[Benign mediastinal teratoma with pericardial symptoms. The utility of echocardiography in diagnosis]. / Teratoma benigno del mediastino a sintomatologia pericardica. Utilità diagnostica dell'ecocardiografia.

The authors describe the clinical case of a 21-year-old girl who was admitted to the hospital because of pericardial symptomatology. On admission, a transthoracic echocardiogram revealed moderate pericardial effusion and an anterior parenchimallike mediastinal mass, that extended as far as the main vessels and the anterior wall of the right ventricle. This report was subsequently confirmed by a computed tomography chest scan. Due to the rupture into the pericardial cavity, which was followed by considerable pericardial effusion, she was immediately taken to the operating room for pericardiocentesis and the decision was then made in order to excise the mass. The hystological diagnosis revealed "benign cystic mature teratoma of the mediastinum". The authors' literature data is included, and the article also emphasizes the importance of using echocardiograms in casualties in order to obtain a differential diagnosis of chest pain.

Ruptured aneurysms of the thoracoabdominal aorta: a case series.

Fifteen cases of ruptured thoracoabdominal aneurysm (-TAA) were encountered in 1987-July 1994. These patients included 13 males (86.6%), 2 females (13.4%) with a mean age of 66.3 years (range 58-78). Surgery was performed on 13 patients of whom 6 (46.1%) died within 30 days. The two other patients had died of heart failure prior to surgery. In 8 of these patients (53.4%) the condition was not diagnosed until clear symptoms had appeared. The ruptured aneurysms were thoracic in 9 cases (60%), abdominal in 6 (40%). The maximum aneurysm diameter in the most frequently ruptured group was 6.1-8 cm (in 9 patients-60%)./ For 5 cases (33.4%) the maximum diameter of ruptured aneurysms included dorsolumbar pain. In one patient a concomitant aortobronchial fistula had produced rupture. Low blood pressure was found in 9 cases (60%). In 5 cases (38.4%) curative surgery was performed within 24 hours of the onset of symptoms. In this group, the mortality rate was 40% (2 patients). In the remaining 8 cases, on whom surgery could not be performed within 24 hours (range 25 hours-4 months) the mortality rate was 50% (4 cases). All four cases of paraplegia (30.7%) were encountered among patients in the second group, 2 of whom died. Follow-up revealed a 5-year mortality rate of 71.4%.

[Natural history and course of aneurysmal disease in patients operated on for abdominal aortic aneurysms]. / Storia naturale ed evoluzione della malattia aneurismatica in pazienti operati per aneurismi dell'aorta addominale.

This study is aimed at analyzing our experience in the evolution of aneurysmatic disease after surgical treatment of the typical subrenal abdominal aortic aneurysm. In fact in some cases we reobserved these patients for the onset of a new important dilatation involving the proximal tract of the abdominal aorta or the common iliac arteries. From 1980 to December 1992, 24 patients out of a group of 1508 patients previously submitted to an aorto-aortic or aorto-iliac reconstructive procedure using dacron prosthetic grafts were reoperated for relapsing aneurysmatic disease. In six cases the dangerous ectasia was located above the proximal aortic anastomosis; in four patients the re-reconstructive procedure was performed clamping the subdiaphragmatic abdominal aorta and performing the proximal anastomosis just below the ostia of the renal arteries. In two cases the aneurysmatic process involved the origins of the visceral vessels and a left thoracophrenolaparotomic access was necessary in order to perform a thoracoabdominal reconstruction reimplanting the visceral arteries on the prosthetic graft. In 18 cases the progressive aneurysmatic process involved the common iliac axis provoking, in some cases, a kinking or a shortening of the aortic prosthetic graft. The results of these reintervention are good with no mortality at operation and a satisfactory middle term (average 3 years) follow-up. Our investigation demonstrates that in a small, but significant (1.6%) percentage of patients the aneurysmatic disease spreads upward and downward involving arterial segments formerly non affected.

[Wall stress in the assessment of left ventricular function in surgery of abdominal aortic aneurysm. Validity and importance of transesophageal echocardiography (TEE) in intraoperative monitoring]. / Lo stress parietale nella valutazione della funzione del ventricolo sinistro nella chirurgia degli aneurismi dell'aorta addominale. Validità ed importanza dell'ecocardiografia transesofagea (TEE), nel monitoraggio intraoperatorio.

