The role of self-expanding vascular stent in superior vena cava syndrome for advanced tumours.

INTRODUCTION: Superior vena cava (SVC) syndrome (SVCS) is a life-threatening occurrence that necessitates prompt treatment. At present, endovascular stenting is proposed as a first-line treatment to relieve symptoms. We assessed the effectiveness, safety and outcome of SVC stent positioning in patients affected with advanced cancer. METHODS: Forty-two patients undergoing stent positioning in the SVC for neoplasms from January 2002 to December 2018 form the basis of this retrospective study. Demographic data, risk factors, associated diseases, symptoms at presentation according to the score proposed by Kishi and the type of SVCS according to Sanford and Doty were collected. Minor and major complications were recorded. Suspected stent occlusion was confirmed by means of recurrence of symptoms followed by a confirmatory computed tomography (CT). RESULTS: Thirty-four (81%) patients had a nonresectable lung tumour invading or compressing the SVC. Five (12%) patients had a non-Hodgkin's lymphoma, and three (7%) had metastatic lymphadenopathies. Nitinol stents (Memotherm®) were employed in 19 (45%) patients, and steel stents (Wallstent™) in the remaining 23 (55%) patients. Thirty-five (85%) patients died during follow up for disease progression and the overall survival rate at 24 months was 11% (standard error (SE)=0.058). Thirteen patients (32%) had a recurrence of SVCS because of stent thrombosis in three (23%) and extrinsic compression from uncontrolled cancer progression in ten (77%). The overall symptom-free interval at 24 months was 57% (SE=0.095). CONCLUSIONS: We recommend the use of the endovascular procedure as a first-line treatment in locally advanced or metastatic tumour in the presence of SVCS.

Open and endovascular treatment by covered and multilayer stents in the therapy of renal artery aneurysms: mid and long term outcomes in a single center experience.

AIM: The purpose of this paper is to evaluate the mid and long terms outcomes of open and endovascular surgical treatment, as well as multilayer stent, in patients affected by Renal Artery Aneurysm (RAA). PATIENTS AND METHODS: Twenty five patients with RAA (24 monolateral and 1 bilateral aneurysm, 26 aneurysms) were observed between 2000 and 2015: 4 were not treated due to the small size of the aneurysm (< 2.5 cm); out of the remaining, 16 underwent endovascular treatment, 2 were treated by open surgery consisting in aneurysmectomy and graft reconstruction and 5 (in 1 patient bilateral) were treated by ex vivo repair and autotransplantation. RESULTS: Out of the 22 patients treated for RAA, one patient operated upon open surgery presented an early thrombosis of a PTFE graft, followed by nephrectomy (4.7%); one patient underwent autotransplantation showed an ureteral kinking without functional consequences. In a follow-up ranging from 1 and 11 years (mean 5 years), no deaths were observed; all the renal arteries repaired were patents and 16 out of 21 patients had a significative reduction of systemic blood pressure. DISCUSSION: The choice of the best treatment is based on aneurysm's morphology according to Rundback's classification. The type I, involving the main renal artery, is always treated by endovascular approach; type II, involving renal artery bifurcations may be treated by open surgery or multilayer stents; type III (hilar or intraparenchymal aneurysms) needs only an open surgical treatment as autotransplantation. CONCLUSION: Based on our experience it seems that most of RAAs may be treated by endovascular technique. The ex vivo autotransplantation represents the first-line treatment in hilar and intraparenchymal aneurysms. Multilayer stents seem to have good outcome in the treatment of aneurysms involving arterial bifurcations. Mid and long term results, related to kidney preservation and to normalization of blood pressure, seems satisfying.

Flow-mediated dilation benefits of mesoglycan in peripheral artery disease.

