Abdominal aortic aneurysm neck morphology: proposed classification system.

BACKGROUND: While aneurysm neck length, angulation and width have all been previously assessed in endovascular abdominal aortic aneurysm repair (EVAR), aneurysm neck shape has not been considered. AIMS: To analyse the influence of aneurysm neck morphology on outcome following EVAR. METHODS: Aneurysm neck morphology in 70 patients undergoing EVAR from April 2001 to May 2004 was determined using pre-operative CT scans and graft plans. Necks were classified as flared, parallel, irregular, conical, barrel or hourglass. End-points were death,Type I endoleak and graft migration. RESULTS: Forty-six per cent of necks were flared, 34% parallel, 9% irregular, 6% conical, 3% barrel and 3% hourglass. Mean follow-up was 20.2 months (range 4-35). There was one Type I endoleak and one graft migration. There were no aneurysm related deaths. CONCLUSIONS: Assessment of aneurysm neck morphology should be part of the routine preoperative workup for EVAR. A classification system of AAA necks is suggested to facilitate this.

The fate of target visceral vessels after fenestrated endovascular aortic repair--general considerations and mid-term results.

OBJECTIVE: To carry out a retrospective analysis of the short and mid-term target vessels (TV) patency following fenestrated endovascular aortic repair (f-EVAR) of abdominal aneurysm (AAA). PATIENTS AND METHODS: Seventeen f-EVAR patients were analysed. The Zenith (Cook) fenestrated graft was used in all cases. Bare renal stents were used where good apposition existed between the stent graft and the aortic wall, and covered stents were chosen when this apposition appeared deficient. RESULTS: A total of 35 TV were treated: twenty with small fenestration and 15 with a scallop. Procedural technical success was achieved in 16 out of 17 patients. All TV were perfused at the completion angiography. Access to TV through small fenestrations was achieved in 18 out of 20 vessels. After a mean follow-up of 20.5 months no type I endoleaks were detected. No late complications were observed in any of the stented TV. One patient with perioperative bilateral renal artery occlusion remains on haemodialysis. One non-target renal artery, opposite a scallop was unintentionally covered. One kidney, initially perfused via a un-stented scallop fenestration, was atrophied 14 months post surgery. One patient died from heart failure. CONCLUSIONS: f-EVAR is a valid and safe treatment option. Our series and the world literature demonstrates a >90% TV preservation rate. Long-term intensive surveillance is required.

Neck irradiation: a risk factor for occlusive carotid artery disease.

OBJECTIVES: to determine whether irradiation is an independent risk factor for carotid atherosclerosis, and propose guidelines for patient follow-up. DESIGN: a retrospective case control study. MATERIALS AND METHODS: two groups of patients with severe carotid artery stenosis (>70%) were compared: 30 post-neck irradiation patients, and a control group of 100 patients with no history of neck irradiation. Disease location and severity were assessed by duplex. The relationship between atherosclerotic risk factors, time since irradiation and carotid artery disease was examined. RESULTS: the average age of study group patients was 67 years (43-86) compared to 69 years (46-89) in the control group. The average interval from irradiation to diagnosis was 14 years (3-53) (median 12.5 years). The study group suffered less from diabetes, ischaemic heart disease, and peripheral vascular disease ( p<0.02). There were no significant differences among risk factors with respect to age, gender, smoking, hypertension, and hypercholesterolemia. Post-neck irradiation patients had a significantly higher prevalence of bilateral disease (p=0.02), and a higher rate of common carotid artery lesions (p<0.002). CONCLUSIONS: neck irradiation should be considered a risk factor for occlusive carotid artery disease. Preoperative angiographic study should be considered, due to frequent involvement of the common carotid artery.

Carotid endarterectomy in awake patients with contralateral carotid artery occlusion.

