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.

Retrospective comparison of a heparin bonded ePTFE graft and saphenous vein for infragenicular bypass: implications for standard treatment protocol.

AIM: The aim of our study is to assess the clinical effectiveness and therefore the medium-term patency of an ePTFE prosthesis treated with Carmeda BioActive Surface (CBAS) heparin technology. METHODS: From January 2003 to June 2005, 74 infragenicular femoral-popliteal grafts were carried out at our institution. All the patients were subjected to Doppler and color Doppler sonography peripheral angiography diagnostic procedures. Surgical procedures were performed on patients with complete occlusion of the femoral-popliteal axis and subgenicular rehabilitation of at least one vessel with acceptable flow, in advanced stage IIB (claudication, < 30 m walking distance), stage III (resting pain) and stage IV (trophic disorders) of Leriche-Fontaine classification. Follow-up was carried out through surgical and Doppler sonography examinations after 1 month, 3 months and then every 6 months throughout the course of the study. RESULTS: Thirty-seven infragenicular bypass procedures using 6 mm ePTFE Propaten grafts and 37 procedures using devalvulated autologous saphenous veins were carried out. CONCLUSIONS: Based on the results obtained, we clearly cannot draw conclusions that are significant from a strictly statistical point of view, both because the study is retrospective and because, by making the population being analysed as homogenous as possible, a number of observations are excluded. However, we tried to draw conclusions that are acceptable from a clinical point of view. Above all, it is certain that should the autologous saphenous vein not be available, Propaten represents a very valid alternative prosthesis, as shown by the event free curve related graft thrombosis analysis of all the patients.

Community reinforcement training for family and significant others of drug abusers: a unilateral intervention to increase treatment entry of drug users.

We randomly assigned 32 concerned family members and significant others (FSOs) of drug users (DUs) to a community reinforcement training intervention or a popular 12-step self-help group. We measured problems arising from the DU's behavior, social functioning of the DU and FSO, and mood of the FSO at baseline and 10 weeks later. We also monitored the FSOs' treatment attendance and treatment entry of the DUs. The treatment groups showed equal reductions from baseline to follow-up in problems and improvements in social functioning and mood of the FSO. However the community reinforcement intervention was significantly better at retaining FSOs in treatment and inducing treatment entry of the DUs.

[Value of intraoperative transesophageal echocardiography during repair of thoracic aorta dissection]. / Utilità dell'ecocardiografia transesofagea intraoperatoria durante interventi di riparazione di dissezione dell'aorta toracica.

The study was designed to assess the diagnostic accuracy and usefulness of intraoperative transesophageal echocardiography (TEE) during repair of aortic dissection. To this end, 32 patients with ascending aortic dissection, undergoing replacement of the ascending aorta, were examined. The diagnosis was validated in each case by intraoperative and/or autopsy findings. The accuracy of TEE was studied in three different periods of surgical operation: before cardiopulmonary bypass (TEE pre-CPB), during CPB (TEE-CPB) and after CPB (TEE post-CPB). In comparison with TEE performed in the intensive care unit 70 +/- 40 min before surgery, TEE pre-CPB showed a higher diagnostic accuracy (100 vs 96%) in classification of the dissection type, a higher sensibility in the identification of intimal tears (83 vs 75%), involvement of the coronary arteries (71 vs 62%) and of aortic arch branches (81 vs 71%); there was no statistically significant difference in the detection of the aortic valve involvement (100 vs 100%). TEE-CPB showed normal perfusion of the true lumen in all but one patient, in whom TEE-CPB showed retrograde perfusion of the false lumen, promptly resolved by fenestration of the false lumen. TEE post-CPB showed persistence of the intimal flap in non repaired segments in all the patients with type I aortic dissection: in 60% of them there was no communication between the true and false lumen; in 40% of them there was a communication between the two lumina, which was proximal in 25% and distal in 15%; all patients did not show thrombosis of the false lumen. TEE post-CPB allowed also the evaluation of flow in left aortic arch branch vessels in 77% of the patients and in the coronary arteries in 70%, and showed well functioning prosthesis in all patients. In each case aortic regurgitation was mild; however, one case had severe insufficiency which was corrected at the time of surgery with annuloplasty. Ejection fraction was normal in 45% of the patients, whereas it was decreased in the remaining patients. Intraoperative TEE during repair of aortic dissection is accurate and useful: it allows improvement in preoperative diagnosis just before CPB, optimizing surgical technique; it gives also important information for the management of patients immediately after CPB and for the follow-up.

[Diagnostic accuracy of transesophageal echocardiography in the diagnosis of aortic dissection: comparison with computerized axial tomography]. / Accuratezza diagnostica dell'ecocardiografia transesofagea nella diagnosi di dissezione aortica: confronto con la tomografia assiale computerizzata.

This study was designed to assess the sensibility, specificity and diagnostic accuracy of transesophageal echocardiography (TEE) and X-ray contrast enhanced computed tomography (CT) in the diagnosis of aortic dissection and its complications. Fifty patients with clinically suspected aortic dissection were examined. Imaging results were validated in each case by intraoperative and/or autopsy findings and/or the results of cineangiography. The Stanford and DeBakey classifications were used to differentiate the dissection type; the patients were also subdivided by TEE according to a modified DeBakey classification. The sensibility of TEE to detect aortic dissection was 100%, significantly higher (p < 0.05) than that of CT for type A dissections (77.2%). The two imaging procedures did not statistically differ (NS) in the detection of type B dissection (CT sensibility 87.5%). The specificity of TEE for the detection of type A aortic dissection was 94%; it was not significantly higher (NS) than that of CT (CT specificity 86.6%). Both TEE and CT had no false negative findings in the diagnosis of type B aortic dissection (100%; TEE vs CT, NS). TEE was reliable in the correct identification of the primary entry site in the ascending aorta (80%), the arch (62.5%) and descending aorta (71.4%), and also in the involvement of coronary arteries (62.5%), and aortic arch branch vessels (71.4%); CT scanning was not effective in detecting any of these complications. Aortic regurgitation was accurately identified by TEE in each case. Both TEE and CT scanning correctly identified thrombosis of the false lumen and pericardial effusion. Intraoperative TEE documented in all patients postrepair persistence of the intimal flap in aortic segments that were not operated; flow in the false lumen was detected in 46.6% of the patients; in 26.6% of them secondary tears, not seen before surgical treatment, were detected. In conclusion, TEE allows a bedside, safe and accurate diagnosis and classification of aortic dissection. It also provides the diagnostic information necessary for the therapeutical decision making. Intraoperative TEE allows improvement in preoperatory diagnosis and gives important information for the management of the patient immediately after cardiopulmonary bypass and in the follow-up.

Intracardiac extension of a calcified ovarian hemangioma--a case report.

The authors report a case of a fifty-five-year-old woman with clinical and echocardiographic diagnosis of right atrial myxoma. At fluoroscopy and phlebography a mobile calcified peduncle was appreciable originating from the left ovarian vein. This passed through the inferior cava to the right atrium where it wound round itself and extended into the right ventricle during diastole. The authors suspected the presence of a vascular leiomyoma. The tumor and its peduncle were removed by pulling through the right atrium during extracorporeal circulation. The site of origin was confirmed at pelvic surgery.