A multicentric experience with open surgical repair and endovascular exclusion of popliteal artery aneurysms.

INTRODUCTION: The aim of this study was to analyse early and follow-up results of the treatment of popliteal artery aneurysms (PAAs) performed with open surgical repair or with endovascular exclusion with endografts in a multicentric retrospective registry involving seven Italian vascular centres. MATERIALS AND METHODS: We retrospectively collected data concerning 178 open surgical interventions (OR group) and 134 endovascular exclusions (ER group) for PAAs performed between January 2000 and December 2011. Early and follow-up results were analysed in terms of mortality, graft patency, reintervention and limb preservation. RESULTS: OR patients were more frequently symptomatic (64%, 115 cases) than patients in the ER group (34%, 51 cases; p < 0.001), had more frequently acute limb ischaemia (23% and 6.5%, respectively; p < 0.001) and had more frequently a run-off score <2 (39% and 26%, respectively, p = 0.03). In the OR group there were no perioperative deaths; six thromboses (3.3%) and one amputation occurred. In the ER group mortality was 1.5%; 13 thromboses (9.7%) and one amputation (0.5%) occurred. Mean duration of follow-up was 30.6 ± 27.5 months. In the OR group primary and secondary patency, freedom from reintervention and limb preservation rates at 48 months were 63.5% (standard error (SE) 0.05), 76.5% (SE 0.05), 72.5% (SE 0.06) and 89.7% (SE 0.05), respectively. The corresponding figures in the ER group were 73.4% (SE 0.04), 85% (SE 0.04), 75% (SE 0.04) and 97% (SE 0.04), respectively. CONCLUSIONS: In this large multicentric retrospective registry, open and endovascular treatment of PAAs are used in different patients with regard to clinical and anatomical characteristics. Both treatments are feasible and safe, providing satisfactory early and long-term results.

Results from an Italian multicentric registry comparing heparin-bonded ePTFE graft and autologous saphenous vein in below-knee femoro-popliteal bypasses.

AIM: The aim of this study was to evaluate early and follow-up results of below-knee bypasses performed with a bioactive heparin-treated ePTFE graft in patients with peripheral arterial obstructive disease (PAOD) in a multicentric retrospective registry involving seven Italian vascular centers and to compare them with those obtained in patients operated on with autologous saphenous vein (ASV) in the same centres in the same period of time. METHODS: Over a nine-year period, ending in 2010, a heparin bonded prosthetic graft (Propaten Gore-Tex, W.L. Gore & Associates Inc, Flagstaff, AZ, USA) was implanted in 556 patients undergoing below-knee revascularization for PAOD (HePTFE group). In the same period of time 394 below-knee bypasses with ipsilateral ASV were performed (ASV group). Data concerning these interventions were retrospectively collected in a multicenter registry with a dedicated database. Early (<30 days) results were analyzed in terms of graft patency, major amputation rates and mortality. Follow-up results were analyzed in terms of primary and secondary graft patency, limb salvage and survival. RESULTS: Among patients of HePTFE group, 413 had critical limb ischemia (74%); the corresponding figure for ASV group was 84% (332 interventions, P<0.001). Eighty-nine patients in HePTFE group (16%) and 207 patients in ASV group (52.5%; P<0.001) had distal tibial anastomosis. Patients in HePTFE group had more frequently adjunctive procedures performed at distal anastomotic sites in order to improve run-off status. Thirty-day death rate was 1.9% in HePTFE group and 0.5% in ASV group (P=0.08). The rates of perioperative thromboses and amputations were 6% and 3.5% in HePTFE group, and 5% and 1.7% in ASV group, without significant differences between the two groups. Mean duration of follow-up was 28.5±22.1 months; 921 patients (97%) had at least one postoperative clinical and ultrasonographic control. Estimated 48-month survival rates were 81% in HePTFE group and 74% in ASV group (P=0.7, log rank 0.1). Primary patency rate at 48 months was significantly better in ASV group (61%) than in HePTFE group (44.5%; P=0.004, log rank 8.1). The rates of secondary patency at 48 months were 57% in HePTFE group and 67.5% in ASV group (P=0.1, log rank 1.9); the corresponding values in terms of limb salvage in patients with critical limb ischemia were 77% and 79.5% (P=0.3, log rank 0.9), respectively. CONCLUSION: Data from this large, retrospective registry confirmed that the indexed heparin-bonded ePTFE graft provides satisfactory early and mid-term results in patients undergoing surgical below-knee revascularization. While autologous saphenous vein maintains its superiority in terms of primary patency, secondary patency and limb salvage rates are comparable.

