Publications by authors named "Luca Del Guercio"

30 Publications

  • Page 1 of 1

Sequential minimally invasive treatment of concomitant abdominal aortic aneurysm and colorectal cancer: a single-center experience.

Ann Vasc Surg 2021 Sep 4. Epub 2021 Sep 4.

Department of Public Health, Minimally Invasive General and Oncological Surgery Unit, University of Naples Federico II, Naples, Italy. Electronic address:

Background: The surgical management of concomitant occurrence of abdominal aortic aneurysm (AAA) and colorectal cancer (CCR) is still controversial. Conversely, benefits from a minimally invasive approach are well known concerning the treatment of both AAA and CCR. The aim of this study is to assess safety and feasibility of a sequential two-staged minimally invasive during the same recovery by EVAR technique and laparoscopic colorectal resection.

Methods: From January 2008 to December 2020 all patients with concomitant AAA and CRC were consecutively treated by EVAR and laparoscopic colorectal resection. Perioperative data were retrospectively collected in order to evaluate short and long-term outcomes following the sequential two-staged procedures.

Results: A total of 24 patients were included. The localization of the aneurysm was infrarenal abdominal aortic in 23 cases and in one case of common iliac artery. EVAR procedure has always been performed first. In 18 patients a percutaneous access has been used while in 6 patients a surgical access has been adopted. Twelve patients had cancer in the left colon, 9 in the right colon, and 3 patients had rectal cancer. No conversions or intraoperative complications had occurred during laparoscopic surgery. The major complications rate after EVAR and CRC surgery was 8.3% and 12.5% respectively. The mean interval between EVAR and CRC treatment was 7.8 ± 1 and the mean length of stay was 15,4 ± 3,6. No deaths occurred during hospitalization and between the procedures. Overall mortality was 20.8% with a mean follow up of 39,41 ±19.2 months.

Conclusion: Elective sequential two-staged minimally invasive treatment is a safe and feasible approach with acceptable morbidity and mortality rates and it should be adopted in current clinical practice to manage concomitant AAA and CRC.
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http://dx.doi.org/10.1016/j.avsg.2021.07.009DOI Listing
September 2021

Position Paper on Young Vascular Surgeons Training of the Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS): State of the Art and Perspectives.

Ann Vasc Surg 2021 Aug 25. Epub 2021 Aug 25.

Vascular Surgery Division, Thorax Institute, Hospital Clinic, Barcelona, Spain.

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded in 2018, with the aim to promote cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic peripheral artery was selected as the very first topic to be investigated by the federation. In this second paper, different experiences from delegates of participating countries were shared to define common strategies to harmonize, standardize, and optimize education and training in the Vascular Surgery specialty.
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http://dx.doi.org/10.1016/j.avsg.2021.08.002DOI Listing
August 2021

Efficacy and Safety of Jotec E-Ventus BX Stent Graft for Iliac Branch Device Procedure: A Retrospective Clinical Study.

Ann Vasc Surg 2021 Aug 23. Epub 2021 Aug 23.

Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa Catanzaro, Italy; Interuniversity Center of Phlebolymphology (CIFL), "Magna Graecia" University, Catanzaro, Italy. Electronic address:

Background: The endovascular aneurysm repair (EVAR) is a successful treatment for aorto-iliac aneurysms. The success of EVAR is enhanced by the use of devices that maintain the patency of targeted arteries namely the iliac branch device (IBD) With this study we aimed to evaluate the association between the use of Jotec E-ventus during EVAR with IBD and prognosis in patients with aorto-iliac aneurysms.

Methods: This is a retrospective, multicentric study enrolling patients referred to our Vascular Surgery Units from January 2015 to January 2020. All patients underwent EVAR with IBD using Jotec E-ventus as bridging stent. Primary endpoint was the development of types I and III endoleaks. Secondary endpoint was the onset of device occlusion with loss of vascular patency.

Results: We studied 32 patients (mean age 71.7±4.5y). Of these, 25 patients were treated with standard EVAR procedure whereas 7 were treated with isolated IBD due to extension of disease involving iliac bifurcation. Median follow-up lasted 15[IQR11-27] months. During follow-up, incidence rates for endoleaks and occlusion were 3.98(95%CI 0.48-14.41) and 1.99(95%CI 0.05-11.12) per 100 pts/year.

Conclusions: Jotec E-ventus during EVAR is associated with a low rate of severe complications in a small cohort of patients with aorto-iliac aneurysms.
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http://dx.doi.org/10.1016/j.avsg.2021.05.053DOI Listing
August 2021

The Impact of Chronic Kidney Disease on Peripheral Artery Disease and Peripheral Revascularization.

Int J Gen Med 2021 23;14:3749-3759. Epub 2021 Jul 23.

Department of Health Sciences, "Magna Graecia" University, Catanzaro, Italy.

Chronic kidney disease (CKD) is a clinical condition characterized by high morbidity and mortality. Globally, CKD is also increasing in prevalence and incidence. The two principal kidney measures namely estimated glomerular filtration rate (eGFR) and albuminuria have been found to be predictors of renal and cardiovascular (CV) endpoints including peripheral artery disease (PAD). The prevalence of PAD was increased in CKD patients and, particularly, in patients with more severe CKD stages. Despite the fact that revascularization strategies are suitable in CKD patients in similar fashion to non-CKD patients, few CKD patients underwent these procedures. In fact, if it is true that revascularization improves prognosis in PAD patients irrespective of baseline eGFR, it was also demonstrated that CKD patients, who underwent revascularization, were at higher risk for amputations, mortality, re-intervention and perioperative complications. With the present review article, we have examined the association between CKD, PAD and peripheral revascularization highlighting data about epidemiology, pathophysiologic mechanisms, and results from previous observational and intervention studies. We have also examined the future perspectives and challenges of research around the association between CKD and PAD.
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http://dx.doi.org/10.2147/IJGM.S322417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315808PMC
July 2021

The use of the Amplatzer Vascular Plug in the prevention of endoleaks during abdominal endovascular aneurysm repair: A systematic literature review on current applications.

