Pseudoaneurysm is due to a disruption in arterial wall continuity. It forms a sac that communicates with the vessel lumen and is surrounded by the compressed, surrounding tissues and not by the wall of the artery from which the lesion arises. Many causes can predispose to the formation of a pseudoaneurysm such as trauma, surgical procedures, anticoagulation. In our patient another important risk factor for the formation of a pseudoaneurysm is ADPKD (autosomal dominant polycystic kidney disease) that can cause vascular complication. The mechanisms leading to the genesis of the pseudoaneurysms in our patient are unknown, but the clinicians should bear in mind when evaluating this type of patients that ADPKD may have a various range of systemic cardiovascular manifestation.

We report on a case of severe cystic adventitial disease involving the popliteal artery in a man aged 42, who in 2009 underwent surgical resection of the cyst and the tract of the involved artery. The arterial reconstruction was then performed with an autogenous graft, using a reversed small saphenous vein interposition. The surgical specimen was histologically examined. The postoperative course was uneventful, and the patient was discharged on the 8th day. Currently, on an 11-year long clinical follow-up, the patient is healthy, and the graft is patent. A pictorial essay of the clinical and pathological findings of the case is presented, along with a brief discussion covering the main issues relevant to the disease manifestations and diagnosis, clinical differential diagnoses, and the treatment options. The pertinent world literature has been reviewed as well.

Background This study aims to develop and validate a new classification system that better predicts combined risk of neurological and neurovascular complications following CBT surgery, crucial for treatment decision-making. Methods Multinational retrospective cohort study with 199 consecutive cases. A cohort of 132 CBT cases was used to develop the new classification. To undertake external validation, assessment was made between the actual complication rate and predicted risk by the model on an independent cohort (n = 67). Results Univariate analyses showed statistically significant associations between developing a complication and the following factors: craniocaudal dimension, volume, Shamblin classification, and Mehanna types. In the multivariate prognostic model, only Mehanna type remained as a significant risk predictor. The risk of developing complications increases with increasing Mehanna type. Conclusions We have developed and then validated a new classification and risk stratification system for CBTs, which demonstrated better prognostic power for the risk of developing neurovascular complications after surgery.

Background: Radiation therapy may accelerate atherosclerosis with progressive stenosis and occlusions of supra-aortic trunks. Methods and Results: We report the case of a 44-year-old woman with radiation-induced occlusion of the supra-aortic trunks presenting with recurrent cerebrovascular insufficiency after an unusual surgical revascularization technique (retrograde femoral-axillary bypass) performed for late failure of previous endovascular treatment. Conclusions: Customized surgical procedure can be considered as a bailout to improve cerebral blood inflow in selected cases.

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 (<3 cm), group II (3 to 5 cm) and group III (>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<0.001), Shamblin class III (P<0.001), Pulmonary disease (P=0.034) and surgery time (P<0.001) were statistically significant. The follow-up of 79 patients (87.8%) showed a 100% overall survival at median follow-up of 37.7 months (range 2-84.7 months) with freedom from local recurrence of 97.8% (77/79); CONCLUSIONS: Surgical resection remains the gold standard to obtain complete recovery, although tumor size is to be considered a risk factor for CNI because large CBTs remain at high risk for CNIs.

To analyze the perioperative results and long-term follow-up of open surgery among patients with a total chronic occlusion of the abdominal aorta.

National Highway Traffic Safety Administration (NHTSA) reports that seat belt use results in a significant decrease in MVC mortality. The rate of obesity is currently extensive. There is limited data on the impact of seat belt use and body mass index (BMI) on mortality and trauma outcomes following MVCs. This study aimed to evaluate the impact of seat belt use and BMI on outcomes in adult trauma patients.A four-year review using our Level I Trauma Center registry. Patients were divided by BMI into normal weight BMI < 25 (NL-BMI), overweight BMI 25–29.9, and obese BMI ≥ 30. Groupings were subdivided by seat belt use into patients wearing a seat belt at the time of injury (seatbeltPOS) and those who were not (seatbeltNEG).11,792 patients involved in MVCs were included in our study. 4515 (38.3%) were NL-BMI, 4583 (38.9%) were overweight, and 2694 (22.8%) were obese. SeatbeltPOS patients had significantly lower mortality compared to seatbeltNEG, regardless of BMI, with 12/1394 (0.86%) in seatbeltPOS compared to 274/10,398 (2.64%) deaths in seatbeltNEG patients (p ≪ 0.001). Evaluated by BMI, overweight and obese seatbeltPOS patients had significantly less deaths 7/900 (0.78%) vs overweight and obese seatbeltNEG patients 179/6377 (2.81%) (p = 0.0004). NL-BMI seatbeltPOS patients also had significantly lower mortality 5/494 (1.01%) compared to NL-BMI seatbeltNEG patients 95/4021 (2.36%), (p = 0.048).Use of a seat belt reduced Trauma Center mortality regardless of BMI. Seat belts should be used by all patients as a mechanism to significantly reduce mortality.

