Multiple thromboembolism with multiple causes in a 69-year-old woman: a case report

<p>Abstract</p> <p>Introduction</p> <p>Aggressive, recurrent embolisms require accurate etiologic diagnosis. We describe the case of a 69-year-old Italian Caucasian woman with recurrent arterial embolisms in whom several sources and triggers of thrombosis were detected.</p> <p>Case presentation</p> <p>The patient, a 69-year-old Italian Caucasian woman, presented with a systemic embolism that was initially attributed to atrial fibrillation. The recurrence of embolisms despite anti-thrombotic therapy prompted a re-evaluation of the clinical presentation. New potential causes of thrombosis emerged in this patient, including thrombocytosis associated with the <it>JAK2 V617F </it>mutation and the very rare mural thrombosis of the descending aorta. A mural thrombus in the pulmonary artery was detected contiguous with the aortic mural thrombosis, raising the possibility of a clinically silent ductus Botalli as the initiating event. The patient was treated with warfarin, aspirin, hydroxyurea, and surgery.</p> <p>Conclusions</p> <p>The diagnosis was achieved via systematic use of imaging procedures and reconsideration of blood tests performed to explore the diagnosis of thrombosis. This allowed a deeper and more detailed analysis of the case beyond the conventional approach, which would have aimed to identify one cause for the condition at hand, in this case, atrial fibrillation. The broader approach that we used resulted in the diagnosis of multiple embolisms from multiple sites and multiple causes.</p

Carotid Artery Diameters, Carotid Endarterectomy Techniques and Restenosis

Background: Restenosis of the carotid artery is a major complication of carotid endarterectomy (CEA). The purpose of this study was to examine the role of CEA techniques on carotid dimensions variation, postoperative versus preoperative multi-segmental diameters and its impact on the development of restenosis at 12 months follow up. Methods: 175 consecutive patients eligible for carotid surgery were included in the study. 75 underwent CEA by patch reconstruction (PR), 53 by eversion (EV) and 47 by primary closure (PC). Before the procedures and at discharge, carotid diameters were measured at four reference points (common carotid, CC; carotid bulb, CB; proximal internal carotid artery, PICA; distal internal carotid artery, DICA) by ultrasonography. The rate of minor (< 50%) and major (≥ 50%) restenosis was evaluated at 12 months follow up. Results: PR produced an increase in all carotid diameters while PC and EV produced a decrease in carotid diameters, having PC affected all diameters while EV affected CB and PICA diameter. However, postoperative diameters had comparable dimension independently of the surgical technique used. The rate of overall and major restenosis did not differ significantly between the three types of surgery. Logistic regression analysis showed that female gender was associated with major restenosis (OR 6.9, 95% CI 1, 23 – 38, 49) irrespective of surgical technique. Conclusion: This study shows that carotid diameters and restenosis rate after CEA are comparable whatever is the surgical technique adopted, and that women are at high risk of major restenosis.Background: Restenosis of the carotid artery is a major complication of carotid endarterectomy (CEA). The purpose of this study was to examine the role of CEA techniques on carotid dimensions variation, postoperative versus preoperative multi-segmental diameters and its impact on the development of restenosis at 12 months follow up. Methods: 175 consecutive patients eligible for carotid surgery were included in the study. 75 underwent CEA by patch reconstruction (PR), 53 by eversion (EV) and 47 by primary closure (PC). Before the procedures and at discharge, carotid diameters were measured at four reference points (common carotid, CC; carotid bulb, CB; proximal internal carotid artery, PICA; distal internal carotid artery, DICA) by ultrasonography. The rate of minor (< 50%) and major (≥ 50%) restenosis was evaluated at 12 months follow up. Results: PR produced an increase in all carotid diameters while PC and EV produced a decrease in carotid diameters, having PC affected all diameter

