Renal artery aneurysm (RAA) is a rare entity that challenges vascular surgeons. We report the case of a 75-year-old male patient with a rare, giant 8 cm RAA and the open surgical approach after a failed endovascular attempt. Resection of the RAA and an aortorenal bypass with a polytetrafluoroethylene graft were performed by exteriorizing the left kidney to expose the renal hilum. We discuss the pros and cons of the attempt to help decision-making in similar RAA complex cases and the role of a multidisciplinary team to achieve the best result.

Concomitant abdominal aortic aneurysm (AAA) and bilateral iliac occlusive disease constitute a challenge for the application of endovascular repair of the aorta. We present the case of an 84-year-old man with an AAA, coronary disease, intermittent claudication of both legs, comorbidities including a hostile abdomen, and a stent protruding in the aneurysm sac following previous stenting of the right common iliac artery, and with a previous thrombosed axillobifemoral graft. We treated him with a hybrid retroperitoneal technique by placing an aortouniiliac (AUI) stent-graft via an intervening graft-conduit sutured to the bifurcation of the left common iliac artery following a semi-closed eversion ring endarterectomy of the left occluded common iliac artery. The intervening graft was then anastomosed to a new femoral-femoral bypass. The patient is in good condition with all vessels patent for twenty-one months following the operation.

Ectopic major renal arteries are rare but anatomically important because they can complicate aortic surgery and make the operation challenging for vascular surgeons. A 68-year-old male was presented with a 5.5-cm aneurysm of the infrarenal abdominal aorta combined with an ectopic main right renal artery arising from the middle of the aneurysm sac, perfusing a normotopic right kidney. The patient also had small right common iliac artery aneurysm. Open repair was performed with reimplantation of the right renal artery on the aortic tube graft, the right kidney was perfused with cold heparinized lactated Ringer solution during operation. The right common iliac artery aneurysm was wrapped with a polyester band. The patient's postoperative courses were uneventful, with normal renal function during 5 years of follow-up. Preoperative planning is important for achieving optimal results in treating complex aneurysms with ectopic main renal artery.

We report the case of a single 46-year-old woman presenting with huge uterine fibroids growing for the last 12 years, resulting in a recent common iliac vein thrombosis. Due to the high risk for pulmonary embolism, an occluding balloon was inserted through the right jugular vein before the abdominal incision and occluded the vena cava just inferior to the renal veins. The tumor was easily mobilized, and the vena cava bifurcation was exposed and controlled until the uterus with the masses was resected. We recommend this method for oncovascular surgeries involving deep vein thrombosis and vein thromboembolism.

Myocardial infarction (MI) is an eversion carotid endarterectomy (eCEA) complication, but most events are unknown, and true incidence and correlation remain controversial. Routine cardiac troponin measurement is a commonly used method for assessing early identification and treatment of MI and stratifying high-risk patients. The aim of the present study is to evaluate the effect of troponin elevation levels following eCEA and to investigate a possible correlation between adverse cardiovascular events and the incidence of postoperative myocardial infarction following emergent vascular surgery. The study included 54 patients who underwent eCEA. High-sensitive troponin I (hsTnI) levels were routinely monitored pre- and postoperatively, with an upper reference range of 34.5 pg/mL for men and 15.6 pg/mL for women. Increases were correlated with demographic and clinical risk factors, as well as clinical or subclinical cardiovascular events. hsTnI was increased in percentage (13%) postoperatively, and non-ST segment elevation MI was diagnosed in eight patients. No patient had clinical symptoms of MI and only two of them presented with simultaneous electrocardiographic changes. Increased levels did not correlate with comorbidities or other surgical risk factors. hsTnI elevation may occur in patients after eCEA and mostly correlates with silent non-ST segment elevation MI that occurred in the early postoperative phase, indicating a possible value as a tool for cardiovascular event diagnosis during the patient's hospitalization.

