Spontaneous sealing of a type Ia endoleak after ovation stent graft implantation in a patient with on-label aortic neck anatomy

We report a case of an early type Ia endoleak after endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm by Ovation Stent Graft implantation and spontaneously resolved without further reintervention. The patient presents a conical aortic neck, but EVAR was performed within the instruction for use proposed by manufactory. At completion angiography, a low-flow type Ia endoleak was present and left untreated. Computed tomographic angiography performed on the third postoperative day showed infolding of the 2 sealing rings. The patient was dismissed without further treatment. At 3-month follow-up, the leak appeared spontaneously sealed with partial expansion of the 2 rings.We report a case of an early type Ia endoleak after endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm by Ovation Stent Graft implantation and spontaneously resolved without further reintervention. The patient presents a conical aortic neck, but EVAR was performed within the instruction for use proposed by manufactory. At completion angiography, a low-flow type Ia endoleak was present and left untreated. Computed tomographic angiography performed on the third postoperative day showed infolding of the 2 sealing rings. The patient was dismissed without further treatment. At 3-month follow-up, the leak appeared spontaneously sealed with partial expansion of the 2 rings

Open conversion after aortic endograft infection. Caused by colistin-resistant, carbapenemase-producing Klebsiella pneumoniae

A 62-year-old man presented with fever, abdominal pain, and malaise 13 months after emergency endovascular aortic repair. Computed tomographic angiograms showed a periprosthetic fluid and gas collection, so infection was diagnosed. Open conversion was performed, involving endograft explantation and in situ aortic reconstruction. Cultures and the explanted prosthesis were positive for carbapenemase-producing Klebsiella pneumoniae, resistant to colistin. Because of the sparse data on endograft infections caused by this pathogen, we placed the patient on an empiric double-carbapenem regimen for 4 weeks. Symptomatic recovery occurred after 21 days. On the 30th day, we deployed a stent to treat a new pseudoaneurysm. Three years later, the patient had no signs of persistent or recurrent infection. We think that this is the first report of aortic endograft infection caused by colistin-resistant, carbapenemase-producing K. pneumoniae.A 62-year-old man presented with fever, abdominal pain, and malaise 13 months after emergency endovascular aortic repair. Computed tomographic angiograms showed a periprosthetic fluid and gas collection, so infection was diagnosed. Open conversion was performed, involving endograft explantation and in situ aortic reconstruction. Cultures and the explanted prosthesis were positive for carbapenemase-producing Klebsiella pneumoniae, resistant to colistin. Because of the sparse data on endograft infections caused by this pathogen, we placed the patient on an empiric double-carbapenem regimen for 4 weeks. Symptomatic recovery occurred after 21 days. On the 30th day, we deployed a stent to treat a new pseudoaneurysm. Three years later, the patient had no signs of persistent or recurrent infection. We think that this is the first report of aortic endograft infection caused by colistin-resistant, carbapenemase-producing K. pneumoniae

Peri-procedural brain lesions prevention in CAS (3PCAS). Randomized trial comparing CGuard™ stent vs. wallstent

Background: Aim of this study was to evaluate peri-procedural incidence of new diffusion-weighted-magneticresonance- imaging (DWMRI) brain lesions in CAS patients treated by carotid mesh stent (CGuard™) or closed-cell stent (Wallstent™). Methods: Consecutive patients with asymptomatic carotid stenosis ≥ 70% were submitted to preoperative DWMRI scan, to exclude the presence of preoperative silent cerebral lesions. Patients were randomized to CGuard orWallstent. DWMRI was performed immediately after the intervention and at 72-hour postoperatively. Moreover, pre and postoperative Mini-Mental-State-Examination Test (MMSE) and aMontreal-Cognitive-Assessment (MoCA) test were conducted, and S100β and NSE neurobiomarkers were measured at 5-time points (preoperatively, 2, 12, 24, and 48 h postoperatively). Results: From January 2015 to October 2016, sixty-one consecutive eligible patients were submitted to preoperative DWMRI scan. Three patients were excluded because of preoperative silent cerebral lesions. In 29 CGuard patients, 1 developed a minor stroke and 8 silent newlesionswere observed in the 72 h-DWMRI (31%): 4 lesions were ipsilateral, and 4 lesions were contra or bilateral. In 29 Wallstent patients, 7 clinically-silent new lesions were found in the 72 h-DWMRI (24.1%; p = 0.38). In 4 cases lesions were ipsilateral and in 3 cases contra or bilateral. S100B values doubled at 48 h in 24 patients, and among them 12 presented new DWMRI lesions. 48-h S100B increase was significantly related to 72-h DWMRI lesions (p= 0.012). Conclusions: In our experience both stents showed an acceptable rate of subclinical neurological events with no significant differences at 72-hour DWMRI between groups. Bilateral/contralateral lesions suggest that periprocedural neurological damage may have extra-carotid sources

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Pressure injury to the chest wall caused by vascular graft and endograft after thoracic and thoraco-abdominal aortic repair

Thoracic and thoraco-abdominal aortic repair remains a challenging issue in vascular surgery, and long-term complications are well described. We report 2 cases of octogenarians with unusual long-term complications after open and endovascular thoracic aortic repair of chest wall pressure injury from the vascular prosthesis. In the first case, a computed tomographic scan of an 80-year-old man showed a pressure injury of the chest wall and rib erosion caused by a Dacron graft. The second case was an 81-year-old woman who presented with external bleeding from the left posterior chest wall. A computed tomographic scan showed a type IA endoleak and chest wall damage with rib erosion and thoracic cutaneous fistulae from the endovascular graft. Both patients were treated by relining the endovascular graft; debriding the surgical fistula was done only in the second case. In our experience, endovascular repair is a good option to avoid a complete open surgical repair

Silent stroke and cognitive decline in asymptomatic carotid stenosis revascularization

The aim of this study was to assess the relationship between serum levels of S100 beta and neuron-specific enolase (NSE), postoperative diffusion-weighted magnetic resonance imaging (DW-MRI) and Mini-Mental State Examination (MMSE) score in asymptomatic patients affected by >= 70% carotid stenosis submitted to carotid endarterectomy (CEA) or carotid artery stenting (CAS), and to compare MMSE scores and DW-MRI findings at follow-up evaluations. Between April 2008 and April 2009, 60 patients were submitted to carotid intervention. All patients underwent DW-MRI and MMSE preoperatively, at 24 hours postoperatively, at 6 months and at 12 months. Neurobiomarkers were assessed for each patient at six time-points. Thirty-two patients were submitted to CEA and 28 to CAS. No mortality was observed. One CAS patient presented with an ischemic stroke. In six CAS patients and one CEA patient, new subclinical ischemic lesions were detected at postoperative DW-MRI (21.4% versus 3%, P = 0.03). In CAS patients, new DW-MRI lesions were significantly associated with MMSE score decline (P = 0.001). At 12 months, patients presenting with new postoperative ischemic lesions showed lower MMSE scores (P = 0.08). CAS patients showed increasing neurobiomarker levels compared with CEA patients (P = 0.02). In conclusion, microembolization effects may persist over time, so it should be avoided whenever possible. Carotid revascularization procedures should be evaluated and compared not only with respect to death/stroke but also to microembolism rates