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Purpose: Abdominal aortic aneurysm (AAA) accompanied by common iliac artery (CIA) aneurysms requires a more demanding procedure owing to the difficulties in obtaining an adequate distal landing zone for the stent-graft limb(s), a potential site of endoleak. The "sandwich technique" is a procedure to increase EVAR feasibility in the setting of adverse or challenging CIA anatomy. Its main advantages include no restrictions in terms of CIA diameter or length or internal iliac artery (IIA) diameter, no need to wait for a specific stent-graft. Our purpose is to describe our single-center experience and one year follow-up results of this new procedure. Materials and Methods: From April 2009 to June 2010, the sandwich technique was performed in our institution in 7 patients treated for AAA and unilateral CIA aneurysms (n. 5) or bilateral CIA aneurysms (n. 2). Inclusion criteria were the presence of unilateral or bilateral CIA aneurysm (independently from its diameter), IIA artery measuring up to 9 mm in its maximum diameter, not dilatation of IIA and EIA. Results: The mean follow-up length was 15 months (range: 14-20 months). All stent-implanted iliac branches remained patent on 1 year follow-up and IIA flow was preserved. None of the patients had symptoms of pelvic ischemia. CT scan follow-up showed aneurysm shrinkage in five patients, without any sign of endoleaks in all cases. Conclusions: In selected cases, the "sandwich technique" showed good outcomes confirming to be a safe and easy to perform way to overcome anatomical constraints and expanding the limits of EVAR. [ABSTRACT FROM AUTHOR]

"Complexity sciences" are an interdisciplinary and transnational domain of study that aims at modeling natural and social "complex systems." They appeared in the 1970s in Europe and the United States, but were boosted in the mid-1980s by the Santa Fe Institute (SFI) under the formula of "science of complexity." This small but famous institution is the object of the present article. According to their promissory ambitions and to the enthusiastic claims of some scientific journalists, complexity sciences were going to revolutionize all of knowledge and even private and public actors who had learned to master them. In the light of this, one would expect to observe a well-established and autonomous research and educational field, capable of reproducing itself through professional institutions. Yet this is not the case. To explain the paradox, I propose to combine different models of history and sociology of emergent and declining domains, in order to give account of the rise and failure of complexity sciences.

Endovascular aneurysm repair (EVAR) offers a minimally invasive treatment to patients with improved short-term and similar mid-term results compared to conventional, open repair. Approximately 20% of patients have an aneurysm neck morphology inadequate for a standard stent-graft and requires an endograft to cross vital aortic side branches to achieve a seal. This work describes the promising single center preliminary results in the management of juxtarenal aortic aneurysm using E-vita stent-graft.

An innovative approach, the JAG tearing technique, was performed during thoracic endovascular aneurysm repair in a patient with previous surgical replacement of the ascending aorta with a residual uncomplicated type B aortic dissection who developed an aneurysm of the descending thoracic aorta with its lumen divided in two parts by an intimal flap. The proximal landing zone was suitable to place a thoracic stent graft. The distal landing zone was created by cutting the intimal flap in the distal third of the descending thoracic aorta with a radiofrequency guide wire and intravascular ultrasound catheter.

Introduction: Iatrogenic ureteral lesions are well-known complications of abdominal and pelvic surgery. A combined radiologic-urologic approach might be necessary to repair these lesions., Materials and Methods: A 69-year-old woman underwent bilateral hysteroannessectomy for endometrial cancer. She then became anuric. A CT scan showed multiple urinomas caused by bilateral ureteral lesions. The continuity of the two urinary tracts was restored using ureteral stents in a combined urologic and radiologic procedure., Results: The patient improved clinically and the renal function returned within normal limits., Conclusions: The combined antegrade-retrograde approach is an effective technique to solve iatrogenic ureteral lesions.