AIM: Mesoglycan, composed of natural glycosaminoglycans, is used for treatment in arterial and venous disease for its benefits on endothelial glicocalix. Little is known about mesoglycan impact on endothelial blood flow regulation. We sought to evaluate the effects of mesoglycan intermittently added to back-ground treatments on impairment of endothelial function in peripheral arterial disease (PAD) patients. METHODS: We studied the effects of a 2+2 months oral treatment with 50 mg b.i.d. of mesoglycan, intervalled by 2 months without mesoglycan, in 540 PAD patients on four occasions (visit 1: baseline, visit 2: 2 months, visit 3: 4 months and visit 4: 6 months). At these time visits we assessed brachial artery endothelial-dependent flow-mediated dilation (FMD), together with femoral intima-medial thickness (IMT), and walking distance (WD). RESULTS: There were significant changes in FMD (1.88%, CI 95%: 1.13, 2.63; P<0.001), IMT (-0.05 mm, CI 95%: -0.07,-0.02; P<0.001) and WD (38,9%, CI 95% 33.2, 44.8; P<0.001). The positive effects and benefit were maintained during the two-months interval without mesoglycan treatment. Significant changes in FMD were observed in a number of patient groups, stratified for risk factors (aging, sex, smoke, diabetes, dyslipidemia, hypertension). CONCLUSION: Two months cycles with mesoglycan improved endothelial function in PAD patients, with a parallel reduction of atherosclerotic damage and amelioration of clinical condition.

Renal Stenting for Kidney Salvage in the Management of Renal Artery Atherosclerotic Stenosis.

We studied the usefulness of preoperative resistance index to select patients who will benefit most from renal stenting. Sixty-two patients underwent renal stenting. All had chronic renal insufficiency with serum creatinine values ranging from 1.5 to 2.5 mg/dL and blood urea nitrogen between 80 and 107 mg/dL. All treated renal artery stenosis were >70%. Reduction in blood pressure in the early stages was observed in 39 (62.9%) patients; 31 (79.4%) patients returned to preoperative values within 12 months. A progressive reduction in creatinine values and blood urea nitrogen was reached in 43 (69.4%) patients, 12 (19.4%) patients remained unchanged, and the remaining 7 (11.2%) patients worsened. The best improvement in renal function was obtained in patients with a resistance index of ≤0.75 A preoperative resistance index up to 0.75 could be used as an indicator to predict which candidates will have improved renal function after stenting.

Vascular injuries in supracondylar humeral fracture: an active approach to diagnosis and treatment.

AIM: The strategy with vascular complications of supracondylar humeral fractures (SHF) is under scrutiny since modern diagnostic techniques, particularly ultrasound investigations, provide earlier and more precise assessment and updated vascular surgical procedures, particularly microvascular ones, obtain excellent results. The purpose of this study was to look prospectively at what could be achieved by early systematic diagnostic investigations and, when appropriate, immediate arterial exploration and repair. METHODS: Sixty-three pediatric patients with SHF were admitted and treated in our Service between January 2007 and February 2014. Besides clinical examination, they were all investigated by color-coded Duplex scanning (CCDS) and ultrasound velocimetry (UV) of the hand. Eighteen patients were pulseless at first observation. Seven of them presented without signs of ischemia and regained their pulse post-reduction; only dislodgement and compression of the brachial artery (BA) was found in those children. In 11 patients, with pink hand in 7 and severe ischemia (white pulseless hand) in 4, lesions of the BA were detected. All were operated upon by various forms of arterial repair. CCDS and UV were used also intraoperatively and during follow-up (1 m-13 y). RESULTS: All patients had favorable early and long-term results: 8 came back to normal conditions, 2 had persistent paresthesia and weakness of the hand and 1 remained with partial disability of forearm and hand. All BA remained patent. CCDS correctly detected all the lesions preoperatively and showed the patency of the arteries after repair. CONCLUSION: Early assessment, use of ultrasound investigations and BA prompt repair seem to be the most logical and fruitful strategy at present time.

The value of ultrasonic diagnosis in the management of vascular complications of supracondylar fractures of the humerus in children.

Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients.

Trancranial Doppler: value in clinical practice.

