[Vascular pathology. A study of some blood parameters indicative of leukocyte activation and platelet dysfunction]. / Patologia vascolare. Studio di alcuni parametri ematici indicativi di attivazione leucocitaria e disfunzione piastrinica.

BACKGROUND: In vascular pathology the endothelial lesions easily reflect on blood cells, inducing a reactive state. In the present study the eventual presence of activation signals in leukocytes and platelets was tested. METHODS: Fifty-eight subjects with major vascular pathology and 14 with lower limbs venous insufficiency were studied, together with a control group of 25 normal subjects. Elastase PMN, superoxide ion, leukocytes and subpopulation count, platelet factor 3, clot retraction, heparin in neutralizing activity (HNA plasmatic and intraplatelet), platelet count and volume were tested. RESULTS: As regards leukocytes, it was observed a significative increase of elastase PMN and monocytes number for both the studied pathologies, of superoxide ion and leukocyte number only for major vascular pathology; for platelets, an inhibition of functionality, revealed by clot retraction test for arterious and venous pathologies and by HNA test only for the venous one. CONCLUSIONS: As regards the leukocyte activation, elastase PMN is particularly responsive to the endothelial lesion both in arterious and in venous districts, while superoxide ion appears to increase in presence of a marked alteration. The level of monocytes is indicative of an inflammatory condition and of leukocytes of an atherosclerotic inflammatory process. As for platelets, the test clot retraction is specifically sensible to the endothelial abnormality in both the arterious and venous pathologies with addition of an abnormal HNA test only in venous insufficiency. This platelet dysfunction is probably due to endothelial release of vasoactive and heparin amplifying substances.

Ruptured abdominal aortic aneurysms: factors affecting the early postoperative outcome.

BACKGROUND: In spite of the progress in diagnosis and treatment of ruptured abdominal aortic aneurysms (RAAA) the mortality rate still remains very high (varying from 15% to 50% according to various experiences). This study is aimed at analyzing the relative contribution of preoperative hemodynamic conditions and of operative and postoperative factors to outcome of patients operated on for ruptured abdominal aortic aneurysms. METHODS: For this purpose a retrospective case series involving 152 patients operated on in emergency for RAAA, during the period 1990-1994, has been reviewed. In this group we examined the site of rupture, the size of the aneurysms, the presence or not of a shock condition at admission, the existence of inflammatory aspects, the adopted type of prosthesis. RESULTS: The mortality rate was 24.3% (37 patients). In 10 patients (27%) the cause of death was an irreversible hemorrhagic shock. Eight patients (21.6%) died for an intestinal infarction. In 7 patients the fatal outcome was due to the development of an acute renal failure. Five patients (13.5%) underwent an acute myocardial infarction and other five a multiorgan failure. Two patients (5.5%) eventually died for respiratory insufficiency. CONCLUSIONS: The results of our study seem to confirm that the outcome of patients affected by rupture of abdominal aortic aneurysms depends not only on the preoperative hemodynamic condition but also on the expertise of the surgical team.

Percutaneous treatment of iliac aneurysms and pseudoaneurysms with Cragg Endopro System 1 stent-grafts.

PURPOSE: To evaluate the feasibility and short-term follow-up results of treating iliac aneurysms by the Cragg Endopro System 1 stent-graft. METHODS: Nine lesions (two pseudoaneurysms and seven atherosclerotic aneurysms) were treated in eight patients by percutaneous implantation of a total of 10 stent-grafts. The procedure was followed by anticoagulation with heparin for 6 days, then antiplatelet therapy. Follow-up was by color Doppler ultrasound scan at 2 days and 3 months after the procedure for all patients, and by venous digital subtraction angiography and/or angio-CT up to 12 months later for four patients. RESULTS: Initial clinical success rate was 100% and there were two minor complications. In one case the delivery system was faulty resulting in failure to deploy the stent-graft. An additional device had to be used. At 3-12 months all prostheses were patent but one patient (12.5%) had a minimal pergraft leak. CONCLUSION: Percutaneous stent-grafting with this device is a safe and efficacious treatment of iliac artery aneurysms.

[Heparan sulfate in the therapy of postphlebitic syndrome. Evaluation of the efficacy and tolerability as compared to mesoglycan]. / Eparansolfato nella terapia a medio termine della sindrome postflebitica. Valutazione dell'efficacia e della tollerabilità nei confronti del mesoglicano.