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.

Inflammation is a part of the initial process leading to atherosclerosis and cholesterol crystals (CC), found in atherosclerotic plaques, which are known to induce complement activation. The pentraxins C-reactive protein (CRP), long pentraxin 3 (PTX3), and serum amyloid P component (SAP) are serum proteins associated with increased risk of cardiovascular events and these proteins have been shown to interact with the complement system. Whether the pentraxins binds to CC and mediate downstream complement-dependent inflammatory processes remains unknown. Binding of CRP, PTX3, and SAP to CC was investigated in vitro by flow cytometry and fluorescence microscopy. CRP, PTX3, and SAP bound to CC in a concentration-dependent manner. CRP and PTX3 interacted with the complement pattern recognition molecule C1q on CC by increasing the binding of both purified C1q and C1q in plasma. However, CRP was the strongest mediator of C1q binding and also the pentraxin that most potently elevated C1q-mediated complement activation. In a phagocytic assay using whole blood, we confirmed that phagocytosis of CC is complement dependent and initiated by C1q-mediated activation. The pathophysiological relevance of the in vitro observations was examined in vivo in human atherosclerotic plaques. CRP, PTX3, and SAP were all found in atherosclerotic plaques and were located mainly in the cholesterol-rich necrotic core, but co-localization with the terminal C5b-9 complement complex was only found for CRP. In conclusion, this study identifies CRP as a strong C1q recruiter and complement facilitator on CC, which may be highly relevant for the development of atherosclerosis.

Inflammatory mechanisms may be involved in atherosclerotic plaque rupture. By using a novel histology-based method to quantify plaque instability here, we assess whether lectin pathway (LP) of complement activation, a major inflammation arm, could represent an index of plaque instability. Plaques from 42 consecutive patients undergoing carotid endarterectomy were stained with hematoxylin-eosin and the lipid core, cholesterol clefts, hemorrhagic content, thickness of tunica media, and intima, including or not infiltration of cellular debris and cholesterol, were determined. The presence of ficolin-1, -2, and -3 and mannose-binding lectin (MBL), LP initiators, was assessed in the plaques by immunofluorescence and in plasma by ELISA. LP activation was assessed in plasma by functional in vitro assays. Patients presenting low stenosis (≤75%) had higher hemorrhagic content than those with high stenosis (>75%), indicating increased erosion. Increased hemorrhagic content and tunica media thickness, as well as decreased lipid core and infiltrated content were associated with vulnerable plaques and therefore used to establish a plaque vulnerability score that allowed to classify patients according to plaque vulnerability. Ficolins and MBL were found both in plaques' necrotic core and tunica media. Patients with vulnerable plaques showed decreased plasma levels and intraplaque deposition of ficolin-2. Symptomatic patients experiencing a transient ischemic attack had lower plasma levels of ficolin-1. We show that the LP initiators are present within the plaques and their circulating levels change in atherosclerotic patients. In particular, we show that decreased ficolin-2 levels are associated with rupture-prone vulnerable plaques, indicating its potential use as marker for cardiovascular risk assessment in atherosclerotic patients.

SummaryThis is the first study to find that environmental Staphylococcus aureus and staphylococcal enterotoxins in a national population of inner-city adolescents with asthma are common and have the potential to drive asthma symptoms.

Plasmacytoid dendritic cells (pDCs) promote tolerance in solid organ transplants and hematopoietic stem cell transplantation (HSCT). pDCs originate from CD34+ hematopoietic progenitors. Following allogeneic hematopoietic stem cell transplant (allo-HSCT), pDC reconstitution in the BM and PB gradually attain levels similar to those in healthy individuals. We have investigated the recovery of pDC following allo-HSCT as a means to predict successful marrow engraftment. We retrospectively studied immune reconstitution of pDC in the BM of 48 patients following allo-HSCT for initial diagnoses of leukemia or other malignancies. Multi-parameter flow cytometry was used to detect the CD45+ CD123bright HLA-DR+ CD4low pDCs in BM aspirates at 2–14 months (median 6 months) post allo-HSCT. Percentages of pDCs were analyzed along with engraftment, acute graft-versus-host disease (aGVHD), event-free survival, relapse and death over a period of up to 39 months (median 30) following HSCT. We report that higher levels of pDCs in the BM post-HSCT are associated with successful engraftment, less severity of aGVHD, lower relapse rate, higher event-free survival and overall survival (P value < 0.05 for all). pDC levels detected at a shorter time interval 2–8 months (median 5 months) following HSCT also showed similar results. We conclude that pDC numbers are associated with HSCT engraftment and overall survival. Flow cytometry offers rapid quantification of pDCs as an early predictor of outcome following HSCT.