Purpose: The aim of the present study was to investigate a potential difference on the arterial stiffness among aneurysm patients and non-aneurysm controls, as well as to explore potential changes between patients treated either with endovascular or open repair. Materials and Methods: A 110 patients with an infrarenal AAA were prospectively enrolled in this study. Fifty-six patients received an EVAR, whereas 54 patients received an open surgical repair. Moreover, 103 gender and age-matched subjects without AAA served as controls. The cardio-ankle vascular index (CAVI) was applied for measurement of the arterial stiffness. Results: CAVI values were statistically higher in the AAA patients when compared with control subjects. Although at 48 hours postoperatively the CAVI values were increased in both groups when compared to baseline values, the difference in CAVI had a tendency to be higher in the open group compared to the endovascular group. At 6 months of follow up the CAVI values returned to the baseline for the patients of the open repair group. However, in the endovascular group CAVI values remained higher when compared with the baseline values. Conclusion: Patients with AAAs demonstrated a higher value of CAVI compared to healthy controls. A significant increase of arterial stiffness in both groups during the immediate postoperative period was documented. The increase in arterial stiffness remained significant at 6 months in EVAR patients. Further studies are needed to elucidate the impact of a decreased aortic compliance after stentgraft implantation on the cardiac function of patients with AAA.

Surgical resection remains the cornerstone for the treatment of oncological disease. When a critical arterial or venous structure is involved in a tumor mass, successful relief of symptoms and long-term oncological control are achieved through careful preoperative planning by an interdisciplinary team that necessarily includes a vascular surgeon. We describe the involvement of a vascular surgeon in the oncology of a 22-year-old woman, who is diagnosed with idiopathic retroperitoneal fibrosis.

Objective: This is a prospective study concerning patients with symptomatic or asymptomatic significant carotid stenosis. Preoperative and intraoperative measurements of the peripheral extension of the carotid atherosclerotic plaque have been compared with postoperative measurements to identify a preoperative method that safely allows the performance of eversion carotid endarterectomy (ECEA). Materials and Methods: The study included 37 patients with symptomatic internal carotid stenosis greater than 70% and 43 patients with asymptomatic stenosis greater than 80%. Four methods were used for establishing criteria: preoperative Doppler examination, intraoperative measurement of the carotid atheroma before artery division, measurement of the removed plaque, and histological measurement of the plaque. Results: Preoperative Doppler examination is a method of estimating the actual distal extension of the internal carotid artery (ICA) atheroma, with correction as dictated by the following formula: AL = 0.6704+0.7685. Doppler In all cases, preoperative ultrasound measurements and intraoperative estimation confirmed the correct decision to proceed with the eversion technique. Conclusion: The peripheral extension of the atherosclerotic plaque of the ICA can be assessed with accuracy by preoperative Doppler study, which can be used with safety as a predicting criterion of the existence of healthy peripheral carotid tissue that allows the performance of the eversion endarterectomy technique.

The technique of the eversion carotid endarterectomy (ECEA), as an alternative to the conventional endarterectomy with primary or patch angioplasty, is an established technique for managing internal carotid artery stenoses and recently its application has been upgraded through the European Society for Vascular Surgery guidelines (Recommendation 55: Class 1, Level A). However, the typical eversion method has been associated with postoperative hypertension due to loss of the baroreceptor reflex; the standard oblique transection at the bulb performed in the eversion endarterectomy interrupts either the baroreceptor sensoring tissue, which is mostly located in the adventitia at the medial portion of the proximal internal carotid artery, or even the proper Hering nerve, a branch of the glossopharyngeal nerve. These actions deregulate the natural negative feedback of the carotid baroreceptor. Guided by the anatomical location of the baroreceptor sensor we have elaborated a slight modification of the classical ECEA to maintain as much as possible of the viable carotid baroreceptor sensoring surface. By extending the oblique incision distal to the carotid bifurcation in the medial part of the internal carotid artery stem, an eyebrow-like part of the proximal internal carotid artery is maintained and the axis from the sensoring tissue to the nerve of Hering is protected and following the endarterectomy, postoperative arterial blood pressure levels are lower than in the classical ECEA due to the maintenance of the efficiency of the baroreceptor reflex. During the period from September 2016 to November 2018, carotid endarterectomy was performed in 57 patients. Twenty-eight of them underwent the typical ECEA and 29 patients had the modified eyebrow eversion carotid endarterectomy (me-ECEA). The changes of blood pressure baseline during the postoperative course in ECEA and me-ECEA group were analyzed and compared. Postoperative hypertension was defined as an elevation of systolic blood pressure (SBP) greater than 140 mm Hg. Patients who underwent typical ECEA had significantly higher postoperative blood pressure values compared with those who underwent me-ECEA. Actually, the mean postoperative SBP was 172.67 +/- 24.59 mm Hg in the typical ECEA group compared with 160.86 +/- 12.83 mm Hg in the me-ECEA group ( p = 0.023). The mean diastolic blood pressure in the ECEA group was 65.42 +/- 11.39 mm Hg compared with 58.06 +/- 9.06 mm Hg in the me-ECEA group ( p = 0.009). Our proposed me-ECEA technique seems to be related to lower rates of postoperative hypertension compared with the typical ECEA, probably due to the sparing of the main mass of the baroreceptor apparatus; this improved modification (me-ECEA) of the typical eversion procedure could represent an alternative ECEA technique with its inherent advantages.