Vascular 2021 Jun 14:17085381211025152. Epub 2021 Jun 14.

Department of Medical and Surgical Sciences, 9325University of Catanzaro, Catanzaro, Italy.

Objectives: The Amplatzer Vascular Plug (AVP) is a vascular occlusion device designed to provide optimal embolization in several fields of the endovascular surgery. A full literature review was conducted to analyze AVPs in comparison with coils for the prevention of endoleaks during endovascular abdominal aortic aneurysm repair.

Methods: A systematic review was designed under PRISMA statement guidelines for systematic reviews and meta-analyses. The results were updated with a subsequent electronic search using Medline and Scopus databases up to December 2019.

Results: Eighteen articles making this comparison were found. In 79.7% of the cases, the target vessel was the internal iliac artery; in 1.6%, the common iliac artery; and in 16.7%, the inferior mesenteric artery. Risk of complications (buttock claudication, groin hematoma, endoleaks, and erectile dysfunction) after AVP was low. A cost comparison revealed that the mean cost for coils was around US$2262, while the average cost for the AVP was US$310.

Conclusions: The AVP is an effective and safe device for occluding peripheral vessels, proved to have lower complications rates. Compared with coil embolization, the AVP technique is potentially associated with lower procedural costs.
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http://dx.doi.org/10.1177/17085381211025152DOI Listing
June 2021

The Role of Immunosuppressive Therapy in Aneurysmal Degeneration of Hemodialysis Fistulas in Renal Transplant Patients.

Ann Vasc Surg 2021 Jul 7;74:21-28. Epub 2021 Feb 7.

Department of Public Health, Vascular Surgery Unit, University Federico II of Naples, Naples, Italy. Electronic address:

Background: Venous aneurysms are long-term complications of arteriovenous fistula (AVF) for hemodialysis with an estimated incidence rate of around 5-6%. The purpose of our study is to investigate the role of immunosuppressive therapy in the development of AVF aneurysms in renal transplant patients, and to determine whether AVF closure following transplantation is necessary.

Methods: Forty-six patients with symptomatic venous AVF aneurysms underwent ligation and resection of their fistulas between January 2013 and January 2020. Immunohistochemical expression of CD3, CD4, and CD8 was assessed on the surgical specimens to characterize lymphocytic infiltrate in the aneurysm wall. Patients were subdivided into "Group A"-kidney transplant patients undergoing immunosuppressive therapy which was comprised of 39 patients and "Group B"-patients who had not undergone kidney transplant which was comprised of 7 patients. The 2 groups did not significantly differ in age, sex nor risk factors for aneurysms.

Results: Group A showed a significantly higher aneurysm diameter (P < 0.0001), mean flow (P < 0.0001) and required a longer duration of surgery (P = 0.0007). A CD3+ lymphocytic infiltrate was significantly more common in Group A than in the Group B (90% vs 29%; P < 0.001). No significant differences in localization (adventitia, media or intima) and type (CD4+ vs CD8+) of lymphocytes were found between the 2 groups.

Conclusion: AVF venous aneurysms were significantly larger and with a more intense T-lymphocytic infiltrate in patients undergoing immunosuppressive therapy. This finding suggests that immunosuppressive therapy plays a role in aneurysm formation, supporting the need for AVF closure in patients with an estimated low risk of rejection.
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http://dx.doi.org/10.1016/j.avsg.2021.01.097DOI Listing
July 2021

Case report of a large cephalic vein aneurysm inducing heart failure in a renal transplant patient with radio-cephalic fistula for haemodialysis.

Int J Surg Case Rep 2020 27;77S:S162-S165. Epub 2020 Aug 27.

Department of Surgical, Oncological and Oral Sciences, Vascular Surgery Unit, University of Palermo, Palermo, Italy.

Introduction: The autologous arteriovenous fistula (AVF) is considered the best vascular access for haemodialysis in patients with chronic kidney disease but in time can lead to several complications.

Presentation Of A Case: Herein we describe a case of a large cephalic vein aneurysm causing heart failure in a renal transplant patient being treated with radio-cephalic AVF for haemodialysis. The patient was judged to be at very high risk for potential catastrophic rupture of the aneurysm and his cardiac function was deteriorating so a surgical resection was offered. Under general anesthesia, a longitudinal incision was performed on the volar side of the forearm and the anastomotic junction was ligated. The cephalic vein aneurysm was isolated and a total resection of the vein, up to the joint of the elbow, was carried out. A specimen was also submitted for histological and immunohistochemical analysis.

Discussion: At present no clear indications pertaining to the need to close an AVF after kidney transplantation exist. Some authors recommend a closing of the fistula in patients with stable renal function to prevent the onset of complications, while others advise never to close the asymptomatic fistula in order to preserve vascular access for haemodialysis in case of graft failure.

Conclusion: Based on our clinical experience, we suggest not ligating vascular access during the first year following transplantation with the exception of patients needing emergent closure. Otherwise, surgical closure to prevent the onset of complications could be considered a viable option in the following subset of patients: those who are 3 or more years from transplantation with good and stable renal function, those with a significant growth of venous aneurysms or have a high AVF flow rate or are young patients.
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http://dx.doi.org/10.1016/j.ijscr.2020.07.055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7876928PMC
August 2020

Ancient schwannoma mimicking a carotid body tumor A case report and review of the literature.

