Abstract: OBJECTIVES: Morbidity and mortality after conventional surgery of aortic arch aneurysms remain high. Alternative techniques are the subject of this report. METHODS AND RESULTS: Open surgery requires cardiopulmonary bypass and hypothermic circulatory arrest. Thoracic endovascular aneurysm repair has a less invasive therapeutic alternative. The number of high-risk patients has considerably increased over the past decade. The proximity of the aneurysm to the supraaortic vessels makes it difficult to achieve a satisfactory proximal landing zone for endovascular stenting. Two methods have been proposed to address this issue: branched stent grafts and extraanatomic bypass, defined as a hybrid approach, which combines aortic debranching and endovascular procedures. Experience with hybrid repair is limited. Today there are no formal guidelines for the management of aortic arch aneurysm in high-risk patients. CONCLUSION: Hybrid repair of aortic arch aneurysm in high-risk patients is a feasible and safer option.
Abstract: This report describes the case of a 60-year-old woman with a history of hysterectomy for myomas, totally asymptomatic, with incidental evidence of a pelvic intracaval mass extending to the right atrium. She underwent a staged procedure (sternothomic and abdominal) through a thoracolaparotomic approach in circulatory arrest and deep hypothermia. Using a one-stage surgical approach, we were able to withdraw one portion of the mass from the right atrium and another from the abdominal inferior vena cava, thus minimizing the risk of unexpected venous or atrial wall injury during surgical manipulation.
Abstract: OBJECTIVES: This study tested the hypothesis that silent embolic infarcts on computed tomography (CT) brain scans can predict ipsilateral neurologic hemispheric events and stroke in patients with asymptomatic internal carotid artery stenosis. METHODS: In a prospective multicenter natural history study, 821 patients with asymptomatic carotid stenosis graded with duplex scanning who had CT brain scans were monitored every 6 months for a maximum of 8 years. Duplex scans were reported centrally, and stenosis was expressed as a percentage in relation to the normal distal internal carotid criteria used by the North American Symptomatic Carotid Endarterectomy Trialists. CT brain scans were reported centrally by a neuroradiologist. In 146 patients (17.8%), 8 large cortical, 15 small cortical, 72 discrete subcortical, and 51 basal ganglia ipsilateral infarcts were present; these were considered likely to be embolic and were classified as such. Other infarct types, lacunes (n = 15), watershed (n = 9), and the presence of diffuse white matter changes (n = 95) were not considered to be embolic. RESULTS: During a mean follow-up of 44.6 months (range, 6 months-8 years), 102 ipsilateral hemispheric neurologic events (amaurosis fugax in 16, 38 transient ischemic attacks [TIAs], and 47 strokes) occurred, 138 patients died, and 24 were lost to follow-up. In 462 patients with 60% to 99% stenosis, the cumulative event-free rate at 8 years was 0.81 (2.4% annual event rate) when embolic infarcts were absent and 0.63 (4.6% annual event rate) when present (log-rank P = .032). In 359 patients with <60% stenosis, embolic infarcts were not associated with increased risk (log-rank P = .65). In patients with 60% to 99% stenosis, the cumulative stroke-free rate was 0.92 (1.0% annual stroke rate) when embolic infarcts were absent and 0.71 (3.6% annual stroke rate) when present (log-rank P = .002). In the subgroup of 216 with moderate 60% to 79% stenosis, the cumulative TIA or stroke-free rate in the absence and presence of embolic infarcts was 0.90 (1.3% annual rate) and 0.65 (4.4% annual rate), respectively (log-rank P = .005). CONCLUSION: The presence of silent embolic infarcts can identify a high-risk group for ipsilateral hemispheric neurologic events and stroke and may prove useful in the management of patients with moderate asymptomatic carotid stenosis.
Abstract: After the incidental intraoperative discovery of a paraganglioma of cranial nerve XII, we searched our hospital database and literature for similar cases to determine whether evidence exists to support the existence of paraganglioma of the hypoglossal nerve. We describe a case of cranial nerve XII paraganglioma, recognized only during surgery, without any indicative preoperative sign or symptom nor diagnostic imaging studies. In light of published findings, only four cases described since 1966, and our experience, the report discusses diagnostic criteria that could aid in establishing a diagnosis of hypoglossal nerve paraganglioma based on a reasonable degree of medical certainty.
Abstract: The authors present the case report of effective conservative treatment in a patient with spontaneous, self-limiting, non-atherosclerotic dissection of the superior mesenteric artery (SMA) without fixed obstruction of the vessel lumen and signs of intestinal ischemia. Treatment with both anti-coagulant and anti-hypertensive agents succeeded in limiting the progression of intimal dissection and in preventing the potential dramatic sequelae of this rare clinical condition. Conservative treatment of spontaneous SMA dissection may be an alternative to surgery, if residual blood flow is maintained.
