Open or endovascular repair of aortoenteric fistulas? A multicentre comparative study.

OBJECTIVES: To compare aortoenteric fistula (AEF) outcome after endovascular (EV-AEFR) or open repair (O-AEFR). DESIGN: Multicentre retrospective comparative study. MATERIALS/METHODS: 25 patients with AEF (24 secondary, 23 males, median age 75 years) after aortic surgery (median four years). Preoperative sepsis was evident in 19 cases. Eight patients were managed with EV-AEFR and 17 with O-AEFR. RESULTS: The two groups were comparable in preoperative characteristics. In-hospital mortality after EV-AEFR was lower compared to O-AEFR (0% and 35%, respectively, p = 0.13). Similarly, morbidity after EV-AEFR was lower compared to O-AEFR (25% and 77%, respectively, p = 0.028). There was a trend for worse recurrence-free, sepsis-free, re-operation-free and AEF-related death-free rates after EV-AEFR, while the early survival advantage of EV-AEFR was lost after two years and the overall long-term survival rates (perioperative mortality included) of the two groups were similar. Preoperative sepsis had no effect on recurrence and sepsis-free rates (p = 0.94 and p = 0.92, respectively), but it was associated with worse two year overall survival (24% vs 50%, p = 0.32). On multivariate analysis, the number of symptoms (two vs one) at presentation was the single predictor of worse re-operation rates, AEF-related and overall survival. CONCLUSIONS: EV-AEFR was associated with no postoperative mortality in this study and can achieve satisfactory short and long-term results, comparable to O-AEFR. Further trials should focus on the role of EV-AEFR in patients at high risk for O-AEFR, due to shock or co-morbidities, or as a bridging procedure.

Role of OPG/RANKL/RANK axis on the vasculature.

Vascular calcification, a degenerative process considered in the past to be a passive procedure, has now been suggested to be related to ossification. Many proteins responsible for bone formation have been identified on the arterial wall. The OPG/RANKL/RANK axis, responsible for ossification and bone mineralization, seems to play a major role in vasculature and atherosclerosis. Mice lacking OPG gene present osteoporosis and arterial calcification, while overexpression of OPG gene leads to osteopetrosis. In the present review the latest knowledge related to the effects of the OPG/RANKL/RANK axis on vasculature, including atherosclerosis, will be analyzed. The clinical significance of circulating OPG and RANKL levels in vascular diseases will also be referred.

Abdominal aortic aneurysm repair in patients with end stage renal disease.

OBJECTIVE: Abdominal aortic aneurysm (AAA) in patients with end stage renal disease (ESRD) represents a challenging therapeutic problem. This study was undertaken to analyze the surgical outcome of AAA repair in patients with ESRD and discuss the optimal peri-operative management of problems that resulted. METHODS: Between January 1995 and January 2005, 11 patients with ESRD underwent abdominal aortic aneurysm repair. All patients were under chronic haemodialysis. Risk factors related to surgical morbidity were evaluated. RESULTS: The average age was 68 years (57-84 years). Nine patients were men: 8 were hypertensive, 6 had diabetes, 4 had coronary artery disease, 3 had suffered a previous stroke, 3 had prior myocardial infarct and 8 were smokers. The duration of haemodialysis was 19 months (range 2 to 46 months). Five of the 11 patients had bilateral common iliac aneurysms in addition to the abdominal aortic aneurysm. The average diameter of infrarenal AAA was 6 cm (4.8-7.5). The mean duration of operation was 191 min. All patients underwent haemodialysis on the day before operation with an average period of 8.5 hours (6-12) and 2 to 20 hours postoperatively. The mean follow-up was 11.5 months (range 1 to 93 months). None of the patients died during the 30-day postoperative period. Two patients died from heart failure 3 and 7 months later. CONCLUSION: Abdominal aortic aneurysm can be repaired in patients with end stage renal disease with good results, despite the increased morbidity and mortality of this population.

Surgical treatment of carotid body tumors without embolization.

AIM: Carotid body (CB) paragangliomas are rare neoplasms, usually benign. This study deals with our 10-year experience in their surgical treatment and the evaluation of its effectiveness, without preoperative embolization. METHODS: During a 10-year period, from 1995 to 2004, we studied the medical records of 11 patients with CB tumors, 8 males and 3 females, whom only one had bilateral tumors. Their age ranged from 23 to 65 years (mean 35 years) and all had a palpable neck mass. Only two of the patients were asymptomatic on admission to our department. Twelve tumors were surgically resected and no patient underwent preoperative selective embolism of his tumor. Two patients had carotid endarterectomies with venous patch angioplasty. No one of the patients underwent radiotherapy or chemotherapy. RESULTS: Perioperative mortality was zero. No stroke or any other cerebral event was observed. One patient, with a grade III tumor, had an injury of the internal carotid artery that was repaired with a vein patch. Three patients had temporal cranial nerve lesions that resolved within 3 months. No malignancy was found even in a 10-year follow-up. CONCLUSIONS: Early surgical treatment is strongly recommended in almost all patients. Their resection is a very challenging operation with good postoperative results. Preoperative embolism of the tumor does not need to be a routine procedure. To exclude malignancy, long term follow-up is necessary.

