Aortoiliofemoral bypass graft in young adults: long-term results in a series of sixty-eight patients.

BACKGROUND: The aim of this study was to investigate surgical indications and the long-term outcomes of aoroiliofemoral reconstructions in adults younger than 45 years. METHODS: Between 1973 and 1990, 1256 patients underwent infrarenal abdominal aortic reconstruction for aortoiliofemoral occlusive disease. Sixty-eight (5.4%) patients (group 1) were less than 45 years old and form the basis of the analysis. They were retrospectively compared with two additional groups of patients 45 years and older selected from the entire series. Patients in group 2 (n = 100) were randomly chosen to determine differences in risk factors, associated diseases, operative indications, preoperative findings, and outcomes. Patients in group 3 (n = 70) were matched with those in group 1 for gender, risk factors, associated diseases, preoperative findings, and operative indications to assess the importance of age in determining the short- and long-term outcomes of aortoiliofemoral reconstructions. RESULTS: Postoperative mortality rates (1.5%, 4%, and 4.3% for groups 1, 2, and 3, respectively) and major complication rates (4.4%, 7%, and 7.1% for groups 1, 2, and 3, respectively) were comparable among the three groups. Ten-year secondary patency rates were 84.6%, 70.6%, and 80.3%, for groups 1, 2, and 3, respectively (p = not significant). Ten-year limb salvage rates were 86.9%, 78.2%, and 80.6%, for groups 1, 2, and 3, respectively (p = not significant). During follow-up a significantly higher percentage of myocardial infarction was recorded in group 1 as compared with group 2 (p < 0.03) and group 3 (p < 0.04). The 10-year survival rate for group 1 was significantly lower than that of group 2 (29.0% versus 46.9%; p < 0.005). CONCLUSIONS: Aortoliofemoral reconstruction in patients younger than 45 years is a safe procedure with low operative risks and good long-term results in patency and limb salvage rates. However, life expectancy is poor because of the high incidence of deaths related to coronary artery disease.

Femorofemoral bypass grafts: Factors influencing long-term patency rate and outcome.

BACKGROUND: Crossover femorofemoral bypass graft (CFFBG) was proposed in the early days of modern vascular surgery to treat patients affected with unilateral iliac artery disease who were a high surgical risk. We investigated factors influencing short- and long-term outcomes of CFFBG: METHODS: The study was designed as a retrospective clinical study in a university hospital setting with a base of 228 patients. Of these patients, 154 (67.5%) presented a high surgical risk. The indication for operation was limb-threatening ischemia in 188 (82.5%) patients. All patients underwent CFFBG: The procedure was performed in 150 patients as the primary operation and in 78 patients after previous vascular graft failure or infection, or both. A preoperative percutaneous transluminal angioplasty was performed in 57 patients (25%) to correct donor iliac artery disease. In 127 patients (55.7%), an associated vascular procedure was performed to improve the outflow. Postoperative complications; 5- and 10-year primary, secondary, and limb salvage rates; and factors influencing short- and long-term results were assessed. RESULTS: Thirteen (5.7%) postoperative deaths occurred. Postoperative mortality and morbidity rates were significantly higher in patients aged more than 65 years (7.9% versus 3.5% and 18.6% versus 6.1%, respectively, P <.03). Primary and secondary patency rates at 5 and 10 years were 70.2% and 48.1%, 82.8% and 63.2%, respectively; 5- and 10-year limb salvage and survival rates were 85.5% and 80.1%, 63.3% and 31.0%, respectively. Ten-year primary and secondary patency and limb salvage rates were significantly lower when the procedure was performed after previous vascular graft failures (50.2% versus 26.5%, P <.007; 74.1% versus 44.1%, P <.01; and 84.3% versus 72.5%, P <.03, respectively). Five- and 8-year patency rates of autogenous vein CFFBG (34.3% and 22.8%, respectively, P <.03) were significantly lower than those of expanded polytetrafluoroethylene (71.1% and 59.8%, respectively) and polyester (77.3% and 50.3%, respectively) CFFBG: Moreover, 5- and 10-year primary and secondary patency rates were significantly better when externally supported grafts were used as compared with those without external support (80.1% and 69.9% versus 61.1% and 21.1%, P <.01; 88.8% and 75.9% versus 78.9% and 45.4%, P <.05, respectively). Multivariate analysis showed that the only variable associated with poor primary and secondary patency and limb salvage rates was the operation performed after previous vascular graft failures (P <.04, P <.03 and P<.05, respectively). CONCLUSIONS: CFFBG allows early and long-term results similar to those obtained with reconstructions originating from the aorta when it is performed as a primary operation when an adequate outflow is provided and externally supported prosthetic material is used.