Ann Ital Chir 2020 Jan 20;9. Epub 2020 Jan 20.

Ancient Schwannoma is a type of peripheral neurogenic tumor formed by the Schwann cells presenting mainly as a benign and asymptomatic lesion. The neurilemmoma tumor appears in different sites and, in cases of cervical location, can mimic a carotid body tumor. Herein we describe a clinical case of a 51-year-old woman with latero-cervical swelling. A contrast-enhanced computed tomography scan revealed a classical wineglass image mimicking a carotid body tumor. During surgery the tumor appeared connected to the cervical sympathetic trunk without carotid involvement. The histological exam confirmed the nature of the mass which consisted of an ancient schwannoma. A subsequent systematic review of the literature on ancient schwannoma incidence and treatment confirms it being a benign and rare lesion primarily treatable with open surgery. KEY WORDS: Ancient Schwannoma, Carotid body tumor, Carotid artery, Vascular surgery.
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January 2020

Long-term Results of Endovascular Treatment of TASC C and D Aortoiliac Occlusive Disease with Expanded Polytetrafluoroethylene Stent Graft.

Ann Vasc Surg 2019 Apr 17;56:254-260. Epub 2018 Oct 17.

Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.

Background: The aim of this study is to retrospectively analyze the early and long-term outcomes of endovascular treatment of Trans-Atlantic Inter-Society Consensus II class C and D (TASC II) aortoiliac occlusive disease with an expanded polytetrafluoroethylene-covered stent graft.

Methods: Between January 2006 and November 2017, 61 patients (53 males, 8 females), with symptomatic aortoiliac stenotic and/or occlusive disease, were treated with VIABAHN (W.L. Gore and Associates, Flagstaff, Ariz) at 2 University medical centers. The morphology of the lesions was evaluated and classified by contrast-enhanced computed tomography angiography. Demographic data, operation details, and postoperative outcomes were collected. Follow-up data were analyzed by a life-table analysis (Kaplan-Meier test).

Results: Mean age of the patients was 64.89 ± 10.77 years (range 44-89). Thirty-seven patients (60.7%) presented with severe claudication (Rutherford 3), whereas 21 (34.4%) were in Rutherford class 4 and the remaining 3 patients (4.9%) suffered from necrotic lesions (Rutherford 5/6). Fifty-six patients were smokers (91.8%), 38 (62.3%) had hypertension, 23 (37.7%) had coronary artery disease, 30 (40.2%) had dyslipidemia, 18 (29.5%) had chronic obstructive pulmonary disease, 6 (9.5%) had renal insufficiency (serum creatinine>2.0 mg/dL) and 24 (39.3%) had diabetes. Technical success was achieved in 59/61 patients (96.7%) with 16 patients (26.2%) requiring combined percutaneous brachial access to obtain iliac recanalization. Perioperative mortality was 1.6%, whereas postoperative major complications occurred in 2 patients (3.6%). The mean number of VIABAHN placed was 1.77/patient. Mean follow-up was 31.5 months (range 1-108) and primary patency at 36 months was 94.9%. Two major amputations of the lower limbs occurred during the follow-up.

Conclusions: Open surgery with the aortobifemoral bypass has been the gold standard treatment for complex aortoiliac occlusive disease although complications and mortality still remain significant issues. Our results suggest that endovascular therapy of TASC C and D iliac lesions using the VIABAHN stent graft is feasible, effective, and has good, long-term patency.
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http://dx.doi.org/10.1016/j.avsg.2018.07.060DOI Listing
April 2019

Ruptured Iliac Pseudoaneurysm after Intravesical Bacillus Calmette-Guérin: Urgent Endovascular Treatment. Case Report and Literature Review.

Ann Vasc Surg 2018 Nov 8;53:269.e1-269.e9. Epub 2018 Aug 8.

Vascular and Endovascular Surgery Unit, Department of Public Health, University Federico II of Naples, Naples, Italy. Electronic address:

Background: Ruptured mycotic aneurysms are an extremely rare complication of intravesical Bacillus Calmette-Guerin (BCG) immunotherapy. Several cases involving various arterial sites, mostly in the thoracic or abdominal aorta, have been described in the literature. BCG immunotherapy rarely causes false aneurysms and open surgical repair using an in situ prosthetic graft is most commonly performed. Further to this, targeted antituberculous treatment is required for at least one year following surgery.

Methods: A 69-year-old man presented at our clinic with fever, lower back pain and malaise. One year before admission he was treated, again, with intravesical BCG for recurrence of a carcinoma.

Results: A large infected pseudoaneurysm of 115mm was treated with the implantation of an aortouniiliac endoprosthesis followed by a crossover femoro-femoral bypass and surgical resection of the mass via an retroperitoneal approach.

Conclusions: Endovascular repair can be considered a valid option in an emergency. A hybrid approach was chosen due to the need for urgent action and the poor condition of the patient who was haemodynamically unstable. In particular, the implantation of an aortouniiliac endoprosthesis at the level of the contralateral iliac axis allowed us to avoid the release of an endoprosthesis at the infected area level. Close patient follow-up with clinical evaluation every three months and a CT-scan yearlyis mandatory following the intervention and during antibiotic therapy. A systematic review of the literature has been subsequently carried out on this specific clinical case, highlighting 47 cases described from 1988.

Case Report: A large infected pseudoaneurysm of 115 mm presented at our clinic was treated with the implantation of an aortouniiliac endoprosthesis followed by a crossover femoro-femoral bypass and surgical resection of the mass via a retroperitoneal approach.