Heparin-bonded expanded polytetrafluoroethylene grafts for infragenicular bypass in patients with critical limb ischemia: 2-year results.

AIM: The use of prosthetic grafts in below-knee (BK) bypasses may be necessary in patients with no available autologous vein and critical limb ischemia not amenable to angioplasty. Such conduits, however, have generally yielded disappointing results. METHODS: A new heparin-bonded expanded polytetrafluoroethylene graft (Gore-Tex Propaten Vascular Graft) designed to provide resistance to thrombosis may be associated with decreased early graft failure and increased patency. This graft was implanted in 27 limbs (26 patients; 18 men; mean age 71 years; Rutherford class 4 to 6 disease) in a BK femoropopliteal and femorodistal location, without perioperative complications and with immediate graft patency. RESULTS: During a mean follow-up time of 24 months, 4 cases of thrombosis occurred, all at least 6 months postoperatively: 2 cases resolved after fibrinolytic treatment, 1 required surgical revision and in 1 case, amputation was required because of a delay in seeking treatment for thrombosis. Two patients died of cardiac disease during follow-up. The 2-year primary and secondary patency rates for the BK bypasses were 85% and 93%, respectively; the limb-salvage rate was 96%. CONCLUSION: These results are encouraging for a prosthetic graft, especially in the light of the severity of the vascular disease in the limbs treated.

Treatment of superficial femoral artery occlusive disease.

The aim of this paper was to compile a literature summary of current treatment modalities for the treatment of superficial femoral arterial (SFA) disease. The English-language literature was searched for studies describing the treatment of SFA occlusive disease using surgical bypass (vein or prosthetic), percutaneous bypass (stent-grafts), bare stents, percutaneous transluminal angioplasty (PTA), and subintimal angioplasty (SA). Inclusion criteria for articles were presentation of primary patency rates, a minimum study population of 10, and baseline characteristics of the study population. Average primary and secondary patency rates for each treatment modality were obtained by weighting the results of each trial by the number of limbs treated. All identified papers were included in the summary, regardless of the study inclusion/exclusion criteria, comorbidities, or patient population. Since the study conditions and patient populations varied widely, this is not intended to be a meta-analysis or for use in directly comparing the efficacy of different treatment modalities; rather, it is to provide general information on their performance under the reported conditions. One hundred and twelve studies met the inclusion criteria for the 6 treatment modalities identified. Compilation of the data revealed different patient populations for the different treatment modalities. For example, PTA was generally used to treat short, stenotic lesions, while endografts and SA were generally used for longer, total occlusions. For this reason, patency rates for the different treatment modalities cannot be directly compared.

Contained rupture of an abdominal aortic aneurysm presenting as obstructive jaundice: report of a case.

Chronic rupture of an abdominal aortic aneurysm (AAA) is a rare occurrence, the presentation of which is unusual, often mimicking other conditions such as femoral neuropathy or radicular compression syndrome. We report herein the case of an 87-year-old woman found to have a contained rupture of an AAA after presenting with back pain and obstructive jaundice. A computed tomography (CT) scan revealed the contained rupture of the aneurysm with a large hematoma compressing the common bile duct. Surgical repair of the aortic aneurysm was successfully performed and the patient remains well.

[Chronic rupture of abdominal aortic aneurysms. (Report of 3 cases)]. / Rottura cronica degli aneurismi dell'aorta addominale. (Su tre casi osservati).

