rome and Emergencies

Visceral artery aneurysms (VAAs), although rare, represent a life-threatening disease with high mortality rates. With the more frequent use of diagnostic tests, there has been an incidental detection of these lesions which are mostly asymptomatic. It follows that surgeons are increasingly called to decide on the most appropriate management of VAAs between an open surgical or endovascular approach and among the different endovascular options currently available. The aim of this retrospective study was to evaluate the results of open surgery and interventional endovascular strategies of visceral artery aneurysms with respect to technical success, therapy-associated complications, and postinterventional follow-up in the elective and emergency situation.. From January 1992 to January 2017, 125 open surgical or endovascular interventions for VAA were performed at our institution. Once the VAA was diagnosed and the indication for treatment was assessed, the preoperative diagnostic work-up consisted of contrast computed tomography (CT) or magnetic resonance imaging (MRI) and, in some patients, digital subtraction angiography. Follow-up included clinical and duplex ultrasound scan (DUS) and contrast-enhanced ultrasound to assess the treated vessel patency and organ perfusion after 1, 6, and 12 months, and yearly thereafter. CT or MRI controls were also performed at 1 year of follow-up and only when DUS was not diagnostic or showed a complication thereafter. After the first 5 years of follow-up, the status of the patient was obtained by a structured telephone survey.. The treatment option was endovascular in 56 of 125 cases (44.8%). Technical success was 98.3%. In one case, the procedure was interrupted for the extensive dissection of the afferent vessel. Twenty-six patients were treated by coil embolization while 29 with covered stenting. The endovascular approach was in emergency in two cases (3.6%). In the endovascular group, mortality was nil. Complications occurred in 5 cases (8.9%): 1 subacute intestinal ischemia caused by superior mesenteric artery dissection, 2 aneurysm reperfusion, 1 stent thrombosis, and 1 massive splenic hematoma. In 69 (55.2%) cases, surgical treatment was preferred, with 24 VAA resections and 45 arterial reconstructions. In 20 cases (29%), open surgery was performed in emergency conditions. In the surgical group, 8 emergency patients (40%) died intraoperatively. The mortality after elective surgical interventions was nil. Complications after surgery were 4 graft late thrombosis (5.8%): asymptomatic in three cases and requiring splenectomy in one.. There is no overall consensus regarding the indications for treatment of VAA. Currently in emergent setting, the endovascular approach should be considered as the first choice because of its reduced invasiveness, faster way to access and bleeding control; this accounts for the lower morality of the interventional therapy than open surgery. Endovascular approach is effective for elective repair of VAAs, but procedure-related complications may occur in a not negligible number of patients. Given comparable mortality rates and low procedure-related complication rate, surgical approach still has space in the elective management of VAAs, especially for aneurysms unsuitable or challenging for the endovascular option in patients with low surgical risk. The size, location, and morphology of VAAs, systemic or local comorbidities, and specific anatomical situations such as previous abdominal surgery should dictate treatment choice.

Topics: Aged; Aneurysm; Arteries; Elective Surgical Procedures; Embolization, Therapeutic; Emergencies; Endovascular Procedures; Female; Humans; Male; Postoperative Complications; Retrospective Studies; Risk Factors; Rome; Stents; Time Factors; Treatment Outcome; Viscera

Acute angioedema represents a cause of admission to the emergency department requiring rapid diagnosis and appropriate management to prevent airway obstruction. Several drugs, including angiotensin-converting enzyme inhibitors (ACE-I), nonsteroidal anti-inflammatory drugs (NSAIDs) and oral antidiabetics, have been reported to induce angioedema. The aim of this prospective observational study conducted in a setting of routine emergency care was to evaluate the incidence and extent of drug-induced non-histaminergic angioedema in this specific clinical setting, and to identify the class of drugs possibly associated with angioedema. Patients admitted to seven different emergency departments (EDs) in Rome with the diagnosis of angioedema and urticaria were enrolled during a 6-month period. Of the 120,000 patients admitted at the EDs, 447 (0.37 %) were coded as having angioedema and 655 (0.5 %) as having urticaria. After accurate clinical review, 62 cases were defined as drug-induced, non-histaminergic angioedema. NSAIDs were the most frequent drugs (taken by 22 out of 62 patients) associated with the angioedema attack. Of the remaining patients, 15 received antibiotic treatment and 10 antihypertensive treatment. In addition, we observed in our series some cases of angioedema associated with drugs (such as antiasthmatics, antidiarrheal and antiepileptics) of which there are few descriptions in the literature. The present data, which add much needed information to the existing limited literature on drug-induced angioedema in the clinical emergency department setting, will provide more appropriate diagnosis and management of this potentially life-threatening adverse event.

Topics: Angioedema; Emergencies; Emergency Service, Hospital; Female; Humans; Incidence; Male; Prospective Studies; Rome

The chimney graft (CG) technique, based on the deployment of a covered stent parallel to the aortic endograft, has been proposed to achieve a safe proximal fixation extending the sealing zone. We report our experience with the CG technique in an emergency setting. Between December 2010 and April 2012, 4 patients underwent the CG technique. The mean age was 79 (range 76-82 years) and 3 patients were men. The median aneurysm diameter was 64.7 mm (range 63-68 mm). Indications for CG were painful proximal para-anastomotic aneurysm in 2 cases and symptomatic juxtarenal aneurysm in the other 2. Target vessels were both the renal arteries. Technical success was achieved in 100% and no intraoperative complications occurred. No stent-related complications, or Type I endoleak, were detected. No death occurred during the postoperative course. Creatinine elevation was observed in 2 cases. At follow-up, no endoleaks or rupture occurred. One patient died of myocardial infarction 3 months after the procedure. The primary patency rate of covered stents was 100%. The CG technique seems to be safe and feasible with an excellent patency rate of covered stents and a low incidence of endoleaks. More evidence in the literature is needed to carry out a validation of this technique in an emergency.