Conclusions: Endovascular repair can be considered a valid option in an emergency. A hybrid approach was chosen due to the need for urgent action and the poor condition of the patient who was hemodynamically unstable. In particular, the implantation of an aortouniiliac endoprosthesis at the level of the contralateral iliac axis allowed us to avoid the release of an endoprosthesis at the infected area level. Close patient follow-up with clinical evaluation every 3 months and a computed tomography scan yearly is mandatory following the intervention and during antibiotic therapy. A systematic review of the literature has been subsequently carried out on this specific clinical case, highlighting 47 cases described from 1988.
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http://dx.doi.org/10.1016/j.avsg.2018.05.068DOI Listing
November 2018

A case of symptomatic popliteal vein aneurysm.

Ann Ital Chir 2018 Apr 20;7. Epub 2018 Apr 20.

We describe a case of a 44 year-old man with a subcutaneous swelling in the left popliteal fossa. The patient complained pain posteriorly to the left knee since several months and presented with a saccular aneurysm of the left popliteal vein (PVA) with reflux clearly evidenced at duplex ultrasound scan (DUS), but in absence of thrombus inside and without clinical signs of embolism. The patient was treated surgically by aneurysmectomy with lateral venorrhaphy according to Aldridge technique and a duplex ultrasound scan after six months revealed a complete patency of the left popliteal vein. According to literature evidences and our center experience, the surgical treatment of the popliteal vein aneurysm represents the gold standard in order to prevent the possible complications like development of thrombus inside the aneurysmatic vein and the consequent embolic risk and it is recommended in all case of a symptomatic saccular type of whatever diameter, and in fusiform type >20 mm, with or without thrombus.

Key Words: Complications, Popliteal vein aneurysm, Vascular Surgery.
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April 2018

The Endovascular Management of an Iatrogenic Superior Gluteal Artery Rupture Following Bone Marrow Biopsy.

Intern Med 2017 Oct 6;56(19):2639-2643. Epub 2017 Sep 6.

Department of Vascular and Endovascular Surgery, University Federico II of Naples, Italy.

We herein report an uncommon case of a life-threatening retroperitoneal hematoma after a bone marrow biopsy. Two hours after iliac crest bone harvesting, the patient experienced syncope and severe hypotension. Urgent contrast-enhanced computed tomography demonstrated extravasation from the superior gluteal artery. Transcatheter coil embolization was performed successfully, without complications. Life-threatening complications caused by retroperitoneal bleeding after bone marrow biopsy are very rare. There are few reports on the use of endovascular treatment in the management of life-threatening hemorrhagic complications after bone marrow biopsy.
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http://dx.doi.org/10.2169/internalmedicine.8195-16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5658532PMC
October 2017

Hemodialysis Arteriovenous Access Occlusion Using the Amplatzer Vascular Plug in Patients with Intractable Arm Edema.

Case Rep Nephrol Dial 2017 May-Aug;7(2):63-72. Epub 2017 Jun 23.

Vascular and Endovascular Surgery Unit, Department of Public Health, University of Naples Federico II, Naples, Italy.

Objectives: Vascular occlusion of hemodialysis arteriovenous access (AVA) using an Amplatzer vascular plug (AVP; St. Jude Medical, St. Paul, MN, USA) is an arising and alternative practice in selected patients; however, few reported cases can be found in the literature. Herein, we report on our experience with endovascular treatment of complicated AVA.

Materials And Methods: From September 2015 to December 2016, 3 patients at our clinic underwent an occlusion of hemodialysis AVA with 2 different Amplatzer vascular plugs: 2 patients with type II and 1 patient with type IV. Of these, 1 patient was treated for an autologous radiocephalic fistula, the second patient was treated for an autologous brachiocephalic fistula located at the elbow, and the third was, instead, treated for a radiocephalic forearm fistula. The reason for closing the AVA in all patients was due to the presence of dialysis-associated steal syndrome with critical hand ischemia and intractable ipsilateral edema.

Results: All AVAs were treated using an AVP. No plug migration, access revascularization, persistent ischemia, nor other complications were observed.

Conclusion: This report suggests that the use of AVP for embolization of complicated AVA is a safe and reasonable alternative to open surgery in selected patients.
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http://dx.doi.org/10.1159/000477663DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5566693PMC
June 2017

Severe Mesenteric Ischemia in a Pregnant Woman with Antiphospholipid Syndrome.

Ann Vasc Surg 2017 Oct 5;44:415.e11-415.e16. Epub 2017 May 5.

Department of Public Health, Vascular and Endovascular Surgery Unit, University Federico II of Naples, Naples, Italy. Electronic address:

The antiphospholipid syndrome (APS), either primary or secondary form, is considered an autoimmune disease with the presence of at least 1 clinical and 1 laboratory abnormalities as defined by the Sydney criteria. Clinical criteria include vascular thrombosis of venous, artery, small vessel in any organ, and recurrent pregnancy pathologies. Mesenteric ischemia is a rare and threatening manifestation of APS. We herein report a case of a 34-year-old pregnant woman referred to our Emergency Room with thoracic and abdominal acute pain. Her past medical history was remarkable for positivity to antiphospholipid antibodies, deep vein thrombosis of the right lower limb, chronic occlusion of celiac trunk, and superior mesenteric artery and recurrent abortions. Imaging revealed acute occlusion of inferior mesenteric artery (IMA). Both a surgical and endovascular thrombectomy were ineffective to obtain durable IMA patency and so the patient underwent antegrade aorta-inferior mesenteric bypass with saphenous vein and resection of an ischemic ileal loop. The medical treatment at discharge was lifelong oral anticoagulant associated with double antiplatelet therapy. To the best of our knowledge, this is the first case reporting a young pregnant woman with APS and mesenteric ischemia submitted to several attempts of revascularization. Aggressive oral anticoagulant and antiplatelet long-term therapy is advised. Moreover, we recommend strict follow-up in those patients in order to early diagnose thrombotic recurrence.
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http://dx.doi.org/10.1016/j.avsg.2017.04.035DOI Listing
October 2017

Endovascular treatment of spontaneous isolated abdominal aortic dissection.