Abstract: A 62-year-old man was incidentally diagnosed with a completely asymptomatic aberrant right subclavian artery (ARSA) aneurysm with a maximum diameter of 4.5 cm. This condition presents a postrupture mortality rate of 50% and the morbidity-mortality rates reported in the literature with traditional open repair procedures are of 25%. In our patient we planned a hybrid procedure and excluded the aneurysm by performing, first, a right carotid-subclavian bypass with ligation of the subclavian artery upstream from the vertebral artery and the internal mammary artery and, the day after, by covering its origin from the aortic arch with the placement of a thoracic endoprosthesis. A third session was necessary, three days later, because of a leak; a complete resolution of the condition was achieved by embolizing the still perfused residual aneurysmal sac with Balt metallic coils.
Abstract: Pseudoaneurysms of the sovra-aortic trunks are uncommon lesions that usually have a post-traumatic etiology. The singular case of a patient who developed an innominate artery pseudoaneurysm (IAP) where a stent had been inserted 12 years earlier to manage severe innominate trunk stenosis is described. A chronic and large (8 cm in diameter) IAP was successfully treated in extracorporeal circulation and deep hypothermic circulatory arrest. The distal tract of the ascending aorta and the proximal aortic arch were substituted; total replacement of the innominate trunk with a singular 8-mm Dacron graft was necessary. We reviewed the literature about the reports of IAPs and the management of this singular lesion.
Abstract: AIM: This article describes four cases of leiomyosarcoma treated in the University Hospital of Turin and reviews current understanding of the biological behavior of the tumor, together with essential diagnostic procedures and established approaches to treatment. METHODS: Between February 2004 and December 2005, four patients (two men and two women; mean age 57.5 years) with leiomyosarcoma of the interior vena cava (IVC) were treated at the Vascular Surgery Unit. Resection and excision of the tumor were carried out (4/4 patients), with resection of the IVC above and below the mass (2/4) and reconstruction of the vein with a Dacron prosthesis with termino-lateral reimplantation of the renal vein in one and placement of a polytetrafluorethylene graft in the other. RESULTS: The postoperative course was unremarkable; the patients were discharged between postoperative days VIII and XI. Oral anticoagulant therapy with dicumarol (3/4) was given to maintain venous or prosthesis patency during the follow-up period. The mean length of follow-up was 23 months (range, 16-28). All patients recovered without local recurrence of disease. CONCLUSION: This malignant slow-growing tumor produces late clinical manifestations, making the study of its natural history clinically important. Currently, surgical excision is the only therapy that can alter disease progression and improve survival. The utility of adjuvant chemo- and radiotherapy remains controversial.
Abstract: An increasing body of health care regulations and the growing concern of physicians and patients about health care services have sharpened the debate surrounding the concept of quality in medicine. Once unknown terms such as audit, peer review, accreditation, ISO 9000, quality assurance (QA), continuous quality improvement (CQI) and risk management have become more familiar but also less clear. Following recent reports, medical error has been cited as a result of a health care system that has not yet fully embraced the tenets of quality management. A clearer explanation of definitions, knowledge and procedures is therefore needed. In Italy, the general debate on surgical risk led to a proposal to implement control systems that would monitor the work of each team member in the operating room, from the patient's arrival to transfer to the floor. But to understand the dynamics of doubtful cases, we need to start from new concepts that release the surgeon from the role of ''high priest in the surgery temple.'' Such concepts would underpin a process analysis of how much is effectively done and by whom. This means, on one hand, developing a greater awareness of one's role and competences, and on the other, delineating the stages within which each health care professional is expected to operate. Entering into the debate are the guidelines scientific societies have drawn up to rationalise and improve health care delivery through recommendations directed at optimizing the efficacy and efficiency of surgical intervention as the result of scientific evaluation and clinical observation. However, the critics in question do not always allow the surgeon to work under a medico-legal ''guarantee'' that covers his medical conduct. Further-more, they can be a double-edged sword in court if not adequately considered and critically evaluated with regard to a specific case, the object of censure and charge. In fact, they can be ''exploited'' as an instrument of accusation or defence in an arena where the mass media rush to blame the surgeon but later forget to duly report the acquittal of charges held against the surgeon. The present article examines the light and dark sides of guidelines, taking as an example those profiled by the Italian Society of Vascular and Endovascular Surgery and based on international guidelines for the treatment of symptomatic carotid stenosis.
