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Background Low reliability of Revised Cardiac Risk Index (RCRI) in predicting major cardiac events (MACE) among Vascular Surgery patients emerged in recent literature, suggesting procedure-specific risk evaluation - particularly in major surgery. Methods-results Comorbidities, perioperative variables, RCRI and MACE were retrospectively analyzed in a consecutive series of 899 elective open abdominal aortic aneurysm (AAA) repairs performed at our Institution. Possible MACE predictors were studied through univariate/multivariable analysis (logistic regression, MVRE) and stepwise-backward elimination/odds ratio (MVR-SBE/OR). Patients were divided by clampsite in 2 subgroups: 1. infrarenal (690 cases); 2. pararenal (209 cases). RCRI resulted predictive for MACE in the whole dataset but its performance resulted lower for pararenal aneurysms (p = 0.11) than for infrarenal ones (p ≤ 0.00). Among RCRI covariates of the whole cohort, dilated cardiomyopathy (p ≤ 0.001), ischemic cardiopathy (p ≤ 0.01) and cerebrovascular disease (p ≤ 0.02) resulted predictive. Peripheral arteriopathy also related to MACE (p ≤ 0.03). At MVR-SBE/OR analysis, the following resulted to be MACE predictors: dilated cardiomyopathy (p ≤ 0.001), cerebrovascular disease (p ≤ 0.02), and surgical access (p = 0.04) in subgroup 1; previous myocardial infarction (p ≤ 0.01), congestive failure (p ≤ 0.03) and chronic pneumopathy (p = 0.04) in subgroup 2. Conclusions Predictability of RCRI in elective AAA surgery is influenced by clampsite and resulted to be lower in aneurysms requiring suprarenal clamping. Variables included in the RCRI show to have different weights when patients are stratified by clampsite. Some variables not included in the RCRI model significantly affect the onset of MACE. RCRI should be revised to elaborate a specific score for AAAs including further MACE predictors, to improve risk assessment and to support proper surgical strategy.

BACKGROUND: The aim of this study is to report our results with carotid body tumor (CBT) surgical management. METHODS: Between 2010 and 2018, 100 CBTs (mean age: 48.0 years, range 21-80 years old) were treated in our center. The patients were classified in 3 groups according to the size: group I (5 cm). RESULTS: Surgical resection was performed in 88 patients and conservative treatment in 2 cases. Nine patients were treated for bilateral involvement and one of them was also treated again for a relapse. Postoperatively, cranial nerve injury (CNI) was significantly higher in group II [3 (8.3%) vs. 16 (31.4%) vs. 2 (15.4%); P=0.030] with no statistical differences between the CN involved. At univariate analysis for CNI, CBT group (P=0.030), maximum diameter (P=0.046), patients presenting with dysphonia (P=0.035) and dysphagia (P=0.007) and patients suffering from any intraoperative complication (P=0.047) were statistically significant. At multivariate analysis the only significant variable was CBT group II (P=0.016). For blood loss, CBT group III (P

BACKGROUND: Carotid plaque has emerged as a marker of coronary heart disease (CHD) risk. Comparison of carotid plaque burden between different race/ethnic groups may provide a relative estimate of their future CHD risk. METHODS: We conducted a population-based study among apparently healthy middle-aged men aged 40–49 years (ERA JUMP study (n=924)) and recruited 310 Whites in Pittsburgh, US, 313 Japanese in Otsu, Japan, and 301 Koreans in Ansan, South Korea. Number of carotid plaque and CHD risk factors was assessed using a standardized protocol across all centers. The burden of carotid plaque was compared between race/ethnic groups after adjustment for age and BMI, and after multivariable adjustment for other CHD risk factors using marginalized zero-inflated Poisson regression models. Cross-sectional associations of risk factors with plaque were examined. RESULTS: Whites (22.8%) had more than four-fold higher prevalence (p