Acta Radiol Open 2016 Dec 5;5(12):2058460116681042. Epub 2016 Dec 5.

Department of Vascular and Endovascular Surgery University Federico II of Naples, Naples, Italy.

Isolated abdominal aortic dissection is a rare clinical disease representing only 1.3% of all dissections. There are a few case series reported in the literature. The causes of this pathology can be spontaneous, iatrogenic, or traumatic. Most patients are asymptomatic and symptoms are usually abdominal or back pain, while claudication and lower limb ischemia are rare. Surgical and endovascular treatment are two valid options with acceptable results. We herein describe nine cases of symptomatic spontaneous isolated abdominal aortic dissection, out of which four successfully were treated with an endovascular approach between July 2003 and July 2013. All patients were men, smokers, symptomatic (either abdominal or back pain or lower limb ischemia), with a history of high blood pressure, with a medical history negative for concomitant aneurysmatic dilatation or previous endovascular intervention. Diagnosis of isolated abdominal aortic dissection were established by contrast-enhanced computed tomography angiography (CTA) of the thoracic and abdominal aorta. All nine patients initially underwent medical treatment. In four symptomatic cases, non-responsive to medical therapy, bare-metal stents or stent grafts were successfully positioned. All patients completed a CTA follow-up of at least 12 months, during which they remained symptom-free. Endovascular management of this condition is associated with a high rate of technical success and a low mortality; therefore, it can be considered the treatment of choice when it is feasible.
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http://dx.doi.org/10.1177/2058460116681042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5152934PMC
December 2016

Giant true Brachial Artery Aneurysm after Hemodialysis Fistula Closure in a Renal Transplant Patient.

Case Rep Nephrol Dial 2016 Sep-Dec;6(3):128-132. Epub 2016 Nov 1.

Operative Unit of Vascular and Endovascular Surgery, University Federico II of Naples, Naples, Italy.

The usual manifestation of brachial artery aneurysms is the incidental finding of a swelling of the arm, combined with paresthesia or pain in some cases. The etiology is often traumatic or secondary to drug abuse. Pathophysiology of brachial artery dilation in these cases is not completely clear. We herein describe a case of a 61-year-old male presenting with a giant, painful, pulsatile mass on his left arm. He was submitted to a cadaveric kidney transplant in 2005. He had a functioning arteriovenous fistula (AVF) on his right arm, and a spontaneously thrombosed radiocephalic AVF on his left arm. The aneurysm was surgically resected, sparing the median nerve that was totally entrapped and an inverted segment of the basilic vein interposed. At the follow-up, the patient did not present neurological or ischemic disturbs, and the vein graft maintained its patency.
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http://dx.doi.org/10.1159/000452299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5121550PMC
November 2016

Use of the directional atherectomy for the treatment of femoro-popliteal lesions in patients with critical lower limb ischemia.

Transl Med UniSa 2016 Nov 1;15:42-47. Epub 2016 Nov 1.

Vascular Surgery Unit, University of Palermo, Palermo, Italy.

Femoro-popliteal PTA for the treatment of critical limb ischemia is frequently associated with unsatisfactory procedural success rates while directional atherectomy (DCA) has improved success rate since claudicant patients undergoing percutaneous treatment of femoro-popliteal obstructive disease. The aim of this prospective study is to evaluate the safety, efficacy and procedural success of DCA, at one year, in the percutaneous treatment of femoro-popliteal obstructive disease in patients with critical limb ischemia.

Methods: From March 2012 to March 2013 18 consecutive patients with critical limb ischemia were treated with DCA (Turbohawk/Covidien-ev3 Endovascular Inc., North Plymouth, Minnesota, USA) for the treatment of femoro-popliteal obstructive disease. Patients were evaluated at 12 months.

Results: Technical and procedural success was achieved in every patient. No in-hospital major adverse cardiovascular events occurred. Primary endpoint: freedom from any amputation was obtained in all patients. Secondary endpoints: clinical (Rutherford class improvement) and hemodynamic success (Ankle-brachial index improvement) was achieved in all patients.

Conclusion: The use of DCA for the treatment of femoro-popliteal obstructive disease is a safe and effective therapeutic strategy for patients with critical limb ischemia. The data included in our study should be considered hypothesis-generating in order to design of a randomized trial comparison with conventional PTA.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5120749PMC
November 2016

Gluteal Compartment Syndrome Following Abdominal Aortic Aneurysm Treatment: Case Report and Review of the Literature.

Int J Low Extrem Wounds 2016 Dec 20;15(4):354-359. Epub 2016 Sep 20.