Abstract: AIM: Varicose veins of the legs are a common condition affecting 10-15% of men and 20-25% of women in the western world. This high prevalence is responsible of high medical and social costs. Most primary varices are associated with greater saphenous vein (GSV) incompetence. A new method, radiofrequency (RF) endovenous obliteration (VNUS-Closure'' procedure), recently has been described as a less invasive and cost-saving alternative to stripping for the treatment of refluxing GSV. METHODS: Twenty-four patients with varicose veins underwent endovenous obliteration of the above knee GSV by VNUS Closure'' procedure. The vein diameters were from 5 to 10 mm. The RF catheter was inserted via percutaneous puncture or through a small skin incision. All operations were performed in local, tumescent anesthesia, under ultrasound guidance. All patients were discharged 2 h after operation. Clinical and ultrasound follow-up was performed at 1 week, and at 1, 6, 12, 24 months. RESULTS: The complete or partial occlusion of the treated segment of the GSV has been achieved in 23 cases. In only one patient persisting patency of the GSV was immediately detected after the procedure. That was successfully treated by ultrasound guided foam sclerotherapy. All patients could resume all normal activities within 3-5 days. Every patient had reduction of varicosities, leg pain, fatigue and oedema. Adverse sequelae were minimal: 2 patients had transient thigh paresthesias. We didn't report deep venous thrombosis or pulmonary embolism (mean follow-up 26.7 months, range 15-33 months). CONCLUSION: A literature review and the authors'experience reveal that, in absence of significant complications, such as deep vein thrombosis and pulmonary embolism, there are significant advantages in the RF endovascular obliteration of the GSV. In effect, the Closure'' procedure, in selected patients, offers reduced postoperative pain, shorter sick leaves, faster return to normal activities compared with vein stripping, and it appears to be cost-saving for society. The mid-term (36 months) recurrence rates after RF obliteration seem to be similar to the results of the conventional surgical management.
Abstract: Activated C protein resistance is a common coagulation defect caused by factor V Leiden mutation and is associated with an augmented risk of predominantly venous thrombosis. Augmented tendency to arterial thrombosis is sporadically reported. This case report describes femoropopliteal thrombosis in a young patient with heterozygous V Leiden factor mutation. Progressive thrombotic occlusion required amputation of the forefoot which resulted in stump dehiscence. Poor blood supply to the perilesional substrate delayed wound healing. An optimal though not yet definitive result was achieved after months of accurate medication. The criticality of lower limb ischemia in an otherwise healthy young patient underscores the grave impact this condition can have on the patient's quality of life and on health care costs.
Abstract: In Italy the diagnostic and therapeutic radiology practice is regulated by special laws, which are changed acting in accordance with EURATOM directive so that other specialists can use radiological instrument, such as orthopedic surgeons and cardilogists do. Medical and technological progress enables vascular surgeons to choose other treatments alternative to conventional surgery in the treatment of some vascular diseases by the use of radiological instruments. In our country there are special laws for the practice of radiology, so we verify if vascular surgeons can legally perform endovascular procedures using radiological techniques.
Abstract: The anatomic anomalies of the supra-aortic trunks and their branches are comparatively frequent observations. They often remain asymptomatic throughout life although in some cases, especially if nothing is known of them, they may complicate surgical interventions involving that anatomical region. The case of a female patient who, during thyroidectomy, suffered the ligature of her external carotid artery which was taken mistakenly for the thyroid, is reported. Dissection of the area made it possible to identify an anomaly of the vascular structures with a carotid bifurcation which turned out to be very low, a very deep internal carotid artery on the prevertebral fascia and an absent lower thyroid artery. In the postoperative period, the patient was subjected to MR of the neck. This showed an anatomical anomaly of the left carotid bifurcation which was much lower than normal. An attempt was made to reconstruct the external carotid artery with a saphenous vein but unsuccessfully. The incident did not have serious complications for the patient but it might be asked whether, given the low cost and the absolute non-invasiveness of the examination, it might not be worth while to carry out a duplex scan of the supra-aortic trunks before going ahead with any operation in the cervical region, in consideration above all of the dangerous nature of these vascular structures and of the usefulness of studying pathologies that often remain silent until the occurrence of an event which might well be catastrophic.
Abstract: Cystic adventitial disease (CAD) of the popliteal artery is a rare but well-known cause of intermittent claudication, especially in young patients. The etiology of the disease is still controversial and the literature reports various hypotheses for its origin. Diagnosis starts with thorough history taking and physical examination; non invasive diagnostic studies comprise color duplex scanner (ECD), computed tomography (CT), better if elicoidal (3D CT) and magnetic resonance imaging (MRI), which can aid in establishing correct recognition of the disease in most cases. A 48-year-old man presented with intermittent right calf claudication that had begun 4 months earlier; the symptom-free interval was about 100 m. MRI and MR angiography of right popliteal fossa revealed the presence of an oval cystic (maximum diameter 45 mm). The caudal aspect of the cyst showed pedicles protruding between the popliteal vein and the popliteal artery that compressed the artery, causing complete occlusion of its lumen. Surgery was performed through the posterior approach using an S-shaped incision; the affected segment of the popliteal artery was successfully excised and replaced with an autogenous external saphenous vein graft. A follow-up is underway, both clinical and with; no cyst recurrence has so far been detected either clinically or by duplex scanner during the 15-month postoperative follow-up period; the graft is patent and the patient is completely symptom free. Severe claudication in young patients, possibly without significant vascular risk factors, should prompt the clinical suspicion of adventitial cystic disease of the popliteal artery. Medical history, clinical examination and non invasive instrumental investigations, such as duplex scanner, elicoidal CT and/or MRI, may aid in establishing the correct diagnosis.
