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Secondary aorto-enteric fistula is one of the most serious complications of abdominal aortic reconstruction. Conventional management includes removal of all infected prosthetic graft, oversewing of aortic stump and restoration of lower limbs blood flow by extraanatomic bypass grafting, reporting high rates of mortality, limb loss, and even infection of the extraanatomic grafts. Dissatisfied by these results, frequently, due to aortic stump blowout or extraanatomic by-pass reinfection, some authors attempted a more conservative approach with au in situ replacement by a new synthetic graft. The aim of this paper was to verify the role of in situ graft replacement. From December 1989, 8 patients with secondary aorto-enteric fistula underwent in situ PTFE graft replacement. One patient (12.5%) died perioperatively for acute myocardial infarction. No limb loss occurred. One patient died after 44 months from pulmonary neoplasia without signs of graft infection. The others are doing well at 34 months follow-up. The authors suggest that, in selected patients, in situ prosthetic graft replacement provides better early and late results than extranatomic bypass.

From a consecutive series of 812 patients at risk of stroke we selected 100 who seemed to be at high risk (excessive stroke risk--ESR) on the following clinical criteria: either multiple reversible ischemic attacks in one carotid territory or multiple (or bilateral) severe stenotic carotid lesions. The patients of the first subgroup received medical therapy and those of the second were referred for surgery. The 100 patients were followed up for 12 months, during which 29 patients had cerebral ischemic events: 17 having stroke and 12 TIA. This study suggests that it is possible to identify beforehand subgroups of ESR patients, thereby facilitating the selection of patients for brain protection and avoiding huge trials of unselected cerebrovascular patients.

In order to evaluate the late results of reconstructive surgery for renovascular hypertension, a review was made on a series of 120 consecutive patients who underwent operations over a 11 year period. There were 82 males (68.3%) and 38 females (31.7%) with a mean age of 48.4 years. Renal artery by-pass grafts were used in 90% (120/133), a thromboendarterectomy in 5.2% (7/133), and other surgical procedures were performed in 4.8% (6/133). Associated vascular procedures were performed in 38.3% (46/120) of patients. Operative mortality was 2.5% (3/120) overall; there was no mortality in the isolated renal artery reconstructions. There was a clinical success (after a mean follow-up of 48 months) in 80.4% of patients. The most important factors influencing clinical result after renal revascularization were: a generalized atherosclerosis (p less than 0.05), duration of hypertension (p less than 0.01) and the early post-operative response of the blood pressure (p less than 0.01). The overall five- and ten-year actuarial survival probabilities were 85 and 68%, respectively. The most common causes of death were myocardial infarction, stroke and cancer. Cox regression analysis for variables influencing survival indicated that persistence of severe hypertension was the major determinant of late survival (p less than 0.05). Hypertension in females is better tolerated, while younger patients appear to have better results and late survival after surgical treatment.

Unexpected anatomical and clinical features of abdominal aortic aneurysm (AAA) may be encountered by the vascular surgeon creating technical problems that increase the normally low mortality rates of this affection. One such variant is the so called inflammatory aneurysm (IA) as a characteristic fibrosis involving the arterial wall and thus surrounding structure scan be observed. In our series of 525 patients affected by AAA the incidence of IA was about 4% (19 cases). Two groups of patients were considered: group A, including all the atherosclerotic patients, and group B 19 patients affected by IA. The latter group referred to a typical painful symptomatology in 84% of the cases: this element is of interest as only 20% of the cases of group A complained of pain. No other significant clinical or laboratory data were recorded which could allow the surgeon to perform a pre-operative differential diagnosis. In all 19 cases that underwent surgical treatment there was a 2-3 cm thick aneurysmal wall with a shiny white surface adhering to the IV portion of the duodenum, vena cava and iliac vessels and in some cases to the ureters. Histological examination of specimens of the aortic wall showed evident signs of atherosclerosis of the media and marked fibrotic thickening of the adventitia with the presence of lymphocyte aggregates: a sign of chronic inflammation. As what concerns indications and surgical treatment, there are no substantial differences. Pre-operative differential diagnosis can be made with CAT scan and ultrasound and the usual operative manoeuvres of aneurysmorrhaphy should be modified.