BACKGROUND: Antithrombotics and profibrinolytics are indicated in several clinical thrombophilic conditions such as postphlebitic syndrome. Heparansulphate, a glycosaminoglycan, shows an antithrombotic activity with low anticoagulant effect. The aim of the study was to evaluate the efficacy and the safety of heparansulphate (100 mg b.i.d.) versus mesoglycan (50 mg b.i.d.), both administered for three months in patients with postphlebitic syndrome. METHODS: The trial was performed in an open-label, controlled, with parallel and randomized groups, design. Thirty patients, with chronic venous insufficiency and a history of venous thrombosis were enrolled. Coagulative and fibrinolytic parameters (PT, aPTT, euglobulin lysis time, fibrinogen, D-dimer, t-PA, PAI-1) and signs and symptoms (cramps, paresthesia, itch, edema, local pain, skin trophism) were assessed at enrollment, 15 days later after the pharmacological washout period and after 1, 2, 3 months of treatment. Safety was evaluated by monitoring any adverse event during the study and performing clinical laboratory tests at the beginning and at the end of treatment. RESULTS: The two drugs showed a superimposable efficacy and very good tolerability. Coagulative and fibrinolytic parameters were positively affected by both treatments and the clinical benefit was particularly evident in the heparansulphate group with a significant decrease "between times" of local pain, edema, paresthesia and itching. CONCLUSIONS: These data support the use of heparansulphate, and in general of glycosaminoglycans, in the postflebitic syndrome.

[Association of rupture abdominal aneurysm and intestinal infarct]. / Associazione fra aneurisma addominale rotto e infarto intestinale.

The authors present one patient with ruptured abdominal aortic aneurysm (rAAA) who complicate with small bowel infarction and coproperitoneum; and two patients who suffered from rAAA and simultaneous colon infarction, successfully treated by one-stage operation. They comment upon this rare pathology and analyze hypothetical causes, considering the scanty literature about it.

[Percutaneous angioplasty (PTA) in the treatment of non-penetrating injuries to the subclavian artery. A clinical case]. / Trattamento con angioplastica percutanea (PTA) di lesione da trauma non penetrante dell'arteria succlavia. Caso clinico.

Non penetrating injuries to the subclavian vessels are uncommon. We present a case of a young patient with an isolated blunt trauma of the right subclavian artery. The patient, a 25 year-old woman, was admitted to our Institute after a motor-vehicle accident, with a physical findings of absent peripheral pulses and right clavicular fracture, confirmed by non-invasive vascular evaluation and X-ray of the chest. Diagnosis was established by an urgent selective angiography that showed a subintimal hematoma with occlusion of the vessel and peripheral ischemia of the arm. The patient clinical status (hemodynamically stable) permitted a conservative management and a transluminal percutaneous angioplasty (PTA) with a trans-femoral catheter balloon. After radiologic treatment, the patient showed good palpable peripheral pulses. Clavicular fracture was treated by esternal stabilization. We believe that in selected patients, without other serious life-threatening injures, the intimal artery injury can be treated by a conservative and now also radiologic Therapy; PTA treatment avoids morbidity and mortality associated with surgical intervention.

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.

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).

[Hemostatic factors of endothelial origin in major vascular pathology]. / Fattori emostatici di origine endoteliale in patologia vascolare maggiore.

There is an altered hemostatic balance in vascular-based diseases. The aim of this study was to compare a group (no. = 38) of vascular patients (aortic aneurysm, carotid obstructions arteriopathies of lower limbs) and a control group (no. = 40) and assess variations in the following endothelial factors: tPA, PAI1, vWf, fibronectin and dimer D, in differentiated degrees according to the type of pathology. These were the indicative signs of endothelial mobilization resulting in the renewed continuity of the stratum with the formation of a hemostatic plug. vWf was found to be particularly significant as a marker of an ongoing atheromasic process and its extension to various vascular districts.

[Risk factors for arteriosclerosis and diet of surgical patients. 10 years of outpatient activity]. / Fattori di rischio per arteriosclerosi e dieta in pazienti di interesse chirurgico. Attività ambulatoriale di 10 anni.