Abstract: Isolated aneurysms of the hypogastric artery are very rare and account for between 0.04% and 0.4% of all intra-abdominal aneurysms. In 85% of cases they are monolateral and are present in association with an aneurysm of the infrarenal abdominal aorta and of the common and external iliac arteries, they make up part of a poly-aneurysmal disease. Unless the patient is an extremely poor condition, surgical treatment is generally indicated for aneurysms greater than 3 cm; close monitoring of those with smaller aneurysms is recommended. Two patients presented with isolated aneurysm of an internal iliac artery which had developed several years after aortoiliac surgery. The one received surgical treatment; the other, who was in poor general conditions and at high risk for surgery, underwent endovascular embolization. Both procedures were successful, with a current follow-up between 15 and 18 months. Endovascular embolization, as performed in the 2(nd) patient, provided an alternative to the surgical procedure. After injection in the aneurysmal sac of the Gianturco spirals, a covered stent was placed in the iliac axis to exclude the inflow of the hypogastric artery. According to our experience of 2 patients, the one treated surgically and the other submitted to a less invasive endovascular procedure, we can state that both methods are practicable. The final choice lies with the vascular surgeon, after weighing the multiple factors that each case involves.
Abstract: The occurrence of a neuritis of the ischiatic nerve and the genito-femoral nerve due to the implant of three stents in the iliac artery, is an extremely rare complication, especially if associated with retroperitoneal fibrosis which caused a nevritis symptomatology. A case of stent migration in the subadventitial space which caused 4 years from angioplasty and stents implant, a nevritis symptomatology. Retroperitoneal fibrosis has been considered as a consequence of the stents presence and of their chronic irritational activity, especially for what concerns the stent migrated in the subadventitial space; the procedure personally performed in this case is reported.
Abstract: We present two cases of left sided inferior vena cava, one unexpectedly observed during an operation of aorto bifemoral bypass in a patient with severe Leriche syndrome and almost complete obstruction of the infrarenal aorta, the second in a patient with an aneurysm of the abdominal aorta, in whom the anomaly was recognized before the operation. This very rare congenital malformation (0.2-0.5%) was not recognized in the first patient by the duplex scanner performed preoperatively, probably because of the low level of suspicion carried on by an experienced operator. Computer tomography angiography or magnetic resonance angiography, which would have surely shown us the anomaly, were not done in the first patient because, in the lack of an aneurysmal disease or other abdominal pathological situations, these investigations were not required before operation. The possible hazards of such an unrecognized malformation are great, mostly in terms of uncontrollable intraoperative hemorrhages, but the final outcome of this case was positive.
Abstract: Two cases of left-sided inferior vena cava observed in a patient affected by Leriche syndrome and the other affected by aortic abdominal aneurysm (AAA) are presented. This very rare congenital malformation (0.2-0.5) was not recognized by the duplex scanner performed preoperatively probably because of the low level of suspicion carried on by an experienced operator. Angio-CT e angio-MR which would have surely showed the anomaly, were not done because in the absence of an aneurysmal disease or other abdominal situations, these investigations were not required before operation. An angio-CT was performed routinely to the patient affected by AAA and so the left-sided vena cava was observed before operation; and then an abdominal arteriography and an ilio-caval venography were required which documented the vena cava anomaly. Surgical interventions didn t have complications. In the case of Leriche syndrome an aorto-bifemoral bypass was performed, and in the case of abdominal AAA an aortic left-iliac right-femoral bypass. Preoperative unrecognizing of this venous malformation is very hazardous mostly in terms of uncontrollable intraoperative hemorrhages. Ultrasonographic diagnosis with duplex scanner has to be very accurate in order to observe not only arterial diseases but also the possible venous anomalies of the abdominal district.
Abstract: Segmentary isolated stenosis or obstructions of the superficial femoral artery in young people are rarely reported. In patients, most of them women, affected by chronic symptomatology of the lower limbs, the aetiology has been referred to fibromuscular dysplasia with unusual localization. We report a case of acute lower limb thrombosis in a young woman caused by a congenital fibrous ring of the superficial femoral artery and the treatment we performed in this situation including the complication that happened after the percutaneous transluminal angioplasty that we carried out in order to reduce the stenosis of the femoral superficial artery. Histological examination of the lesion demonstrated the nature of the fibrous ring caused by an embryological anomaly, followed by a secondary thrombosis in a woman not using oral contraceptives and without any alteration of the coagulation chain. Fibromuscular dysplasia of the femoral artery is commonly caused by previous thigh injuries, thromboembolic events with recanalization of the artery or arteritis, but in some cases appears to be the consequence of primitive intimal dysplasia. When a fibromuscular dysplasia is suspected, all authors agree on the necessity for a screening of the two preferential localizations of the disease: common carotid artery and renal artery, in the case reported the result was negative.