Simultaneous venous gangrene in both lower and upper limbs. A case report.

Cancer-related venous gangrene is an extremely rare paraneoplastic syndrome. Here, we present the case of a woman, who suffered from cervical cancer of the uterus and was admitted to our Clinic with venous gangrene in both the right lower and upper limbs. Neither the anticoagulant therapy, nor thrombolysis, succeeded in improving her clinical condition. Cancer is one of the most important causes of venous thromboembolism. Venous gangrene is rarely seen in these patients. Despite adequate therapy, venous gangrene in some very rare occasions may progress to affect further limbs. Mortality in these patients remains very high.

Simultaneous surgical treatment of abdominal aortic aneurysm and bilateral aneurysms of the internal iliac artery.

INTRODUCTION: The purpose of this study is to present our experience in the management of patients with abdominal aortic aneurysms (AAA) and aneurysms in both the internal iliac arteries (IIA) at the same time. METHODS: Between 2000 and 2005, a series of 13 patients with AAA and also aneurysms in both the IIA, were treated in our clinic. They were all men with a mean age of 74 years. The size of the IIA aneurysms (IIAA) ranged from 2.0 to 8.0 cm (mean, 3.4 cm). All patients underwent an aneurysmatectomy of the AAA and placement of a prosthetic bifurcated aorto-biiliac or -bifemoral bypass, by a transperitoneal approach. The management of one of the two IIAA was the aneurysmatectomy and the direct revascularization of the healthy peripheral portion of the remaining IIA with the ipsilateral leg of the aorto-biiliac bypass. The other IIAA was treated with proximal ligation of its neck and aneurysmorraphy. RESULTS: No patient died during the first 30 postoperative days. Morbidity was about 7.7% (one patient suffered from 'trash foot', which was treated successfully with conservative measures). Finally, the mean stay in hospital was 7 days and no patient clinically presented symptoms of pelvic or colonic ischaemia. CONCLUSIONS: Simultaneous treatment of AAA and bilateral IIA aneurysms is a technically difficult, but safe procedure, if it is performed meticulously. Revascularization of at least one internal iliac artery is strongly recommended in order to avoid dangerous complications, such as pelvic or colonic ischaemia.

Pharmacokinetics of liposomal aerosolized cyclosporine A for pulmonary immunosuppression.

BACKGROUND: The results of pulmonary transplantation are compromised by acute and chronic rejection. We hypothesized that a liposomal form of aerosolized cyclosporine A (CsA) would be selectively deposited and concentrated in the lungs. The theoretical advantage of this therapy is selective pulmonary immunosuppression with prolonged utilization. METHODS: Eighteen dogs were endotracheally intubated; aerosolized liposomal CsA was administered for 15 min. CsA levels were measured in whole blood, lung, trachea, heart, kidney, liver, and spleen at various times after treatment. RESULTS: The lung rapidly absorbs aerosolized liposomal CsA; other organs have much lower concentrations. The retention of pulmonary CsA delivered by liposome aerosol is approximately 120 min in this model. CONCLUSIONS: Aerosolized liposomal CsA is selectively deposited and concentrated in the lungs; other organs absorb less CsA.

The predictive value of dipyridamole-thallium scintigraphy for cardiac risk assessment before major vascular surgery.

BACKGROUND: We prospectively examined the ability of dipyridamole thallium scintigraphy (DTS), as a preoperative screening test, to predict postoperative cardiac complications in patients undergoing peripheral arterial operations. METHODS: From November 1993 to November 1995, a DTS study was routinely performed preoperatively in 167 consecutive patients who underwent arterial operations in our hospital. The clinicians were blinded to DTS results. The type of operation was: carotid endarterectomy (n = 53), abdominal aortic aneurysm repair (n = 45), aortobifemoral bypass (n = 31), femoropopliteal bypass (n = 32) and others (n = 6). Clinical and scintigraphic data were collected and analyzed uni- and multivariantly in order to identify those variables that correlate with postoperative cardiac complications. RESULTS: Fifteen adverse cardiac events (three deaths, five myocardial infarctions, seven unstable anginas) occurred postoperatively among 167 patients (mortality: 1.8%, morbidity: 7.2%). Forty-four patients (26.3%) had a normal scintigraphic study, sixty (35.9%) had fixed defects and sixty-three (37.7%) had reversible defects. The most powerful predictive factors of cardiac complications in the multivariate analysis were the synchronous existence of three markers of coronary artery disease (angina pectoris, previous myocardial infarction, Q sign on ECG) and the presence of a reversible defect in the anterior segment of the left ventricle on DTS study. CONCLUSIONS: This study demonstrates that the careful and detailed clinical examination is of paramount importance in detecting "high risk" patients and that DTS should be performed as a supplementary test since it offers significant information and further classifies patients of intermediate risk to develop postoperative cardiac complications.