OBJECTIVE: To verify the applicability and the clinical significance of left ventricular wall stress determinations by intraoperative transesophageal echocardiography (TEE) during resections of abdominal aortic aneurysms. DESIGNS: Prospective comparison of changes in left ventricular wall stress between two groups of patients with and without coronary artery disease. SETTING: Operatory room of Universitary Institute. PATIENTS: Twenty-three patients with abdominal aortic aneurysms; 8 had clinically evident coronary artery disease (CAD+); 15 patients did not have clinical or electrocardiographic evidence of coronary artery disease (CAD-). INTERVENTIONS: Resection of the aortic aneurysm and insertion of a synthetic prosthesis. MEASUREMENTS AND MAIN RESULTS: During operation transesophageal monitoring of left ventricular volumes and wall stress was performed during induction of anesthesia (T1), for two minutes after aortic clamping (T2), at the end of the proximal anastomosis (T3), for two minutes after aortic declamping (T4) and at the end of the procedure (T5). Circumpherential stress at end systole (sES) and end diastole (sED) was more sensitive than hemodynamic and volumetric parameters in detecting changes i function of the ischemic myocardium. In detail we observed: a significant increase of sES in CAD+versus CAD- at T2: 98 (sd 18) vs 83 (sd 14) 10(3) dyne/cm2. a significant increase of sED in CAD + versus CAD- at T2: 28.5 (sd 6) vs 22 (sd 4.5) 10(3) dyne/cm3. a similar trend of sES and sED at T4: 73 (sd 20.5) vs 46 (sd 15) 10(3) dyne/cm2 and 31 (sd 12) vs 16 (sd 7.7) 10(3) dyne/cm2 respectively. a significant increase of sED in CAD + at T5 (about 20' after T4): 26.5 (sd 9.5) vs 16 (sd 5.2) 10(3) dyne/cm2 which is expression of a persistent reduction of ventricular compliance in the ischemic patients. CONCLUSIONS: Wall stress modifies MVO2 and subsequently is sensitive in detecting changes in myocardial performance. TEE could valuably integrate routine hemodynamic monitoring of patients with coronary heart disease who undergo surgical resection of abdominal aortic aneurysms.

Spontaneous aorto-caval fistulas from ruptured abdominal aortic aneurysms.

Thirty-six cases of abdominal aortic aneurysms rupturing into the vena cava and two iliac aneurysms rupturing into iliac veins are reported. This group represents 10% of the total number of observed ruptured abdominal aortic aneurysms (388). Such a condition is therefore quite rare but should be considered positively because the reported mortality rate is less than with ruptured aneurysms in general. Nevertheless, a spontaneous aorto-caval fistula is responsible for a critical haemodynamic deterioration and sudden worsening of the general condition of the patient and therefore prompt surgical repair is mandatory. The overall mortality rate in our series was 21% (8 cases).

Splanchnic artery aneurysms.

From 1970 to October 1991, 26 patients affected by splanchnic artery aneurysms were observed and treated at the Department of General and Cardiovascular Surgery, University of Milan, Italy. Three splanchnic artery aneurysms were operated on in emergency. Visceral artery aneurysms are often completely silent and are generally detected during diagnostic procedures performed in order to clarify some diagnostic questions. When symptomatic they present a characteristic clinical picture of the involved vascular district. Two patients affected by aneurysmal disease of the proper hepatic artery died after operation. All the other splanchnic aneurysms underwent a successful surgical procedure. This study is aimed at analyzing some characteristic clinical pictures, diagnostic methods, therapeutic procedures and postoperative results.

[The surgical prevention of pulmonary embolism. Comments on 100 patients treated by different methods]. / Prevenzione chirurgica dell'embolia polmonare. Considerazioni su 100 pazienti trattati con diverse metodiche.

A series of 100 patients suffering from deep venous thrombosis with prior episodes of pulmonary embolism or ilio-caval floating thrombi, submitted to surgery for the prevention of new embolic episodes, is analysed. Indications are discussed together with the various prevention techniques adopted over the past 5 years. Special attention is paid to the analysis of 11 patients operated on in the last 2 years by thrombectomy of the infra- and suprarenal vena cava.

Locoregional fibrinolysis using tissue plasminogen activator in 2 cases of acute thrombosis of the renal artery.

The use of tissue plasminogen activator gave good results in the treatment of acute coronary thrombosis. Comparable results appear to have been obtained in the first clinical trials in cases of acute thromboses of the peripheral arteries. A successful experiment in the locoregional treatment of acute thrombosis of the renal artery is reported.

