To determine the best treatment for high-risk patients with abdominal aortic aneurysms (AAA). We reviewed a prospective database of all patients who underwent conventional (OPEN) or endovascular aneurysm repair (EVAR) between January 1998... more
To determine the best treatment for high-risk patients with abdominal aortic aneurysms (AAA). We reviewed a prospective database of all patients who underwent conventional (OPEN) or endovascular aneurysm repair (EVAR) between January 1998 and December 2002. Patients were preoperatively classified according to the American Society of Anesthesiology (ASA). Comorbidities and medical risk factors were categorized according to the Ad Hoc Committee on Reporting Standards. Perioperative mortality and morbidity rates were analyzed according to the type of surgical procedure (OPEN vs EVAR) and ASA class. Patients in ASA classes I and II were excluded. Continuous data were expressed as mean +/- standard deviation. All data were calculated using the cumulated actuarial method of event outcome probability. Kaplan-Meier curves were constructed and the log-rank statistic and chi squared test were used for comparative data. P values less than 0.05 were considered to indicate statistical significan...
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Research Interests: Surgery, Medicine, Humans, Female, Male, and 6 moreAged, Middle Aged, Adult, Time Factors, Retrospective Studies, and Aneurysm
ABSTRACT
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The purpose of this study was to seek factors predicting outcome after open surgical repair of juxtarenal abdominal aortic aneurysms (AAAs). From a series of 733 patients treated for AAAs, 92 patients underwent elective conventional open... more
The purpose of this study was to seek factors predicting outcome after open surgical repair of juxtarenal abdominal aortic aneurysms (AAAs). From a series of 733 patients treated for AAAs, 92 patients underwent elective conventional open repair with suprarenal clamping. We assessed postoperative cardiorespiratory and renal morbidity and mortality and survival at 1, 3, and 5 years. One patient (1.1%) died after an acute myocardial infarction. Postoperative complications including myocardial infarction and renal failure arose in 22 patients (23.9%). Significant predicting factors of renal failure were a preoperative creatinine clearance ≤ 40 mL/min ( p = .03) and female sex ( p = .004). Kaplan-Meier survival analysis showed an overall survival rate of 98.9% at 1 year and 88.6% at 3 and 5 years. In patients carefully selected by preoperative imaging criteria to undergo open juxtarenal AAA repair, appropriate intraoperative management guarantees a good immediate postoperative outcome.
Research Interests: Surgery, Risk assessment, Medicine, Humans, Female, and 15 moreMale, Risk factors, Aged, Middle Aged, Myocardial Infarction, Sex Factors, Retrospective Studies, Biological markers, Risk Factors, Risk Assessment, Creatinine, Constriction, Patient selection, renal insufficiency, and Cardiovascular medicine and haematology
Background —Accumulation of LDL within the arterial wall appears to play a crucial role in the initiation and progression of atherosclerotic plaque. The dynamic sequence of this event has not been fully elucidated in humans. Methods and... more
Background —Accumulation of LDL within the arterial wall appears to play a crucial role in the initiation and progression of atherosclerotic plaque. The dynamic sequence of this event has not been fully elucidated in humans. Methods and Results —In 7 patients with previous transient ischemic attack or stroke and critical (>70%) carotid stenosis, autologous native [ 125 I]-labeled LDL or [ 125 I]-labeled human serum albumin were injected 24 to 72 hours before endarterectomy. Carotid specimens obtained at endarterectomy were analyzed by autoradiography and immunohistochemistry. Autoradiographic study showed that LDL was localized prevalently in the foam cells of atherosclerotic plaques, whereas the accumulation in the lipid core was negligible. Immunohistochemistry revealed that foam cells that had accumulated radiolabeled LDL were mostly CD68 positive, whereas a small number were α-actin positive. No accumulation of the radiotracer was detected in atherosclerotic plaques after inj...