The effect of extend of caval resection in the treatment of inferior vena cava leiomyosarcoma.

BACKGROUND: A wide and complete surgical resection is the principle modality of therapy in the management of retroperitoneal sarcomas. It is current opinion that, also for inferior vena cava (IVC) leiomyosarcomas, an extended resection of either retroperitoneal tissue and vena cava should be performed. The aim of the study was to investigate the influence of the venous extent of resection on local recurrence and longterm outcome. METHODS: Up to August 1994, 218 patients were enrolled into The International Registry of Inferior Vena Cava (IVC) Leiomyosarcomas. For the purpose of this study we considered 120 patients who underwent a radical resection of the IVC tumor (i.e. removal of all gross disease with microscopic tumor-free margins and no evidence of distant metastases). Resection included an IVC rim in 53 patients and an IVC segment in 67. RESULTS: There were 3 (2.5%) early postoperative deaths and 7 (5.8%) major complications. Postoperative deep venous thrombosis of the lower limbs was diagnosed in 21 (17.5%) patients and was treated by anticoagulant therapy and/or elastic stocking without long-term sequelae. Overall, tumor recurrence was observed in 67 (57.3%) patients at a mean follow-up of 32 +/- 4 months. Seven, 13 and 4 patients who underwent caval wall resection and 9, 29 and 5 patients submitted to a caval segmental resection had either local recurrences, distant metastases or local and distant metastases (p = NS). Survival rates of the two groups were 55% and 37% at 5-year and 42% and 23% at 10-year, respectively (p = NS). CONCLUSION: An extended venous resection in IVC leiomyosarcoma does not influence local recurrence rate nor long-term outcome.

Isolated true atherosclerotic aneurysm of the profunda femoris artery. Case report.

The authors report a case of true isolated atherosclerotic aneurysm of the profunda femoris artery. On the basis of a careful search of the literature some aspects of this rare disease are illuminated in terms of its low incidence, pathologic background and treatment; the last should always be aggressive due to the high possibility (about 50%) of major complications mainly represented by rupture. Simple aneurysmectomy without flow re-establishment may be allowed only if the femoropopliteal tract is normal

Comparison of femorofemoral and aortofemoral bypass for aortoiliac occlusive disease.

BACKGROUND: Role and results of femorofemoral bypass grafting, usually reserved to high-risk patients affected with unilateral iliac artery occlusion, are still debated. EXPERIMENTAL DESIGN: retrospective clinical study. SETTINGS: University Hospital. PATIENTS: seventy-six high-risk patients (group 1) who underwent a primary expanded polytetrafluoroethylene (ePTFE) externally supported femorofemoral bypass graft were retrospectively compared to two additional groups of patients selected from the entire series of patients who underwent an aortobifemoral bypass graft. Patients of group 2 (n=80) were randomly chosen to determine differences in risk factors, associated diseases, previous abdominal operations, operative indications, preoperative findings and outcome. Patients of group 3 (n=50) were matched for sex, risk factors, associated diseases, previous abdominal operations, operative indications and preoperative findings with those of group 1 to assess the importance of the type of operation in determining the outcome of the procedure. RESULTS: Postoperative mortality (6, 4 and 6%, respectively), 5-year primary and secondary patency (71, 80, 83% and 80, 87, 87%, respectively) and limb salvage rates (78, 87 and 87%, respectively) were similar among the groups (p=NS, p=NS, p=NS, respectively). Five-year survival rate of group 2 was significantly better than that of group 1 and 3 (p<0.04 and p<0.04, respectively). CONCLUSIONS: Primary ePTFE externally supported femorofemoral bypass graft in high-risk patients is safe and produces long-term results similar to aortofemoral reconstruction.

