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A case of a giant aneurysm of the right renal artery is described. A female patient, 65 years old, normotensive, affected by a great aneurysm of 7 cm per 6 cm, localized in the renal ilus and determining a chronical pyeloneprosis is observed. She was operated on for nephrectomy because the aneurysm and the kidney were strictly closed. The patient recovered her health. The current status of the art is then analysed.

The authors analyze their experience of surgical treatment of post-mastectomy lympho-edemas of the upper arm. They have performed 14 operations, each upon patients with praecox or later oedema, following Cariati's classification, and with median age of 56.5 years. Seven patients were present at the follow-up in 6 has been performed microsurgical lympho-venous anastomosis, in 1 a fasciotomy of the forearm and in 1 patient some silastic tubes were positioned in her subcutaneous tissue. An improvement of the subjective symptoms has been recorded in 57.14% of the patients, while the objective ones have improved in 50% of the patients. The authors think that the microsurgical treatment of the lymphedema post-mastectomy of the upper arm is the first choice nowadays.

Purpose: The effects of ultrasonic endarterectomy, evaluated experimentally and clinically, were compared with the results obtained with controversial endarterectomy., Experimental: An ultrasonic vascular dissector with a frequency of 29 kHz was used for ultrasonic endarterectomy. Gross and histologic observation was made on 22 fresh human cadaver atherosclerotic vessels, of which 16 were treated with ultrasound endarterectomy and 6 conventionally. Clinical: Twenty-eight patients requiring carotid endarterectomy were chosen at random. Seven patients underwent ultrasonic endarterectomy after traditional access surgery, while 21 patients were treated with conventional endarterectomy. In the clinical study, an intraoperative gross observation of the endarterectomized surfaces was made, followed by duplex scanning after 18 and 24 months., Results: Histologic observation of the cadaveric revealed particularly smooth surfaces in 87.5%; there was no debris, flaps, or vessel damage in any of the ultrasonically treated samples. In contrast, the traditional technique produced regular surfaces without residual debris in only 50% of the experimental cases. Favorable results were also seen in the clinical carotid experience, in which there was no need to surgically correct the ultrasonically endarterectomized surface in any case. In fact, achieving a satisfactory outcome was greatly facilitated by the use of ultrasound. In the conventionally treated patients, however, only 19% (4) demonstrated a smooth luminal surface on gross observation even after surgical correction. No postoperative complications were encountered in either group, and no restenosis has occurred in ultrasonic endarterectomy-treated patients after 2 years., Conclusions: Favorable experimental results using ultrasonic endarterectomy prompted the successful clinical application of this new technique in carotid stenosis treatment. Whether or not ultrasonic endarterectomy can reduce postoperative morbidity and restenosis is still under study.

Infection is one of the most serious complications that can occur in a patient who had an arterial surgical procedure with implantation of synthetic prosthetic grafts. The incidence of this complication is higher when the prostheses are placed in superficial area than when inserted deeply. Generally the first manifestation of infection is the appearance of pseudoaneurysm at the site of the anastomosis. In our experience the overall of incidence is of 4.2%. In this report we analyzed the clinical manifestations, the diagnosis and the types of surgical approaches followed by us.

The paper describes the authors personal experience of the surgical treatment of thoracoabdominal aneurysms. Thirty-five patients underwent surgery during the period from 1972 to the present. Operative mortality is compared according to the different surgical approaches used. Special attention is paid to the techniques of protecting the spinal cord, and in particular to liquor drainage.

Between 1974 and 1989, 42 patients have been operated on at the Istituto di Chirurgia Generale e Cardiovascolare of University of Milan, for traumatic pathology of the thoracic aorta: in 14 cases it occurred an acute rupture at the level of aortic isthmus and in 28 cases a posttraumatic fals aneurysm. We had an operative mortality of 28% (4 cases) in the acute rupture: 3 patients died for neurological complications which were present at hospitalization. In one case appeared a serious ARDS. We had no surgical deaths in patients operated on for the posttraumatic false aneurysm. In 15 cases, the patients suffered for a postoperative paraplegia. Surgical indications are discussed, overall for the posttraumatic false aneurysms. The authors consider the advantage and the risks of the use of ECC and of total heparinization of the patients.