Research Interests: Immunohistochemistry, Macrophages, Medicine, Humans, Internal Medicine, and 15 moreFemale, Male, Clinical Sciences, Aged, Public health systems and services research, Carotid Endarterectomy, Autoradiography, Circulation, Lipoprotein a, Carotid Stenosis, Injections, foam cells, Carotid Arteries, Human serum albumin, and Cardiovascular medicine and haematology
Research Interests: Chemistry, Free Radicals, Atherosclerosis, Free Radical, Copper, and 15 moreFemale, Feasibility Studies, Animal Model, Apolipoprotein B, Clinical Sciences, Biodistribution, Adult, Accumulation, Carotid Artery, Copper sulfate, Carotid Stenosis, Atherogenesis, Electrophoretic Mobility, foam cells, and Cardiovascular medicine and haematology
Research Interests: Treatment Outcome, Stroke, Humans, Female, Brain Ischemia, and 12 moreRisk factors, Diagnostic Imaging, Recurrence, Clinical Sciences, Middle Aged, Risk Factors, Elsevier, Predictive value of tests, Thrombolytic Therapy, Carotid Stenosis, Cardiovascular medicine and haematology, and Diagnostic errors
Research Interests: Magnetic Resonance Imaging, Risk assessment, Medicine, Prospective studies, Humans, and 15 moreFemale, Male, Recurrence, Aged, Carotid Endarterectomy, Chi Square Distribution, Risk Assessment, Logistic Models, Predictive value of tests, Carotid Stenosis, Cerebral Angiography, Recovery of Function, Disability Evaluation, Patient selection, and Medical and Health Sciences
After fourty years of practice in carotid surgery the rate of neurologic complications related to technical defects seems not to be reduced and still is responsible of 30-40% of all perioperative strokes. Intraoperative quality control... more
After fourty years of practice in carotid surgery the rate of neurologic complications related to technical defects seems not to be reduced and still is responsible of 30-40% of all perioperative strokes. Intraoperative quality control seem at present, of outmost importance to further reduce the impact of technical defects on perioperative neurological complications. Angiography, Duplex Scanning and more recently angioscopy have been utilized as intraoperative assessments. All of them demonstrated imperfections of arterial reconstruction potentially at risk for early and late patency failure and indicated immediate intraoperative correction. In some report this behaviour determined a relevant reduction both on perioperative results and lesser incidence of early restenosis. Concerning postoperative control of carotid endarterectomy early restenosis represent the most important and more common failure after carotid endarterectomy. In spite of the efforts to clear the causes of this ph...
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Early restenosis represent the most important and more common failure after carotid endarterectomy. For this reason, after its first description made in 1976 by Stoney and String, it raised general interest among vascular surgeons. In... more
Early restenosis represent the most important and more common failure after carotid endarterectomy. For this reason, after its first description made in 1976 by Stoney and String, it raised general interest among vascular surgeons. In spite of the efforts to clear the causes of this phenomenon, none of the numerous papers published in the literature has defined a specific cause determining restenosis. Nevertheless, at present, this hyperplastic response of the arterial wall to trauma after operation is generally considered benign because it is rarely responsible for new neurological symptoms or early internal carotid artery occlusion. This unanimous conviction has been achieved after years of instrumental and clinical postoperative follow-up performed all over the world. At the same time and probably for these reasons, recently, a new discussion has begun about the usefulness and cost-effectiveness of prolonged Duplex scanning postoperative surveillance of the endarterectomized caro...
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The appropriateness of early carotid endarterectomy (CEA) in patients with acute ischemic stroke is still unsettled. The aim of this study was to verify the safety and feasibility of early CEA in a consecutive series of patients with... more
The appropriateness of early carotid endarterectomy (CEA) in patients with acute ischemic stroke is still unsettled. The aim of this study was to verify the safety and feasibility of early CEA in a consecutive series of patients with acute ischemic stroke observed in an emergency Department Stroke Unit. During a 24-month study, out of 756 patients with acute ischemic stroke 33 (4.4%) were scheduled for early CEA. Endarterectomy procedures were distinguished according to the time between the onset of stroke and operation as emergency (within 8 hours), early CEA (1-18 days). Patients with impaired consciousness or an infarct larger than 2.5 cm on computed tomographic (CT) or magnetic resonance (MR) scans or both were excluded from surgery. All patients underwent spiral CT, echo-color-Doppler (ECD) sonography, transcranial Doppler (TCD) sonography and, when necessary, MR angiography within 6 hours of admission. No patient underwent conventional angiography. Most patients were operated ...
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After fourty years of practice in carotid surgery the rate of neurologic complications related to technical defects seems not to be reduced and still is responsible of 30-40% of all perioperative strokes. Intraoperative quality control... more
After fourty years of practice in carotid surgery the rate of neurologic complications related to technical defects seems not to be reduced and still is responsible of 30-40% of all perioperative strokes. Intraoperative quality control seem at present, of outmost importance to further reduce the impact of technical defects on perioperative neurological complications. Angiography, Duplex Scanning and more recently angioscopy have been utilized as intraoperative assessments. All of them demonstrated imperfections of arterial reconstruction potentially at risk for early and late patency failure and indicated immediate intraoperative correction. In some report this behaviour determined a relevant reduction both on perioperative results and lesser incidence of early restenosis. Concerning postoperative control of carotid endarterectomy early restenosis represent the most important and more common failure after carotid endarterectomy. In spite of the efforts to clear the causes of this ph...