Topics: Aged; Aged, 80 and over; Aneurysm, False; Aortic Aneurysm, Abdominal; Aortography; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Emergencies; Endovascular Procedures; Female; Humans; Male; Rome; Stents; Tomography, X-Ray Computed; Treatment Outcome

Hospitals without percutaneous coronary intervention (PCI) capabilities are used to transfer patients who need coronary angiography and/or PCI to other centers. In order to optimize economic resources and hospital bed management, PCIs might be performed with an in-service organization, with re-transfer to the community hospital immediately after the procedure. The aim of our study was to evaluate the safety of a consecutive, unselected series of in-service PCIs compared to PCIs performed in patients admitted to hospitals with cath-lab capabilities.. During 2008, 1030 PCI procedures were performed at the European Hospital and Aurelia Hospital: 905 in patients admitted to a hospital with PCI capabilities (Group I) and 125 (12%) with an in-service strategy (Group II) referring from the Città di Roma Hospital. All treatment protocols were preventively uniformed and standardized.. The two groups were statistically comparable in terms of baseline clinical characteristics and/or procedural findings, with the exception for older age (66 +/- 10 vs 70 +/- 10 years, p = 0.004) and a higher prevalence of acute coronary syndromes (56 vs 88%, p < 0.001) and femoral vascular access (94 vs 98%, p = 0.03) in Group II. The rate of left ventricular ejection fraction < or = 35% (20 vs 13%, p = 0.06), multivessel PCI (23 vs 19%, p = 0.4), and glycoprotein IIb/IIIa inhibitor use (15 vs 13%, p = 0.5) was similar between the two groups. Among patients treated with an in-service strategy, 2 (1.6%) were not transferred to the community hospital, because of hemodynamic instability. The in-hospital rate of major clinical events (death for cardiovascular causes, cerebrovascular events, urgent revascularization, stent thrombosis) was 0.75% and 0.8% (p = 0.8), 1.8% and 1% (p = 0.4) for periprocedural myocardial infarction, 1.7% and 1.9% (p = 0.5) for major bleeding, 1.1% and 1.6% (p = 0.6) for vascular complications, in Group I and II, respectively. Left ventricular dysfunction was the only independent predictor of major clinical events (p = 0.003).. A strategy of in-service organization for PCI presents a similar rate of in-hospital clinical events and complications compared to an overnight stay into a hospital with PCI capabilities. Such a strategy may be utilized in order to optimize economic resources and hospital bed management.

Topics: Acute Coronary Syndrome; Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Coronary Angiography; Emergencies; Feasibility Studies; Female; Humans; Male; Middle Aged; Myocardial Infarction; Patient Transfer; Referral and Consultation; Retrospective Studies; Risk Factors; Rome; Safety; Surgery Department, Hospital; Survival Analysis; Time Factors; Treatment Outcome

Identification and treatment of patients with acute chest pain due to acute coronary syndrome is a common and difficult challenge for emergency physicians. The aim of this study was to establish: a) the reliability of diagnosis of acute myocardial infarction met in the emergency ward, b) the length of the patient's hospital stay with acute myocardial infarction discovered and treated in the emergency ward either with primary angioplasty or with thrombolysis.. We analyzed the data collected in the emergency ward of the San Camillo Hospital in Rome from January 1 to June 30, 2000, with patients suffering from chest pain and diagnosis after hospitalization. The reliability of diagnosis of acute myocardial infarction was calculated from the comparison of the diagnosis in the emergency ward and the diagnosis at hospital discharge.. From January 1 to June 30, 2000, 45,810 patients have asked for help at the emergency ward; 2334 (5.1%) of these were suffering from chest pain. The diagnosis of acute myocardial infarction was done in the emergency ward in 147 cases (141 hospitalized, 4 deceased, and 2 transferred to other hospitals), equal to 65% of all those discharged with the same diagnosis in the period under examination. In 66 out of the 141 cases hospitalized (46.8%) primary angioplasty was successfully performed; in 14 (9.9%) only coronary angiography was performed (primary angioplasty unfeasible); in 22 (15.6%) thrombolysis was administered whereas in 38 cases (27.0%) other treatments were used. The average stay for the different groups turned out to be 9.8 +/- 4 days for primary angioplasty and 12.9 +/- 4 days for thrombolysis: the difference was relevant.. The accuracy value of the diagnosis of acute myocardial infarction made in the emergency ward of our Hospital is the same as that published in the international literature and demonstrates the high level of treatment of chest pain. Furthermore, the shorter hospital stay obtained by primary angioplasty in comparison with thrombolysis seems to strengthen the already favorable cost-benefit ratio of primary angioplasty in comparison with thrombolysis.

Topics: Adult; Aged; Aged, 80 and over; Chest Pain; Emergencies; Female; Hospitals; Humans; Length of Stay; Male; Middle Aged; Myocardial Infarction; Reproducibility of Results; Rome