1 University Federico II of Naples, Naples, Italy.

Compartment syndrome (CS) is a pathological increase of the interstitial pressure within the closed osseous fascial compartments. Trauma is the most common cause, followed by embolization, burns, and iatrogenic injuries; it usually involves the limbs. The major issue when dealing with CS is the possibility to do an early diagnosis in order to intervene precociously, through a fasciotomy, reducing the risk of tissue, vascular and nervous damage. Although it is an infrequent condition, it is potentially life threatening. In our case report, we present a 59-year-old patient, smoker, affected by hypertension, dyslipidemia, chronic renal failure, and morbid obesity who came at our attention for a 6-cm abdominal aorta aneurysm, treated with an aorto-aortic graft. Within 24 hours from surgery, the patient presented acute ischemia of the right lower limb due to thrombosis of the common iliac artery and underwent the positioning of a kissing stent at the aortic bifurcation. In the immediate postoperative period, a relevant increase in serum creatinine, creatine phosphokinase, and myoglobin value was recorded, associated with clinical presentation of swelling in the right buttock with intense pain. The diagnosis of gluteal CS was confirmed by the measurement of the gluteal compartment pressure, which resulted of 110 mm Hg. The treatment of the CS consisted in gluteal dermofasciotomy, surgical debridement of the buttock, and positioning of negative pressure medication, associated with infusive therapy, avoiding hemodialysis. Because of the epidural anesthesia only later on it was possible to observe a persistent plegia of the right lower limb, which was solved within 1 month of neurological and physical therapy. With our experience, we can state that the CS is an extremely severe complication that can occur in vascular surgeries and it should therefore be kept in mind in the short-term postoperative period in order to guarantee a precocious diagnosis and immediate treatment.
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http://dx.doi.org/10.1177/1534734616663748DOI Listing
December 2016

Pre and postoperative evaluation of transcranial Doppler pulsatility index of the middle cerebral artery in patients with severe carotid artery stenosis.

Ann Ital Chir 2016 ;87:209-13

Unlabelled: In the management of severe carotid artery stenosis particular importance must be given to the evaluation of the risk of perioperative cerebral ischemic events. Our study analysed the possible relationship between the pre-operative middle cerebral artery Gosling Index, calculated after transcranial Doppler (TCD), and intra-operative stump pressure (SP), in order to identify patients with higher risk of ischemic accidents. Moreover, we studied pre- and post- operative Gosling Index values in association with possible events during follow-up. In a one-year time lapse 47 patients underwent either carotid endoarterectomy (CEA) or carotid artery stenting (CAS) with proximal embolic protection system. All patients were subject to pre- and post-operative TCD with calculation of the Gosling Index and intra-operative SP. We observed that higher pre-operative Gosling Index values are associated with lower intra-operative SP values, elements that represent a higher risk for cerebro-vascular ischemic accidents; this result is particularly evident when observing the diabetic sub-population. An increase in ischemic events did not present statistically significant differences when observing the populations treated with CEA or CAS. TCD and SP are valid and simple exams that can help identify precociously patients with a higher risk of cerebro-vascular accidents related to surgical or endovascular treatment.

Key Words: Carotid artery stenosis, Carotid endarterectomy, Endovascular treatment.
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October 2017

Management of finger gangrene caused by steal syndrome in vascular access for hemodialysis Personal experience and a brief review of the literature.

Ann Ital Chir 2015 May-Jun;86(3):239-45

Introduction: Severe dialysis-associated steal syndrome (DASS) is an uncommon and severe complication after arteriovenous fistula (AVF) creation that can lead to finger gangrene and amputation. As the number of patients on hemodialysis increases in western countries the number of patients at risk for DASS will continue to rise.

Methods: We retrospectively reviewed all patients who underwent a surgical intervention for the management of DASS with finger gangrene from January 2004 to July 2013. Demographic data, pre-operative work-up, procedure details and outcomes were collected. A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles. Cross-references from these articles were also used.

Results: A total of nine patients were identified. Mean age was 53 years, 67% were women. All patients presented with finger tissue loss or gangrene. Surgical procedures included AVF closure/ligation (5), distal artery ligation (DRAL) (2), distal revascularization with interval ligation (DRIL) (1), banding (1). All patients had improvement of symptoms during follow-up. No major amputation occurred.

Conclusions: Surgical interventions to correct DASS in patients with finger gangrene are mandatory while conservative management is not recommended. The decision for which type of procedure is made individually, according to clinical symptoms, technical findings, and patients' general state of health.
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September 2017

Emergency endovascular management of the common femoral artery rupture due to radiotherapy for scrotal carcinoma.

Acta Radiol Short Rep 2015 Jan 6;4(1):2047981614545154. Epub 2015 Jan 6.

Department of General Surgery, University Federico II of Naples, Naples, Italy.

We describe the case of a 72-year-old man with massive hemorrhage and shock resulting from rupture of the left common femoral artery as a complication of radiotherapy in the groin for cancer of the scrotum. This complication is extremely rare, presents dramatically, and is usually fatal. The patient was successfully treated with a stent graft deployment in order to achieve immediate hemostasis maintaining blood flow to the leg. Open surgery is not ideal in those cases especially when there is extensive tumor involvement of the groin causing altered anatomy and increasing the risk of re-bleeding.
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http://dx.doi.org/10.1177/2047981614545154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4299364PMC
January 2015

Acute lower limb ischemia complicating pemetrexed and carboplatin combination chemotherapy for malignant pleural mesothelioma.

Ann Ital Chir 2014 Nov 3;85(ePub). Epub 2014 Nov 3.

Pemetrexed and Carboplatin are two well-known chemioterapic agents used for the treatment of many tumors, especially for lung cancer and mesothelioma. Peripheral ischemic events related to Pemetrexed and Carboplatin are rarely reported. We herein report a case of lower limb acute ischemia related to combined treatment of Pemetrexed and Carboplatin. A 68-year-old woman was given the chemiotherapic treatment with combination of Pemetrexed and Carboplatin after pleural resection for a malignant pleural mesothelioma. Immediately after the second cycle of treatment, the patient experienced sudden acute left lower limb ischemia. Symptoms resolved after an intra-operative thrombolytic and spasmolytic therapy.
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November 2014

Accidental Coverage of Both Renal Arteries during Infrarenal Aortic Stent-Graft Implantation: Cause and Treatment.

Case Rep Vasc Med 2014 3;2014:710742. Epub 2014 Dec 3.