Iliorenal bypass for the treatment of type-3 Takayasu's disease. A case report with 10-year follow-up.

The case of a 16-year old female with severe renovascular hypertension resulting from type-3 Takayasu's arteritis is reported. The entire thoracic and abdominal aorta was affected by an active inflammatory process and all its branches were stenotic or occluded. After the early failure of a percutaneous balloon angioplasty of the left renal artery, an iliac to renal artery bypass graft using a reversed autologous saphenous vein was performed through a retroperitoneal tunnel The patient is asymptomatic and the graft is patent at 10-year follow-up.

Management of abdominal aortic prosthetic graft infection requiring emergent treatment.

The purpose of this study was to investigate mortality and morbidity rates and long-term outcome of patients who underwent emergency treatment of abdominal aortic prosthetic graft infection. Between January 1984 and December 1993, 18 men aged fifty-nine +/- sixteen years were operated on as an emergency for an acute life-threatening complication of aortic prosthetic graft infection. The grafts had been implanted for abdominal aortic aneurysm in 9 patients and aortoiliac occlusive disease in 9, from one to one hundred seventy months previously. Five (28%) patients presented with a hemorrhagic shock due to a fistula between the vascular reconstruction and the small bowel (4 patients) or the right ureter (1 patient) and 13 (72%) had generalized sepsis. The grafts were always radically explanted. Extraanatomic revascularization procedures included 6 axillopopliteal and 12 axillofemoral bypass grafts. Operative mortality was 39% (7 patients), and 3 (9%) limbs were amputated within thirty days. Two (11%) patients died after seven and twelve months, respectively, of septic complications, and 1 (5%) patient died after six months from an unrelated cause. Eight (73%) patients are still alive at a mean follow-up of fifty +/- thirty-four months, but in 3 the extraanatomic bypass was removed for infection and 5 major amputations were performed. Two-year survival and limb salvage rates were 44% and 50%, respectively. Aortic prosthetic graft infections that require emergent treatment continue to demonstrate high early and late mortality and limb loss rates despite aggressive intervention and limb salvage procedures. Newer methods of managing these complications should continue to be investigated.

[Segmental vasculitis. Report of a case involving the popliteal artery]. / Vasculiti segmentarie. Su un caso interessante l'arteria poplitea.

A case of occlusion of the popliteal artery, in a young female patient with limb threatening ischemia, probably due to a segmental vasculitis, is reported. The surgical treatment, consisting of a femoro-distal bypass, was able to improve dramatically tissue perfusion; however, due to septic complications, major limb amputation was unavoidable. It is stressed that the treatment of vasculitis should be adapted to each individual case; in selected patients, surgical revascularization appears to offer the only possibility of correcting a "desperate" situation.

[High-porosity and normal-porosity prostheses. Differences in growth factor release]. / Protesi ad alta porosità od a porosità normale. Differenze nel rilascio di fattori di crescita.