The authors report on a group of 44 patients operated on for vascular disease, treated with antiplatelet therapy (picotamide). These patients were followed up for a period of 12 months with clinical and instrumental controls (Doppler ultrasound) in order to evaluate the evolution of atherosclerotic disease.

Aneurysms of the sciatic artery are quite rare. In the literature fewer than 100 cases of gluteal aneurysms have been reported; most have arisen from the superior or inferior gluteal artery; only few cases were aneurysms of an anomalous persistent sciatic artery (6 cases diagnosed angiographically and treated). In our own experience, the overall incidence of this anomaly, in patients undergoing angiography is very low, in the order of 0.025%. In our case the iliac femoral axis showed hypoplasia and required an internal iliac-popliteal bypass. For the location and the propensity atherosclerotic involvement of the persistent sciatic artery, an aneurysm should be considered in all patients with a pulsatile posterior thigh mass, with or not symptoms of peripheral vascular disease.

The authors discuss the indications for emergency carotid endarterectomy, based on their experience between 1956 and 1975 when 15 patients with completed stroke and internal carotid occlusion (Group I) underwent this operation, and after 1975 when emergency revascularization was performed in 22 patients with unstable neurological deficit (Group II) and 21 patients with TIA's associated with preocclusive internal carotid stenosis (Group III). The good early and late results show that surgery was indicated in these cases. An attempt to identify the patients at high risk of acute ischemia on the basis of clinical or anatomical findings is made to ascertain the physiopathologic patterns of cerebral ischemia.

Muscular flow measurements were carried out in 34 patients with peripheral chronic arterial occlusive disease using the 133-xenon clearance method. The reactive hyperemia technique was preferred to the walking test. All the patients were investigated by angiography and 46 limbs were available for assessment. Control flow measurements were done after treatment in the following groups: arterial reconstruction in ten limbs of nine patients, unilateral lumbar sympathectomy in three and medical therapy in seven. Follow-up was from three to 12 months. The findings of flow measurements were of limited value in identifying the distribution of the arterial disease, but they provided a reliable means to predict the results of direct arterial repair in various procedures. They also proved to be a valuable method to assess the results of surgery. This does not seem to apply to lumbar sympathectomy or conservative treatment.

In patients with aortoiliac disease and a stenosis of one or two renal artery, renal hypertension is rarely the sole mechanism of the elevated blood pressure. The preservation of nephron mass being the aim of the renal revascularization, we firmly believe that only three tests are required for the operative decision: renal ultrasonography, nephroscintigraphy and global and selective aortography.

To evaluate the results in a series of patients submitted to aortofemoral bypass due to an unilateral iliac occlusion.Retrospective follow-up study. A total of 95 patients underwent, between 1975 and 2000, aortofemoral bypass because of unilateral iliac occlusion. Most of them (71 patients) were claudicants, Fontaine stage II b, while 12 complained rest pain and 12 suffered ischemic ulcers. Mean follow-up was 128 months (min 2.5 - max 292).Immediate success was obtained in 88 cases (92.6%), 7 patients were submitted to early redo with restored patency in 6 cases. One month global patency was gained in 98.9% (94 cases). The mean Ankle-brachial index (ABI) improvement was 0.35. At a mean follow-up of 128 months the cumulative patency was 90.8%. During the follow-up, 15 graft occlusions were observed, followed by 9 successful reoperations achieving a 5-year secondary patency of 92.1%. The contralateral iliac artery evolved toward an occlusion in 10 patients (10.5%) during a long time observation (104 months average).The unilateral aortofemoral bypass confirmed an excellent long term outcome regarding effectiveness and graft related complications. The low contralateral occlusion rate, in our series, does not justify a more aggressive approach as first surgical option.

Midline and transverse incision are commonly used in upper abdominal surgery. A comparison of the two procedures with respect to the respiratory function, assessed by spirometry, blood gas analysis, inspiratory and expiratory pressures, and thoraco-abdominal respiratory synchronism, was made in two groups of patients after surgery on the abdominal aorta. 32 patients affected by abdominal aortic obstructive or aneurysmatic disease, candidates for aortoiliac revascularization, were randomized into two groups of 17 (group A) and 15 (group B) patients respectively. Group A underwent midline laparotomy and group B supraumbilical transverse laparotomy. Ventilatory function and blood gas analysis were determined on the day before operation and on the second and eight postoperative day. All patients showed a depressed ventilatory function postoperatively, but the impairment was significantly minor after transverse laparotomy.