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Patients at risk of hyperperfusion syndrome after carotid endarterectomy are often severely hypertensive and have a high grade internal carotid artery stenosis with disordered autoregulation due to a loss of reserve capacity (RC).... more
Patients at risk of hyperperfusion syndrome after carotid endarterectomy are often severely hypertensive and have a high grade internal carotid artery stenosis with disordered autoregulation due to a loss of reserve capacity (RC). Cerebral RC can be studied by sophisticated and expensive technical devices (SPECT, PET). Recently it has been demonstrated that the transcranial Doppler (TCD) and acetazolamide provocation test can be used to assess RC. From September 1991 to January 1992, 36 patients were studied by the TCD and acetazolamide test prior to carotid endarterectomy to identify patients at high risk of the hyperperfusion syndrome. Preoperatively, the patients were studied by TCD at rest and after vasolidation with acetazolamide 1 g intravenously (i.v.). Mean blood flow velocity on the middle cerebral artery (MCAv) was recorded for the following 20 min at 5 min intervals. MCAv at rest was 49 +/- 17 cm/s. After acetzaolamide infusion in 33 patients (92%), the mean MCAv was 62 +...
Research Interests: Brain, Humans, Hypertension, Blood brain barrier, Female, and 15 moreMale, Risk factors, European, Aged, Middle Aged, Homeostasis, Acetazolamide, Carotid Endarterectomy, Risk Factors, Reperfusion injury, Cerebral Hemorrhage, Brain Edema, Carotid Stenosis, Transcranial Doppler sonography, and Postoperative Complications
Patients with severe bilateral carotid lesions (stenosis and contralateral internal carotid occlusion) are at high risk of having a stroke, and carotid endarterectomy has been proposed as the best treatment. In spite of improvements in... more
Patients with severe bilateral carotid lesions (stenosis and contralateral internal carotid occlusion) are at high risk of having a stroke, and carotid endarterectomy has been proposed as the best treatment. In spite of improvements in surgical technique, this operation is still associated with significant perioperative complications (5-13%) which are frequently (up to 40%) correlated with intolerance to internal carotid artery clamping. For this reason, intraoperative cerebral monitoring able to accurately detect ischaemia during surgery would be useful. Reviewing our experience from the last 7 years in 74 patients operated on for stenosis and contralateral occlusion of the internal carotid artery, we found a 1.3% neurological morbidity and 1.3% mortality rate. Presenting symptoms included focal transient ischaemia attacks (TIAs) in 57 patients, stroke in 16 patients and two patients were asymptomatic. Half of these patients (37) were operated on under general anaesthesia with elec...
Research Interests: Electroencephalography, Humans, Blood Pressure, Female, Male, and 15 moreBrain Ischemia, Risk factors, Dental Local Anesthesia, General Anesthesia, Aged, Middle Aged, Adult, Carotid Endarterectomy, Risk Factors, Intraoperative Neurophysiological Monitoring, Carotid Stenosis, Constriction, Carotid Arteries, Arterial Occlusive Diseases, and Intraoperative complications
In the early treatment of the patients with cerebrovascular insufficiency due to internal carotid artery stenosis, the presence of a cerebral infarct and especially the blood brain barrier breaking (BBB) are considered by many as a... more
In the early treatment of the patients with cerebrovascular insufficiency due to internal carotid artery stenosis, the presence of a cerebral infarct and especially the blood brain barrier breaking (BBB) are considered by many as a contraindication to early reperfusion by carotid endarterectomy (CEA). Generally, it has been recommended to differ the operation at least for 4-6 weeks because of the high risk to convert an ischemic infarct into an hemorrhagic one. On the other hand, because unfavorable natural history has been reported as for the progressing unstable neurological deficit as for the minor recent strokes, respectively by Millikan and Dosik, it seem to be justified a more aggressive management with the aim of: 1) eliminating the stenosis as embolic source of emboli; 2) obtaining early brain reperfusion to increase the probability of good recovery. Some previous experiences reported in the literature demonstrated satisfactory results of early reperfusion even in presence o...
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The authors report their experience from 1985 to 1988 with 75 consecutive patients affected by bilateral carotid artery stenosis in whom only one side was surgically treated and the other had a minor (15-45%) asymptomatic carotid... more
The authors report their experience from 1985 to 1988 with 75 consecutive patients affected by bilateral carotid artery stenosis in whom only one side was surgically treated and the other had a minor (15-45%) asymptomatic carotid stenosis. These patients have been followed for a period ranging from 10 to 50 months (mean follow-up 21 months) by clinical examinations and non-invasive investigations (Doppler CW, Duplex scanner). The non-invasive evaluation included assessment of haemodynamic data and characterisation of plaque morphology (regular vs. irregular or ulcerated surface, homogeneous vs. heterogeneous plaque). During follow-up eight patients died: two (2.6%) from acute myocardial infarction, four from stroke (5.3%), and two (2.6%) from other causes. Twenty-five patients (33.3%) had neurological symptoms related to the unoperated side: and four suffered stroke (5.3%). Twenty-one patients had TIAs (28%) related to the observed side. During follow-up five out of 29 (17.2%) homog...