Abstract: A syndrome of peripheral obliterating arterial disease characterised by aortoiliac steno-occlusion is reported in the literature under the name small aorta syndrome, occurring in young women of small stature with relatively typical risk factors. Starting from an analysis of the studies reported in the literature and on the basis of our own results, we have attempted to ascertain whether small aorta syndrome represents an independent nosological entity. By analysing studies on the small aorta syndrome and in the light of a recent study made by our group on arterial diameters measured in cadavers, which highlights a significant correlation between aortic diameter and age, it can be affirmed that a pathology of this nature does not respond to absolute criteria for existence. Therefore, the aortoiliac diameter in women suspected of being affected by small aorta syndrome appears to be broadly in proportion to that expected in healthy women of the same age. Small aorta syndrome does not therefore appear to represent a separate nosological entity. It takes the form of a hypoplastic vascular disorder, which is probably congenital, correlated to other arterial districts in the same subject. However, it may encourage the onset of early symptoms in women of small stature.
Abstract: The authors report the observation of one case of vagal paraganglioma occurred in a young woman. The tumor manifested itself as a left sub-mandibular tumescence; the very first diagnostic approach was achieved through echography, which showed a mass behind the internal carotid artery and compressing the internal jugular vein. The following examinations, represented by neck CT, NMR, angiography and fine needle aspiration initially directed towards the suspicion of chemodectoma. Only at operation, the anatomical situation of the tumor, which encapsulated the vagus nerve and the subsequent results of the hystological examination revealed the correct diagnosis of vagal paraganglioma.
Abstract: The authors report a case of acute superior mesenteric and right renal artery embolism that occurred during an interventional radiological procedure on the abdominal aorta of a young diabetic woman. The onset of a severe abdominal pain during the procedure evoked the clinical suspicion of intestinal ischemia related to the dislodgement of atheroembolic material into the mesenteric artery; the event was correctly diagnosed, but the surgical therapy was delayed by many hours because of the fact that the patient was in a peripheral hospital of the region and had to be transferred to our institution. Fortunately in spite of the considerable delay, the operation was fully successful, probably because of the favourable location of the embolus, which allowed collateral splanchnic circulation to maintain a good metabolic balance.
Abstract: The incidence of vascular complications due to drug abuse is at present increasing due to new types of drugs and to the different ways of intake of such substances. The vascular complications related to drug abuse may affect venous, arterious and lymphatic districts and in particular: ischemia following intra-arterial injections, arterious and venous pseudoaneurysm, vasculitis, aneurysms, aortic dissections, abscesses complicated by erosions of vessels, arteriovenous fistulas, compartment syndrome, superficial and deep venous thrombosis, septic trombophlebitis, puffy hand syndrome. The scientific knowledge in this matter is incomplete because of the new pathological cases and the lack of information regarding the efficacy of different treatments. The authors report four patients affected by vascular pathologies due to drug abuse. In one case, a heroin addict has undergone multiple fasciotomies for compartimental syndrome arising because the patient maintained an innatural posture for several hours during an overdose coma. In a second case, a segmental right subclavear deep venous thrombosis has been treated by pharmacological therapy with satisfactory functional recovery of the arm. A third patient has been successfully submitted to intra-arterial pharmacological vasodilatation for generalised lower limbs vasospasm caused by drug abuse. In the last case, the voluntary swallowing of a great dose of cocaine caused the patient's death after multiple ischemic and hemorrhagic cerebral episodes. After the description of these cases, a review of the recent literature and some observations on this topic are presented. A better knowledge of vascular complications due to drug abuse should improve the therapeutical approach of these patients.
Abstract: Safe surgical repair of an abdominal aortic aneurysm in conjunction both with nephrectomy (for monolateral or bilateral kidney carcinoma) or with radical cystectomy and orthotopic urinary diversion (for bladder carcinoma) can be performed. These combined surgical procedures can be performed without morbidity due to excessive blood loss, increased operative time or vascular graft infection. A nephrectomy associated with abdominal aortic aneurysm repair can be performed both by a median single surgical approach or by a double one during the same intervention. The authors describe and discuss 4 case reports and the techniques required for these combined procedures.