We have studied the kinetics of smooth muscle cell growth in the tunica media of human arteries obtained from 12 patients affected by obstructive vascular disease, and one case operated because of a trauma. The studies were carried out on arterial samples by autoradiography after in vitro labelling with 3H-thymidine. Different patterns of radioactive nucleotide uptake were detected. On nine elastic and muscular arteries without pathological changes it was demonstrated that the turnover of smooth muscle cells in human medias was very low, and similar to that found in experimental animals. The medias under atherosclerotic plaques showed variable levels of tritium uptake. Although the number of cases surveyed was limited, a possible explanation is that the different levels of uptake could depend on the different evolutive stages of the atherosclerotic process. It cannot, however, be excluded that the proliferative activity of the smooth muscle cells may be related to focal damages of the tunica media.

In the early treatment of the patients with cerebrovascular insufficiency due to internal carotid artery stenosis, the presence of a cerebral infarct and especially the blood brain barrier breaking (BBB) are considered by many as a contraindication to early reperfusion by carotid endarterectomy (CEA). Generally, it has been recommended to differ the operation at least for 4-6 weeks because of the high risk to convert an ischemic infarct into an hemorrhagic one. On the other hand, because unfavorable natural history has been reported as for the progressing unstable neurological deficit as for the minor recent strokes, respectively by Millikan and Dosik, it seem to be justified a more aggressive management with the aim of: 1) eliminating the stenosis as embolic source of emboli; 2) obtaining early brain reperfusion to increase the probability of good recovery. Some previous experiences reported in the literature demonstrated satisfactory results of early reperfusion even in presence of BBB. The Authors present 4 cases of early CEA in patients with BBB. After the CT scan the patients have been submitted preoperatively to non invasive tests (duplex scanning and transcranial Doppler sonography) to assess the presence of the internal carotid artery stenosis and the viability of the intracranial cerebral arteries with special regard to the middle cerebral artery. All the patients underwent CEA in loco-regional anesthesia and particularly systemic blood pressure was carefully monitored and any hypertensive status was early corrected by prompt antihypertensive therapy (i.v. nitrates and or calcium blocking agents).(ABSTRACT TRUNCATED AT 250 WORDS)

Ninety-two patients undergoing vascular surgery took part in a controlled clinical trial to study the effectiveness of a new low molecular weight (LMW) heparin for prevention of post-operative deep vein thrombosis. Forty-six patients were treated daily, for 7 days after operation, with a single subcutaneous injection of 15,000 Anti X-activated Factor Units of the new LMW heparin; the remaining 46 patients were treated, for the same period, with 2 daily subcutaneous injections of 5,000 International Units of calcium heparin. Deep vein thrombosis detection was by the radioactive fibrinogen uptake test, performed each day during therapy in all patients. A very low incidence of sub-clinical deep vein thrombosis was observed; in 3 (6.5%) patients in the LMW heparin group and in 4 (8.6%) patients of the calcium heparin group. The results of laboratory investigation showed that the antithrombotic activity (inhibition of Factor Xa) of the LMW preparation was significantly greater than that of calcium heparin, while activated partial thromboplastin time was greater in the calcium heparin group. The new preparation also showed better local tolerance, with less pain on subcutaneous injections.