OBJECTIVES: Patients with severe stenosis of an internal carotid artery with contralateral occlusion (ICO) are at an increased risk for stroke, and therefore surgical treatment is usually recommended. Carotid endarterectomy (CEA) under regional anesthesia enables constant monitoring of neurologic status and selective shunting in cases of clinically evident cerebral ischemia. In this study, we assess the selective use of shunts based solely on changes in neurological status in awake patients with ICO undergoing CEA as well as their complication rates. METHODS: During 1996-1998, we studied intraoperative findings and results of CEA under regional anesthesia with clinical monitoring of neurological status in two groups: (1) patients with stenosis (> 70% by NASCET) and contralateral occlusion (n = 50) and (2) patients with stenosis and no contralateral occlusion (n = 94). RESULTS: Shunt insertion was required in 42% of group 1, and 6% in group 2. All of the patients in group 1 requiring shunts had stump pressures < 50 torr. The average stump pressure of group 1(40 torr) was significantly lower than that of group 2 (75 torr), and was also lower than that of patients with severe contralateral stenosis (35 patients, 76 torr). Perioperative stroke rates were identical in both groups (2.1%). CONCLUSION: Since ICO patients are at a high risk for brain ischemia during ICA clamping, they require shunt insertion frequently. Patients with no contralateral occlusion require shunting at a much lower rate - even in the presence of severe contralateral stenosis. Regional anesthesia allows for early detection of brain ischemia and therefore, the perioperative results in both groups are similar.

Primary rectal malignant melanoma: report of two cases.

Primary rectal malignant melanoma is an exceptionally rare neoplasm associated with an extremely poor prognosis despite aggressive surgical treatment. We present two female patients with bulky tumors of the lower rectum that were diagnosed as malignant melanoma, above the squamocolumnar junction. Both patients underwent abdominoperineal resection and postoperatively were treated with autologous melanoma cell vaccine. One patient is considered disease free for months after surgery; the second one developed supraclavicular lymph nodes and right lung metastasis after 7 months.

Abdominal aortic aneurysm and aortic occlusive disease: a comparison of risk factors and inflammatory response.

OBJECTIVE: to compare patients with abdominal aortic aneurysm (AAA) and aortic occlusive disease (AOD) with regard to risk factors for atherosclerosis, co-morbid conditions and inflammatory activity. PATIENTS AND METHODS: a total of 155 patients undergoing abdominal aortic surgery between January 1993 and October 1997: 82 (53%) had aneurysmal disease and 73 (47%) had occlusive disease. Principal risk factors were compared: age; gender; smoking; hypertension; hyperlipidaemia; diabetes mellitus; severe peripheral vascular disease (PVD) and ischaemic heart disease. Aortic wall tissue samples were obtained during surgery. A prospective blind analysis was performed for the presence of inflammatory cytokines TNF-alpha, IL-1 beta, IL-6 and TGF-beta. RESULTS: the average age of AAA patients was 74 years (50-88), while that of AOD patients was 61 years (43-82) (p<0.0001). Diabetes mellitus was found to be much more prevalent in the AOD group (p<0.001), while hypertension and severe PVD were more prevalent in the AAA group (p<0.001). No differences were found concerning any of the risk factors. Inflammatory cytokine activity: AAA tissue samples contained significantly higher mean TNF-alpha and IL-6 levels compared to the AOD samples (5.6+/-2.7 x 10 E-4 vs. 4.4+/-2.7 x 10 E-5 atmoles/microl (p=0. 01), and 0.6+/-0.4 vs. 0.01+/-0.006 atmoles/microl (p=0.02) respectively). No differences were found related to IL-1 beta and TGF-beta. CONCLUSIONS: (1) Patients with AAA have fewer atherosclerotic risk factors than do patients with AOD. (2) Patients with AAA and AOD have significantly different inflammatory activity. (3) The data supports the hypothesis that AAA and AOD are probably two different pathological entities.

Synchronous colorectal and renal carcinomas: a noteworthy clinical entity. Report of five cases.

PURPOSE: This study was designed to highlight the incidence of synchronous colorectal and renal carcinomas and to review the literature on that issue. The case reports of five patients who presented with synchronous colorectal and renal cell carcinomas are presented. METHODS: A retrospective study, using systematic medical chart review, analyzed the cases of all patients who underwent large-bowel resection for colorectal cancer in our department between December 1996 and December 1998. RESULTS: Among 103 patients who underwent colorectal surgery during that period, five cases of synchronous colorectal and renal carcinomas were detected (4.85 percent). CONCLUSIONS: Based on our findings, we recommend the routine use of preoperative imaging studies to exclude synchronous asymptomatic renal lesions in patients presenting with colorectal cancer.