Department of Vascular and Endovascular Surgery, University Federico II of Naples, Naples, Italy.

The purpose of this paper is to report a salvage maneuver for accidental coverage of both renal arteries during endovascular aneurysm repair (EVAR) of an infrarenal abdominal aortic aneurysm (AAA). A 72-year-old female with a 6 cm infrarenal abdominal aortic aneurysm was treated by endovascular means with a standard bifurcated graft. Upon completing an angiogram, both renal arteries were found to be accidentally occluded. Through a left percutaneous brachial approach, the right renal artery was catheterized and a chimney stent was deployed; however this was not possible for the left renal artery. A retroperitoneal surgical approach was therefore carried out with a retrograde chimney stent implanted to restore blood flow. After three months, both renal arteries were patent and renal function was not different from the baseline. Both endovascular with percutaneous access via the brachial artery and open retroperitoneal approaches with retrograde catheterization are feasible rescue techniques to recanalize the accidentally occluded renal arteries during EVAR.
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http://dx.doi.org/10.1155/2014/710742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4269180PMC
December 2014

Prevalence and severity of asymptomatic coronary and carotid artery disease in patients with abdominal aortic aneurysm.

Angiology 2015 Apr 25;66(4):360-4. Epub 2014 Jun 25.

Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy

We evaluated the prevalence and severity of occult coronary artery disease (CAD) and cerebrovascular disease (CeVD) in patients with abdominal aortic aneurysm (AAA). We studied 100 consecutive patients with no history of CAD, normal electrocardiogram, normal systolic function, and no angina or dyspnea. All patients underwent carotid Doppler study and invasive coronary angiography. Significant CAD was observed in 61% of patients. In all, 51% of patients with significant CAD showed either left main (n = 7), 3-vessel (n = 17), or proximal left anterior descending (n = 7) CAD, corresponding to 31% of the total cohort. Cerebrovascular disease was detected in 53% of patients, and in 38% of them was significant (peak systolic flow velocity ≥125 <230 cm/s). In 36% of patients with CeVD either left main (n = 5), 3-vessel (n = 11), or proximal left anterior descending (n = 3) CAD was observed. Severe asymptomatic CAD is prevalent in AAA, and 31% of patients fulfill indications for coronary revascularization.
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http://dx.doi.org/10.1177/0003319714540319DOI Listing
April 2015

Carotid and vagal body paragangliomas.

Transl Med UniSa 2013 6;6:11-5. Epub 2013 May 6.

Vascular Surgery, Federico II University of Naples, Italy.

Between 1972 and 2012, 25 patients presenting 32 paragangliomas of the neck were observed. Tumor locations included the carotid body (CBTs) in 21 patients and the vagus nerve in 4. Four patients had bilateral CBT and one a bilateral vagal tumor; a metachronous bilateral jugulare paraganglioma was diagnosed in one patient with bilateral CBT Shamblin type III. Five patients presented CBTs type II and three type III. Preoperative embolization was performed in 5 CBTs, with no significant difference in blood loss. Twenty-nine paragangliomas were resected (with three internal carotid artery resection): there were no cerebrovascular accident or perioperative death. Nine patients (36%) had cranial nerve palsy prior to surgery and a postoperative nerve dysfunction occurred in four other tumors (16%). Persistent nerve deficits occurred in 3 patients (12%). No evidence of malignancy was shown, intraoperatively or during a postoperative follow-up period (9 months to 18 years; mean: 8 years).
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3829792PMC
November 2013

Effects of ranolazine in symptomatic patients with stable coronary artery disease. A systematic review and meta-analysis.

Int J Cardiol 2013 Nov 7;169(4):262-70. Epub 2013 Sep 7.

Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy.

Background: Ranolazine (R), as add-on therapy in symptomatic patients with chronic stable coronary artery disease (CAD), has been tested in randomized clinical studies. Aim of the study was to assess in a meta-analysis the effects of R on angina, nitroglycerin consumption, functional capacity, electrocardiographic signs of ischemia and hemodynamic parameters in patients with chronic CAD.

Methods: Randomized trials assessing the effects of R compared to control on exercise duration, time to onset of angina, time to 1mm ST-segment depression, weekly nitroglycerin consumption and weekly angina frequency were included in the analysis. The effects of R compared to control on heart rate and blood pressure were also analyzed.

Results: Six trials enrolling 9223 patients were included in the analysis. At trough and peak levels, R compared to control significantly improved exercise duration, time to onset of angina and time to 1mm ST-segment depression. Additionally, R compared to control significantly reduced weekly angina frequency and weekly nitroglycerin consumption. Finally, R compared to control did not significantly reduce supine systolic and diastolic blood pressure as well as heart rate, standing heart rate and diastolic blood pressure, whereas it modestly reduced standing systolic blood pressure. At sensitivity analysis, results were not influenced by concomitant background therapy.

Conclusions: In symptomatic patients with chronic CAD, R, added to conventional therapy, effectively reduces angina frequency and sublingual nitroglycerin consumption while prolonging exercise duration as well as time to onset of ischemia and to onset of angina with no substantial effects on blood pressure and heart rate.
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http://dx.doi.org/10.1016/j.ijcard.2013.08.131DOI Listing
November 2013

Embolization of a symptomatic pseudoaneurysm developing after transplant nephrectomy.

Intern Med 2013 15;52(2):291-2. Epub 2013 Jan 15.

Department of Vascular and Endovascular Surgery, University Federico II of Naples, Italy.

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http://dx.doi.org/10.2169/internalmedicine.52.9041DOI Listing
October 2013

Endovascular treatment of abdominal aortic anastomotic pseudoaneurysm. The experience of two centers.