Abstract: The objective of this article is the presentation of a new device, simple, easy to use, at low cost, for the prevention of postoperative haematoma following surgery of varicose veins of the lower limbs. It consists in a two-part device that functions as an elastic and pneumatic bandage, that wraps thigh and leg, with the knee articulation free and that is placed immediately before the stripping of the saphenous vein when all the surgical wounds are closed, except the supramalleolar one. While the head of the stripper is pulled, the device is inflated by air with a compression of 40-50 mmHg and the last surgical wound is sutured. Pneumatic compression is held for 24-36 hours, allowing the patients to walk and, in the meantime, to control the colour and the temperature of the foot. The advantages of this device are: easy use and low costs; compression on the area of the saphenous vein and of the main collaterals; uniform but moderate pressure on all the limb circumference.
Abstract: We present a case of left-sided inferior vena cava unexpectedly observed during an operation of aorto bifemoral bypass in a patient with severe Leriche syndrome and almost complete obstruction of the infrarenal aorta. This very rare congenital malformation (0.2-0.5%) was not recognized by the duplex scanner performed preoperatively, probably because of the low level of suspicion carried on by an experienced operator. AngioCT or angioMR, which would have surely shown us the anomaly, were not done because, in the lack of an aneurysmal disease or other abdominal pathological situations, these investigations were not required before operation. The possible hazards of such an unrecognized malformation are great, mostly in terms of incontrollable intraoperative hemorrhages, but the final outcome of this case was positive.
Abstract: BACKGROUND: Mesoglycan is a natural glycosaminoglycans preparation, with antithrombotic and pro-fibrinolytic activities, which has been shown to be clinically effective in a number of vascular atherosclerotic disorders with thrombotic risk. METHODS: In the present investigation we studied the effect of mesoglycan in patients with acute episodes of relative lower limb ischemia (Stage IIb according to Leriche-Fontaine classification) coming to our observation. Mesoglycan was administered according to the following schedule: a 10-days period of endovenous mesoglycan (90 mg/day), given in day-hospital regimen, followed by a 20-days period of oral mesoglycan (100 mg/day). The treatment schedule was repeated for two months and then patient continued with oral mesoglycan. We present the preliminary results obtained on 36 patients which were followed for a mean period of 12 months. RESULTS: From February 1995 thirty-six patients, 24 males and 12 females, aged between 45 and 83 years (mean +/- SD: 69.8 +/- 7.5) coming to our observation for acute relative lower limb ischemia were enrolled. At baseline, the diagnosis was Fontaine's IIb stage (walking distance < or = 200 m) in all patients, 17 patients presenting walking distance < 100 m. After 3 and 6 months of mesoglycan treatment a significant improvement of symptoms and signs was observed in all patients but one. At the end of the 6-months period, 29 patients (81% of the study population) became to a Fontaine's IIa degree, with a significant increase in walking distance (in 70% three times their basal value) and improvement of symptoms and recovery time. After treatment, Winsor Index was not significantly modified. Similar results were obtained after 12 months of follow-up. During the study period only one patient included in the trial needed surgical revascularisation. The administration of mesoglycan was well tolerated, with only minor complaints in two patients (one case of headache and one of diarrhea). During the endovenous administration of mesoglycan most patients (81%) presented values of aPTT almost double than baseline, which returned to normal values at the end of the administration. CONCLUSIONS: The present preliminary results show that, in patients with acute episodes of relative lower limb ischemia, mesoglycan (administered according to the described protocol) is an effective and safe agent able to improve symptoms (walking distance, pain, leg appearance) and to possibly delay the need of surgical interventions.
Abstract: A case of post stenotic aneurysm of the inferior mesenteric artery (IMA) is reported. This case underlines the importance of a correct diagnosis by instrumental methods such as Duplex Scanner, CT and Arteriography, mainly when the first diagnosis is aneurysm of the abdominal aorta (AAA). Our patient showed, furthermore, the occlusion of the celic axis, of the superior mesenteric artery and of both hypogastric arteries; thus his intestinal vascularization was represented, from the gastric fundus until the rectum, only by the inferior mesenteric artery and its collateral network. The operation consisted in the resection and reimplantation of the vessel on the left side of the terminal abdominal aorta, after removal of the dilated segment. This location was chosen because of the coexistence of a mild dilatation of the aorta of 2.8 cm and considering possible aortic surgery for AAA in the future.
Abstract: In a patient already operated for abdominal aortic aneurysm fifteen months previously, because of the onset of aspecific vertigo, instrumental investigations of the supra aortic vessels showed us the presence of a non palpable mass, in the left side of the neck. Duplex Scanner, angio-CT and Angiography let us suspect the presence of an aneurysm located somewhere in the course of the thyrocervical trunk. At the operation the aneurysm, which we originally suspected to be a false and a possibly iatrogenic one, in the reality was a true aneurysm and was located at the termination of the thyrocervical trunk, just in the first segment of the inferior thyroid artery. The case is reported because of its rarity and the difficulties in the preoperative diagnosis.