Aim of Study: To evaluate the feasibility of ipilimumab treatment for metastatic melanoma outside the boundaries of clinical trials, in a setting similar to that of daily practice., Methods: Ipilimumab was available upon physician request in the Expanded Access Programme for patients with life-threatening, unresectable stage III/IV melanoma who failed or did not tolerate previous treatments and for whom no therapeutic option was available. Induction treatment with ipilimumab 10 mg/kg was administered intravenously every 3 weeks, for a total of 4 doses, with maintenance doses every 12 weeks based on physicians' discretion and clinical judgment. Tumors were assessed at baseline, Week 12, and every 12 weeks thereafter per mWHO response criteria, and clinical response was scored as complete response (CR), partial response (PR), stable disease (SD), or progressive disease. Durable disease control (DC) was defined as SD at least 24 weeks from the first dose, CR, or PR., Results: Disease control rate at 24 and 60 weeks was 29.6% and 15%, respectively. Median overall survival at a median follow-up of 8.5 months was 9 months. The 1- and 2-year survival rates were 34.8% and 23.5%, respectively. Changes in lymphocyte count slope and absolute number during ipilimumab treatment appear to correlate with clinical response and survival, respectively. Adverse events were predominantly immune related, manageable, and generally reversible. One patient died from pancytopenia, considered possibly treatment related., Conclusion: Ipilimumab was a feasible treatment for malignant melanoma in heavily pretreated, progressing patients. A sizeable proportion of patients experienced durable DC, including benefits to long-term survival.

Endovascular aneurysm repair (EVAR) is a minimally invasive treatment that can be offered to most patients with an aortic aneurysm. Patients who are rejected from standard EVAR often have more extensive aortic pathology and more medical comorbidities. The advent of fenestrated and branched stent grafts gives us an opportunity to treat the most demanding aortic aneurysms endovascularly. Fenestrated stent-grafts, however, are costly and time-consuming to manufacture, which limits their applicability, especially in the emergency setting. The chimney graft is a stent placed parallel to the aortic stent-graft to preserve flow to a vital aortic branch that was overstented to obtain an adequate seal. The technique can be used as a planned operation but also as a rescue procedure to salvage a side branch unintentionally covered during EVAR. As visceral branches of the aorta are usually directed caudally these vessels are, therefore, preferably catheterized from a brachial approach. We describe a case of a successful positioning of the chimney graft using only the femoral approach. The only femoral approach to position a renal chimney graft isn't recommended for the routine procedure but it is proved to be useful in selected case and when other treatment options are excluded.

Aim of the Study: Oncological patients are particularly prone to the onset of septic complications such as abdominal abscesses. The aim of our study was to analyze clinical and microbiological data in a population of oncological patients, submitted to percutaneous ultrasound-guided drainage (PUD) for postoperative abdominal abscesses., Patients and Methods: Data from 24 patients operated on for neoplastic pathologies and treated with PUD for abdominal abscesses during the postoperative period were reviewed. In all cases cultural examination with antibiogram was performed., Results: In 5 out of 24 patients (20.8%), the abdominal abscesses appeared after the discharge, with a mean hospital stay of 34.2 +/- 24.9 days. In six out of 24 patients (25%) there were multiple abscesses localizations. The cultural examination was positive in 23 patients and negative only in one patient. Abscesses localized only in the upper abdominal regions had a significant prevalence of monomicrobial cultural examinations (57.1%) with respect to the results for abscesses placed in the lower abdominal regions, that were polymicrobial in 88.8% of cases (p = 0.027). An antibiogram demonstrated a stronger activity of beta-lactamines, chinolones, and glycopeptides with respect to aminogycosides, cephalosporins, and metronidazole., Conclusions: In oncological patients, the planning of the empiric antibiotic therapy should be based on the anatomotopographic localization of the abdominal abscess and on the typology of the operation performed giving preference to beta-lactamines, chinolones and glycopeptides.

