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Aim of this work is to evaluate the morphological changes of the waveforms found in the parenchyma of the renal transplant rejection, establishing the prognostic significance.46 patients with symptomatic renal allograft underwent color Doppler ultrasound examination. The ultrasound characteristics were evaluated. The Resistive Index (RI), the morphological waveforms (divided into two groups: group A with regular waveforms, group B with irregular waveforms). Color Doppler pattern (R.I. and waveforms) were compared to histological and cytological specimens and to mean values of creatinine before and after therapy.In group A, the creatinine values varied between the start of rejection symptoms and after some days, giving a significant statistic result. Group B didn't show any important variations. The RI mean value was higher in group B. Significant results concerning correlation between Doppler parameters and histological specimens were not observed.The conclusion is drawn that in renal transplant rejection it is important to keep in mind also the variation of the waveforms to establish the clinical prognosis.

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.

Lumbar sympathectomy still has an important role in the surgical treatment of occlusive peripheral arterial diseases of the lower limbs located below the inguinal ligament, when the presence of peripheral lesions makes revascularization difficult. A consecutive series of 143 patients who underwent lumbar sympathectomy was considered, and the clinical, angiographic and haemodynamic findings evaluated. Haemodynamic studies on these patients showed a relation between the clinical improvement and the pressure index, measured at the ankle before lumbar sympathectomy. The patients with pressure index values above 0.5 had a symptomatic improvement whereas the patients with a pressure index below 0.3 gave less good results. It is therefore believed that lumbar sympathectomy showed not be considered a second operative choice but an elective operation, especially in patients affected by lesion of the superficial femoral artery, the popliteal artery and its branches, with pressure indices above 0.5 where revascularization is not possible.

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.

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.

Urinary fistulae between ureter and iliac arteries are very uncommon. A case of fistula connecting ureter and bypass between iliac and femoral arteries is reported. This kind of surgical complication, due to arterial lesion during coxo-femoral arthroprosthesis implant has never been reported in the literature.

Optimal strategy (staged or combined) for the treatment of patients with concurrent severe carotid and cardiac disease is still controversial. Moreover, carotid artery stenting (CAS), has become a valid alternative to carotid endarterectomy (CEA) and has been proposed for the treatment of cardiac patients. The authors report the preliminary results of a new therapeutic strategy consisting in combined CAS and cardiac surgery.An initial series of 22 patients underwent combined CAS and cardiac surgery in the same operating room and under general anesthesia. All filter-protected CAS procedures were performed under only heparin and aspirin. A cervical approach (3-cm cervicotomy) was used in patients with documented vessel tortuosity or severe aorto-iliac occlusive arteriopathy. In all the other cases a femoral access was used. A double antiplatelet regimen was initiated in the early postoperative period, once major bleedings were excluded.Among the 22 patients who underwent this combined procedure, no deaths, no myocardial infarctions and one controlateral stroke (overall complication rate: 4.5%) were observed. This stroke was observed after transcervical CAS, coronary artery bypass and mitral valve replacement. No major postoperative bleedings nor stent thrombosis were observed.Combined carotid stenting and cardiac surgery, performed in the same operating room under only heparin and aspirin, seems a safe and effective strategy for the treatment of patients with concomitant carotid and cardiac disease.