Search

Objective: Static 3-dimensional (3D) printing became attractive for operative planning in cases that involve difficult anatomy. An interactive (low cost, fast) 3D print allowing deliberate surgical practice can be used to improve interventional simulation and planning. Background: Endovascular treatment of complex aortic aneurysms is technically challenging, especially in case of narrow aortic lumen or significant aortic angulation (hostile anatomy). The risk of complications such as graft kinking and target vessel occlusion is difficult to assess based solely on traditional software measuring methods and remain highly dependent on surgeon skills and expertise. Methods: A patient with juxtarenal AAA with hostile anatomy had a 3-dimensional printed model constructed preoperatively according to computed tomography images. Endovascular graft implantation in the 3D printed aorta with a standard T-Branch Cook (Cook® Medical, Bloomington, IN, USA) was performed preoperatively in the simulation laboratory enabling optimized feasibility, surgical planning and intraoperative decision making. Results: The 3D printed aortic model proved to be radio-opaque and allowed simulation of branched endovascular aortic repair (BREVAR). The assessment of intervention feasibility, as well as optimal branch position and orientation was found to be useful for surgeon confidence and the actual intervention in the patient. There was a remarkable agreement between the 3D printed model and both CT and X-ray angiographic images. Although the technical success was achieved as planned, a previously deployed renal stent caused unexpected difficulty in advancing the renal stent, which was not observed in the 3D model simulation. Conclusion: The 3D printed aortic models can be useful for determining feasibility, optimizing planning and intraoperative decision making in hostile anatomy improving the outcome. Despite already offering satisfying accuracy at present, further advancements could enhance the 3D model capability to replicate minor anatomical deformities and variations in tissue density. [ABSTRACT FROM AUTHOR]

Objective: Subclavian artery aneurysms (SAA) are rare and usually involve the proximal segment of the artery. In this setting traditional surgical treatment or hybrid procedures are associated with significative morbidity rate so that new endovascular solutions are preferred. Methods: Authors report a case of a patient with an intrathoracic left SAA involving the aortic arch's outer curve. Patient's comorbidities contraindicated open surgical treatment while anatomical issues were not favourable to hybrid or standard endovascular solutions. Thus a single-branched custom-made thoracic stent-graft (Castor, MicroPort Medical, Shanghai, China) was implanted. Results: Technical success was achieved with no intra-operative complications and technical steps of the procedure are accurately described. A pre-discharge CT scan showed the correct position of the endograft, complete aneurysm exclusion and branch patency. Conclusion: Single-branched thoracic stentgrafts could be a good option in unfavourable anatomies with supra-aortic vessels disease involving the aortic arch, with good results in terms of morbidity and early outcomes. [ABSTRACT FROM AUTHOR]

Purpose: We describe the feasibility and early results of iliac stenting using a physician-modified endograft (PMEG) to preserve a transplant renal artery in patient with iliac occlusive disease. Case Report: A 70-year-old male patient, with sub-occlusive left common iliac artery stenosis at the level of the transplanted kidney arterial anastomosis, presented with left critical limb ischemia (CLI) and pseudo-transplant renal artery stenosis (pseudo-TRAS) symptoms. He was treated with a physician-modified fenestrated covered stent introduced percutaneously via ipsilateral femoral artery after failure of simple angioplasty (percutaneous transluminal angioplasty, PTA). The modified graft was created by performing a square fenestration graftotomy on a Medtronic iliac limb stent graft (Medtronic Cardiovascular, Santa Rosa, CA, USA). The procedure was technically successful with no intraoperative complications. Procedural time was 110 minutes, including 35 minutes for device modification. On short-term follow-up, the patient had early improvement of renal function and resolution of CLI. The iliac and transplant renal artery remained patent with no sign of stent migration or kinking on 6 months surveillance computed tomography angiography and 1 year color Doppler ultrasonography. Conclusion: Use of PMEG to preserve visceral branches in occlusive iliac disease is a feasible endovascular technique with encouraging technical success and satisfying early results. [ABSTRACT FROM AUTHOR]

Objectives: Endovascular procedures are now the standard of care for endovascular aortic aneurysm repair but treatment of hostile proximal neck anatomy is still challenging. New endografts were brought to the market specifically designed to accommodate severe neck angulation. Authors describe a preliminary experience and early results using the Gore Excluder Conformable endograft (W. L. Gore & Associates, Flagstaff, Ariz) and its active control system in severe neck angulation with a standardized technical approach to achieve precise deployment in this hostile anatomy.Methods: From June 2019 to May 2020, five patients with abdominal aortic aneurysm and severe neck angulation (≥70°) were treated with the Gore Excluder Conformable endograft at two different centers. Deployment of this endograft in this kind of anatomy should be aggressive starting over the level of renal arteries due to risk of distal migration downward on the external curvature and difficulty in upward repositioning. Authors suggested a standard technique with a routine through-and-through axillary-femoral approach, using a floppy guidewire together with preventive cannulation of the lower renal artery if a short neck (<15 mm) is associated.Results: Endovascular aortic procedures were successfully completed in all patients. Final deployment of the stent graft using our standardized technical approach was extremely precise in all cases even if redeployment of the graft was necessary in all cases. No other secondary procedures were needed. At 30 days, no type IA endoleak was recorded and no aneurysm-related secondary procedures were performed. Median follow-up for this group of patients was 5.2 months (range 1-11). Early results revealed no type IA endoleak and no migration at Ct angiogram. No aneurysm-related secondary procedures were required.Conclusion: Routine use of through-and-through axillary-femoral guidewire associated with selective pre-cannulation of the lower renal artery allows a precise deployment of the Gore Excluder Conformable endograft in difficult anatomies possibly affecting early outcomes. [ABSTRACT FROM AUTHOR]