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 intra-operatively 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.

Introduction: In the rising era of endovascular treatment of thoracoabdominal aortic aneurysms (TAAAs), the analysis of long-term survival and visceral vessels patency after open surgical repair is crucial to allow future comparisons between these different approaches. This study reports the late outcomes of a single-center experience on open TAAA repair, focusing on the results of different techniques adopted for renal and splanchnic revascularization. Methods: Data were analyzed for 382 consecutive TAAA repairs performed between January 2009 and July 2015 (294 males; mean age 65.9 ± 10.1 years). TAAA extent was classified as Crawford types I (32), II (138), III (106), and IV (102) and Safi type V (4). Surviving patients were followed-up by means of computed tomography angiography (CTA) and office visit at 3 and 12 months, and yearly thereafter. Kaplan–Meier analysis was performed for overall survival, patency of reconstructed visceral vessels (celiac trunk, CT; superior mesenteric artery, SMA, right renal artery, RRA; left renal artery LRA), and reinterventions on visceral arteries. Also, visceral vessel long-term patency was analyzed in subgroups of patients according to the revascularization strategy (patch-inclusion of all vessels, Group 1; LRA separate reattachment + patch inclusion of the remaining vessels, Group 2; separate reattachment of all visceral vessels, Group 3). Results: In-hospital mortality and paraplegia occurred in 7.6% and 8.1% of patients, respectively. Of the 353 survivors, 338 adhered to follow-up protocol, and adequate CTA images were available in 247 patients (952 visceral vessels analyzed). Overall survival was 87%, 84% and 64% at 1, 3, and 5 years, respectively. At the same time-points, visceral vessel patency was 99%, 98% and 98% for CT, 100%, 100% and 100% for SMA, 100%, 96% and 96% for RRA, and 91%, 87% and 82% for LRA. Estimates for reinterventions on visceral vessels were 1.2%, 6.3% and 17% at the same time-points, respectively. Patients experiencing occlusion of at least one visceral vessel at follow-up were 10/94 (10.6%) in Group 1, 17/127 (13.4%) in Group 2, and 2/26 (7.7%) in Group 3. Conclusion: Open TAAA repair performed in high volume centers remains a safe and durable method, even in the endovascular era. Long-term patency of visceral vessels is high, irrespective of the technique used for revascularization. The left renal artery appears to be the vessel most prone to occlusion in time, even in case of single separate reattachment. Disclosure of Interest: None Declared.

SummAry Paragangliomas (Pgl) are rare lesions of the neuroendocrine system; in the neck, they usually affect the carotid glomus (carotid body tumours-CBT). This retrospective analysis reports our experience in management of these lesions in patients treated by surgical resection. Between 2000 and 2014, 33 patients were surgically treated at our institution, obtaining a series of 44 cervical Pgls. Tumour character istics, family history, diagnostic procedures, surgical treatment, short- and long-term outcomes were reviewed. A female prevalence was found (76% of cases). Familial cases occurred in 9 patients (20%); 6 presented with bilateral lesions and 1 had multiple paragangliomas. lymph node metastasis was not found in any patient. All lesions were classified into three groups according to the latero-lateral diameter. Complete resection of the Pgl was performed in all patients. mortality was null; transitory cranial nerve deficit occurred in 20% of cases with permanent palsy in 6.7%. no perioperative stroke/TiA were observed. Surgical resection of Pgl should be considered as the only therapeutic option because it can ensure complete removal of the disease. Patients with bilateral lesions and positive family history should be referred for genetic analysis. Preoperative planning of the surgical procedure by integrated diagnostic imaging and a full mastery of vascular surgery techniques are mandatory to minimise the risk of the most common postoperative complications. long-term follow-up is recommended, particularly in patients with familial disease or sporadic lesions treated in an advanced stage.

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 video-tapes 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. (C) 2015 Elsevier Ireland Ltd. All rights reserved.

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.

Infections of the aorta, eventually associated with aneurysm development, are rare (0.5-2.6%) with higher rates observed in Eastern countries (13%) 1-6. Only small series are available from the literature, so it is very difficult to identify risk factors for this disease; most patients are aged, with generalized sepsis and serious comorbidities often associated with a depressed immune response. Hospital mortality rates are high (16-44%) in spite of improvements in imaging, surgical techniques and available antimicrobial therapy; most of deaths are observed in patients with infections by Salmonella or Staphylococcus Aureus, in ruptured aneurysms and when the suprarenal aorta is affected 1. This retrospective, single-center study reports early and late results of treatment in 12 patients observed in the last 20 years.