The value of TCD in clinical practice is well established since it can be used to measure cerebral vasomotor reactivity and to detect and grade vasospasm (VSP) following subarachnoid haemorrhage and cerebral blood perfusion consequences of extracranial ICA stenosis or occlusion. Intracranial steno-occlusive disease can be detected more reliably by transcranial color-coded imaging (TCCI) that provides a two-dimensional imaging of parenchymal and vascular anatomy of brain too. In patients with suspected brain TCD diagnostic criteria for brain death have a sensitivity of 91 to 100% and specificity of 97 to 100% and they are particularly useful when clinical and EEG evaluations are difficult. TCD is a sensitive technique for real time detection of microembolic signals (MES) from prosthetic cardiac valves, myocardial infarction site, atrial fibrillation, aortic arch atheroma and this suggests the use of TCD for monitoring response to antithrombotic therapy. There is also a high correlation between contrast-enhanced TCD and trans-esophageal echocardiography for detecting paradoxical embolism through right-to-left cardiac or pulmonary shunts. Microembolization detected by TCD monitoring may confirm features of unstable carotid artery plaques as imaged by Duplex scanning and there is an increasing evidence that asymptomatic MES from unstable carotid plaques are an independent factor for ischemic stroke. TCD can be used as a monitoring tool during cardiac surgery and cerebrovascular operations to determine critical hemodynamic changes in cerebral arteries and to identify high-intensity transients referred to air or particulate emboli. Several research studies of the past 10 years have shown that MES may be detected by TCD during all phases of CEA and CAS and that sustained microembolism after carotid flow restoration is an indication of impending postoperative or post-procedural occlusion. Our series showed a clear difference between the number of patients with MES and the incidence rate of MES in each patient submitted to CAS (100% of cases with 35-250 MES in each case) and to CEA (74% of cases with 2-30 MES in each case). We also observed a decrease in the incidence rate of microembolic events by TCD during CAS with or without brain protection devices , 18.% and 40%, respectively. There is a statistically significant difference between the neurological deficit related to embolism during CEA (1.8% of cases) and during CAS(9 %). Furthermore DWI has shown a higher prevalence of postoperative small areas of brain ischemia due to asymptomatic embolism occurring during CAS than after carotid surgery according with a higher incidence of patients suffering from neuropsychological impairment after CAS as compared with those submitted to CEA . The use of TCD can provide new insights into pathophysiology of cerebral steno-occlusive and functional diseases, it can helps in risk stratifications of patients with cardio-embolic sources and in the choice and monitoring of medical, surgical or endovascular treatment. TCD monitoring during carotid revascularization either surgical or endovascular can alert the operator to take appropriate measures to avoid brain ischemia and provides useful data for choice and control of the different brain protection devices.

[Carotid-carotid bypass. Indications and results]. / Bypass carotido-carotideo. Indicazioni e risultati.

AIM: The aim of this study is to evaluate the indications for a carotid-carotid bypass and its therapeutic efficacy. METHODS: Between January 1995 and December 2001, 42 out of 782 patients with obstructive lesions of carotid vessels were submitted to carotid-carotid bypass. Preoperative investigations included Duplex scanning, transcranial Doppler and cerebral CT in all the patients, angiography in 24, spiral CT in 8, MR angiography in 6. Carotid bypass was planned pre-operatively in 13 cases due to internal carotid occlusion in 4, to pseudo-occlusion in 8 and to restenosis in 1. In the remaining 29, due to a too thin residual wall or to the lack of a good clivage plane, a carotid bypass was planned intraoperatively. A PTFE graft was employed in 30 cases while the autologous saphenous vein in 12. Four patients were lost in a 12-80-month follow-up. No intra or postoperative mortality was recorded. RESULTS: Three patients died during the follow-up. In 1 patient the death followed an ischemic stroke due to bypass occlusion. Four bypasses became occluded, in 3 cases without clinical signs. Eight patients suffered by transient superior laryngeal nerve iniury. CONCLUSIONS: Carotid bypass, as an alternative to CEA, provides good results in the treatment of the patients with carotid stenosis, pseudo-occlusion or segmental occlusion. In most of the cases the surgical technique is planned intraoperatively but in selected cases angiographic findings, spiral CT and color flow duplex can suggest in the preoperative phase that carotid bypass is the best choice.

Carotid surgery without angiography is possible and safe.

BACKGROUND: To evaluate the possibility to perform carotid surgery without angiography. METHODS: From January 1994 to June 1998, 514 patients with carotid obstructive disease were operated upon, 225 of them (43.8%) without previous angiography; 55 out of 68 (80.8%) during the last six months. Eighty-one (36.0%) had lateralizing symptoms, 50 aspecific ones (22.2%) and 94 were asymptomatic (41.8%). All patients were investigated by color-coded duplex sonography (CDS) of the arteries at the neck and by transcranial Doppler (TCD) and computed tomography (CT). One hundred eighty-eight patients were operated upon under local anaesthesia and 37 under general anesthesia; 204 had a carotid endartereotomy (90.7%) with patch angioplasty in 154 (75.5%), and 21 required a bypass graft (9.3%). In 26 patients (11.5%) an indwelling shunt was needed. RESULTS: Findings at surgery were consistent with CDS for plaque composition, ulcerations and degree of stenosis. There were no early deaths. Neurologic or ocular deficits occurred in 2 cases (0.9%). No strokes were observed in follow-up from 6 to 34 months. CONCLUSIONS: Carotid endarterectomy can be done without angiography in selected cases provided CDS plus TCD are of high quality. Under such conditions it can be considered a safer way to deal with carotid obstructive disease.

