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Peppermint essential oil (EO) is obtained by the steam distillation of the Mentha × piperita L. aerial parts; it is widely used in several fields including chewing gums, confectionary, oral hygiene products, pharmaceuticals and liquors. Most peppermint EO is nowadays produced in United States but Italy has maintained a commercial production of peppermint EO confined to a restricted area in Piedmont (Torino and Cuneo Province) dated from the 18th century. Piedmont peppermint EO is produced from a single mint variety, i.e., the Mentha × piperita L. var. Italo-Mitcham (black mint), it is considered of very high quality and characterised by freshness and long lasting sweetness. In this study, peculiar flavour characteristics of peppermint EO have been investigated by Gas Chromatography-Olfactometry (GC-O) using the Aroma Extraction Dilution Analysis (AEDA) approach. Among the compounds responsible for intense sweet, coconut, coumarin-like notes, the most intense odorant was menthofurolactone (i.e., 3,6-Dimethyl-4,5,6,7-tetrahydro-benzo[b]-furan-2(3H)-one – CAS [16642-41-4]). This trace odour-active compound belongs to p-menthane lactones family that represents a class of minor components in peppermint EO although they highly affect the overall flavour profile. The presence of menthofurolactone and related compounds (i.e., chemical signature) in different samples was confirmed by combining bi-dimensional retention data and spectral data collected at 70 and 12 eV by Comprehensive Two-Dimensional Gas Chromatography coupled to Time-of-Flight Mass Spectrometry (GC×GC-TOF MS) featuring tandem ionisation. A selection of raw peppermint EOs from different geographic origin were accurately profiled by GC×GC-TOF MS to further investigate the distribution of these key-aroma compounds and reveal diagnostic signatures of p-menthane lactones family. Piedmont peppermint EOs showed a diagnostically higher amount of this trace-odorant, and related compounds, compared to the other commercial EOs, as an evidence of its contribute to Piedmont EO rich and round flavour profile. A dedicated fingerprinting approach based on diagnostic signatures of potent odorants within specific retention windows, validate this correlation and poses solid foundation to an objective qualification of this highly valuable product.

International guidelines strongly recommend statins alone or in combination with other lipid-lowering agents to lower low-density lipoprotein cholesterol (LDL-C) levels for patients with asymptomatic/symptomatic carotid stenosis (AsxCS/SCS). Lowering LDL-C levels is associated with significant reductions in transient ischemic attack, stroke, cardiovascular (CV) event and death rates. The aim of this multi-disciplinary overview is to summarize the benefits and risks associated with lowering LDL-C with statins or non-statin medications for Asx/SCS patients. The cerebrovascular and CV beneficial effects associated with statins, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and other non-statin lipid-lowering agents (e.g. fibrates, ezetimibe) are reviewed. The use of statins and PCSK9 inhibitors is associated with several beneficial effects for Asx/SCS patients, including carotid plaque stabilization and reduction of stroke rates. Ezetimibe and fibrates are associated with smaller reductions in stroke rates. The side-effects resulting from statin and PCSK9 inhibitor use are also highlighted. The benefits associated with lowering LDL-C with statins or non-statin lipid lowering agents (e.g. PCSK9 inhibitors) outweigh the risks and potential side-effects. Irrespective of their LDL-C levels, all Asx/SCS patients should receive high-dose statin treatment±ezetimibe or PCSK9 inhibitors for reduction not only of LDL-C levels, but also of stroke, cardiovascular mortality and coronary event rates. © 2022 Elsevier Inc.