Objective: To find out the extent of involvement of the para-aortic nodes in patients with adenocarcinoma of the gastric cardia. Design: Open prospective study. Setting: Teaching hospital, Italy. Subjects: 23 patients with advanced adenocarcinoma of the cardia (type II, n = 10, and type III, n = 13) who were treated by total gastrectomy with resection of the distal oesophagus and extended lymphadenectomy (D4) between January 1997 and June 1999. These were compared with 21 patients with advanced carcinoma of the proximal third of the stomach who had total gastrectomy with D4 lymphadenectomy during the same period. Lymph nodes were retrieved immediately postoperatively and assigned to the appropriate station according to the classification of the Japanese Research Society for Gastric Cancer. Main outcome measures: Number of para-aortic and other nodes involved. Results: 22 of the 23 patients had lymph node metastases, and in 5 the para-aortic nodes were involved (N4). N3 lymph nodes were involved in only 1 patient, despite involvement of para-aortic nodes. Among the 5 patients with N4 metastases, 1 had only N1 metastases in addition, with no involvement of N2 or N3 nodes. Patients with involved N4 nodes had more nodes involved overall than those who did not (mean (SD) 17 (5) compared with 8 (12)). Conclusions: 5/23 patients with advanced carcinoma of the cardia had involved para-aortic nodes. This may have some prognostic value, but larger studies of D4 lymphadenectomy specimens is required. [ABSTRACT FROM AUTHOR]

Primary aortoduodenal fistula is a serious and rare complication of abdominal aortic aneurysms. This life-threatening disease results most commonly from an abdominal aortic aneurysm, with the fistula forming between the aorta and the third or the fourth portions of the duodenum. Diagnosis is often difficult and urgent adequate surgical treatment as soon as possible is the only therapeutic option to save the lives of these patients. In this paper we report the case of a 76-year-old female admitted to our institution for massive haematemesis, melaena, severe hypotension and violent back pain. The urgent diagnostic work-up revealed an abdominal aortic aneurysm with a strong suspicion of duodenal fistulisation. The diagnosis was confirmed in the operating room, where the patient was immediately submitted to closure of the fistula and in situ aortic reconstruction using an aortic homograft. The postoperative course was uneventful and after 6 months the patient is doing well without any recurrence of infection.

The association between abdominal aortic aneurysms (AAA) and cancer is becoming more and more frequent, giving rise to several questions regarding the therapeutic and surgical management strategies for both diseases. Endovascular aneurysm repair (EVAR) is the treatment of choice for complex and high-risk patients. In this study we reviewed our experience with patients concomitantly affected by any type of cancer and AAA treated by EVAR at our institution over the last six years. From April 2001 to July 2007, 497 AAA patients underwent open or endografting repair in the 1st Division of General Surgery--Service of Vascular Surgery of the University of Verona. In 53 cases (10.6%) an association with a solid neoplasm was found and 27 of these patients (50.9%) were treated by EVAR. Twenty patients underwent a two-stage approach, with EVAR performed first, while in 5 cases a one-stage approach was preferred on the basis of the general condition of the patients, the site of the tumour to be resected, the logistic possibilities and increased experience of the operators with EVAR. Two patients received chemotherapy after EVAR. There was no in-hospital mortality and four perioperative complications (14.8%) were registered. During a mean follow-up of 25.7 months (range: 2-64 months) 5 deaths occurred, 2 in the short term and 3 in the long term, none of which were related to AAA treatment. Three type-2 endoleaks occurred that sealed spontaneously and 62.9% of the treated aneurysms had a mean 20% decrease in diameter while the others presented no variations. In our experience, EVAR was a safe and effective treatment of AAA patients with concomitant malignancies with a relatively low procedure-related morbidity and no mortality. A simultaneous surgical approach can be achieved safely, performing EVAR as the first step without significant risks. Simultaneous treatment has the advantage of avoiding a second major procedure and eliminates the risk of aortic aneurysm rupture in the postoperative period or during chemotherapy in patients who are usually in poor general condition. Care must be taken with regard to the choice of the device to be used and the possible vascular complications of the visceral circulation. In our opinion, EVAR should be considered the treatment of choice in these patients, taking into account, however, that this treatment is not always feasible in all cases and that in patients with a normal life-expectancy (tumour-cured) it may not always be the right choice. Thus, a multidisciplinary approach is necessary in the individual evaluation of these challenging patients in order to make the right decisions.