To determine the best treatment for high-risk patients with abdominal aortic aneurysms (AAA).We reviewed a prospective database of all patients who underwent conventional (OPEN) or endovascular aneurysm repair (EVAR) between January 1998 and December 2002. Patients were preoperatively classified according to the American Society of Anesthesiology (ASA). Comorbidities and medical risk factors were categorized according to the Ad Hoc Committee on Reporting Standards. Perioperative mortality and morbidity rates were analyzed according to the type of surgical procedure (OPEN vs EVAR) and ASA class. Patients in ASA classes I and II were excluded. Continuous data were expressed as mean +/- standard deviation. All data were calculated using the cumulated actuarial method of event outcome probability. Kaplan-Meier curves were constructed and the log-rank statistic and chi squared test were used for comparative data. P values less than 0.05 were considered to indicate statistical significance.Of the total 375 patients who underwent AAA repair, 168 (45%) belonged in ASA classes III and IV (85 submitted OPEN and 83 EVAR to repair). Among general risk factors only coronary artery disease differed significantly between the 4 groups (P = 0.04). The Bonferroni correction identified a statistically significant difference between ASA classes III and IV for the OPEN technique and for EVAR (P = 0.007 and P = 0.012). Neither 30-day morbidity or mortality differed significantly according to ASA class and surgical technique. The median follow-up was 19 months (range 5-60 months). The overall survival was 78% at 60 months. Survival rates during follow-up differed significantly in the 2 risk classes (ASA III 5/123, 4% vs ASA IV 9/38, 24%), (P = 0.0001). The deaths in the ASA class 4 patients (12/14; 86%) were caused by preexisting medical comorbidities (in 9 patients cardiovascular, in 1 cancer and in 2 cirrhosis).Except patients with small aneurysms (6 cm), in whom the risk of death at 1-year due to comorbidities exceeds the risk of a ruptured aneurysm, all patients at high surgical risk (ASA class IV) benefit from AAA repair. Patients with small aneurysms must undergo strict surveillance to assess growth and aneurysmal wall changes to prevent unexpected rupture.

Surgical repair of abdominal aortic aneurysm (AAA) is frequently associated with DIC. 15 patients affected by AAA were studied to evaluate the risk of consumption coagulopathy and the efficacy of daily low-dose calcium heparin prophylaxis. The coagulation parameters investigated showed a postoperative decrease of AT III activity levels and platelet count the other laboratory tests did not show any significant modifications. Low dose heparin was effective in preventing coagulation activity or thrombotic episodes. No thromboembolic complications were observed, except nonfatal myocardial infarction.

The appropriateness of early carotid endarterectomy (CEA) in patients with acute ischemic stroke is still unsettled. The aim of this study was to verify the safety and feasibility of early CEA in a consecutive series of patients with acute ischemic stroke observed in an emergency Department Stroke Unit.During a 24-month study, out of 756 patients with acute ischemic stroke 33 (4.4%) were scheduled for early CEA. Endarterectomy procedures were distinguished according to the time between the onset of stroke and operation as emergency (within 8 hours), early CEA (1-18 days). Patients with impaired consciousness or an infarct larger than 2.5 cm on computed tomographic (CT) or magnetic resonance (MR) scans or both were excluded from surgery. All patients underwent spiral CT, echo-color-Doppler (ECD) sonography, transcranial Doppler (TCD) sonography and, when necessary, MR angiography within 6 hours of admission. No patient underwent conventional angiography. Most patients were operated on under cervical block (CB) anesthesia; general anesthesia (GA) was used only for those with an unstable neurological deficit. Selective shunting was used on the basis of intra-operative transcranial Doppler in patients under GA and the onset or worsening of neurological deficit under CB anesthesia.Of the 6 patients operated on within a median 6 hours after the onset of stroke, 1 (16.5%) had a fatal hemorrhagic transformation of the infarct, while the remaining 5 (83.5%) stopped fluctuating or progressing and had a favourable neurological outcome. Of the 16 patients operated on within a median 36 hours and of the 11 patients operated on within 7 days, none deteriorated after operation.Emergency CEA is feasible for acute ischaemic stroke provided that strict selection criteria are applied and the door-to-surgery interval is kept short (within 8 hours). Early CEA for secondary prevention is feasible and safe, confirming that a delayed operation is in most cases unwarranted. Large randomized trials are warranted before implementing emergent and early CEA in routine clinical practice.

One of the most common source of lower extremity atheroembolization is the aorta and particularly the infrarenal segment. Complex atherosclerotic plaque can lead the patient to gangrene and major amputation. When the origin of embolization is a focal lesion, endoluminal methods could be an alternative to surgical treatment. Although the experience with aortic stent is limited, the results obtained so far seem to be encouraging. The case of a mid-age heavy smoker woman with a history of the abrupt onset of painfull cyanotic toes in the left foot and subsequent complete gangrene of the first digit in the same foot is herein reported. Angiography and CT scan revealed an high-grade calcified aortic infrarenal plaque. Because of the discrete characteristic of the lesion, an endovascular approach with a Palmaz stent was elected. The stenosis was successfully treated: the patient experienced the complete resolution of the toe painfull cyanosis within 3 months, the stent remained patent through a 24 months follow-up and no subsequent embolic episodes were observed.