We evaluated the outcomes of revascularization in patients with chronic limb-threatening ischemia (CLTI) treated in real-world settings. This is a prospective multicenter cohort study with 12-month follow-up enrolling patients (n = 287) with CLTI undergoing open, endovascular, or hybrid lower extremity revascularization. The primary end point was amputation-free survival (AFS) at 12 months. Cox proportional analysis was used to determine independent predictors of amputation and restenosis. At 30 days, major adverse cardiovascular and major adverse limb events (MALE) rates were 3.1% and 2.1%, respectively. At 1 year, the overall survival rate was 88.8%, the AFS was 86.6%, and the primary patency was 70.5%. Freedom from MALE was 62.5%. After multivariate analysis, smoking (hazard ratio [HR] = 2.2, P = 0.04), renal failure (HR = 2.3, P = 0.03), Rutherford class (≥5) (HR = 3.2, P = 0.01), and below-the-knee disease (HR = 2.0, P = 0.05) were significant predictors of amputation; iloprost infusion (>10 vials) (HR = 0.64, P = 0.05) was a significant protective factor. Cilostazol administration (HR = 0.77, P = 0.05) was a significant protective factor for restenosis. Results from this prospective multicenter registry offer a consistent overview of clinical outcomes of CLTI patients at 1 year when adequately revascularized. Medical treatment, including statins, cilostazol and iloprost, were associated with improved 1-year freedom from restenosis and amputation.

The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery Guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g. silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are 5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.

The aim of this study was to compare the results of complex aneurysm (hostile neck anatomies) repair in high-risk patients with two minimally invasive techniques, fenestrated endografting (f-EVAR where EVAR stands for endovascular aneurysm repair) and minilaparotomy.All high-risk patients (N.=50, group 1) with hostile neck abdominal aortic aneurysms (AAAs) operated in the vascular surgery department of the "Policlinico Universitario G. Martino" of Messina (Italy) during a 5-year period (January 2006-December 2010) were cross-matched with 50 similar patients (group 2) treated in the Vascular Surgery Department of the "Hopital Cardiologique" University of Lille (France) with similar anatomies, comorbidities and risk factors. The patients in group 1 underwent open minilaparotomy surgery, and the patients in group 2 were treated with f-EVAR. The aim of our study was to compare perioperative complications, survival and reintervention rates.Perioperative cardiac complications occurred in 5 patients (10%) in group 1, and 1 patient (2%) in group 2 (P0.092). Renal impairment not requiring permanent hemodialysis was significantly higher in group 1 (14% vs. 2% P0.027), as well as respiratory complications (32% vs. 2% P0.0001). Five patients (10%) in group 1 underwent reintervention vs. 4 patients in group 2 (P0.7268). There was no statistically significant difference for survival rates at 30 days (92% in group 1 and 96% in group 2; P=0.399); at six months (90% vs. 96%; P=0.239); at one year (90% vs. 96%; P=0.239); and at two years (84% vs. 94%; P=0.110). However, we observed statistically significant differences in survival rates at three years (74% vs. 94%; P0.006); at four years (70% vs. 86%; P0.005); and at five years (65% vs. 68%; P0.003).Our results showed that both techniques are effective in the treatment of AAA with hostile neck in high-risk patients. Although operative mortality rate was not statistically different, f-EVAR showed better results in terms of early complications and late survival.

Brucellosis is a zoonosis, caused by bacteria belonging to the genus Brucella. Aortic involvement is a rare complication, often following embolization from infective endocarditis. However, contiguous propagation from vertebral involvement may occur. We report the case of an 81 year old patient abruptly presenting with aortic rupture due to Brucella melitensis infection. The diagnosis of aortic rupture was made by CT. The patient underwent urgent endovascular treatment using endoprosthesis deployment in the abdominal aorta and iliac arteries. Long term antibiotic treatment was given. Resolution of the acute event was obtained without further surgical treatment. 18 months after endovascular treatment, the patient remains in good health.