BACKGROUND: The majority of mid- and long-term synthetic vascular graft failures are due to anastomotic neointimal fibrous hyperplasia. The major cause of this phenomenon is the absence of an endothelial lining within prosthetic grafts. We investigated the PDGF-BB and bFGF release by umbilical vein endothelial cell cultured on precoated standard porosity or high porosity expanded polytetrafluoroethylene (ePTFE) vascular grafts. METHODS: Endothelial cell harvested from umbilical veins were cultured into standard (30 microns internodal distance) or high porosity (60 microns internodal distance) cPTFE disks. ePTFE disks uncoated or precoated with collagen type I, fibronectin and Matrigel were used and endothelial cell cultured into plastic wells coated as ePTFE disks or uncoated plastic wells served as controls. Scanning electron microscopy study assessed endothelial cell coverage. The presence of PDGF-BB and bFGF in serum-free conditioned media from endothelial cells cultured into ePTFE grafts and endothelial cell cultured into wells was determined by the inhibition antibody-binding assay 48 hours after insertion. RESULTS: Endothelial cell coverage was similar in uncoated and coated ePTFE grafts and no differences were observed between standard or high porosity grafts. The release of PDGF-BB and bFGF was significantly higher either for standard porosity or high porosity ePTFE grafts as compared with endothelial cell cultured into plastic wells (p < 0.05 and p < 0.05, respectively). The release of PDGF-BB and bFGF was independent from the various substrates either for endothelial cell cultured into standard or high porosity ePTFE grafts or plastic wells. CONCLUSIONS: Our findings pointed out that in ePTFE grafts smooth muscle cellsc proliferated only under endothelial cell at the anastomoses, along seeded synthetic grafts or in areas of transmural ingrowth where smooth muscle cells followed endothelial cell migrating into the graft. This is probably due to an alteration of the interactions between the endothelial cell, the matrices and the synthetic prosthesis.

[Sarcomatoid renal carcinoma. A case report]. / Il carcinoma renale sarcomatoso. Presentazione di un caso.

Renal sarcomas are rare tumors. Prognosis is overall dismal. Adjuvant therapies should follow radical nephrectomy but no standardized regimen has been at present defined. We report a case of a patient affected by a sarcomatoid renal tumor to detect the best therapeutic approach to this rare tumor.

[Unusual clinical presentation of Meckel's diverticulum. A case report]. / Inusuale presentazione clinica del diverticolo di Meckel. Descrizione di un caso clinico.

Meckel's diverticulum (Md) is the most common congenital anomaly of the gastrointestinal tract. It results from an incomplete obliteration of the omphalomesenteric duct during fetal life. It is frequently located on the antimesenteric border of the ileum at 80 cm from the ileum-cecal valve. It contains heterotopic mucosa in 30% of the cases and in 70% of these the mucosa is of the gastric type. The most common complication in childhood is represented by hemorrhage. Preoperative diagnosis is often difficult. Barium enema, Tc-99 scintigraphy and selective mesenteric angiography usually can permit diagnosis. In adults occlusion, perforation, diverticulum infection, Littre's hernia and tumors represent the complications of Meckel's diverticulum. A case of Md is reported because of the unusual clinical presentation.

[Adrenocortical carcinoma. Current approaches in diagnosis and treatment]. / I carcinomi del corticosurrene. Attuali orientamenti di diagnosi e trattamento.

Adrenocortical carcinoma is a rare malignant tumor. The survival rate is related to a radical tumor resection. However, adrenocortical carcinomas are usually diagnosed in advanced stage. Although some cases of long-term regressions of metastases under op'-DDD (Mitotane) therapy have been sometimes reported the overall efficiency of mitotane in prolonging life remains controversial. Between May 1975 and January 1994, 9 patients were surgically treated for adrenocortical carcinoma at our institution. There were 6 females and 3 males, mean age 40.8 years (median 40 years). Five (55.6%) patients presented with abdominal pain, whereas 4 (44.4%) patients had symptoms of hormone secretion (cortisol). One patient was lost at follow-up. Overall survival rate was 16.8 +/- 5.9 months, the survival rates according to tumor stage were: stage I. 58 months (1 case), stage II. 6 and 16 (2 cases; mean 11 months), stage III. 7, 15.17 and 22 (4 cases, mean 15 months) and stage IV. 9 months (1 case). The progression of the disease is not controlled by the administration of op'-DDD and the best treatment is represented by surgery.