Surgical treatment of thoracic outlet syndrome: immediate and mid-term results

Introduction: We report the results from a consecutive series of patients treated by scalenectomy or cervical rib resection for clearly symptomatic or paucisymptomatic thoracic outlet syndrome (TOS) over a 6-year period. Material and methods: From September 1999 to August 2005, 14 surgical decompressions were performed in 12 patients with unremitting signs and symptoms of nerve or vascular compression at the thoracic outlet. The symptoms of TOS were due to involvement of the brachial plexus in 8 cases (57.1%). A sign of vascular obstruction could be detected in 10 cases (71.4%): in 6 cases (42.8%) the presentation was predominantly arterial (arm claudication, coldness, Raynaud’s phenomenon and distal embolisation) and in 4 cases (28.5%) was related to vein compression with congestion and swelling of the affected arm or vein thrombosis. Two patients presented as emergencies with critical upper limb ischaemia or distal vessel embolisation. Results: The median follow-up period was 28.2 months (range 8-78 months). Results were evaluated in terms of technical success, lack of complications (temporary or permanent plexus injury, temporary or permanent phrenic palsy), relief of symptoms. Outcome data were divided into immediate/perioperative and mid-term results. Perioperative results: There was no operative mortality. Technical success was achieved in all patients in excision of the fibrous band with scalenectomy and in cervical rib excision. Mid-term results: In 4 patients with venous symptoms complete relief was achieved in 75%. In all patients who experienced arterial complications we registered complete relief. In patients with neurological presentation we detected complete relief in 5 (62.5%), relief of some symptoms in 2 (25%) and no improvement in 1 (12.5%). Conclusions: Scalenectomy performed by a standard supraclavicular approach seems to allow relief in the majority of patients with symptoms of neurological, arterial or venous compression at the thoracic outlet. Nevertheless, we emphasize the importance of an objective method of evaluation and the necessity of a prolonged follow-up. Key words: thoracic outlet syndrome, scalenectomy, cervical rib resection

IL TRATTAMENTO ENDOVASCOLARE DELL’ANEURISMA DELL’AORTA ADDOMINALE: NOSTRA ESPERIENZA ENDOVASCULAR TREATMENT OF ABDOMINAL AORTIC ANEURISMS: OUR EXPERIENCE

Background. This report prospectively analyzes collected data of endovascular treatment of abdominal aortic aneurysms in 114 patients selected to receive stent implantation based on anatomic criteria and surgical risk. Methods. From December 2002 to May 2006, 114 patients with abdominal aortic aneurism receive endovascular treatment. 108 were men (94,7%) and 6 female; age range was 57-86 years with mean age of 73.3. The mean maximum diameter of the AAA was 5.71 cm (range 3.7- 13.0). Three different types of stents were used most of which were bifurcated in design (97,3%). Endograft used were: Excluder, Talent; Zenith-Cook. Results. No perioperative mortality was observed; 5 (4,3%) type I and 11 (9,6%) type II endoleak were detected; Iliac extension with exclusion of the internal iliac artery was required in 27 cases. We observed 2 right branch, 2 iliac lesions, 2 ematoma and 1 distal vessels embolization surgically treated Mean follow-up period was 18,6 months. 17 patients died during follow-up. 11 endoleak were discovered during follow-up and in 3 cases thrombosis of a branch occurred. Mean aneurysm diameter, neck diameter, iliac or hypogastric diameter or the clinical characteristics showed no statistical significant differences among the three group (on the results). In each group influence of aneurysm and neck morphology and diameter on type I or II endoleak was analyzed but no statistical significant differences were detected among the three groups except for type-II endoleak in the Talent group that was registered in 100% of no mural thrombus – aneurysms (p<0,05). Conclusions. Together with aneurysm sac growth andbranch vessels’ patency, structural failures continues to be a challenging problem. As long as no solution will be find out for them endovascular aneurysm repair will remain an imperfect long-term treatment and continued follow-up will be mandatory. Key words: Aortic aneurysm, Aortic surgery, Endovascular treatment