Purpose To correlate the degree of plaque vulnerability as determined by contrast-enhanced ultrasound (CEUS) with histological findings. Secondary objectives were to optimize the CEUS acquisition technique and image evaluation methods. Materials and methods Fifty consecutive patients, either symptomatic and asymptomatic referring to our department in order to perform carotid endarterectomy (TEA), were enrolled. Each patient provided informed consent before undergoing CEUS. Ultrasound examination was performed using high-frequency (8–14 MHz) linear probe and a non-linear pulse inversion technique (mechanical index: 0.09–1.3). A double contrast media injection (Sonovue, 2 mL and 4 mL; Bracco, Italy) was performed. Two videotapes were recorded for every injection: early “dynamic” phase and late “flash” phase, performed with 6 high mechanical index impulses. Movies were quantitatively and qualitatively evaluated. Qualitative and quantitative evaluation were statistically compared to immunohistological diagnosis of vulnerable plaque, considered as gold standard. Results Qualitative CEUS evaluation obtained high statistical results when compared to immunohistological results, with values of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of 94%, 68%, 87%, 85% and 86%, respectively, which became higher if considering only asymptomatic patient, with a NPV of 91%. Nevertheless, quantitative software evaluation proved less effective and could not reach similar results. Conclusion Carotid plaque enhancement assessed with CEUS well correlates with histological assessment of plaque instability. CEUS may provide valuable information for plaque risk stratification and may play a role in the indication to treatment of patients with carotid stenoses, particularly in asymptomatic population.

Background: In the era of rising endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs), the analysis of visceral vessel (VV) patency after open surgical repair is crucial to provide a future benchmark between these different approaches. This study reports the late outcomes of a single-center experience with open TAAA repair, focusing on the results of different techniques adopted for renal and splanchnic revascularization. Methods: Data were analyzed for 382 consecutive open TAAA repairs performed between January 2009 and July 2015 (284 men; mean age, 66 ± 10 years). Follow-up of surviving patients was carried out by computed tomography angiography and office checkups at 3 and 12 months and yearly afterward. Kaplan-Meier analysis was performed for overall survival, patency of reconstructed VVs (celiac trunk, superior mesenteric artery, right renal artery, left renal artery), and reinterventions on visceral arteries. Furthermore, VV long-term patency was analyzed in subgroups of patients according to the revascularization strategy (patch inclusion of all vessels, group 1; one-vessel separate reattachment and patch inclusion of the remaining vessels, group 2; separate reattachment of all VVs, group 3). Results: In-hospital mortality and paraparesis/paraplegia occurred in 7.6% and 8.1% of patients, respectively. Among the 353 survivors, 338 complied with the follow-up protocol, and adequate computed tomography angiography images were available in 247 patients (952 VVs were analyzed). Overall follow-up survival was 94%, 91%, and 70% at 1 year, 2 years, and 5 years, respectively. At the same time points, VV patency was 99%, 98%, and 98% for celiac trunk; 100%, 100%, and 100% for superior mesenteric artery; 100%, 96%, and 96% for right renal artery; and 91%, 87%, and 82% for left renal artery (log-rank test, P < .0001). Estimates for reinterventions on VVs were 1.2%, 6.3%, and 17% at the same time points. Freedom from occlusion of any VV at 1 year and 3 years was 95% and 87% for group 1, 89% and 79% for group 2, and 92% and 92% for group 3, respectively (log-rank test, P = .13). Conclusions: Long-term patency of VVs after open TAAA repair performed in high-volume centers is high, regardless of the technique employed for revascularization. The left renal artery appears to be most prone to occlusion over time.

To analyze the clinical features, surgical management and oncologic results of a series of six patients undergoing seven operations for resection of uterine leiomyoma extending into the right cardiac chambers.A retrospective review of patients operated on for surgical resection of a pelvic leiomyomatous mass originating from the uterus and extending into the right cardiac chambers was performed. The most common symptoms at presentation were syncope and dyspnea; two patients were asymptomatic. Four patients had been misdiagnosed as having intracardiac thrombus or primary cardiac tumor. The intracardiac and upper intracaval portion was removed under circulatory arrest in moderate hypothermia; the remaining portion was removed by caval incision. In one patient with cardiogenic shock, the sole intracardiac portion of the mass was removed at primary surgery. A mean of 2.8 +/- 1.5 years of follow-up was available, consisting of clinical and radiological tests (computed tomography scan, echocardiography).There were no cases of operative mortality in the present series. No recurrence was observed at the end of the follow-up in all cases of complete resection of the mass from its intracardiac to its pelvic end. Conversely, in the only case in which partial resection was performed due to the patient's clinical condition, recurrence of the intracardiac involvement was observed 6 months after primary surgery.Radical resection is curative for uterine leiomyomatosis extending into the right cardiac chambers. Surgery can be afforded with acceptable risks. A high level of suspicion for intracardiac extension of pelvic leiomyomatosis should be retained in the presence of a floating mass within the right cardiac chambers. Such a finding should prompt radiographic evaluation of the abdomen and the pelvis.