Transcranial Doppler in 178 patients before, during, and after carotid endarterectomy.

From July 1991 to March 1995, 178 patients who underwent 198 carotid surgical repairs were investigated preoperatively, intraoperatively, and postoperatively by transcranial Doppler sonography (TCD). Preoperative TCD evaluation showed stenosis of the middle cerebral artery (MCA) in 4 patients (2.2%), siphon stenosis in 3 (1.6%), incomplete circle of Willis in 23 (12.9%), a decrease of mean blood flow velocity more than 70% of the basal value during digital common carotid compression in 31 (17.9%), and a critical reduction of vasomotor reactivity (no significant increase of mean blood flow velocity in the MCA during breath-holding test) in 34 (19.1%). Nine patients (5%) had surgery without preoperative angiography. In those patients the indication for surgery was based on color Doppler imaging and TCD investigations. Ninety surgical procedures were carried out under general anesthesia and 188 under locoregional anesthesia. In 37 surgeries (31.7%) a shunt was inserted. The use of a shunt was based on a decrease of mean blood flow velocity in the MCA below 50% of the basal value under general anesthesia or loss of consciousness combined with a decrease of mean blood flow velocity in the MCA higher than 70% of the basal value when locoregional anesthesia was employed. Intraoperative TCD monitoring showed a decrease of mean blood flow velocity in the MCA due to shunt malfunction in (8.3%) of 36 surgeries, turbulence of blood flow during declamping in 79 procedures (39.8%), and microembolic events in 10 patients (5%) that were related to one transient and one permanent neurological deficit. Another permanent deficit occurred in a patient without TCD signs. After surgery, TCD reliably detected an early asymptomatic occlusion of the carotid artery, hyperperfusion syndrome in 12 (6.0%), and an increase of vasomotor reactivity in 10 (29.4%) of 34 surgeries.

Composite grafts for critical ischaemia.

A total of 236 femoropopliteal below the knee and 64 femorotibial bypasses were carried out for critical ischaemia of the lower limbs using various prosthetic materials. These were evaluated in order to assess the patency of composite grafts (29 cases) compared with autogenous saphenous veins (189) and polytetrafluoroethylene (PTFE) (82). The composite graft was made by anastomosing a segment of autogenous vein in the distal position and joining it by an end-to-end oblique anastomosis to a PTFE prosthesis in the proximal position. These grafts were employed when an adequate autogenous vein could not be used for the entire length of the bypass. The graft-graft anastomosis was never placed near the knee-joint and if the PTFE segment had to cross the knee, it was always of the externally supported type. There were no early occlusions in the composite grafts. A total of 257 grafts were available for assessment at a mean of 4 years (range 6 months to 15 years). The patency for autologous saphenous vein was: 81.2% (121/142 femoropopliteal and 13/23 femorotibial). The patency for PTFE was 67.1% (41/58 femoropopliteal and 4/9 femorotibial) and for composite grafts was 76% (10/11 femoropopliteal and 9/14 femorotibial). There was no significant difference in patency between the autologous saphenous vein and the composite grafts, both in the femoropopliteal and femorotibial positions. Both were significantly better than PTFE grafts. Composite grafts are the best alternative when an autologous saphenous vein is not available.

[Considerations on the pathogenesis, diagnosis and therapy of renal venous aneurysm]. / Considerazioni di patogenesi, diagnosi e terapia degli aneurismi venosi renali.

An aneurysms of a renal vein is very uncommon an entity and even more so when a visceral vein is affected. The venous aneurysms are generally asymptomatic and are detected either at post-mortem examination or by Echography, CT scan or MR investigation. Occasionally they become symptomatic because of rupture, thrombosis and embolism, but even in those cases they are difficult to be diagnosed and can be life threatening particularly when bleeding occurs. Exceptionally an aneurysm of a visceral vein is an unexpected intraoperative finding and is detected during an abdominal procedure undertaken for other pathology. In our experience a true aneurysm of the main trunk of the left renal vein was detected during a procedure of aorto-bifemoral by-pass graft repair for chronic aorto-iliac occlusive disease. The aneurysm was resected and the vein repaired by direct suture. Congenital weakness of the vein wall was very likely the cause as suggested by the extreme thinness and media atrophy of the aneurysm and normal appearance of the wall of renal vein and inferior vena cava. Differences between varices and aneurysms of the renal veins are discussed as well as indications for surgical treatment.