[Thrombectomy of the infra- and suprarenal cava to prevent pulmonary embolism in the presence of deep venous thrombosis. Personal experience with 11 surgically-treated cases]. / Trombectomia della cava infra- e soprarenale quale prevenzione dell'embolia polmonare in presenza di TVP. Esperienza personale su 11 casi operati.

DVT is a fairly frequent event and often fails to be recognised. Its main complication, pulmonary embolism, is the third cause of death in Italy with more than 70,000 deaths per annum. In the presence of infra- and suprarenal floating thrombi, cases in which the application of neither intraluminal nor extraluminal filters is indicated, the treatment of choice is thrombectomy with direct surgical access to the cava. Personal experience of 11 patients operated in the past 16 months with excellent surgical success is analysed. The indications and surgical techniques adopted are described.

Surgical treatment of abdominal aortic aneurysm. A ten-year experience (1980-1989) referred to 1725 patients operated on.

The authors' experience of surgical management of abdominal aortic aneurysms (AAA), in 1725 consecutive patients, operated on in a ten years period (1980-1989) is presented. Surgical indications, operative technique, and outcome of elective and emergency procedures are analyzed. A ten years follow-up period is also presented. This shows a significantly better survival rate in surgically treated patients than in nonoperated cases.

[Atheromatous material mobilization syndrome after thrombolytic therapy with streptokinase in acute myocardial infarct]. / Sindrome da mobilizzazione di materiale ateromasico a seguito di trattamento trombolitico con streptokinasi per infarto miocardico acuto.

Streptokinase fibrinolysis is a widely accepted and applied therapy in acute myocardial infarction with good clinical and ECG results. Nevertheless this therapy is not devoid of complications that sometimes can be very serious. In this paper the Authors report the case of a patient 52 years old who has been treated with streptokinase for an acute myocardial infarction with good ECG results but that about eight hours later showed an important cholesterol embolization syndrome with visceral and lower extremity lesions. The patient died about 36 hours later. The Authors emphasize the necessity to exclude aortic aneurysm before using thrombolytic agents and to evaluate carefully the possibility to abstain from this procedure in the presence of certain aneurysmal lesions.

[Clinical observations on 38 cases of inflammatory aneurysm of the abdominal aorta out of a total of 2014 operated cases]. / Considerazioni cliniche su 38 casi di aneurisma infiammatorio dell'aorta addominale su un totale di 2.014 AAA operati.

The paper reviews 2014 cases of aneurysm of the abdominal aorta treated over the past 10 years at the Institute of General and Cardiovascular Surgery of the University of Milan directed by Prof. Ugo Ruberti, and analyses 38 which showed inflammatory characteristics. In spite of the low frequency of this type of aneurysm (1.8%), preoperative diagnosis is important since surgery entails greater technical difficulties than surgery for an atherosclerotic aneurysm of the abdominal aorta. In this respect the study of preoperative ESR and white blood cell levels is important: the review showed an increased ESR in 71% of cases in which the aneurysm was clearly inflammatory (a percentage which was twice that found in patients with atherosclerotic aneurysms) and increased white blood cells in 32% of cases compared to 2.6% in atherosclerotic aneurysms. Contrary to previous reports, CAT and abdominal echography were not particularly important. However, in those cases where the aneurysm was thought to be inflammatory on the basis of these findings, the Authors chose to operate once the diagnosis had been made without waiting for steroid therapy to reduce the extent of inflammation due to the well-known risk of rupture and the controversial efficacy of medical therapy.

Cardiological risk in patients undergoing abdominal aortic aneurysm surgery. An analysis of 523 cases.

The paper reports a consecutive series of 523 patients undergoing abdominal aortic aneurysm surgery, paying particular attention to the cardiological risk factor. Coronary disease was present in 167 (31.9%) cases and the overall mortality rate was 1.7%: 5 cases (3%) in the group of coronary disease patients; 4 cases (1.2%) in the group of noncoronary disease patients. All fatal cardiac complications during the postoperative period occurred in those patients who presented coronary cardiopathies before surgery. The preoperative cardiological risk was therefore much greater and more significant in this group of patients. This risk factor should therefore be assessed prior to the operation in order to prepare the necessary medical or even surgical therapeutic measures.