Selective shunting during carotid endarterectomy (CEA) is advocated to reduce shunt-related stroke. Cerebral monitoring is essential for temporary carotid shunting. Many techniques are available for cerebral monitoring; however, none is superior to monitoring the patient's neurological status (awake testing) while performing the procedure under local anesthesia (LA). Cerebral oximetry (CO) has previously been used to show the adequacy of cerebral circulation in patients undergoing CEA. This investigation was designed to compare the performance of the INVOS-4100 cerebral oximeter and the neurologic functions, by means of detecting cerebral ischemia induced by carotid cross-clamping, in patients undergoing CEA under LA, namely cervical plexus block.Patients scheduled for CEA under LA were included. Patients converted to general anesthesia (GA) or other types of operations other than CEA were excluded from this study. We enrolled 100 consecutive patients from January 2009 to December 2010. Bilateral regional cerebrovascular oxygen saturation (rSO(2)) was monitored in all patients, in addition to the awake testing. Changes in rSO(2) following carotid artery clamping were recorded. A drop greater than 20% was considered as an indicator of cerebral ischemia that might predict the need for carotid shunting. Patients were only shunted based on the awake testing.Of the 100 patients undergoing CEA under LA, 9 showed a significant drop in rSO(2) (range: 22.6-32.8%, mean: 26.4%): only three of them required shunting, while the remaining 6 had no changes in consciousness after internal carotid artery (ICA) cross-clamping and it was not necessary to place a shunt (false positive). Compared to the preclamping values, a significant decrease in rSO(2) was found on the hemisphere of the operated side, while no significant change was observed contralaterally. Ninety-one patients had no significant changes of CO values: in 89 of them there was no consciousness deterioration, so we didn't place a shunt (true negative), but 2 patients showing a non-significant post-clamping decline in CO saturation (1.5% and 18.2%) required shunting based on the awake testing (2 false negative). In the current study, the median drop in rSO(2) was 19% (range: 1.5-26.4%) in the 5 patients that required shunting. This represents a sensitivity of 60% and a specificity of 25% for CO in comparison to the awake testing.The results of this study suggest that the usefulness of CO in predicting cerebral ischemia is modest. Cerebral monitoring with INVOS-4100 has a high negative predictive value, but the positive predictive value is low.

We suggest an alternative endovascular treatment for gluteal artery aneurysm using Floseal a matrix of bovine gel and thrombin component. A 70-year-old woman, presented with claudicatio of the lower left limb after 150 m walking and pain at the sciatic nerve irradiation. A pulsating and painful mass was present in the lower gluteal region. No history for previous trauma, nor for orthopedic surgery. The suspect of aneurysm of the left gluteal artery was confirmed by Color Doppler Ultrasound and by computed tomography (CT) showing a fusiform aneurysm in the lower gluteus artery. In order to rule out infective cause, blood coltures were taken. Compression of the sciatic nerve was confirmed by electromyography study. Patient was treated by endovascular treatment. We performed angiography, with a selective study of the lower left gluteus artery, and embolization of the aneurysm by an injection of FloSeal (hemostatic) and fibered platinum coil. At the discharge, we observed absence of pulsation in gluteus region and the complete resolution of clinical symptom. The Color Doppler Ultrasound scan showed a complete occlusion of the aneurysm. This case appears quite peculiar, for the absence of any pelvic trauma, orthopedic operations or previous penetrating lesions, responsible of vascular lesions as reported in literature. The large aneurysm dimensions made the embolization procedure quite difficult, and brought us to use FloSeal. The treatment we proposed may be useful in the treatment of peripheral aneurysms of great dimension, and may be an alternative to the more traditional ones.

