Demographic, Clinical and Hematological Predictors of Carotid Atherosclerotic Plaque Histology

Aims: This retrospective observational study was aimed to identify hematological predictors of histological heterogeneity of carotid atherosclerotic plaques (CAPs). Results: The mean values of all demographic, clinical and haematological parameters did not differ between patients with or without symptomatic CAD. In univariate analysis, intraplaque hemorrhage was associated with male sex (r=0.18; p=0.032), superficial thrombosis with low hemoglobin (r=- 0.18; p=0.033), fibrosis with enhanced RDW (r=0.24; p=0.005), presence of foam cells with high WBC count (r=0.22; p=0.001), neovascularisation with high WBC count (r=0.17; p=0.048), whilst the presence of inflammatory infiltrate was also associated with high WBC count (r=0.17; p=0.043). Conlusions: The results of this retrospective observational study confirm that some traditional and inexpensive hematological parameters such as WBC count, hemoglobin and RDW may help identifying patients with more severe forms of CAD

Treatment of popliteal artery aneurysms by means of cryopreserved homograft

Autologous saphenous vein is considered the gold standard conduit in the femoral-popliteal revascularization for popliteal artery aneurysms (PAAs). In several cases, it may be absent or unsuitable for length or diameter and so it may be considered unfit for a conduit. In such patients, a synthetic graft or the endovascular correction can be useful, but results are controversial. In this retrospective case series, we have analyzed the safety and efficacy of the cryopreserved homograft (CHg) as a conduit in the PAA revascularization

Surgical Treatment of Symptomatic Aortic Aneurysm in a Patient with Anti-neutrophil Cytoplasmic Antibody-associated Vasculitis: Case Report and Review of the Literature

Vasculitis is an heterogeneous group of syndromes, which shares inflammation of blood vessel wall as the main feature. Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a necrotizing vasculitis, with few or no immune deposits, predominantly affecting small vessels (i.e., capillaries, venules, arterioles, and small arteries), associated with ANCAs specific for myeloperoxidase or proteinase 3. Clinical manifestations may be heterogeneous but an involvement of lungs and kidneys frequently occurs. AAV of large vessels is a very rare condition whose standard therapy is medical approach. Surgical revascularization has been described in selected patients after medical failure or in emergent settings. We report the case of a patient affected by symptomatic infrarenal aortic aneurysm related to AAV, who underwent in-situ reconstruction by means of cryopreserved homograft

Red blood cell distribution width predicts 1-month complications after percutaneous transluminal angioplasty

Background: The identification of patients at higher risk of developing percutaneous transluminal angioplasty (PTA)-related complications is pivotal for achieving better clinical outcomes. We carried out a single-center, observational, retrospective study to explore whether in-hospital changes of red blood cell distribution width (RDW) may help predicting early development of PTA-related complications.Methods: The study population consisted of all consecutive patients who underwent PTA for severe peripheral artery occlusive disease (PAOD) during a 2-year period. RDW was measured at hospital admission and discharge, and the delta was calculated. Patient follow-up was routinely performed 1-month after hospital discharge, and was based on thoughtful medical assessment and arterial ultrasonography. The control population consisted of 352 ostensibly healthy subjects.Results: The final PTA group consisted of 224 patients. Hemoglobin was lower, whilst mean corpuscular volume (MCV) and RDW were higher in PAOD cases than in controls. Overall, 11 PAOD patients (4.9%) developed clinically significant PTA-related complications 1-month after hospital discharge. Patients who developed 1-month PTA-related complications had lower hemoglobin concentration, but higher RDW and delta RDW than those who did not. Patients with delta RDW >1 had 60% higher risk of developing 1-month PTA-related complications and 88% higher risk of developing early reocclusion. Overall, RDW exhibited an area under the curve (AUC) of 0.68 and 0.74 for predicting 1-month PTA-related complications and early reocclusion, respectively.Conclusions: The results of this study suggest that RDW may play a role for guiding the clinical decision making of PTA patients immediately after hospital discharge