We report a case of acute necrotizing pancreatitis after extraperitoneal repair of an abdominal aortic aneurysm (AAA). Acute pancreatitis (AP) is an uncommon complication of vascular surgery; however, managing its local and general consequences, including the eventual pancreatic abscess and the risk of prosthetic infection, presents formidable challenges.

Objective This study presents a retrospective analysis of long-term outcomes and factors influencing early and late results of a 20-year experience with open repair of atherosclerotic pararenal abdominal aortic aneurysms (PAAAs). Methods Records of consecutive patients who underwent open repair of PAAA between 1990 and 2010 at a tertiary referral care center were analyzed for demographics, comorbidities, operative variables, complications, and 30-day mortality. Long-term results were also assessed through a local electronic medical database and direct follow-up. Variables influencing early and late results were evaluated by univariate and multivariate logistic regression analyses, stepwise backward elimination, and Cox proportional hazard regression. Results The study included 200 patients (94% men; mean age, 69.5 years) who were monitored for a mean of 107.3 months. The aneurysm was juxtarenal in 78% of patients, suprarenal in 19.5%, and type IV thoracoabdominal in 2.5%. Mortality at 30 days was 2.5%. At least one major complication occurred in 51.5%. Postoperative acute renal failure (pARF) occurred in 11% of the patients, 3% had temporary hemodialysis, but only 0.5% required chronic hemodialysis. pARF was significantly related to preoperative renal function ( P = .009), visceral ischemia >30 minutes ( P = .05), and supraceliac or supramesenteric clamp site ( P = .005). Respiratory complications (13.8%) were associated with an increasing stage of chronic obstructive pulmonary disease ( P = .020), proximal clamp site ( P = .047), and intraoperatively infused crystalloids ( P = .014). Cardiac complications (12.8%) were related to previous myocardial infarction ( P = .031) and proximal clamp site ( P = .003). Late deaths were observed in 21.5%. Mean survival was 50 months, with Kaplan-Meier survival estimates of 78% at 5 years and 60.5% at 10 years. Variables influencing long-term survival included age (hazard ratio [HR], 2.67; P = .01), chronic obstructive pulmonary disease stage 2 (HR, 5.14; P = .01) and stage 3 (HR, 4.54; P = .03), postoperative cardiac complication (HR, 3.93; P ≤ .00), previous myocardial infarction (HR, 1.47; P = .02), peripheral artery disease (HR, 1.97; P = .03), and smoking (HR, 1.17; P = .02). Survival and late-onset renal insufficiency were unaffected by preoperative renal function. Late renal failure was observed in 6.2% of the patients but did not predict mortality. Conclusions Conventional surgical repair of PAAAs can be performed with acceptable short-term and long-term mortality. Although pARF is frequent, chronic hemodialysis at discharge is rare. Cardiac and respiratory complications are also common and associated with worse survival. Our data represent a potentially useful benchmark for complex endovascular repairs of this type of aneurysm.