Background/aims: There are great controversies regarding the surgical management of abdominal aortic aneurysm (AAA) with coexistent gastrointestinal cancers. The aim of this study was to report our experience of AAA with concomitant gastric cancer and to compare our results with the literature., Methodology: From January 1988 to December 2002, six patients with simultaneous diagnosis of AAA and gastric cancer were operated on at the First Department of General Surgery, University of Verona, Italy. The study was completed with the review of the literature data collected by Medline search., Results: The surgical treatment of the cases observed at our Institution, 2 treated by a staged procedure, 2 by synchronous surgery and 2 in which the AAA remained untreated due to the evidence of metastatic disease at laparotomy, were described. Furthermore 47 cases, previously described in literature, 21 who underwent staged surgery, 23 with a synchronous procedure and 3 in which the treatment was limited to the tumor were analyzed., Conclusions: 1) Synchronous treatment of AAA and gastric cancer is feasible, 2) it can be done with an adequate extent of gastric resection and nodal dissection in the majority of cases, 3) it has a complications rate comparable to the staged procedure.

Humeral neck fracture is rarely associated with injury of the nearby axillary artery and in the English literature only 29 such cases have been reported. An injury of the distal axillary artery secondary to reduction and fixation of a humeral neck fracture is a very rare and unusual complication, to the best of our knowledge has never been reported in literature. In this paper we report the case of entrapment of the distal axillary artery in the humerus rhyme fracture in a 9-year-old child who suffered a nighttime car-accident with her father. At admission, the child presented a left humeral neck fracture with no other lesions and no neurologic problems in her limb; peripheral pulses present in her left hand at palpation. After closed reduction and pinning of the fracture with 2 K-wires, the left upper limb became ischemic and pulseless and the child was transferred at our Institution for diagnosis and treatment. In this paper we discuss the treatment to be adopted in this very unusual situation.

Treatment of femoral artery pseudoaneurysms includes US-guided compression, endovascular coil embolisation or stenting, thrombin injection and open surgical repair. Thrombin injection is currently the standard approach to all non-complicated pseudoaneurysms of the peripheral arteries. Between January 2001 and December 2004, 59 pseudoaneurysms of the femoral artery were submitted to percutaneous US-guided thrombin injection in our surgery division. Complicated pseudoaneurysms, patients in whom percutaneous treatment failed, and chronic pseudoaneurysms with large necks were excluded from this kind of treatment and underwent surgical repair. Eighteen patients were on therapeutic anticoagulation (30.5%) and none of the pseudoaneurysms had an associated arteriovenous fistula. All patients were submitted to clinical and ultrasound follow-up at 24 hours and at 1, 6 and 12 months, and thereafter at yearly intervals for evaluation of recurrences. The thrombin injection was successful in 57/59 patients (96.6%) while two patients (3.4%) were submitted to surgical treatment after failure of the procedure. In 1 patient (1.7%) an additional injection was necessary to achieve complete thrombosis of the pseudoaneurysm. No complications occurred; none of the patients reported discomfort and there was no request for sedation. No recurrences were seen at follow-up. Nowadays US-guided percutaneous thrombin injection is the treatment of choice for femoral artery pseudoaneurysms. Surgical treatment is reserved to rare selected cases. More studies are necessary to evaluate further indications for treatment of visceral or small distal artery pseudoaneurysms.

At present, the standard management of subclavian artery aneurysms is surgical repair. Endovascular treatment of these aneurysms with implantation of a covered stent graft is a relatively new technique that appears to be both feasible and safe. We present the case of a large true aneurysm of the left intrathoracic subclavian artery that was successfully treated with two stent grafts on March 2001. A one-year follow-up CT scan revealed a type 1 secondary endoleak that was successfully treated with a third stent graft. The patient was closely monitored with CT scans that 32 months later confirmed both the patency of the graft and the complete exclusion of the aneurysm, which had decreased in size. At this moment, this is the only case reported in the literature with such a long follow-up but further long-term clinical results will be necessary to fully define the effectiveness of this technique.

Acute cholecystitis is one of the most frequent causes of admissions to surgical departments. The development of liver abscesses is an uncommon and underrated complication of acute cholecystitis. In this study we report on our experience with the treatment of 5 cases of liver abscesses secondary to acute cholecystitis. All 5 cases were characterised by a lengthy period between the onset of acute cholecystitis symptoms and the subsequent diagnosis of a secondary liver abscess. In 4 out of 5 patients, admission for liver abscess occurred 12, 30, 50 and 120 days, respectively, after the acute cholecystitis episode. The liver abscesses were successfully treated with percutaneous drainage under US guidance (4 cases) and 4 patients underwent percutaneous cholecystostomy to treat the acute cholecystitis. After resolution of the acute phase, an elective cholecystectomy was performed in 4 out of 5 cases. Failure to diagnose acute cholecystitis at onset or inappropriate treatment of the condition could lead to the development of liver abscesses.