Thoracic Aortic Pseudoaneurysm after Esophageal Perforation and Mediastinitis Caused by Accidental Ingestion of a Mutton Bone: A Case Report on Staged Endoscopic and Endovascular Treatments

Background Esophageal perforation involving the thoracic aorta is a rare but potentially life-threatening event. Esophageal wall dehiscence, aortoesophageal fistula, mycotic aneurysms, or mediastinitis may complicate this challenging condition, and a multidisciplinary approach is mandatory. Aggressive endoscopic and medical therapy followed by thoracic endovascular aneurysm repair (TEVAR) may be a valuable approach to reduce the mortality rate of this catastrophic event. Case Report A 79-year-old man presented at the emergency department with a 2-day history of worsening dysphagia and fever, suddenly appeared after consuming mutton meat. Esophagogastroduodenoscopy and computed tomography (CT) scan at admission showed a bone fragment penetrating the esophagus very close to the thoracic aorta, associated with signs of mild mediastinitis. After endoscopic removal of the bone, an esophageal fistula occurred. A conservative approach by means of endoscopic clipping of the esophageal perforation, nasojejunal tube for enteral nutrition and broad spectrum antibiotic therapy was preferred at this stage. Control chest X-ray with oral water-soluble contrast (Gastrografin) and repeat CT at 10- and 20-day follow-up showed a complete resolution of the esophageal fistula and mediastinitis. On the other hand, an increase of the aortic pseudoaneurysm was noted. This was treated by means of TEVAR. Subsequent clinical evolution was uneventful, and the patient was discharged in optimal clinical conditions with a 4-week course of home antibiotic therapy. The 6-month follow-up was uneventful. Conclusions Foreign body esophageal perforation causing mediastinitis and aortic pseudoaneurysm is a very rare and challenging situation that requires a strict follow-up and an intensive multidisciplinary approach. A staged approach, first by endoscopy followed by endovascular treatment, may be safe and effective in selected patients

Is there any role for super-extended limphadenectomy in advanced gastric cancer? results of an observational study from a western high volume center

Background: Although the Japan Clinical Oncology Group (JCOG) 9501 trial did not find that prophylactic D3 lymphadenectomy led to any survival advantage over D2 lymphadenectomy, it did find that the prognosis of subserosal and N0 gastric cancer patients improved. The aim of this retrospective observational study was to compare survival after D2 or D3 lymphadenectomy in different patient subgroups. Methods: The study considered all of the patients who underwent D2 or D3 lymphadenectomy at a high-volume center in Verona (Italy) between 1992 and 2011. After excluding patients with Bormann IV or neuroendocrine tumors, early gastric cancers, or non-curative resections, the analysis involved 301 R0 patients: 100 who underwent D2, and 201 who underwent D3 lymphadenectomy. Post-operative deaths and deaths due to recurrences were considered as terminal events in the survival analysis. Results: The D2 patients were significantly older than the D3 patients at baseline (69.8 +/- 2.3 vs. 62.2 +/- 10.7 years). The median number of retrieved nodes was 29 (interquartile range: 24.5-39) after D2, and 43 (34-52) after D3. The five-year disease-related survival rate was similar after D2 (44%, 95% confidence interval (CI) 34-54%) and D3 (41%, 34-48%) (p = 0.766). A Cox model controlling for sex, age, tumor site, Lauren histology, and T and N stages showed that the risk of cancer-related death after D3 was similar to that recorded after D2 (hazard ratio 0.97, 95% CI 0.67-1.42). There was a significant interaction between the T status and the extension of the lymphadenectomy (p = 0.012), with the prognosis being better after D2 in T2 and T4b patients, and after D3 in T3 patients. Conclusions: The findings of this study suggest that D3 lymphadenectomy is not routinely indicated for patients with advanced gastric cancer, although differences in survival after D3 across T tiers deserve further consideration

Red blood cell distribution width (RDW) is an independent predictor of post-implantation syndrome in patients undergoing endovascular aortic repair for abdominal aortic aneurysm

