Spread of SARS-CoV-2 (COVID-19) in a High-Volume Hospital: Vascular Surgery Impact

Increasing population rates of coronavirus disease 2019 (COVID-19) are occurring in several countries and continents. The impact regarding vascular activity, consequences and complication is scarce and makes the future perspective unclear. The aim of this report is to describe the changes in a high-volume University Hospital, relevant for future decisions. The mortality and morbidity should be higher not only in COVID+ patients but also in vascular patients

The Use Of Selective Filtration Of Monocytes From Peripheral Blood In Patients With Vascular Ulcers Promotes Healing. A Pilot Study In A High Volume Vascular Surgery Centre

Introduction: Monocytes have a documented action to promote the healing of trophic lesions through the regenerative action of the transformation of M1 macrophages into M2 macrophages, with multilineage potential comparable to that of mesenchymal stem cells (MSC). Patients affected by peripheral artery disease in Rutherford 5 and 6 stage may be considered suitable. The monocytes can be harvested from peripheral venous blood and injected both in peri-arterial leg areas and in ulcerative lesions. Methods: From 2015 to 2018, 200 procedures were performed in our centre for obstructive arterial disease of the lower limbs, causing PAD. Twelve (12) patients were considered non-revascularisable (5.5%). This was a first therapeutic approach in 7/12 (58.3%), while it was proposed as a therapeutic alternative in patients already subjected to previous operations and / or revascularisation attempts in 5 (41.6%). Demographic and clinical features are collected. An informed consent was obtained in all patients. In 72.5% three or four cycles were performed. All patients followed post-operative medical therapies and adjuvant medications during the months following treatment. Results: Comorbidities included hypertension in 91%, CRC in 63%, dyslipidaemia in 90%, cardiopathy in 72%, COPD in 63%, diabetes in 20%, smoking in 55% (of which 50% ex-smokers) at median follow up of 18 months DS (+/- 7 months) the survival rate was 81.8% (ES 0,11) the limbs savage was 51.1% (ES 0,15). Amputation rate was respectively: minor 45.5% and major 9%. Considering minor amputation as a limb salvage, this percentage increased to 83.4%. Four deaths unrelated to therapy were observed. The pain with VAS score measurement varied from reduction in 36.3% to disappearance in 27.2%. Data regarding TCp02 has increased : a post-operative median level in the examined patients was 24.8 mmHg T2. Conclusion: The filtration procedure with mononuclear cells is safe and must be applied selectively. In high volume centres it is possible to evaluate candidate patients for this type of intervention. Additional procedures must be associated to complete the therapeutic procedure. Due to the increasing complexity and comorbidity of patients, careful selection is required; a multidisciplinary approach and accurate patient follow up is needed. Multicentre studies with multiple cases are needed to validate the Results

Pulmonary embolism: Successful treatment of floating thrombus in SFJ after vena cava filter insertion and surgical thrombectomy

The floating venous thrombus in the common femoral vein has a high potential risk for pulmonary embolization. Clinical treatments, using anticoagulants or fibrinolytic, open thrombectomies, or thrombectomies by endovascular devices have all been used. Our case describe an obese patient affected by floating thrombus coming from GSV and diving in comm

An unusual complication after endovascular aneurysm repair for giant abdominal aortic aneurysm with aortocaval fistula: High bilirubin levels

Abdominal aortic aneurysm has among its rare complications the aortocaval fistula. It is observed in less than 1% of all abdominal aortic aneurysms and represents 3%–7% of clinical presentation in case of rupture. A male patient was presented to the emergency department with pulsating mass with continuous vascular systo-diastolic bruit, located in the lower part of abdomen with the back pain radiating anteriorly in lower abdomen. After diagnosis of abdominal aortic aneurysm with aortocaval fistula, a trimodular Endurant endograft was placed. Migration of the endoprosthesis was treated with Endoanchor and endovascular aneurysm sealing device. In the postoperative course, the patient had jaundice due to high bilirubin levels, cholestasis and increased hepatocyte cytolysis: aspartate aminotransferase and alanine aminotransferase. The treatment with appropriate continuous filtration rapidly reduced bilirubin values and the patient gradually improved

Cervical manipulation and cerebrovascular ischemia. A rare but dangerous association. Monocentric experience in a high CEA volume center and literature review.

Abstract Background: A correlation between stroke and cervical manipulation in the neck is reported in the literature with increasing frequency, and each new publication seems to rekindle the debate. The manipulations in the cervical region is potentially dangerous for arterial vessels. The aim of this work is to analyze the incidence of these events in the experience of a center with high volume surgery, in which emergency interventions are performed for acute cerebrovascular Ischemia. Methods: Data were collected regarding patients undergoing carotid endarterectomy surgery for neurological symptoms of cerebrovascular insufficiency over a seven-year period. Results: The intervention was conducted urgently in 66 cases for acute symptoms (7.6%) with a median symptom interval / CEA: 39.4 ± 5.4 h) in 32 cases for hemispheric transient ischemic attack, while in 34 for minor stroke. Only in 1 case (1.5%) did a condition of severe spondyloarthrosis of the cervical spine occur in acute carotid plaque in C4-C5. In another case (1.5%) a cervical trauma caused by beatings is documented. Conclusions: Manipulations of the neck and cervical spine can rarely cause or contribute to worsening neurological symptoms, however they should always be considered

Successful conversion strategy in patient submitted to EVAR demanding open surgery: comparative analysis 1997-2011 vs 2012-2020