A rare case of arteriovenous fistula between an internal mammary artery and a pulmonary artery is presented. The clinical history of recurrent bronchitis and dyspnoea during exercise, the presence of right parasternal murmur with normal heart size and normal blood gases justified the execution of an arteriovenous thoracic angiography which revealed the presence of a cirsoid aneurysm supplied by the internal and external mammary arteries. Diagnostic investigation and surgical indication in patients with the rare fistulous communication between the internal mammary artery and the systemic or pulmonary circulation are analysed.

Even today, traumatic lesions of the popliteal artery mean in a large percentage of cases (from 25% to 45% according to recent reports) loss of the extremity, notwithstanding the considerable advances made by reconstructive vascular surgery. The most important series are reported in relation to events of war in the past (Korea, Vietnam) and more recently. As for lesions in everyday life, the highest percentage is the result of road and particularly motorbike accidents. A review of the most recent literature shows that the prognosis for lesions of the proximal and middle segment of the popliteal artery is greatly improved while in lesions of the distal portion and particularly the trifurcation, the percentage of failure with consequent amputation is still very high (from 30% to 40% of cases). Here personal experience of 6 cases of lesions of the popliteal artery due to osteovascular trauma observed in the past two years is reported, the diagnostic procedures and therapeutic treatment adopted being discussed.

A series of 104 patients observed and surgically treated for abdominal aortic aneurysms, in the General and Cardiovascular Surgery Department of Milan University during 1987 in analysed. Particular attention is paid to the diagnostic procedures especially in those cases when the condition was found by chance during clinical examinations requested for different pathologies.

Experience of the operative treatment of 45 popliteal aneurysms in 41 patients is reported. The importance of immediate surgical reconstruction whenever a popliteal artery aneurysm has been detected is stressed. In fact, the patency rate of the arterial substitutes which are utilised in the reconstructive technique, and therefore the fate of the affected limbs, is chiefly based on the presence of a sufficient run off. Ischaemic complication due to peripheral embolization or sudden thrombosis of the aneurysmatic sac is very often followed by the irreversible closure not only of the tibioperoneal arteries but also of most collateral vessels.

A series of 262 observed cases of aneurysm of the thoracic aorta is examined in which 216 cases of surgical correction were performed between 1974 and 1987. Dissecting aneurysms and post-traumatic pseudoaneurysms, although of different aetiology and morbid anatomy, are also included since the surgical technique adopted is similar in all groups. Clinically different aspects of acute and chronic lesions are analyzed. Of all preoperative examinations, angiography is preferred as it gives the most precise definition of the aortic lesion. This is especially necessary in the case of acute dissection or rupture of thoracic aorta although the role of CAT scan is becoming progressively more important. In cases of aortic dissection with massive aortic valve insufficiency, the substitution of the ascending aorta and aortic valve with reimplantation of coronary arteries, in accordance with Bentall's technique is also indicated. The improvement in surgical results is emphasized, since surgical mortality has decreased from 30.6% to 22% in the last eight years. This is due to improvement in surgical technique, to extra corporeal circulation and myocardial protection.

Extension into vena cava and right atrium of tumor thrombus from a renal cell carcinoma presents a surgical challenge. The use of cardiopulmonary by-pass, hypothermia and cardiac arrest with temporary exsanguination has allowed the successful surgical excision of this tumor. During 1986 and 1987 3 patients with cancer of kidney invading the vena cava were operated on with this surgical technique. No deaths occurred. The possibility of curing this type of cancer with minimal operative risk and good results is discussed.

The statistical incidence, etiopathogenesis, diagnostics and surgical treatment of acute ruptures of the thoracic aorta are described. A personal series of 7 cases is reported; surgical techniques, benefits and risks of extracorporeal circulation during surgical treatments are analysed and discussed.

Aortic dissection is a catastrophic event with a high mortality rate for untreated patients. One hundred and thirteen patients with acute aortic dissection were observed in the IInd Surgical Department of Milan University from 1974 to 1985; 55 had type I and II aortic dissection and 58 had type III aortic dissection. All patients with type I and II and about 50% of patients with type III aortic dissection underwent surgical correction. In the second type III group the aortic lesion was surgically corrected only when visceral ischaemia or ischaemia of the lower limb was recognized. In the other type III cases, medical treatment was preferred. The mortality rate was lower after medical treatment (15%) than after surgical treatment (37%). Follow-up was performed for the majority of patients and was recently completed with non-invasive techniques like Magnetic Resonance. It accurately shows the residual dissection and follows, the development of occlusion of the false lumen without any risk to the patients.