External carotid artery repair in cerebrovascular insufficiency.

From January 1985 to October 1992 ten patients were submitted to reconstruction of the external carotid artery (ECA). Nine were males and one female with age that ranged from 64 to 74 years, mean 68. All were symptomatic due to TIAs in seven and amaurosis fugax in four of this group, previous completed stroke plus TIAs in two and chronic low perfusion in one. Associated risk factors were smoking (8 pts: 80%), coronary disease (5 pts: 50%), hypertension (4 pts: 40%), diabetes (4 pts: 40%) and peripheral arterial obstructive disease (2 pts: 20%). All patients were submitted to non invasive (Doppler C. W., Echo-color Doppler) studies as well as angiography. All the patients had an occlusion of the internal carotid artery (ICA) unilateral and homolateral to external carotid stenosis in 8 and bilateral in 2; in addition three patients had a non haemodynamic stenosis of the contralateral ICA. One patient had an occlusion of the common carotid artery with collateral supply to the ECA; nine had severe stenosis of the ECA at the origin. In one case a homolateral vertebral stenosis was detected as well as a prevertebral contralateral subclavian stenosis in another one. Surgery was advised to correct amaurosis fugax, to increase external-internal collateral supply in order to avoid cerebral ischaemia and prior to contralateral ICA endarterectomy. All patients were operated upon under general anesthesia; an endarterectomy with a PTFE patch was performed in 9 cases, while in one a subclavian-ECA bypass was carried out using an autologous vein segment.(ABSTRACT TRUNCATED AT 250 WORDS)

Cirugía de pacientes con infección por VIH y SIDA: Análisis de los procedimientos quirúrgicos y/o invasivos / Surgery in patients with HIV infection and AIDS: Analysis of and/or invasive surgical procedures

Se revisaron las historias de 30 pacientes que ingresaron al Hospital Vargas de Caracas, entre los años 1983-1988, con los diagnósticos de infección por VIH o SIDA. Todos eran masculinos, con edad promedio de 39.09 años. El 56.8% refirió ser homosexual, el 43,3% enfermedad de transmisión sexual, el 20% hepatitis y sólo el 10% recibió transfunciones previas, dos de los pacientes eran hemofílicos. De los signos y síntomas al ingreso la fiebre, pérdida de peso, infecciones respiratorias, diarrea, adenopatías y lesiones cutáneas; fueron las más frecuentes. El VIH resultó positivo en el 96,6% de los casos. La Rx de Tórax fue normal en el 36,6%. Al 36,6% de los pacientes se les practicó algún procedimiento quirúrgico, siendo los más frecuentes: Biopsia ganglionar, drenaje de absceso perinatal, toracotomía mínima y biopsia de piel. El 72,7% se realizó en quirófano. De los procedimientos invasivos la endoscopia digestiva inferior se realizó en el 27.77% de los casos seguido de la punción lumbar y la endoscopia digestiva superior con 19.44% respectivamente. Un total de 46,6% de los pacientes fallecieron durante su hospitalización. Se enfatiza el manejo quirúrgico de pacientes con infección por VIH, reportándose los procedimientos quirúrgicos e invasivos comúnmente realizados, revisandose además frecuente y las normas establecidas para prevenir el riesgo de infección

Primera experiencia en el Hospital Vargas en el manejo quirúrgico de la sepsis intra-abdominal con técnica abierta y malla de Marlex con cierre cremallera / First experience in Hospital Vargas in the surgical management of intra-abdominal sepsis treated with the open management methods

La sepsis intraabdominal continúa siendo uno de los grandes retos en cirugía ya que su mortalidad sigue siendo elevada. En el afán de buscar métodos más eficaces para el manejo de esta entidad surge nuevamente el llamado "Manejo Abierto de la Cavidad Abdominal". El propósito de nuestro trabajo es hacer una revisión amplia en cuanto al manejo quirúrgico de la intraabdominal y presentar el primer caso manejado en el Hospital Vargas de Caracas según la técnica abierta con malla de Marlex y cierre tipo cremallera