Abdominal abscesses arising postoperatively constitute a serious problem, particularly in the field of oncological surgery. The aim of our study was to interpret clinical and microbiological data relating to a population of oncological patients, undergoing ultrasound-guided drainage for postoperative abdominal abscesses, so as to be able to better plan empiric antibiotic therapy. We therefore retrospectively analysed the data of 24 patients operated on for neoplastic pathologies and treated with ultrasound-guided percutaneous drainage for abdominal abscesses during the postoperative period. Microbiological and clinical data showed that abscesses located in the lower abdominal regions almost always present a polymicrobial growth, though abscesses in the upper regions are more frequent. Moreover, the antibiotic assay results prompted us to consider the use of beta-lactamines, quinolones and glycopeptides more favourably, in view of their greater efficacy against the microbes tested. Thus, the planning of empiric antibiotic therapy should be based above all on the anatomical-topographic location of the abdominal abscess and on the type of operation performed, with thorough assessment of the use of the above-mentioned antibiotics.

Background: Recent years have witnessed a rapid and continuous evolution in the diagnosis of biliary obstructive disease. Traditional methodologies, such as US (ultrasonography), CT (computed tomography), ERCP (endoscopic retrograde cholangiopancreatography) and PTC (percutaneous transhepatic cholangiography), have been supplemented by MRCP (magnetic resonance cholagiopancreatography) and CCT (cholangio computed tomography) The purpose of our study was to compare the reliability of diagnostic US, MR and other imaging techniques in intrinsic biliary obstructive disease., Material/methods: Between June 1999 and July 2003 we conducted a prospective study on 131 patients--60 males and 71 females--ranging in age from 37 to 79 years, with clinical features of biliary obstructive disease. Imaging studies were done on each patient using several different techniques. The US, MRCP, CCT and ERCP results were read by radiologists blinded to other imaging findings., Results: US is generally accurate in diagnostic imaging of obstructive biliary disease. MRCP and CCT are significantly more accurate only in completing the staging of malignant stenosis., Conclusions: If the suspicion posed by clinical and laboratory findings is not confirmed at US, the diagnosis must be achieved with the aid of MRCP or--where MRCP does not provide a diagnosis--CCT, so as to select candidates for therapeutic ERCP, PTC or surgery. If laboratory and clinical findings are supported by US, ERCP is required for therapeutic purposes, or--if necessary--surgery is performed.

The aim of this study was to compare the diagnostic reliability of US with MR arthrography in diagnosing supraspinatus tendon tears. Surgical findings were used as the gold standard in detecting tears. A total of 44 patients were assessed with transverse and longitudinal US scans with respect to the long axis of the rotator cuff tendons and then examined with MR arthrography. This technique involved free-hand injection of contrast medium into the shoulder joint. At surgery 20 incomplete and 24 complete tears were observed. Ultrasound offered good results for the large tears, but its sensitivity decreased proportionally with the size of the tears. Magnetic resonance arthrography correctly diagnosed 43 tears, whereas only one false-negative diagnosis of tendinosis was made for a partial tear on the bursal side. Since it improves the diagnosis of small tears, MR arthrography must be performed on all patients for whom surgical repair is necessary in order to restore normal functions.

Purpose: We investigated the usefulness of a mechanical stress device to increase widening of the articular rima in CT studies of the meniscus on forced varus and valgus., Material and Methods: September 1997 to October 1998, we examined 284 patients with symptoms and clinical signs of meniscal injury. CT was performed during forced varus and valgus, depending on the site of the suspected damage, in 70 of 284 patients. We used an FOV of 18 cm, with a potential difference of 140 kVp and power of 170 mA. The reconstruction matrix was 512 x 512 and acquisition time was 3 s. A set of 8-10 partially overlapping scans were acquired craniocaudally, with slice thickness of 1.5 mm and gap of 1 mm. The mechanical strainer was locked in the correct position and a second set of 4-5 images acquired at the meniscus. Then the patients were submitted to arthroscopy to check the radiological findings., Results: CT performed in forced varus and valgus had 96.8% specificity, 97.3% sensitivity and 97.1% diagnostic accuracy. Sensitivity was 100%, specificity 96% and diagnostic accuracy 98% in the medial meniscus, while we had 88.9%, 100% and 94.7% respectively in the external meniscus., Conclusions: CT with a mechanical stress device was extremely useful in defining the meniscal loose edge. It also showed the exact shape and complexity of meniscal injury, even in the cases with narrow articular rima or those where conventional CT had performed poorly.