Hybrid open and endovascular repair of recurrent visceral aortic patch aneurysmal expansion after previous thoracoabdominal aortic aneurysm repair: case report and description of technique

The rate of morbidity and mortality in patients undergoing open repair for thoracoabdominal aortic aneurysm (TAAA) still remains too high, ranging from 2% to 40%. In recent years "hybrid" techniques have been developed (EVAR and retrograde surgical revascularization) for the treatment of TAAA. This procedure has proved to be more effective to reduce the high risks of complication related to this kind of operation resulting in a lower morbidity and mortality rates when compared to traditional surgical techniques. A 77-year old patient who had previously been undergone surgical exclusion of a TAAA by using a straight aorto to aortic bypass graft (end to end fashion) with visceral patch, was referred to our behalf for the presence of a recurrent Crawford Type IV aortic aneurysm expansion of 10.5 cm length on diameter. Considering the serious co-morbidities of the patient and the high risk of mortality related to the traditional redo surgery, the hybrid technique was considered to repair this recurrent aneurysm by using a surgical debranching of the visceral and renal arteries from the aorta associated to the their retrograde revascularization before to perform the endovascular exclusion of the aneurysm at the same time in a single operation. Over a period of 12 months the patient was alive in good health, a follow-up by computed tomography (CT) scan confirmed the correct position of the endograft, without endoleaks, the patency of the bypasses and the reduction on diameter of the aneurysmal sac. The combined hybrid procedure (endovascular and open surgical approach) for treatment of complex TAAA is to be considered a feasible and effective surgical technique, but a larger number of cases and a longer follow-up are required either to validate this procedure or to get a more significant and statistical comparison to the traditional approach.

Combined spinal and epidural anesthesia for open abdominal aortic aneurysm surgery in vigil patients with severe chronic obstructive pulmonary disease ineligible for endovascular aneurysm repair. Analysis of results and description of the technique

This study evaluated the feasibility of open infrarenal abdominal aortic aneurysm (AAA) surgery under peridural and spinal anesthesia (vigil patient) alone in high-risk patients with severe chronic obstructive pulmonary disease (COPD) ineligible for endovascular aneurysm repair (EVAR) or open surgery in general anesthesia. Between January 2005 and July 2007, seven patients underwent open AAA surgery with combined spinal and epidural anesthesia ([CSEA] without intubation) alone. Regional abdominal anesthesia was established by spinal anesthesia at L2-3 (levobupivacaine plus fentanyl) associated with peridural anesthesia at T7-8 (levobupivacaine). In this series (6 males and 1 female) the average age was 76.5 years (70-87); the AAA measured 7 cm in diameter on average (range 6-12.2). The survival rate was 100% (7/7 patients) at 6-12 months postoperative; no morbidities occurred during the postoperative phase. Owing to the small size of the series, no statistically significant conclusions can be drawn; even so, repair surgery was found to be effective, without the occurrence of morbidities or mortalities. In high-risk patients (severe COPD), open surgical repair of infrarenal AAA may be done with CSEA alone without intubation when, because of the patient's health, general anesthesia would pose too high a risk or when EVAR is unfeasible. Furthermore, the authors believe that surgical AAA repair under CSEA in vigil patients is a valid treatment option in those subjects with a high operative risk (severe COPD) and untreatable by either open AAA surgery under general anesthesia or EVAR.

Visceral artery aneurysms: series of 17 cases treated in a single center

AIM

The aim of this study is to evaluate early and long term results obtained with a retrospective review in 8-year experience with surgical/endovascular treatment of visceral artery aneurysm (VAA) in a single center.

METHODS

Between 2001 and 2008 in our vascular surgery unit visceral artery aneurysms were diagnosed with CT and/or angiography in 17 patients (9 male), mean age 66 years old (range: 18 to 78). All patients underwent surgical or endovascular treatment of splanchnic artery aneurysm. In 14 patients the localization was single, in 3 it was multiple. The arteries involved were: splenic artery 53%, superior mesenteric artery 17.7%, pancreaticoduodenal artery 17.7%, celiac axis 5.8% and hepatic artery 5.8%. The 29.4% of the patients presented with aneurysm rupture. Coil embolizzation was used in 11.6% of the cases while surgery was used in 88.4% of the cases.

RESULTS

Total survival rate was 94.2%, the survival rate in emergency cases was 80% while it was 100% in elective cases. Follow-up revealed excellent results after an average of 46 months (range: 8-102).

CONCLUSION

The worst prognosis for ruptured cases associated with the good result of the surgical/endovascular treatment in elective cases, suggests active interaction for such pathologies; in emergency cases the mortality incidence is too high. Today endovascular treatment presents lower morbidity and mortality rates and shorter hospitalization, but surgery is still a good therapeutic option for the treatment of the VAA, in subjects with low surgical risk, determining a definitive and long-lasting correction of the aneurysmal pathology and guaranteeing the correct perfusion of the organs, by grafts; moreover many aneurysms are not suitable for endovascular treatment.