Background and Objectives: The clinical characteristics and patient outcome of a group of patients treated for differentiated thyroid carcinoma (DTC) were analyzed in order to assess the relative influence of different prognostic factors. Materials and Methods: We retrospectively reviewed data about sex, age, size and histologic behavior of the tumor, extrathyroid extension of the tumor, lymph node status, distant metastasis at diagnosis, surgical procedures, and overall survival from 234 patients treated for DTC. Data were submitted to a statistical analysis. Results: Using a univariate analysis, we found that survival rates were significantly influenced by age (P = 0.0001), size (P = 0.018), extra-thyroidal extension (P = 0.000001), lymph node involvement (P = 0.03), and distant metastases (P = 0.049). Age and size were independent prognostic factors at multivariate analysis (t = 2.694 and t = 2.443, respectively). Conclusions: On the basis of our results and of a review of the literature, we conclude that total thyroidectomy is the treatment of choice in DTC, except for small (

Retrospective review of aorto-iliac infections in a single vascular surgery center.From a retrospective review of their experience in the last 20 years, the Authors analyze a series of 12 cases of aorto-iliac infection. Prognostic factors, surgical options and results are discussed and compared with the literature.Infections of the aorta eventually associated with aneurysmal degeneration are uncommon (less than 3% of all aortic aneurysms) but still a life-threatening condition with high hospital mortality (25%). No statistical evaluation can be drawn from small series; however, early results are apparently influenced by emergency surgery and comorbidities affecting the immune response; in-situ reconstruction is associated with better long-term results (patency 100%, recurrent infection 0%).In our experience, in situ aortic grafting reconstruction associated with proper antibiotic therapy obtained satisfactory results in terms of mortality and long-term survival Endovascular treatment can be adopted in critical patients with prohibitive surgical risk.

Adrenal cysts are rare (0, 064%–0, 18% in autopsy series) and less than 500 cases have been reported in the western literature. Incidental diagnosis of adrenal cysts, however, is reported with increasing rates. We observed 12 patients with adrenal cyst. Each of them had a careful laboratory and instrumental evaluation; all the patients were operated. In our series about 67% of the patients were symptomatic (6 patients with abdominal pain, 1 with palpable mass, 1 with hemorrhagic shock). No biochemical alteration was observed. Conversely we observed an unusual subclinically hyperfunctioning cystic adenoma, potentially progressive to a clinically recognizable endocrine syndrome. US, CT and MRI had a sensitivity of 66, 7%, 80% and 100% respectively. Adrenalectomy was performed in all patients. The pathological findings were: 1 epithelial cyst (cystic adenoma), 2 endothelial cysts (vascular cystic ectasia with adenomatous adrenocortical hyperplasia and 1 vascular cyst) and 9 pseudocysts. On the basis of these results, we conclude that a careful hormonal, morpho-functional and instrumental evaluation is indicated in all adrenal cysts, even if the available diagnostic procedures, even when combined, cannot always define their nature. Surgical excision, when possible by laparoscopic approach, is indicated in presence of symptoms, endocrine abnormalities (even when subclinic), complications, suspicion of malignancy and/or large size (>5 cm). Adrenal gland must be excised en bloc, also because of the possible presence of other adrenal lesions.

Background. Recurrence of adrenal cortical carcinoma (ACC) after radical surgery is a common finding. Although successful reoperations have been reported with encouraging results, most published experiences are anecdotal and based on few cases. We report the results of surgical treatment for recurrent ACC in a multiinstitutional series. Methods. One hundred eighty-eight cases of ACC were collected in a national registry. A complete follow-up was obtained in 179 cases. At initial diagnosis 92 patients had local disease (stage I or II). One hundred seventy patients underwent surgical treatment, considered radical in 140; in this group, recurrent disease was observed in 52 cases (37%) after a mean disease-free interval of 21.7 months. Results. Adjuvant chemotherapy was ineffective in ameliorating the prognosis. The mean survival in 20 patients who underwent reoperation was significantly higher (15.85 ± 14.9 months) than in nonreoperated cases (3.2 ± 2.9 months). Five-year actuarial survival in reoperated patients is significantly better than in nonreoperated patients (49.7% versus 8.3%, respectively). Conclusions. Although the prognosis of this tumor is still poor, surgery is the only effective therapy; reoperation allows survival comparable to that observed in patients without recurrent disease. An aggressive strategy for recurrent ACC is advisable until prospective studies demonstrate a real effectiveness for chemotherapy.