Ann Ital Chir 2012 Nov-Dec;83(6):509-13

Department of Vascular and Endovascular Surgery, University of Palermo, Palemo, Italy.

Introduction: Abdominal aortic pseudoaneurysms are a rare but serious complication of aortic surgery. Treatment with traditional open surgery is associated with a high rate of perioperative mortality and morbidity. Endovascular treatment is less invasive and guarantees lower mortality and morbidity rates. The aim of this study was to evaluate the role of short-, medium- and long-term endovascular treatment of these pseudoaneurysms.

Materials And Methods: Over the past 10 years, 14 patients with abdominal aortic aneurysms, which developed after prior aortic surgery, underwent endovascular treatment involving implantation of an endoprosthesis at our institutions. Exclusion criteria were emergency treatment and suspicion of an infected prosthesis. A Cheatham-platinum covered stent mounted on a balloon catheter was implanted in one patient and self-expandable stent-graft in the other 13. No fenestrated or custom-made prostheses were used.

Results: The procedure had a 100% technical success rate. There was no postoperative mortality. Two type I endoleaks, observed at aortography at the end of the procedure, were not seen on the CT scan taken one month later. Three patients (21.4%) had major perioperative complications which consisted of early occlusion of a branch of the endoprosthesis, (treated with a femoro-femoral crossover bypass graft), a transient ischemic attack, and jaundice. The long-term mortality rate, at an average follow-up of 37.4 months, was 21.4%. None of the deaths was related to the procedure.

Conclusions: Endovascular treatment of patients who develop anastomotic pseudoaneurysm after surgery of the abdominal aorta is safe and effective both in the short and long term. In our opinion it is the treatment of choice for this category of patients.
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January 2013

External iliac artery pseudoaneurysm complicating renal transplantation.

Interact Cardiovasc Thorac Surg 2009 Jun 16;8(6):654-60. Epub 2009 Mar 16.

Department of Vascular and Endovascular Surgery, University Federico II, Naples, Italy.

Objectives: To assess the etiology, management and outcome of iliac pseudoaneurysms following renal transplantation.

Methods: Eleven patients who underwent repair between 1982 and 2007 were identified. Five (Group 1) presented pseudoaneurysm at the anastomosis of the donor renal and native iliac arteries, and six (Group 2) presented iliac pseudoaneurysm following transplant nephrectomy. Intraoperative cultures and immunohistochemical examinations were obtained from all surgical cases to determine the existence of a relationship between infection or transplant rejection and pseudoaneurysm formation.

Results: Endovascular repair (EVR) was used to treat three patients, while eight patients underwent open repair (OR). Transplant nephrectomy was needed in all cases but one after anastomotic pseudoaneurysm repair. After pseudoaneurysm excision, arterial reconstruction was performed in all cases, with a limb salvage rate of 100%. At 30 days, no patients died in the EVR subgroup. In the OR subgroup, one patient died of sepsis (12.5%). Cultures taken from the pseudoaneurysm wall and content grew Candida albicans and E. coli in two febrile patients. Pathologic evaluation of donor renal arteries revealed evidence of chronic rejection in three patients (60%) in Group 1, and in two (33.3%) in Group 2. No patients in either Group presented late infection, failure of vascular reconstruction nor pseudoaneurysm recurrence. The follow-up ranges from 20 to 89 months.

Conclusions: The etiology of pseudoaneurysms in this location is multifactorial, however, an association with chronic rejection must be considered. Though rare, the development of pseudoaneurysms at the donor renal-external iliac artery anastomosis results in high rates of transplant nephrectomy. Less invasive endovascular techniques offer a new therapeutic option in this challenging scenario notwithstanding the fact that they require further validation.
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http://dx.doi.org/10.1510/icvts.2008.200386DOI Listing
June 2009

Decreased paraoxonase-2 expression in human carotids during the progression of atherosclerosis.

Arterioscler Thromb Vasc Biol 2008 Mar 7;28(3):594-600. Epub 2008 Feb 7.

Dipartimento di Biochimica e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, Via S. Pansini 5, 80131 Napoli, Italy.

Objective: Many gene products involved in oxidation and inflammation are implicated in the pathogenesis of atherosclerosis. We investigated paraoxonase 2 (PON2), 5-lipoxygenase (5-LO), and 5-LO activating protein (FLAP) expression and malondialdehyde (MDA) levels in carotid lesions to assess their involvement in plaque formation.

Methods And Results: We measured gene expression and MDA levels in atherosclerotic plaques from 59 patients undergoing carotid endarterectomy, and in plaque-adjacent tissue from 41/59 patients. Twenty-three fetal carotids and 6 mammary arteries were also investigated. Real-time polymerase chain reaction and immunohistochemistry revealed decreased PON2 expression in plaques versus adjacent regions (P<0.005, P<0.001, respectively), mammary arteries (P<0.031, P<0.001, respectively), and fetal carotids (both P<0.001). mRNA levels of 5-LO and FLAP were higher (P<0.038, P<0.005, respectively) in lesions versus fetal carotids. MDA was higher in plaques versus plaque-adjacent tissue and fetal carotids. PON2 mRNA was downregulated by oxidative stress in 5 ex vivo experiments, thereby indicating its possible atheroprotection role.

Conclusions: We demonstrate that PON2 mRNA and protein are decreased in plaques versus plaque-adjacent tissue, mammary arteries, and fetal carotids. Our data indicate that the protective effect of PON2 could fail during atherosclerosis exacerbation; this was confirmed by the increase of MDA levels. The increase of 5-LO and FLAP mRNA expression confirms their role as inflammatory markers associated to atherosclerosis.
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http://dx.doi.org/10.1161/ATVBAHA.107.154658DOI Listing
March 2008
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