Abstract: The Authors report their experience in the treatment of venous and arteriovenous malformations, which in this paper are divided into two subgroups, pure venous malformations (VMs) and arteriovenous malformations (AVMs). A pure surgical indication was evident in less than 50% of cases (48.1%), while more conservative treatments were performed in remaining patients. Considering the particular characteristics of the disease, a complete surgical radicality isn't always possible, so surgery must be considered in selected cases.
Abstract: The diagnosis of Buerger's disease, like that of all arteritis, especially in the onset phase, can be difficult. The general criteria proposed by several authors, with the aim of codifying the verification of the disease, are sometimes too schematic and this collides with the existence of very variegated and polymorphous clinical situations, as well as totally atypical and unusual clinical patterns. On this subject we consider useful to report a case of Buerger's disease that presented some peculiar characteristics, the most important of which was the existence of an aneurysm of the left superficial temporal artery.
Abstract: In a recent publication, reporting the sixth case of aortic angiosarcoma, probably induced by the implantation of a dacron vascular prosthesis, Weiss et al. have done a literature review concerning the association between the presence of vascular prostheses and the onset of mesenchymal neoplasms. Although they consider the incidence of this association very low, they also point out the hypothesis, largely supported by experimental studies, that vascular prostheses can play the role of aetiological co-factor or factor in the onset of these tumors. We consider useful to report a case of malignant fibro histiocytoma arising around a femoral vascular prosthesis in a patient operated on for aneurysm of the femoral artery.
Abstract: Ischaemic colitis has many and different clinical features as it is often linked to the severity of ischaemic injury. In this paper two patients with clinical features of Crohn's disease are reported. In both patients the diagnosis has been confirmed with endoscopy and biopsy. They have been treated with specific therapy until they developed bowel obstruction in one case and peritonitis in the other. Both patients underwent laparotomy and the histological specimen showed a picture of ischaemic colitis. In one case a Dixon's resection was done, in the other Hartmann's operation.
Abstract: Thirty-one patients, ranging in age from 57 to 78 years (mean 66), with the exclusion of cases with doubtful possible results, underwent abdominal aortic aneurysmectomy for asymptomatic AAA and had cultures from the aneurysmal wall and endovascular thrombus to identify possible microbiological source of future graft infection; 5 (16%) of 31 cultures yielded bacterial growth and the most common organism isolated was staphylococcus epidermidis. During an average follow-up of 15.4 months no graft infection was noted in patients with positive or negative aortic cultured. A literature review stresses the same disparity between positive cultures obtained at the aneurysmectomy and subsequent low graft-infection rate. It is concluded that the aneurysm wall itself does not represent an important source of early or late graft infection and it's suggested that the bacterial presence both in the wall and thrombus could be explained by an exogenous contamination at the operation time.
Abstract: The authors report their experience in the management of a rare case of bilateral popliteal artery entrapment syndrome occurred to their observation. This unusual pathological entity, arising mostly in young subjects and unilaterally, in this case was bilateral and developed in a 51 years old patient. The clinical case is fully documented by multiple Echo-Doppler and arteriographic examinations which clearly demonstrate the peculiar characteristics of the disease. Finally the patient received a two stage surgical treatment with a good global result. The Authors stress the importance of a correct diagnostic approach to this unusual disease to avoid the possibility to misdiagnose it.
Abstract: A case of solitary rectal ulcer is presented. Different views on the pathogenesis are discussed. Symptoms were nonspecific: anal pain, rectal tenesmus and bleeding. On sigmoidoscopy, the lesion has a characteristic appearance, but the definitive diagnosis of benignity must depend upon the recognition of specific histopathologic features in rectal biopsy specimens from ulcer margins. In this case, the surgical treatment was satisfactory, but frequently neither medical nor surgical treatment achieve relief of symptoms or healing of the lesion.
Abstract: The Authors report their preliminary experiences concerning the use of transcranial Doppler (TCD) in the pre- and postoperative monitoring of extracranial carotid surgery. TCD is a non invasive method of investigation able to give informations about the distribution of cerebral blood flow and about the mechanisms of compensation of Willis' circle. Furthermore, TCD showed itself to be very useful in the postoperative qualitative evaluation of surgery, pointing out, as a general rule, an increased flow in the middle cerebral artery after thromboendarterectomy of internal carotid artery. This haemodynamic modification, if present, is perceptible since the immediate postoperative period and becomes more evident and definitely stable at a distance of 20-30 days after operation, likewise the definitive stabilization of Willis' circle's haemodynamics.