Isolated aneurysm of the inferior thyroid artery repair with coil embolization

A 68-year-old female patient with a suspected aneurysm of the inferior thyroid artery was admitted to the authors' Unit of emergency after an accident. The echography of the thyroid revealed a ''suspected'' aneurismal dilation of the inferior thyroid artery (max. diameter 30 mm.). The patient underwent an angiograph of the supra-aortic trunk, which detected a small round formation at the base of the left inferior thyroid artery (found to be unaffected by aneurismal pathologies), the aneurysm was excluded by coil embolization. The postoperative course was uneventful and the patient was discharged in one day without complications. The follow-up with colour Duplex, at 4-8 months, showed the normal vascularization of the neck arterial vessels and was confirmed the absence of aneurysmal dilations. Aneurysms of the inferior thyroid artery are extremely rare, in scientific literature only 28 cases have been reported of which 32.9% regard ruptured aneurysms in the thyroid artery and 10.7% led to mortality. They may cause dysphagia and/or respiratory difficulties. Therefore, treatment is always recommended, even in asymptomatic cases, by surgical exclusion or coil embolization.

[Gastrointestinal stromal tumors. A case of small intestine stromal tumor (SIST) with an uncertain biological aspect]

Tumors of the small intestine are relatively rare. The diagnosis is difficult to establish because the symptoms are vague and non-specific. Although the small intestine constitutes 75% of the length and over 90% of the mucosal surface area of the gastrointestinal tract, only 1 to 2% of gastrointestinal malignancies occur in this segment. Metastases are usually present at the time of diagnosis. The outcome of these patients can be improved if the possibility of a malignant small bowel tumor is considered in all cases of unexplained abdominal pain or gastrointestinal bleeding, especially in younger age. Malignant tumors occur with increasing frequency in distal small bowel with a preponderance of malignant lesions in the ileum compared with the jejunum and the duodenum. Adenocarcinoma is the most common tumor of the primary malignant small bowel tumors, followed by carcinoid, lymphoma and leiomyosarcoma. Mesenchymal tumors of the gastrointestinal tract, traditionally regarded as smooth muscle tumors, have demonstrated different cellular differentiations based on immunohistochemical and ultrastructural features. Therefore the terms leiomyoma and leiomyosarcoma have been replaced by a more encompassing term, gastrointestinal stromal tumor (GIST). The majority of GISTs occurs in the stomach; stromal tumors involving the small intestine (SISTs) are far less common but seem to have greater malignant potential. The clinical a case of a small intestinal stromal tumor (SIST), localised in the jejunum and characterised by an uncertain histological aspect, is presented and a review of the literature is made.

[Rectus abdominis free flap breast reconstruction. A series of 23 cases]

Free TRAM flap breast reconstruction was performed in 23 patients from july 1993 through november 1995 at the Saint-Louis Hospital in Paris. The surgical team was composed of eight different surgeons. In all cases a delayed breast reconstruction procedure was performed. All patients in this series had previously received radiation therapy and 82.6% patients presented with excess body weight. Decision to perform a free flap procedure was confirmed peroperatively under two conditions. Adequate caliber of the donor and recipient vessels was required, allowing the anastomoses to be performed without magnification in most cases. Preservation of the thoraco-dorsal vessels was the rule so as to allow later use of a latissimus dorsi flap if necessary. Thus in 8 of the 31 cases in which a free flap was initially indicated a pedicled flap was actually performed so as to satisfy the above conditions. All procedures were performed by two surgical teams working simultaneously. Flap harvest met local tissue requirements in all cases. A lateral strip of rectus abdominis muscle and fascia was preserved when this appeared feasible. The abdominal wall was reinforced by prosthetic means in 82.6% of cases. The average operative time was 9 hours. Results were considered satisfactory or very satisfactory in most cases. The complication rate was 39.1%. Among the complications noted were 1 case of partial flap necrosis, 1 case of fat necrosis, 1 abdominal hernia, 1 abdominal bulge (both abdominal complications occurred in patients in whom no prosthetic material was used for abdominal repair). This complication rate also includes revision of the microsurgical anastomoses in 2 cases; in both cases the flap survived completely. This study tends to suggest that the free TRAM flap for breast reconstruction is a reliable technique. It is the authors' belief that it should replace the bipedicled TRAM flap since it combines ample flap vascularization with minimal rectus harvest.

[Complications related to the existence of a lunotriquetral synostosis]

The authors report the observation of a patient, in whom coexisted a hypersolicitation of the wrists, a congenital lunatotriquetral fusion, a stress fracture of the hook of the hamate and a VISI, giving evidence of a medial carpal instability. They analyse the factors, which allow to understand the relations between these different elements. They caution against arthrodesis, advocated in the treatment of VISI.