No abstract

Isolated and spontaneous superior mesenteric artery dissection is a rare cause of acute abdominal pain. Whereas there is widespread consensus on conservative treatment of asymptomatic forms, revascularization would seem indicated in symptomatic complicated cases. A 73-year-old man presented with worsening epigastric pain. A computed tomography scan revealed an isolated and spontaneous superior mesenteric artery dissection with aneurysmal evolution of the false lumen, involving multiple side branches. The postdissection aneurysm was treated by endovascular exclusion with flow-diverting stents. The abdominal pain was completely relieved, and the patient remained asymptomatic at follow-up.

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IntroductionPercutaneous endovascular abdominal aortic aneurysm repair (PEVAR) using the Perclose ProGlide suture mediated closure device is currently performed on a global scale. A safe, effective, and cheap technique for achieving haemostasis during PEVAR is described that allows the reversible downsizing of the arteriotomy, without using any other devices.TechniqueThe procedure consists of pulling the blue thread of the pre-implanted ProGlide, advancing the knot close to the arterial wall by pushing it with the dilator of a small introducer sheath, and maintaining the system under tension by grasping the end of the blue thread with a haemostat until bleeding control is achieved.DiscussionSeventeen PEVAR femoral access downsizing procedures have been performed between February and June 2018 and no complications were observed. The technique could be useful in everyday practice and has now become the author's standard practice.

artery (ICA) direct reimplantation were performed under shunting. Before suture completion, the shunt was removed, the carotid crossclamped (second clamping) and then the suture secured. Primary endpoints were 30-days mortality and relevant neurologic complication rate (RNCR), defined as the combination of perioperative major and minor stroke. A logistic regression was performed to identify predictors of RNCR among clinical and procedural factors, including also time period (2010-2014 vs 2015-2018) and operator experience (number of CEA per year). Results: One-hundred-sixty-nine CEAs were performed for crescendo TIA (n¼141, 83.4%) or acute ischemic stroke (n¼28, 18.9%). Mean age was 73.9AE7.4 years and 117 (69.2%) were male; 32 patients (18.9%) had concomitant contralateral stenosis !70% and 12 patients (7.1%) had contralateral ICA chronic occlusion. Mean delay of surgery from last symptom was 3.7AE5.4 days (median 2 days, range 0-60 days) and urgent surgery (< 48 hours) was performed in 65 cases (38.4%). Mean duration of surgery was 96AE28 minutes; first and second clamping time were 3.7AE1.1 minutes and 2.4AE0.7 minutes respectively. Standard CEA was performed in 107 patients (63.3%) while 62 (36.6%) received eversion CEA. There were no perioperative deaths; perioperative RNCR was 1.8% (major stroke: n¼ 2, 1.1%; minor stroke: n¼ 1, 0.6%). The presence of ischemic cerebral lesion at the preoperative CT (OR 2.55, 95%CI 0.11-27.60; P¼.45), contralateral carotid stenosis/occlusion (OR 0.52, 95%CI 0-17.7; P¼.99), clamping time (OR 0.27, 95%CI 0.04-1.43; P¼.10), urgent setting (OR 0.17, 95%CI 0.05-1.29; P¼.08), as well as operator experience (OR 1.2, 95%CI 0.23-12.32; P¼.66) and time period (OR 2.46, 95%CI 0.02-NA; P¼.99) were not significantly associated to increased RNCR risk. Conclusion: Routine shunting with delayed insertion after plaque removal seems to be a safe and effective technique, that contributed to maintain a low RNCR in neurologically symptomatic patients independently from major clinical factors, operator, and time period. Standardization of the surgical technique may be mandatory to maintain results over time.