"Marsupial cava" and ruptured abdominal aortic aneurysm. A case report and review of the literature.

A patient with a ruptured abdominal aortic aneurysm underwent an emergency operation. A rare anomaly of inferior vena cava, known as "marsupial cava," was found. The iliac vein confluence crossed anteriorly (rather then posteriorly) the right common iliac artery. Even though the patient had undergone a computed tomography scan, this rare anomaly had not been detected and therefore was unexpected by the surgeon. The aim of this report is to describe the technical details required to perform the aortic reconstruction and to stress the importance of routine computed tomography scans and their careful reading in the case of stable patients before retroperitoneal operation. This is, to our knowledge, the first report of an aortic prosthetic grafting for ruptured aortic aneurysm in association with a marsupial cava.

[Incidence and treatment of vascular prosthesis infection in the groin. Personal experience]. / Incidenza e trattamento della infezione protesica vascolare a livello inguinale. Esperienza personale.

The incidence of prosthesis infection in the groin ranges between 1 and 3%, with high morbidity and mortality rates. Contamination, irrespective of whether it is endogenous or exogenous, may occur during surgery of afterwards due to a secondary bacterial load which is often associated with a traumatic surgical technique for tissues, often in emergency surgery or re-operations. MATERIALS AND METHODS. Over the past 5 years a total of 410 prosthetic alloplastic grafts have been made by our Division of Vascular Surgery with at least one anastomosis at an inguinal level. The materials used for prosthesis were dacron and PTFE. Thirty-one infections were observed in the groin of which 11 involved the prosthesis and 20 were apparently restricted to the superficial and deep layer of the dermis. A cell culture test and antibiogram was always performed. Surgical or medical therapy (loco-regional + general) was used according to individual cases. RESULTS. With regard to the 11 patients with manifest infections of the prosthesis, only trans-obturator bypass surgery gave positive long-term results, whereas other operations (femoro-femoral bypass, axillo-popliteal bypass) were not satisfactory. Of the other 20 patients treated using loco-regional and general medical therapy, 9 developed pseudo aneurysm over time for which it was then necessary to resort to surgery. DISCUSSION AND CONCLUSION. Currently there is no universally accepted treatment protocol for the management of prosthesis infection. However, it is generally considered useful to isolate any pathological agent (using routine biopsies of arterial wall or thrombo-endoluminal fragments during the primary operation) before infection can develop so as to be able to commence specific antibiotic therapy. In this context the authors underline the more devastating action of some bacteria (pseudomonas, Staphylococcus aureus) in comparison to others (Staphylococcus epidermidis). Turning to therapeutic measures, when there are anatomical grounds and with the greatest possible respect for periarterial tissues, it is considered that trans-obturator bypass is preferable in the presence of manifest infection of the prosthesis, whereas medical therapy can be used (loco-regional + general) if infection is limited to the surface layers of the inguinal area. Possible complications over time may be corrected using surgery and in situ reconstruction if infection is no longer present.

[Controversies regarding an algorithm and the type of surgical treatment in popliteal aneurysms]. / Controversie sull'algoritmo e sul tipo di trattamento chirurgico degli aneurismi poplitei.

Having outlined their 20-year experience in the treatment of popliteal aneurysms (PA), the authors discuss the type of therapeutic approach used. From the authors' point of view an overly aggressive approach to PA is unnecessary, and the decision to adopt a given therapy must instead be weighed up on the basis of the careful clinical evaluation of each individual case, taking into account the patient's clinical conditions at the time, the pathological anatomy of the lesion and its consequences. The authors divide primary PA into symptomatic and asymptomatic cases; in the latter surgery is definitely indicated and the possible contraindications represented by anesthesiological risk or small aneurysm diameter need not be evaluated. In the case of symptomatic PA, treatment varies depending on whether they are manifested by rupture, acute ischemia or chronic ischemia. While there are no grounds for uncertainty regarding the need for immediate surgery in the first case, in the second and third cases the authors attribute decisive importance to the evaluation and possible improvement of run-off before surgical correction. In the event of acute arterial insufficiency of the limb, the careful assessment of clinical conditions (degree of loss of sensitivity, motility and cutaneous vascularization) and anamnestic data (possible presence of signs and symptoms of previous chronic arterial insufficiency) allow the surgeon to decide whether or not to resort to immediate surgery or to obtain an improved run-off by using loco-regional fibrinolytic therapy and therefore postpone surgical treatment.(ABSTRACT TRUNCATED AT 250 WORDS)