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The contribution of the external carotid artery to cerebral blood flow in the presence of an internal carotid occlusion or severe stenosis is well documented. This study was undertaken in order to try and exploit the external carotid... more
The contribution of the external carotid artery to cerebral blood flow in the presence of an internal carotid occlusion or severe stenosis is well documented. This study was undertaken in order to try and exploit the external carotid artery as a collateral pathway to avoid cerebral ischaemia during carotid surgery. The main problem is to ascertain when the external carotid artery is relevant to cerebral perfusion, and to assess if the insertion of a shunt from the common to the external carotid artery is a useful way of ensuring adequate cerebral perfusion in patients with cerebral ischaemia during carotid clamping. In order to do this, it was necessary to assay the haemodynamic role of the external carotid artery by means of a technique which monitors cerebral function in a reliable way. We tried to evaluate this possibility by an intra-operative haemodynamic study during carotid surgery in 35 patients operated on under local anaesthesia. The insertion of a shunt between the common and external carotid artery was able to reverse brain ischaemia during clamping in four of eight patients with a neurological deficit during temporary carotid occlusion. In selected cases therefore cerebral protection with an external carotid shunt might be a valuable adjunct in the performance of carotid surgery.
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Research Interests: Cognition, Risk assessment, Prospective studies, Humans, Female, and 15 moreMale, Risk factors, Angioplasty, Aged, Middle Aged, Biological markers, Chi Square Distribution, Risk Factors, Risk Assessment, Predictive value of tests, Cognition disorders, Carotid Stenosis, Neuropsychological Tests, Diffusion magnetic resonance imaging, and Cardiovascular medicine and haematology
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The location of the carotid bifurcation and a very distal extension of internal carotid atherosclerotic disease may challenge vascular surgeons performing carotid endarterectomy (CEA) by increasing technical difficulty and possibly the... more
The location of the carotid bifurcation and a very distal extension of internal carotid atherosclerotic disease may challenge vascular surgeons performing carotid endarterectomy (CEA) by increasing technical difficulty and possibly the incidence of cranial nerve damage or palsies. The objective of the present study is to report on the safety of CEA with mandibular subluxation (MS) and to compare results of CEA in 2 groups of patients treated by standard CEA or by MS-CEA according to rates of major neurologic complications, death, and the occurrence of postoperative peripheral nerve palsy. Between July 2000 and June 2012, 1,357 CEAs were performed. MS was additionally used in 43 patients. Only patients with primary atherosclerotic internal carotid artery (ICA) lesions in the 2 groups (38 in the MS-CEA group and 1,289 in the standard CEA group) were considered for comparative analysis. MS-CEA patients were more frequently male (P = 0.03), presented more frequently with symptomatic lesions (P = 0.007), longer lesions (P = 0.01), and had common ICA bypass implantation (P = 0.02). Mean follow-up was 68.75 ± 37.87 months (range: 1-144 months). No perioperative neurologic mortality and no prolonged discomfort related to MS was recorded. The overall neurologic morbidity rate (major stroke/minor stroke/transient ischemic attach) was comparable in the 2 groups (P = 0.78). The overall immediate peripheral nerve injury rate was 7.89% in the MS-CEA group and 5.27% in the standard CEA group (P = 0.73). Three cases of permanent dysphonia in the standard CEA group (0.23%) and 1 case of dysphagia in the MS-CEA group (2.63%) were reported at follow-up (P = 0.24). MS-CEA can be a very useful technical adjunct for high-located carotid bifurcations or challenging carotid lesions, with an overall risk comparable to that of standard CEA.
Research Interests: Rome, Humans, Female, Male, Mandible, and 15 moreDislocations, Incidence, Risk factors, Clinical Sciences, Aged, Middle Aged, Adult, Risk Factors, Cerebrovascular Disorders, Predictive value of tests, Carotid Stenosis, Patient Positioning, Peripheral nerve injuries, Severity of Illness Index, and Reconstructive Surgical Procedures
We describe the occurrence of monolateral aseptic sialadenitis following non-iodinated contrast medium (ICM) administration for a carotid artery stenting procedure in a 71-year-old man. The mechanism for iodide-induced sialadenitis may be... more
We describe the occurrence of monolateral aseptic sialadenitis following non-iodinated contrast medium (ICM) administration for a carotid artery stenting procedure in a 71-year-old man. The mechanism for iodide-induced sialadenitis may be idiosyncratic or related to toxic accumulation of iodide. The risk for sialadenitis is directly related to serum iodide levels (> 10 mg/100 mL) and inversely related to normal renal function so that in renal impairment, ICM can be eliminated through alternative pathways such as the salivary glands and other excretory organs.