The follow-up of arteriopathic subjects who have already been hospitalized (abdominal-peripheral vascular district 79% of patient and supra-aortic branch district 21%) has been carried out for around 10 years using an out-patient regime at the Institute of General and Cardiovascular Surgery of Milan. During outpatient visit the main risk factors for arteriosclerosis are routinely checked and treated if required; among the various therapies for metabolic control particular emphasis is placed on diet since its influence on the metabolism is well known, above all in the long term. The efficacy of this treatment has been evaluated by evaluating blood chemical changes (total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, VLDL and glycemia) in a group of patients who followed the diet in comparison to a group which did not. The results obtained show that in dieting patients there was a statistically significant decrease in blood values for total cholesterol, LDL cholesterol, triglycerides and VLDL, together with a decrement, which failed to reach statistical significance, in glycemia and HDL cholesterol. In non-dieting patients it was found that all parameters increased but that this was only statistically significant for total cholesterol and HDL cholesterol. The control of risk factors for arteriosclerosis through diet therapy therefore appears to be satisfactory even for secondary prevention in surgical arteriopathic subjects. It is important to underline that these results were not obtained under conditions of clinical research but in the reality of day-to-day clinical and therapeutic activity whose efficacy is vitally important for scientific health.

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.

[Major interventions in vascular surgery with and without autotransfusion. Comparison of coagulation and hemodynamic parameters]. / Interventi di chirurgia vascolare maggiore con e senza autotrasfusione. Confronto di parametri coagulativi ed emodinamici.

Twenty out of 32 patients undergoing major vascular surgery received autologous blood transfusion and hemostatic and hematological parameters were evaluated in both transfused and non-transfused groups. Blood and urine samples were also analysed. No acceleration of the hemostatic process was observed during either surgery or the postoperative period; free hemoglobin present in reinfusion sacks (?), even in high doses, was immediately restored to normal values in the patient's circulation. A slight effect was observed at the renal level alone. These findings confirm the good qualitative level of the procedures used to reinfuse blood lost during surgery.

[Reconstructive surgery of the abdominal aorta in a case of left-positioned inferior vena cava. Clinical case and review of the literature]. / Chirurgia ricostruttiva dell'aorta sottorenale con vena cava inferiore sinistroposta. Caso clinico e revisione della letteratura.

An unsuspected left-sided inferior vena cava (IVC) can present a formidable challenge for the surgeon attempting abdominal aortic surgery. The incidence of congenital anomalies of the post-renal (infrarenal) vena cava is approximately 3%, with double inferior vena cava most frequently occurring. The authors refer to a case of isolated left-sided vena cava in a 53 year old man who underwent an aorto-femoral bypass graft for aorto-iliac occlusive disease. On the basis of a literature review the authors recall the incidence and the embryology of this anomaly, and analyze its surgical implications, with particular reference to abdominal aortic surgery.

[The clinical picture and surgery of pheochromocytomas. Our experience over 25 years]. / Clinica e chirurgia dei feocromocitomi. Nostra esperienza in 25 anni.

The pheochromocytoma syndrome, caused by an abnormal secretion of catecholamines, is a rare pathology responsible for 0.1-2% cases of hypertension in the overall population considered. Although in the past we deemed the pheochromocytoma could cause prevalently the typical syndrome characterized by paroxysmal hypertensive crises, now we think that the usual clinical presentation is a continue or subcontinue hypertensive state (65%). In this paper the authors refer the clinical experience acquired in 25 years in the General and Cardiovascular Institute of the University of Milan (head: Prof. Ugo Ruberti), analyzing epidemiological aspects and pathogenesis of pheochromocytoma, with particular care to diagnostic methodologies and referring the therapeutic choices. From 1965 until today 40 patients have been surgically treated for pheochromocytoma mono or bilateral. 43 operations have been done, carrying out 46 adrenalectomy. Two complication must be referred: an ictus cerebri consequent upon an hypertensive crisis and one death caused by intraoperative ventricular fibrillation. Normalization of arterial pressure has been obtained in all patients.

[The rupture of an abdominal aortic aneurysm in a patient with a fused horseshoe kidney. A clinical case report]. / Rottura di aneurisma dell'aorta addominale in paziente portatore di rene fuso a "ferro di cavallo". Descrizione del caso clinico.

An emergency operation for a ruptured aortic aneurysm can be very difficult in the presence of horseshoe kidney. This concomitance is rare but represents an interesting challenge for vascular surgeons. The authors report a case of 80 year old male patient who reached the operating theatre for ruptured aortic aneurysm. Unexpectedly a preaortic horseshoe kidney was found. The authors describe the surgical technique adopted to get rapidly to the aneurysm collar preserving kidney integrity.

[Arteriovenous fistula of the left renal peduncle after nephrectomy. A clinical case]. / Fistola artero-venosa del peduncolo renale sinistro dopo nefrectomia. Caso clinico.

The Authors report a case of arterio-venous fistula of the left renal pedicle, twenty six years after nephrectomy. The diagnosis was made by clinical signs and confirmed by angiography. Treatment was surgical with complete removal of the fistula.

[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.