Prosthetic bypass for restenosis after endarterectomy or stenting of the carotid artery

OBJECTIVE: The objective of this study was to evaluate the results of prosthetic carotid bypass (PCB) with polytetrafluoroethylene (PTFE) grafts as an alternative to carotid endarterectomy (CEA) in treatment of restenosis after CEA or carotid artery stenting (CAS). METHODS: From January 2000 to December 2014, 66 patients (57 men and 9 women; mean age, 71 years) presenting with recurrent carotid artery stenosis ≥70% (North American Symptomatic Carotid Endarterectomy Trial [NASCET] criteria) were enrolled in a prospective study in three centers. The study was approved by an Institutional Review Board. Informed consent was obtained from all patients. During the same period, a total of 4321 CEAs were completed in the three centers. In these 66 patients, the primary treatment of the initial carotid artery stenosis was CEA in 57 patients (86%) and CAS in nine patients (14%). The median delay between primary and redo revascularization was 32 months. Carotid restenosis was symptomatic in 38 patients (58%) with transient ischemic attack (n = 20) or stroke (n = 18). In this series, all patients received statins; 28 patients (42%) received dual antiplatelet therapy, and 38 patients (58%) received single antiplatelet therapy. All PCBs were performed under general anesthesia. No shunt was used in this series. Nasal intubation to improve distal control of the internal carotid artery was performed in 33 patients (50%), including those with intrastent restenosis. A PTFE graft of 6 or 7 mm in diameter was used in 6 and 60 patients, respectively. Distal anastomosis was end to end in 22 patients and end to side with a clip distal to the atherosclerotic lesions in 44 patients. Completion angiography was performed in all cases. The patients were discharged under statin and antiplatelet treatment. After discharge, all of the patients underwent clinical and Doppler ultrasound follow-up every 6 months. Median length of follow-up was 5 years. RESULTS:No patient died, sustained a stroke, or presented with a cervical hematoma during the postoperative period. One transient facial nerve palsy and two transient recurrent nerve palsies occurred. Two late strokes in relation to two PCB occlusions occurred at 2 years and 4 years; no other graft stenosis or infection was observed. At 5 years, overall actuarial survival was 81% ± 7%, and the actuarial stroke-free rate was 93% ± 2%. There were no fatal strokes. CONCLUSIONS: PCB with PTFE grafts is a safe and durable alternative to CEA in patients with carotid restenosis after CEA or CAS in situations in which CEA is deemed either hazardous or inadvisable

Splenic hamartoma associated with abdominal discomfort and pain. Case report

Hamartomas are benign splenic neoplasms asymptomatic in most of the cases. Symptoms, when present, may either be related to the growth of the mass with abdominal discomfort and pain or be related to a hypersplenism syndrome. Certain preoperative diagnosis cannot be made with current diagnostic imaging. Splenectomy is therefore indicated in order to obtain histological diagnosis, rule out malignancy or achieve regression of symptoms. We report the case of a 39-year-old woman referred for a splenic hamartoma causing pain located on the upper abdominal quadrant. She underwent splenectomy through a left subcostal access followed by complete resolution of symptoms. Resection of splenic masses is indicated to complete diagnosis, achieve cure and, when present, relieve symptoms

Open surgery for aneurysms of the splenic artery at the hilum of the spleen. Report of three cases

Introduction: Aneurysms of the splenic artery (SAA) located at the hilum of the spleen are not well fit for endovascular or laparoscopic treatment. Open surgery may still be the best option of treatment. Presentation of cases: We report the cases of 3 female patients of a mean age of 59 years (range, 45–68 years) with a hilar (n = 2) or parahilar (n = 1) SAA undergoing successful open surgical resection, through a short left subcostal access. Recovery was uneventful and mean, postoperative length of stay was 4 days (range, 3–5 days). Discussion: Results of this report support surgical resection and splenectomy for the treatment of SAA located at the hilum of the spleen. For this particular location endovascular treatment may not be advised, as coil embolization can be followed by a massive splenic infarction precipitating the need for splenectomy, due to the exclusion of backflow from the left gastroepiploic artery through the short gastric vessels. As well, endovascular exclusion through insertion of an endograft may not be feasible due to the absence of a distal landing zone, as stent grafting requires a normal caliber artery of sufficient length on each side of the aneurysm. Conclusion: Surgical excision and splenectomy, through a short subcostal incision, remains a viable option of treatment for hilar SAA

Outcome of inferior vena cava and noncaval venous leiomyosarcomas

Background. Leiomyosarcoma (LMS) is a rare tumor arising from the smooth muscle cells of arteries and veins. LMS may affect both the inferior vena cava (IVC) and non-IVC veins. Because of its rarity, the experiencewiththeoutcomeofthediseaseoriginatingfromtheIVCcomparedwiththatwithnon-IVCoffspring isoveralllimited.Inthisstudy,wecomparedtheclinicalfeaturesandoutcomesafteroperativeresectionofIVC and non-IVC LMS to detect possible significant differences that could affect treatment and prognosis. Methods. Twenty-seven patients undergoing operative resection of a venous LMS at a single tertiary care center and one secondary care hospital were reviewed retrospectively and divided into 2 groups: IVC-LMS (Group A, n = 18) and non-IVC LMS (Group B, n = 9). As primary end points, postoperative mortality and morbidity, disease-specific survival and, if applicable, patency of venous reconstruction were consid- ered. Bivariate differences were compared with the v 2 test. Disease-specific survival was expressed by a life- table analysis and compared using the log-rank test. Results. No postoperative mortality was observed in either group. Postoperative morbidity was 28% in group A and 11% in group B (P = .33). The mean duration of follow-up was 60 months (range, 13– 140). Disease-specific survival was 60% in group A and 75% in group B at 3 years (P = .48), and it was 54% in group A and 62% in group B at 5 years (P = .63). Seven grafts were occluded in group A (39%) and 1of 3 were occluded in group B (33%) (P = .85). Conclusion. IVC and non-IVC LMS exhibit similar outcomes in terms of postoperative course and survival. Operative resection associated with vascular reconstruction, if applicable, eventually followed by radiation and chemotherapy may be curative and is associated with good functional results