There is a lack of guidelines concerning common carotid artery (CCA) occlusive disease in the presence of a patent internal carotid artery (ICA). A novel surgical technique that disobliterates an occluded CCA was successfully performed in three cases. The detailed surgical steps are presented herein. After proximal division of the CCA behind the sternoclavicular junction, the occluded CCA was endarterectomized via antegrade ring stripping. After removal of the atheromatous core, the CCA was everted, and the wall remnants were cleaned under direct vision. Simultaneous eversion endarterectomy of the ICA was performed when necessary. After reversion of the CCA, it was transposed and anastomosed to the ipsilateral subclavian artery distal to the orifice of the vertebral artery. This novel technique can be used in selected cases by experienced surgeons.

Introduction Secondary pancreatic metastasis from other solid organ malignancy is rare and accounts for less than 2% of all pancreatic tumors. The aim of this study is to highlight that colorectal metastatic disease in the pancreas could be in selected cases an indication for surgery rather than for palliative chemotherapy. Case Presentation We present a case of a 62-year-old Caucasian female with a history of rectal adenocarcinoma. Four years ago, the patient underwent low anterior resection of the rectosigmoid, post neoadjuvant chemoradiotherapy, with adjuvant chemotherapy. During her follow-up, imaging examinations revealed a lesion in the pancreatic neck with features indicating primary pancreatic cancer. Near-total distal pancreatectomy with en bloc splenectomy was performed. Histopathology revealed metastatic disease compatible with colorectal adenocarcinoma as the primary cancer. Second-line chemotherapy was decided from the institutional tumor board. The patient remains disease free one year later. Conclusion Pancreatic lesions in patients with a history of extrapancreatic malignancy should raise suspicions of metastatic disease. Surgical intervention is a legitimate treatment option for these pancreatic lesions, since they represent solitary disease deposits and of course in the context of multidisciplinary meeting decisions, and after proper and extensive staging investigations.

Penetrating atherosclerotic ulcers (PAUs) of the aorta are defined as atherosclerotic lesions with aortic intima and media ulceration, which may lead to a complete rupture of the adventitial wall. The present article aimed to report an unusual case of a surgically treated patient with abdominal aorta PAU with an illustration of the key features and to review and analyze the existing literature data. PAUs typically develop in elderly and hypertensive patients and in patients with advanced atherosclerosis. Although originally described for the descending thoracic aorta, a similar clinicopathological entity also occurs in the abdominal aorta. Patients with symptoms of a PAU should be treated immediately if they are fit for surgery. Exceptive observation by imaging modalities is necessary in patients with asymptomatic small (<2 cm) PAU, with or without focal dissection.

Parangliomas (PGLs) of the head and neck are quite rare tumors, and although the exact estimation of their incidence is difficult, they represent less than 0.5% of all head and neck tumors. They may arise from the carotid body, the vagal, tympanic, jugular paraganglia [1]. Less than 5% of head and neck PGLs originate from the vagus nerve [2]. The cranial nerve X or vagus nerve is the dominant nerve of the parasympathetic division of the autonomic nervous system; the vagus paraganglioma (VPGL) is a primary example of an endocrine tumor associated with the vagus nerve [3].

Paraganglia are clusters of cells originating from the neural crest with histological and cytochemical characteristics of neuroendocrine cells. Paragangliomas of the head and neck represent less than 0.5% of all head and neck tumors and they usually occur between the ages of 40 and 50. Paragangliomas in childhood and in adolescence are extremely rare; only 23 case reports have been reported in the recent literature. In childhood, the estimation of malignant potential is 3–10%; therefore, early diagnosis and treatment of carotid body paragangliomas are mandatory. However, due to the rarity of these lesions in young patients, they are often not included in the differential diagnosis of solid masses in the neck area, a fact that may lead to misdiagnosis or delay in treatment. We present, herein, two extremely rare cases of patients in adolescence who were diagnosed with a carotid body paraganglioma and were treated surgically in our unit. One of the patients was diagnosed and treated at the age of 15 years while the other had a long-standing tumor in the neck that was followed up by a general surgery outpatient service as a branchial cleft cyst at the age of 15 years and was eventually treated surgically 8 years later. Carotid body tumor was not considered in the initial differential diagnosis because of its rarity at this age range.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Vagal paragangliomas (VPGLs) represent <5% of all head and neck paragangliomas (PGLs) and show a 17% to 20% risk of malignancy. We present a rare case of a 50-year-old gender with a left VPGL in her neck. To date, approximately 200 cases have been reported. The tumor showed web-like adhesions and arterial supply from the external carotid artery. We performed en bloc resection including a part of the vagus nerve. The superior laryngeal nerve was preserved with the “human communicating nerve” which maintains neural communication in >70% of humans, providing motor fibers to the larynx. The patient recovered uneventfully and was discharged on the 3rd postoperative day. These tumors are therapeutically challenging owing to their proximity to vital neck and skull base structures. Early detection decreases surgical morbidity and mortality. Preservation of viable neural tissue is important in advanced disease.