Rupture of an abdominal aortic aneurysm often presents with an abdominal pain, hypotension and a pulsatile abdominal mass. In the last years same clinical reports describe patients with less apparent clinical signs who were found later in their evaluation to have a contained rupture of an abdominal aortic aneurysm. The diagnosis may be delayed by consideration of other disease causing similar symptoms (herniated disc, renal colic). In these patients with confusing abdominal symptoms CT scan provides a rapid and noninvasive diagnosis. We report three cases of contained rupture of an abdominal aortic aneurysm evaluated by computed tomography with different clinical presentation: back pain for erosion into the lumbar vertebral bodies, lower extremity neuropathy and obstructive jaundice. All patients were operated on within 24 hours on admission; there was no operative mortality and survival was 100% at one year.

Aneurysm of the celiac trunk: diagnosis with US-color-Doppler. Presentation of a new case and review of the literature.

Aneurysms of the celiac trunk are the rarest forms of aneurysms of the visceral arteries. Since 1958, when Schumaker reported the first case to be successfully treated surgically, only 69 cases have been reported in the international literature. The detection of such aneurysms, which are often asymptomatic, is mostly occasional. Approximately 15-20% of cases may be complicated by rupture with a mortality rate of around 80%. This eventuality makes surgical treatment mandatory even in asymptomatic cases. The authors report on their experience with the surgical treatment of one case of aneurysm of the celiac trunk and then go on to review the relevant literature.

[Occlusion of the common iliac artery caused by mycotic endocarditis]. / Occlusione dell'arteria iliaca comune da endocardite fungina.

Mycotic endocarditis has an incidence of 6.7% of all the forms of endocarditis and in 33-75% of the cases it complicates with peripheral embolization, more frequently to the lower limbs. Although the prognosis of the mycotic endocarditis is improved in the last years, it remains particularly serious especially when it's associated with arterial peripheral embolization. The authors report their experience in the surgical treatment of one case of occlusion of the iliac artery secondary to mycotic endocarditis, making a review of the Literature on this matter.

[Salmonella C infection of aortic abdominal aneurysm]. / Infezione di aneurisma dell'aorta addominale da salmonella di gruppo C.

The infected aneurysms of the aorta represent the 0.65% of all the aneurysms and they are associated with high morbidity and mortality. The vascular infections from Salmonella are not particularly frequent, even if in the last years their reports are more numerous. The authors report their experience in the surgical treatment of one case of aneurysm of the abdominal aorta infected by group C Salmonella, making a review of the Literature on this matter.

[True aneurysm of the profunda femoris artery. Case report and literature review]. / Aneurisma vero dell'arteria femorale profonda. Caso clinico e revisione della letteratura.

Aneurysms of the profunda femoris artery rarely occur as an isolated lesion because of anatomical position and characteristics of wall tissue. The case of a 79-year-old man admitted to the hospital because of acute pain and swelling of the right leg with pulsating tumor in the groin is reported. Duplex scanning and angiography, performed in order to establish the diagnosis and to plan the operation, demonstrated a right large aneurysm of the deep femoral artery (8 x 12 cm). At operation, the aneurysm was resected associated to a PTFE Stretch graft replacement because the autogenous saphenous vein was not available. A review of the literature on the clinical manifestation and management in emergency or elective surgery of the isolated true atherosclerotic aneurysm of the deep femoral artery, is presented.

[Aneurysm of the celiac trunk. Presentation of a clinical case and review of the literature]. / Aneurisma del tripode celiaco. Presentazione di un caso clinico e revisione della letteratura.

The aneurysms of the celiac trunk are the rarest aneurysms of the visceral arteries. From 1958 only 69 cases have been reported in the international literature. They are frequently asymptomatic and their discovery is more often occasional. They can rupture in 15-20% of the cases with a mortality approaching 80% of the cases. This explains the need of a surgical treatment even in the asymptomatic cases. Personal experience in the surgical treatment of a case of aneurysm of the celiac trunk is reported and a survey of the literature on this matter is made.

Vater's papilla and periampullary area villous adenoma: personal experience about nine cases and review of the literature.