Abstract: A Duplex-Scanner was used to screen 62 patients with severe hypertension, queried renovascular. Ten results were technically unsatisfactory and in the remaining 52 highlighted flow alterations in the renal arteries of 29 patients were found. Control angiographies confirmed renal artery stenosis in 27 cases. Comparative statistical analyses proved the test to be both highly sensitive and specific, considering other screening methods currently used in diagnosing renovascular hypertension--which include endovenous digital subtraction angiography. Results confirmed the Duplex-Scanner as a reliable renovascular hypertension screener as well as being a non-invasive method with no potentially toxic effects.
Abstract: The Authors refer their surgical experience in those particular cases in which, after performing an aneurysmectomy or an endarterectomy of common femoral artery, the residual arterial wall appears too thin and weakened. In these not very rare cases, can be indicated, as an additional and prudent manoeuver in order to avoid a possible evolution towards suture disruption or pseudoaneurysm formation, the wrapping or banding of the endarterectomized tract of artery by the mean of dacron prosthesis, sutured around the artery longitudinally. This simple technique, performed in 4 patients, appears easy and safe to perform, offering the advantage to guarantee a biological arterial lumen.
Abstract: The study concerns 3053 cases of esocrine pancreas carcinoma observed between 1976 and 1981 in Piemonte, Italy. The authors discuss about the principal risk factors associated with that disease (age, sex, geographical distribution), the treatment and the methodological problems in an epidemiologic study concerning pancreatic carcinoma.
Abstract: The authors studied the inter- and postoperative complications arising in a series of 690 consecutive interventions on thyroid. The results showed a cipher mortality and a 3% aggregate morbidity. In 0.9% of cases, compressive hematomata in the thyroid loggia, collapse of the tracheal wall due to tracheomalacia or bilateral paralysis of the vocal cords determined an acute respiratory stoppage. 1.4% of the treated patients suffered from alterations in the motility of the vocal cords, ascribable to damage of the recurrent nerves. 0.9% of cases showed a postoperative parathyroid insufficiency, the nature of which, however, was always temporary. The incidence of complications, in the whole, resulted significantly higher in the patients undergoing iterative surgery, in respect of those operated on the first time.
Abstract: In conjunction with the University Calculation Centre and the Piedmont Region, a computerised study was made of all patients (31,514 cases) admitted to Piedmont hospitals for phlebopathy and peripheral lymphopathy, including pulmonary embolism, in the period 1976-79. An account is given of the method used, the material, and the statistical technique. An 18.9% prevalence of women was noted. Occupation, age category, type of pathology, and treatment adopted were assessed for phlebopathies in toto and for each type. The data for each public health unit, divided by age category, were correlated with the general cases for the Region and those for each unit. In this way, it was possible to determine the incidence of phlebopathies in each unit and over the Region as a whole in relation to age. A map of the Region showing areas of higher, lower, and not significantly different from the regional mean hospitalisation (i.e. phlebopathy) was prepared. The significance of the different incidences in the several units is discussed in relation to their populations, geographical location, raye of migration, and types of occupational activity.
Abstract: The second part of this research project looks at two very different pathologies. Pulmonary embolisms are usually emergency admissions, while lymphopathies, and this may well be an incorrect term, usually receive outpatient treatment and are only hospitalised in cases of serious incapacitation. Whereas lymphopathies were so few as to prevent any conclusions being drawn, regional admissions of pulmonary embolism occur every 28 hours and 44 minutes i.e. about 1 case per day. No particular relation between the distribution of pulmonary embolism and geographical area, level of industrialisation or migration was discovered. On the contrary there are few areas with higher figures than the expected regional average and these may be attributed to better medical organisation. Finally it should be emphasised that while cases of pulmonary embolism increase with age, the rise is less substantial than might have been expected.
Abstract: The authors report the results of different types of surgical treatment performed on a sample group of 51 patients chosen on a total of 308 patients operated for cancer of the colon rectum in the period 1965-1979. They also make their considerations about the most common complications arising in the early and late post operative period, the quality of life achieved by the patients and the survival rate related to the various types of operations performed.
Abstract: In the 1976-79 period, 8040 cases of thrombophlebitis, equivalent to 0.17% of the population, were admitted to Piedmontese hospitals, an average of 1 admission every 4 hours and 3 minutes. The present study revealed a numerical and percentage increase with increasing age. The figures per age group from each individual clinic revealed two large areas in the East and South West of the Region where phlebitis cases were numerically lower than the regional average. In other areas figures were higher than estimated, while still others produced statistically insignificant figures. An interpretation of these results is attempted.
Abstract: With the aid of the University and Piedmont Region Computer Centre all cases of varicose admitted to Piedmontese hospitals between 1976 and 1979 were examined. One admission every 1 hour 35 minutes is the regional average. In terms of age there is a numerical prevalence (8526 cases) of the under forty-fives, while in percentage terms, admissions appear to increase in proportion to age. Admissions in age groups to all the individual clinics were correlated with a view to the evaluation of any variations from the regional average, without incidentally confirming these figures. Detailed statistical analysis was employed to correlate the study.