Internal carotid artery rupture caused by carotid shunt insertion

Introduction: Shunting is a well-accepted method of maintaining cerebral perfusion during carotid endarterectomy (CEA). Nonetheless, shunt insertion may lead to complications including arterial dissection, embolization, and thrombosis. We present a complication of shunt insertion consisting of arterial wall rupture, not reported previously. Presentation of case: A 78-year-old woman underwent CEA combined with coronary artery bypass grafting (CABG). At the time of shunt insertion an arterial rupture at the distal tip of the shunt was detected and was repaired via a small saphenous vein patch. Eversion CEA and subsequent CABG completed the procedure whose postoperative course was uneventful. Discussion: Shunting during combined CEA-CABG may be advisable to assure cerebral protection from possible hypoperfusion due to potential hemodynamic instability of patients with severe coronary artery disease. Awareness and prompt management of possible shunt-related complications, including the newly reported one, may contribute to limiting their harmful effect. Conclusion: Arterial wall rupture is a possible, previously not reported, shunt-related complication to be aware of when performing CEA

Schwannoma of the descending loop of the hypoglossal nerve. Case report

Schwannomas of the descending loop of the hypoglossal nerve are very rare. They are slow-growing tumors that may masquerade a carotid body tumor

Laparoscopic modified double stapling technique with transanal resection for low anterior resection of rectal cancer

BACKGROUND AND AIM: Anterior resection of the rectum with a total mesorectal excision is the standard surgical technique for the treatment of rectal cancer. Laparoscopic low anterior resection (LALAR) is an alternative to open surgical approach and was validated in diverse randomized control trials to be as safe and oncologically effective. That said, confronting a low rectal tumor in an obese patient with a narrow pelvis can be technically challenging even for the most expert surgeon. METHODS: We propose a modified double stapling technique with transanal eversion and staple resection of the rectal stump. RESULTS: We applied the above technique in 3 patients with a dubious distal resection margin due to patient/tumor characteristics. The mean length of operation was 272 minutes and a R0 resection with a mean number of 16 nodes could be obtained in all the patients. No recurrence occurred during a follow-up of 28 months. CONCLUSIONS: We conclude that this technique is a feasible, safe and valid adjunct to the double staple technique whenever intraabdominal application of the linear staple is difficult or unsafe. KEY WORDS: Colorectal cancer, Laparoscopic anterior resection, Double, Low colorectal anastomosis, Stapling technique

Laparoscopic lavage/drainage as a bridge treatment for perforated diverticulitis with purulent peritonitis associated with an abdominal aortic aneurysm A retrospective case-control study

Laparoscopic lavage /drainage (LALA) or surgical resection are both methods of treatment for perforated diverticulitis with purulent peritonitis (Hinchey Stage III). In case of associated abdominal aortic aneurysm (AAA), laparoscopic lavage/drainage could be an interesting bridge option to treat sepsis before endovascular exclusion of the aneurysm and resection of the sigmoid. We performed LALA as a bridge treatment of peritonitis before elective, staged endovascular exclusion of the aneurysm (EE) and elective resection of the colon

True aneurysm of the proximal occipital artery. Case report

INTRODUCTION: True aneurysms of the proximal occipital artery are rare, may cause neurological symptoms due to compression of the hypoglossal nerve and their resection may be technically demanding. PRESENTATION OF CASE: The case of an aneurysm of the proximal occipital artery causing discomfort and tongue deviation by compression on the hypoglossal nerve is reported. Postoperative course after resection was followed by complete regression of symptoms. CONCLUSION: Surgical resection, as standard treatment of aneurysms of the occipital artery, with the eventual technical adjunct of intubation by the nose is effective in durably relieving symptoms and preventing aneurysm-related complicatio

Response to: reimplanting the superior mesenteric artery on the infra-renal aorta

We thank Manenti et al2 for their comments. Acute intestinal ischemia and intestinal resection associated with chronic, ostial stenosis/ occlusion of the superior mesenteric artery (SMA) represents a completely different clinical setting and pattern of associated problems than chronic mesenteric ischemia associated with long stenosis/occlusion of the SMA, which is the actual object of our article. We agree with Manenti and his associates that reimplantation of the SMA on the aorta, usually on its right antero-lateral aspect just below the origin of the renal arteries is an excellent method of revascularization. It is the ideal technique when the quality of the aortic wall is good or a well-patent aortic graft is in place and the lesion is confined to the first centimeter of the SMA.1 Short, ostial stenoses of the SMA associated with soft or mildly calcified plaques are well managed by endovascular treatment, whereas we think that heavily calcified stenoses or occlusions are still best treated by operative revascularization. Acute ischemia due to embolism to an undiseased SMA is treated by embolectomy via a transverse arteriotomy after dissecting the artery just out the root of the mesentery. When dealing with long SMA stenoses in contaminated fields, bypass with autogenous greater saphenous vein is a viable alternative, but can involve an excessively long course of the graft, because the greater saphenous vein is more prone to twisting and kinking than Dacron (Intervascular Datascope, La Ciotat, France) or polytetrafluoroethylene