Digestive and nutritional alterations are a common occurrence after pancreatic resections. The authors report the results of a multiparametric evaluation performed in a group of 26 patients submitted to total or cephalic pancreatectomy. Patients were divided into two groups according to the surgical procedure; group A (n = 13) included gastroresected patients and group B (n = 13) included those submitted to pylorus-sparing pancreatic resection. Subclinical digestive and absorptive impairment has been found in 61.5% of group A patients; the nutritional status was clinically poor in four cases from the same group. Digestive alterations have also been found in 69.2% of group B cases, but nutritional status was always satisfactory in the whole group. The more positive results obtained with the pylorus-sparing technique encourage wider adoption of this procedure.

One hundred patients with pancreatic cancer were evaluated between March 1981 and December 1989. This study showed that 61 were not candidates for definitive surgery because of nonoperability (28 patients) or nonresectability (33 patients). An additional 25 patients had cancers that were unresectable because of metastases (13 patients) or local spread of disease (12 patients) discovered at laparotomy. Fourteen patients had resectable cancers. Ten were treated by total pancreatectomy, three by distal pancreatectomy and one by pancreatoduodenectomy (Whipple). There were two operative mortalities. The median patient survival time was 20.5 months. Two patients survived 5 years. Five patients are alive at 3, 14, 18, and 47 months. Palliative surgical procedures performed in 18 patients included 10 biliary bypasses, 9 gastrojejunostomies, and 6 T-tube placements. This was associated with an operative mortality rate of 11%. The median survival time was 5 months. Other palliative measures included endoscopic placement of biliary and pancreatic stents (47 patients, 2.7% mortality rate), endoluminal radiation therapy, interstitial radiation therapy and external beam radiation therapy. The median survival time of patients so treated was 4.5 months.

Objectives. Carotid Body Tumor (CBT) is a rare lesion of the neuroendocrine system but it is the most common form of head and neck paraganglioma (PGL). Our objective is to discuss the optimal management of these lesions to provide the best outcome of patients treated by surgical resection. Patients and Methods. A retrospective evaluation was obtained by review of the records of 20 patients with 26 CBT treated at our institution between 2000 and 2012. Primary tumor characteristics, diagnostic protocols, surgical treatment, short and long-term outcomes were collected and analyzed. Results. A total of 26 CBTs resections were performed on 20 patients; the age range was 21-89 years. There was a female prevalence (14 women-80% and 6 men-20%). Familial cases occurred in 6 patients (30%); of these, 3 patients had bilateral lesions and 1 patient multiple paragangliomas. In all cases no lymph node metastasis was found. All lesions were grouped into three groups according to the latero-lateral diameter: Group I3 cm; Group II 35cm; Group III5cm. All patients were managed by surgical resection of the CBT. There were no operative deaths. Overall we found transitory neurological impairment in 15,3% and permanent neurological deficit in 7,6% of cases. No complications occurred in all resections of Group I tumors. In Group II only 1 resection was followed by dysphonia by recurrent nerve palsy (after vagal nerve en-bloc resection). In Group III only 1 resection was followed by permanent vagus nerve palsy. Conclusions. Surgical removal of the tumor is the only treatment that can ensure a complete eradication of the disease. Family screening is of great importance in patients with hereditary forms. Careful preoperative planning of surgical procedure by integrated diagnostic imaging and a full mastery of the surgical technique can minimize the risk of the most common postoperative complications. Lifelong follow-up is mandatory to make early diagnosis of recurrent disease.

Parathyroid carcinoma is a rare disease in normal population as well as in patients with end-stage renal disease. Approximately 700 cases have been reported and, of these, 20 occurred in patients receiving chronic hemodialysis. We describe a case of parathyroid carcinoma in a 59-year-old female patient with end-stage renal disease secondary to membranous glomerulonephritis treated by hemodialysis since 1995. In September 1998, the calcium level was 12.4 mg/dl and intact parathyroid hormone serum levels were 1366 pg/ml (normal range, 25-65). A routine ultrasonographic examination of the neck revealed enlargement of two parathyroid glands, the left inferior gland being the largest and measuring 2×3×2 cm. In October 1998, resection of two parathyroid glands was performed. On the basis of histology, which documented the presence of proliferating cells arranged in sheets or in a trabecular pattern, numerous mitosis and vascular invasion, a diagnosis of parathyroid carcinoma was made.