The objective of this systematic review of the literature is to evaluate whether a laparoscopic operation can be performed on patients with occlusive or abdominal aortic aneurysm as a minimally invasive and durable alternative. For this purpose, the literature was reviewed and laparoscopic surgery results were compared with those of conventional and endovascular surgery. All series were included, even when containing also one case. Operative and clamping times, mortality and morbidity and hospital stay were evaluated. Thirty-five studies were identified about conventional (4), minilaparotomy (4), endovascular (4), total (12) and video-assisted (11) laparoscopic surgery. Operative and clamping times were shorter for video-assisted procedures than total-laparoscopic procedures. The mortality rate ranged from 3% to 4.5% for conventional surgery, from 0% to 3% for endovascular surgery, from 0% to 6% for total-laparoscopic surgery and from 0% to 4.2% for video-assisted laparoscopic surgery. A variable morbidity was described for all techniques, with a higher incidence in total-laparoscopic surgery. Mean hospital stay was similar for laparoscopic surgery procedures. The learning curve of a surgical team performing laparoscopic surgery improves theLaparoscopic abdominal aortic surgery is feasible and may offer good postoperative recovery with excellent mid-term patency. Shorter hospital stay and simple mid-term follow-up allow more comfort for the patient and probably monetary savings for the community. A steep learning curve is needed. For these reasons laparoscopic video-assisted technique can be considered a third means of treating severe occlusive and aortic aneurysm, but only new instruments for performing aortoprosthetic anastomoses can diffuse the total laparoscopic technique as a routine approach.

Leiomyosarcoma of the inferior vena cava (IVC) is a rare tumor that frequently produces non-specific symptoms. Surgical treatment is complex. In this review of our experience, we highlight replacement modalities of the vena cava or other vessels after complete tumor resection.During the last 20 years, we treated 12 patients (6 women and 6 men; age range, 38-72 years) with IVC leiomyosarcoma, all apparently free of distant metastases. Tumor location, graft patency, long-term survival and tumor recurrence were recorded. The tumor arose from the IVC in 8 patients; in 2 cases the intracaval mass reached the right atrium; in 4 patients the tumor arose from the femoroiliac axis. Surgical approach was by sternolaparotomy in 5 cases and by median xyphopubic access in 7. Extracorporeal circulation (ECC) was needed in 2 cases. All tumors were removed by en bloc resection. The IVC was directly sutured in 2 patients and patched in 4; no reconstruction was necessary in 2 patients; the IVC was replaced in the remaining cases. Four patients had an additional arteriovenous fistula. One patient underwent bifurcated Dacron graft replacement of the aortic carrefour involved by tumor.Two patients died postoperatively. One patient developed late stenosis of the polytetrafluoroethylene (PTFE) graft, which was treated by stenting. The mean follow-up period was 35 months. The 4-year survival rate was 51% and survival free of recurrence was 63%.Leiomyosarcoma of the IVC is an uncommon tumor that produces non-specific symptoms. In the absence of distant malignancy, an aggressive approach can obtain late survival free of recurrence.

Management of vascular traumas is frequently delayed. Vascular injuries after elective operation for bone lengthening or correction of a deformity are very'rare situations. We describe 3 cases. Case 1: male, aged 22, undergoing corticotomy for bone lengthening; immediately presented acute limb ischaemia due to a partial lesion of the popliteal artery, documented by U.S. After 7 h, direct reconstruction of the artery and fasciotomies were performed. Case 2: male, aged 27, undergoing directional osteotomy for genu varus correction. For 30 days, constant increase in leg volume and decrease in function. US showed an important haematoma at the popliteal level; arteriography documented a partial lesion of the infra-genicular popliteal artery and a voluminous false aneurysm. Direct correction of the artery and fasciotomies were performed. Case 3: male, aged 22, undergoing corticotomy for leg lengthening; immediately presented leg pain with decreased distal pulses. After 4h, there was an increase in leg volume, and arteriography showed a total lesion of the infra-genicular popliteal artery and an arteriovenous fistula. Popliteo-tibial bypass with the contralateral greater saphenous vein and fasciotomies were performed. After 1 month endovascular closure of the fistula was obtained. All patients had recovered after two months with only minor leg insufficiency. Patency of the bypass and absence of infections or delayed false aneurysms were achieved. Vascular injuries after elective orthopaedic procedures are very rare situations. Such lesions are caused by an osteotomy via corticotomy performed percutaneously. The variety of clinical presentations accounts for the difficulty in diagnosing such lesions and for the delays in implementing treatment. It is very important to obtain an early diagnosis complete with an arteriography.