BACKGROUND:Phleboliths are a common finding, especially in the pelvic veins. There are generally multiple thrombi associated with vascular malformations, trauma, or iatrogenic or noniatrogenic intravenous foreign bodies.METHODS:Herein, we report a unique case of a single moving phlebolith in the cephalic vein of a 65-year-old man, not associated with any vascular lesion, trauma, or foreign body.RESULTS:Too many cases of phleboliths have been reported in the literature since 1948, referred to vascular disorders, injuries, or foreign bodies. Only this work we are presenting refers to a phlebolith not associated with other vascular, pathological, or traumatic lesion.CONCLUSION:Phleboliths not associated with other vascular lesions are not common and less rare when not associated with injuries or iatrogenic interventions. Clinicians should be aware of the existence of this pathology and include it as the differential diagnosis of various pathological conditions.

INTRODUCTION:Although rare, co-existence of abdominal aortic aneurysms with urological manifestations, suggests a challenging surgical entity in terms of successful aneurysmal repair along with minimally or null urological complications.CASE REPORTS:There are neither available data regarding the incidence of their co-existence nor consensus regarding optimal surgical management. Given the infrequency of their simultaneous presentation, the report of unusual cases as well as proposal for successful surgical management, are always useful and educative.CONCLUSION:Precise imaging pre-operatively and meticulous surgical technique intra-operatively are of utmost importance and suggest our vast allies in successful outcomes. Herein, we present our small case series of 3 interesting cases.

Lymphangiomas are rare benign malformations of the lymphatic system, commonly present in children, over the head and neck area. Occasionally, they can grow significantly in size and especially those located over the cervical region can cause airway obstruction and become life-threatening. Recurrent lymphangiomas usually occur during the early postsurgical period and 80% of them within the first 3 to 5 years. However, in a new onset of clinical manifestations affecting the head and neck, even many years after the successful surgical treatment, a recurrent lymphangioma should be considered in the differential diagnosis. We present herein the second reported case, to our knowledge, of a recurrent left-sided neck lymphangioma in a young man, 23 years after a successful surgical treatment that initially took place 6 weeks after his birth.

Although the aneurysm of the splenic artery represents the third most common abdominal arterial aneurysm next to the aortic and iliac aneurysms, the aneurysm of the gastroepiploic artery is extremely rare occurring at a frequency of 3-4% of all visceral arteries' aneurysms; only 17 cases have been reported in the English literature. We present the case of a 65-year-old woman with an asymptomatic visceral artery aneurysm, which was an incidental ultrasonography finding. Magnetic resonance imaging showed an arterial aneurysm close to the peripheral splenic artery with intense tortuosity of the celiac and splenic artery. Abdominal computed tomography angiography confirmed the existence of an arterial aneurysm with a diameter of 2.3 cm near the splenic hilus without identifying the involved vessel. Endoluminal treatment was considered cumbersome due to anticipated anatomic obstacles; the patient underwent an elective open surgery in which the tortuosity of the celiac and splenic arteries and the aneurysm of the left gastroepiploic artery were revealed. The aneurysm was resected after proximal and distal ligation of the gastroepiploic artery; the flow of the splenic artery was intact. Histologically, it was a true aneurysm. The patient left the hospital on the fourth postoperative day without any complication. Historically, most aneurysms of the gastroepiploic arteries have been observed in men in the sixth decade of their life and after rupture; in modern times, their early incidental apocalypse is frequent due to the widespread use of imaging studies. Diagnostic approach and preoperative planning is of paramount importance to avoid complications. Current therapeutic modalities include catheter-based techniques or laparoscopic surgery.