: Late open conversion in our center has been reviewed in the past 8 years, comparing 1997-2011 (first period group A) with 2012-2020 (second period group B). A retrospective analysis of patients treated at our centre by standard EVAR for infrarenal aortic aneurysm requiring late open conversion between January 1997 and February 2020 was performed. All stent grafts were implanted according to their current IFU all patients. The data concerning intra and postoperative complications were collected. Post-operative evaluated data include: ICU (Intensive Care Unit) stay, major peri-operative (<30 days) complications, in hospital mortality, length of hospital stay, 30-days mortality, and mid-term outcomes. Between January 2012 and February 2020 (group B), in our institution 8 patients previously treated by stent graft with endoleak underwent open surgery. The incidence of conversions and the 30-day mortality rate were compared with that of previous years, from January 1997 to December 2011 (group A). 481 patients submitted to EVAR in a second part of the analysis have been considered, 8 patients underwent late open conversion (1.7%) (Group B) due to endoleak. Among January 1997 and December 2011 overall 268 EVAR were performed; during this first study period, surgical conversion had been performed in 14 patients (5.2%) (Group A). The average time from EVAR to open conversion was four years (range 12-88 months) in Group B, and it was 30 months (range 1-82 months) in Group A. In most cases, in both group A and group B the proximal aortic cross-clamping were infrarenal. After the emergent procedure in Group B (12.5%), we have observed a death, whereas three patients died in Group A in urgent situations (21.4%). The more frequent indication for open surgery is the Endoleak type 1 and migration in the two considered periods. Adherence with current IFU and the technical progress in endoprosthesis design maintain lower rate incidence. In most cases, open surgery for prostheses that require explantation can be performed with infrarenal clamping. Partial removal of the endoprosthesis in selected cases makes open conversion easier and appears durable. The results are unfair by numerous comorbidities; in both periods, urgent graft removal seems to elevate both mortality and morbidity, compared to elective surgery

Endovascular Management of Juxtarenal and Pararenal Abdominal Aortic Aneurysms: Role of Chimney Technique

The use of chimney technique in endovascular repair of abdominal aortic aneurysms (ChEVAR) has had a secondary role. Although it was first developed in an emergent/urgent setting, the publication of various important studies has helped overcome scepticism towards this technique in elective procedures. This paper reviews current evidence about ChEVAR, focusing on clinical results, technical notes and comparisons with other techniques. The new ChEVAR findings show favourable mid- and long-term clinical outcomes, even in elective patients. These results, comparable to those related to fenestrated endografts, have been achieved through standardisation in planning and materials. An adequate endograft oversizing associated to the right aortic neck length is fundamental to avoid ChEVAR-related complications, such as type 1a endoleaks. These data indicate that ChEVAR, compared to other complex endovascular treatments, has comparable outcomes along with features that could make it an essential option in every clinical setting

Ischemic stroke and floating thrombosis in dissection of the common carotid artery in patient at third week of pregnancy: Surgical technical success and maintenance of pregnancy

Thrombosis, especially in pregnancy, is due to a prothrombotic state and involves the venous system. Localization in an arterial segment is rare. Floating carotid arterial thrombosis is a very rare occurrence, but it is very devastating. The authors report the case of a pregnant patient in whom are associated a thrombotic predisposition and a traumatic event of the neck which resulted in a limited dissection and a floating thrombosis of the common carotid artery. The onset was characterized by sudden neurological deficits, including numbness of the right-hand fingers and right limb weakness, which regressed after admission. The patient underwent a surgical operation with success. Her pregnancy continued, and an ultrasound scan 12 months later confirmed the patency of the prosthesis, in the absence of neurological symptoms. Hormonal changes may reveal the condition of thrombophilia, which, however, occurs more frequently in the venous system and is a condition related to the free-floating thrombus. No guidelines exist for medical or surgical management. The endovascular approach appears to present a greater risk of embolization as an alternative to open surgery. This case demonstrates that the prothrombotic state and the presence of neurological symptoms are suggestive of arterial thrombosis in pregnancy and that the multidisciplinary approach is mandatory to achieve good results

Contemporary outcomes of in-situ saphenous vein bypass in the endovascular era: update on LIMBSAVE registry

Latest ESC-ESVS1 and SICVE2 Guidelines stated that in patients who are not at high risk for surgery, bypass is still indicated for long femoropopliteal lesions when an autologous vein is available. The autologous saphenous vein remains to be the conduit of choice

The endovascular management of open aortic surgery complications with emergency stent-graft repair in high-risk patients

The aim of the study was to demonstrate the utility of endovascular stent-graft repair for emergency management of aorto-iliac surgery complications. Between 1997 and 2004, in our institute, 201 patients underwent transluminal endovascular graft placement. In 3 patients (1.4%), previously submitted to conventional aortic surgery, endovascular treatment was carried out due to the occurrence of late complications: 1 secondary aortocaval fistula, 1 impending rupture of aortic pseudoaneurysm and 1 secondary aorto-enteric fistula. All candidates were high surgical risk patients (ASA III-IV) suitable for endoprosthesis positioning by endovascular stent-graft implantation presenting with severe worsening conditions in an emergency situation. The patients were treated under local anesthesia and mild sedation. After treatment there was complete resolution of the clinical presentation and an improvement of general conditions in all 3 patients. In the 1(st) patient legs edema disappeared and in the 2(nd) patient mesogastric pain is absent, respectively at 30 and 8 months. The 3(rd) patient, with secondary aorto-enteric fistula, was submitted 2 months later to aortic graft removal and axillo-bifemoral bypass because of infection development. For the treatment of abdominal aortic surgery complications in high risk patients, particularly in emergency situations, endovascular approach is a feasible and safe alternative to conventional open repair. Further evaluation of this technique and longer follow-up will determine its exact role in the management of these life-threatening complications