Background: This observational, retrospective study aims establishing the role of red blood cell distribution width (RDW) for identifying abdominal aortic aneurism (AAA) patients at risk of developing post-implantation syndrome (PiS) after endovascular aneurysm repair (EVAR).Methods: The study population consisted of all patients undergoing EVAR for AAA at the University Hospital of Verona (Italy), between June 1, 2016 and May 31, 2018. Blood samples for measuring hemoglobin, mean corpuscular volume (MCV) and RDW were collected at hospital admission and the day after EVAR. The primary endpoint was PiS development. Delta variations were calculated as the ratio between values measured after and before EVAR.Results: The final study population consisted of 124 patients (10 women and 114 men; median age, 75 years), 55 of whom developed PiS. In patients with or without PiS hemoglobin significantly decreased after EVAR, whilst RDW significantly increased in patients with PiS and decreased in those without. Age, sex, hypertension, diabetes and renal failure were similar in patients who developed PiS or not, whilst a positive history of coronary artery disease was more frequent in PiS patients. Although hemoglobin and MCV changes after EVAR did not differ in patients with or without PiS, delta RDW was higher in those with PiS. The rate of patients with delta RDW (>)1 was significantly higher in patients with PiS that in those without (61.8% vs. 34.8%; P=0.002). In multivariate analysis, delta RDW remained independently associated with PiS (beta coefficient, 2.023; P=0.001). A delta RDW (>)1 after EVAR was associated with similar to 3-fold enhanced risk of PiS (odds ratio, 3.04; P=0.003) and exhibited a good prognostic performance (area under the curve, 0.69; P(<)0.001).Conclusions: Calculation of delta RDW after EVAR seems an efficient prognostic tool for stratifying the risk of developing PiS, especially in the early postoperative period

Clinical pathways in gastric cancer care

The diagnostic–therapeutic pathways (DTPs) are emerging as useful instruments for clinical management of complex diseases as gastric cancer, whose treatment is challenging and requires a multidisciplinary approach. However, the DPTs of patients with gastric cancer are still not defined yet. The aim of this study was to define the optimal DPT to be applied for patients with gastric cancer in the Veneto region. Rather than defining the ideal DTPs a priori, we conducted a preliminary research by analyzing the differences in the actual DPTs for patients with gastric cancer among different hospitals (hub and spokes) in Veneto. Then, the final DPT was elaborated based on the current available best clinical evidences; however, also the areas of homogeneity among the actual DPTs of the included centers as well as the critical issues that had emerged by our preliminary analysis were taken into account for pathway design. High heterogeneity in actual DTPs of patients with gastric cancer was observed among the analyzed centres. Moreover, some of the major criticisms have been found at crucial points of the current pathways. Based on these data, a reference path that is applicable to the whole-regional health network was constructed. The reference DTP is focused on multidisciplinary team management of patients with gastric cancer. Clinical pathways are essential tools to properly manage complex diseases such as gastric cancer. As such, more efforts should be done to implement their use

Preliminary Experience with Prophylactic Thoracic Endovascular Aortic Repair in Patients Affected by Advanced Esophageal Cancer

Bleeding from the thoracic aorta is potentially fatal in patients with advanced esophageal cancer (AEC). Esophageal malignancy is the third most common cause of aortoesophageal fistula, after thoracic aortic aneurysm and ingestion of foreign body. The involvement of aortic wall often contraindicates chemoradiotherapy (CRT) treatment, thus reducing life expectancy of these patients. Thoracic endovascular aortic repair (TEVAR) is a well-described mini-invasive technique that can be also applied for coverage of the aortic lumen in case of invasion by esophageal cancer. Only few cases have been published with this atypical indication. Between 2016 and 2018, in our tertiary hospital 3 patients affected by AEC involving the thoracic aorta were treated by means of prophylactic TEVAR. All procedures were uneventful, and all patients were reconsidered fit for preoperative or definitive CRT

Carotid Endarterectomy with Modified Eversion Technique: Results of a Single Center

Carotid endarterectomy (CEA) has a wide range of approaches based on personal expertise and preference. We evaluated our outcome with CEA with modified eversion technique (meCEA) under local anesthesia and whether the surgeon's experience could influence it