Villous tumor of the duodenum is a rare disease. The authors report their personal experience from 1987 to 1993 with nine cases of duodenal villous tumors. The treatment was pancreatoduodenectomy in four cases, segmental resection of the duodenum in two cases and submucosal excision in three cases. The authors review the literature of the last 15 years in which only 241 cases of duodenal villous tumors are reported; in this review the clinical, diagnostic and therapeutic characteristics of the disease are analyzed. This malignancy presents peculiar characteristics for histologic diagnosis and pathology classification. For this reason, even surgical treatment deserves careful reflection to guarantee a curative procedure and to formulate a positive prognosis.

[Duodenocephalopancreatectomy with preservation of the pylorus in ampullary cancer]. / La duodenocefalopancreatectomia con conservazione del piloro per il carcinoma ampullare.

The Authors report their experience in the surgical management of ampullary cancer using the Longmire-Traverso technique of pancreatoduodenectomy with pylorus preservation. They consider this operation as the most functional in restoring digestive continuity.

Clinical and pathologic correlations in patients with periampullary tumors.

Perioperative data on 87 patients undergoing pancreatoduodenectomy for periampullary tumors were correlated with pathologic study of operative specimens to identify the accuracy of diagnosis and the factors affecting survival. Accuracy of endoscopic retrograde cholangiopancreatography and computed tomography in locating lesions was 75% and 44%, respectively. Histologic diagnosis before or at the time of resection was available in only 61% of the patients. Carcinoma was correctly diagnosed clinically by the pathologist or the surgeon in 95% (83/87) of patients with 4 patients found to have benign disease on final pathologic examination. Intraoperative diagnosis of site of origin was incorrect in 18% (16/87) of patients. In 28% (23/83) of patients, pathologists identified nodal metastatic disease missed by the surgeon. Survival correlated with nodal and margin status and tumor grade. Tumor size demonstrated no predictive capacity. Although preoperative diagnostic accuracy is less than optimal, surgeons can usually diagnose malignant lesions but more often fail to identify tumor origin and nodal disease. We continue to advocate resection for patients with periampullary lesions thought to be malignant and resectable without a positive histologic diagnosis.

[Early gastric cancer (case contribution)]. / Early gastric cancer (contributo casistico).

Early gastric cancer (e.g.c.) was detected in 23 patients (7.8%) from a total of 293 gastric cancers observed from 1970 to 1985. Clinical and pathological aspects are discussed. In 19 cases the surgical treatment was subtotal gastrectomy for lesions of the middle and lower third, in 4 cases total gastrectomy for tumors of the upper third and of the greater curvature.

[Injuries caused by traffic accidents: passive safety and restraint systems in automobiles]. / Traumi da incidenti stradali: la sicurezza passiva e i sistemi di ritenuta nell'automobile.

In this article are considered the multiple instruments today employed in cars, in order to prevent or ameliorate the lesions caused to the occupants in case of road accident. The acquisitions in the differentiated structure of the car, in the windshield, in the components of the passenger cell are described, and the peculiar importance of the restraint systems is evidenced.

[Injuries caused by seat belts]. / Le lesioni da cintura di sicurezza.

The effectiveness of seat belts is largely proved. Nevertheless, this safety device produces typical lesions, for very violent accidents, or if it is malpositioned. The pathogenetic criterium of these lesions ("seat belt syndrome") is described, while a complete revision of literature is presented. The importance of emergency care in the identification and treatment of these lesions is emphasized.

[Restraint systems for children transported in automobiles]. / I sistemi di ritenuta per i bambini trasportati in automobile.

This article deals with the currently available restraint devices for car passengers up to adolescence, since standard seat belts cannot be directly used with children.

[Limitations of the Italian Institute of Statistics' surveys in automobile accidents]. / I limiti dei rilevamenti ISTAT negli incidenti automobilistici.

In this article is carried out an analysis of the actual criteria used by the Italian Institute of Statistics (ISTAT) in the survey of car accidents, and some clues to improve their quality are suggested. The role of the epidemiologic information in preventing road traumatology is emphasized.