position of these authors, that effective prevention of stroke should also be addressed to asymptomatic carotid stenoses, is justified by data from the literature showing that only a minority of strokes is preceded by transient neurological symptoms or ischemic attack.

Abdominal aortic aneurysm (AAA) occurs mostly in patients over the fifth decade of age, in which it is not uncommon to diagnose concurrent diseases. Furthermore an AAA can be found by chance, performing investigations for another illness. The question of the kind of approach to two associated diseases must therefore be resolved. We analyze various abdominal pathologies, whether malignant or benign, and other associated diseases, including frequent coronary heart disease. The interesting new perspectives offered by the endovascular exclusion of AAA, in respect of traditional prosthetic surgical repair, are discussed.

Endovascular exclusion of iliac artery aneurysms after aortic grafting for AAA. Isolated iliac artery aneurysms are quite rare, whereas they are more frequent in association with abdominal aortic aneurysms. Aneurysmal dilatation may also affect iliac arteries in the long-term follow-up after aorto-aortic grafting for abdominal aortic aneurysms. The reported clinical case deals with two large aneurysms of the common and internal right iliac arteries, which were corrected by means of an endograft, adopting a less invasive endovascular approach at a lower risk, with a successful short and mid-term outcome. A brief review of recent literature on the topic confirms the effectiveness of the endovascular treatment.

Purpose: To describe a case of improved renal function and renovascular hypertension after percutaneous treatment of a renal artery aneurysm. Case report. A 72-year-old hypertensive woman with a hilar saccular aneurysm of the right renal artery underwent percutaneous coil embolization under local anesthesia. Four individual, soft, detachable platinum embolization coils were successfully inserted in the aneurysm with incomplete aneurysm exclusion. Nonetheless, the patient's blood pressure and renal function returned to normal. The arteriogram at 3 months demonstrated complete exclusion of the lesion and good renal perfusion. The patient remains normotensive with documented improved renal function at 18 months after treatment. Conclusions: Superselective coil embolization is an effective treatment for renal artery aneurysms that display proper morphological features. The long-term outcome of this less invasive therapy still must be assessed, but it appears plausible that embolotherapy of renal artery aneurysms can correct secondary hypertension and deteriorating renal function.

Endovascular Repair of Aortic False Aneurysm - Case Report and Considerations about the Serious Pathological Condition. Aortic graft false aneurysm represents a rare, but serious disease, because of the absence of symptoms and of the dangerous complications: abdominal rupture and aortoenteric fistula. A clinical case is reported of a false aneurysm arising from the reimplantation of the inferior mesenteric artery and a polar renal artery on a end-to-end infrarenal aortic graft, inserted to repair an aneurysm. The case was treated by exclusion of the pseudoaneurysm by means of a stent graft, inserted through the femoral artery. Surgical reinterventions for graft false aneurysms are associated with high morbidity and mortality, due to the difficult dissection through scarred tissues and adhesions caused by the primary surgery, due to the problems connected with aortic clamping and with the frequent intimate adhesions between false aneurysm and duodenum, with consequent possible contamination of the graft. The positioning of a stent graft through the femoral artery under local anaesthesia, drastically reduces the invasiveness and the possible complications of the surgical repair. We think therefore that endovascular exclusion, when applicable, should represent the treatment of choice for arterial graft pseudoaneurysm.

Cerebral Protection during Carotid Surgery The prevention of stroke is the first aim of Carotid Endarterectomy surgical procedure. But carotid clamping and consequent blood flow interruption may cause cerebral ischemia. The aim of this work is to analize pros and cons of different intraoperative cerebral monitoring and cerebral protection methods, in order to prevent ischemic damage. The Procedures adopted by our Team as well as the surgical results achieved are shortly described.

Endovascular Repair of Aortic False Aneurysm - Case Report and Considerations about the Serious Pathological Condition. Aortic graft false aneurysm represents a rare, but serious disease, because of the absence of symptoms and of the dangerous complications: abdominal rupture and aortoenteric fistula. A clinical case is reported of a false aneurysm arising from the reimplantation of the inferior mesenteric artery and a polar renal artery on a end-to-end infrarenal aortic graft, inserted to repair an aneurysm. The case was treated by exclusion of the pseudoaneurysm by means of a stent graft, inserted through the femoral artery. Surgical reinterventions for graft false aneurysms are associated with high morbidity and mortality, due to the difficult dissection through scarred tissues and adhesions caused by the primary surgery, due to the problems connected with aortic clamping and with the frequent intimate adhesions between false aneurysm and duodenum, with consequent possible contamination of the graft. The positioning of a stent graft through the femoral artery under local anaesthesia, drastically reduces the invasiveness and the possible complications of the surgical repair. We think therefore that endovascular exclusion, when applicable, should represent the treatment of choice for arterial graft pseudoaneurysm.