Abdominal aortic aneurysms surgery in over 75 years old patients. Experience in 142 cases treated between 1980-1989.

The paper describes the Authors' experience of abdominal aortic aneurysm surgery in over 75-year-old patients. One hundred and forty-two cases were operated over a 10-year period (1980-89). Seventy-two patients were treated electively and 70 underwent emergency surgery following rupture of the aneurysm. Operative mortality during elective surgery was comparable to that in younger patients, whereas the mortality rate during emergency surgery was notably higher than that in under 75-year-old patients. Follow-up confirmed that the life expectancy of operated patients is significantly better than that of patients with untreated abdominal aortic aneurysms.

[Surgery of thoraco-abdominal aneurysms. Personal experience in 35 cases]. / La chirurgia degli aneurismi toraco-addominali. Esperienza personale su 35 casi.

The paper describes the authors personal experience of the surgical treatment of thoracoabdominal aneurysms. Thirty-five patients underwent surgery during the period from 1972 to the present. Operative mortality is compared according to the different surgical approaches used. Special attention is paid to the techniques of protecting the spinal cord, and in particular to liquor drainage.

Traumatic pathology of the thoracic aorta. Personal experience based on 42 cases.

Between 1974 and 1989, 42 patients have been operated on at the Istituto di Chirurgia Generale e Cardiovascolare of University of Milan, for traumatic pathology of the thoracic aorta: in 14 cases it occurred an acute rupture at the level of aortic isthmus and in 28 cases a posttraumatic fals aneurysm. We had an operative mortality of 28% (4 cases) in the acute rupture: 3 patients died for neurological complications which were present at hospitalization. In one case appeared a serious ARDS. We had no surgical deaths in patients operated on for the posttraumatic false aneurysm. In 15 cases, the patients suffered for a postoperative paraplegia. Surgical indications are discussed, overall for the posttraumatic false aneurysms. The authors consider the advantage and the risks of the use of ECC and of total heparinization of the patients.

Myocardial hydatid cyst ruptured into the pericardium: cross-sectional echocardiographic study and surgical treatment.

We describe a patient with a large intramyocardial hydatid cyst lying in the postero-lateral segment of the left ventricle near the atrioventricular groove level which ruptured into the pericardial sac, resulting in cardiac tamponade. Cross-sectional echocardiographic examination from a modified four-chamber apical view showed the multiloculated cyst and the breach connecting it to the pericardial sac, allowing for the definitive diagnosis and indication for emergency cardiac surgery. The risks of pericardiocentesis and invasive diagnostic procedures could thus be avoided.

Surgical treatment of thoracic aortic aneurysms. Personal experience.

A series of 262 observed cases of aneurysm of the thoracic aorta is examined in which 216 cases of surgical correction were performed between 1974 and 1987. Dissecting aneurysms and post-traumatic pseudoaneurysms, although of different aetiology and morbid anatomy, are also included since the surgical technique adopted is similar in all groups. Clinically different aspects of acute and chronic lesions are analyzed. Of all preoperative examinations, angiography is preferred as it gives the most precise definition of the aortic lesion. This is especially necessary in the case of acute dissection or rupture of thoracic aorta although the role of CAT scan is becoming progressively more important. In cases of aortic dissection with massive aortic valve insufficiency, the substitution of the ascending aorta and aortic valve with reimplantation of coronary arteries, in accordance with Bentall's technique is also indicated. The improvement in surgical results is emphasized, since surgical mortality has decreased from 30.6% to 22% in the last eight years. This is due to improvement in surgical technique, to extra corporeal circulation and myocardial protection.

Acute aortic dissection. Personal experience.

Aortic dissection is a catastrophic event with a high mortality rate for untreated patients. One hundred and thirteen patients with acute aortic dissection were observed in the IInd Surgical Department of Milan University from 1974 to 1985; 55 had type I and II aortic dissection and 58 had type III aortic dissection. All patients with type I and II and about 50% of patients with type III aortic dissection underwent surgical correction. In the second type III group the aortic lesion was surgically corrected only when visceral ischaemia or ischaemia of the lower limb was recognized. In the other type III cases, medical treatment was preferred. The mortality rate was lower after medical treatment (15%) than after surgical treatment (37%). Follow-up was performed for the majority of patients and was recently completed with non-invasive techniques like Magnetic Resonance. It accurately shows the residual dissection and follows, the development of occlusion of the false lumen without any risk to the patients.