[Veno-venous crossover bypass according to Palma: our experience]. / Il bypass veno-venoso crossover sec. Palma: nostra esperienza.

Four cases of Palma's operation (veno-venous cross-over bypass) performed from 1986 through 1992 for occlusive venous disease are reported together with an extensive follow-up. After a synthetic review of the literature, the authors conclude that this operation should no more be considered an experimental procedure, even if a definite statement of its long-term usefulness (and therefore of the indication) is still lacking.

[Entrapment syndrome of the popliteal vein: results of the surgical treatment]. / La sindrome da intrappolamento della vena poplitea: risultati del trattamento chirurgico.

Entrapment of the popliteal vein has been rarely reported. Purpose of the present study was to evaluate the long-term results of vein decompression in the popliteal vein entrapment syndrome. Between August 1986 and June 1994, 35 patients (49 limbs) were operated on for popliteal vein entrapment syndrome at our Institution. There were 28 female and 7 male (mean age 44.5 +/- 13.5 years). Seven limbs had associated a popliteal artery entrapment syndrome. Twenty-three (49.6%) limbs presented with skin changes ascribed to venous disease. Preoperative diagnosis consisted on Doppler CW, Duplex Scan, venography and ambulatory venous pressure measurements. Surgical management consisted on the division of the anomalous structure causing entrapment. In 35 (71.4%) limbs subfascial ligation of perforating veins was associated. The patients were followed-up (mean 61 +/- 7 months) with venography and AVP. No deaths occurred and morbidity was 14.3%. Doppler CW and Duplex Scan were not accurate to diagnose the entrapment. Ambulatory venous pressure and venography accurately diagnosed the syndrome. Age and preoperative status did not affect long-term results (p = NS). Long-term operative success was negatively influenced by associated procedures for ligation of perforating veins (p < 0.03). Popliteal vein entrapment syndrome should be early diagnosed to prevent incompetence of perforating veins. Surgical treatment of cases not requiring ligation of perforating veins had a better long-term success rate. Treatment at later stages allows symptom amelioration but does not prevent the consequences of a long-standing chronic venous disease.

[Preoperative blood storage and intraoperative blood recovery in elective treatment of abdominal aorta aneurysm]. / Predesposito e recupero intraoperatorio di sangue nel trattamento elettivo degli aneurismi dell'aorta addominale.

We evaluated the efficiency and costs-effectiveness of blood predonation and intraoperative salvage in elective abdominal aortic aneurysm surgery. Between January 1992 and January 1994, 66 patients (59 male and 7 female, aged 69.9 +/- 0.8 years) who underwent elective surgical repair of an AAA were selected for the study. Thirty-six (54.5%) patients (Group 1) intra- and/or postoperatively received homologous blood whereas 30 (45.5%) patients (Group 2) received autologous blood predonation and intraoperative blood aspiration and reinfusion. The two groups were similar for demographic data, aneurysmal diameter and associated diseases and/or risk factors (p = NS). Operative mortality was comparable between the two groups (p = NS). The mean intraoperative blood loss was 803.4 +/- 104.5 ml in group 1 and 812.8 +/- 44.8 ml in group 2 (p = NS). Group 2 patients received intra- or postoperatively a mean of 0.8 +/- 0.2 units of homologous blood (p < 0.001). Aneurysmal diameter did not influence the transfusion requirement between the two groups (p = NS). The cost per unit of homologous banked blood was significantly higher (p < 0.01). Cumulative costs of the procedures did not show statistical differences between the two groups (p = NS). Aortic surgery is the ideal target for predonation and intraoperative blood salvage.

Carotid endarterectomy in young adults: is it a worthwhile procedure?

PURPOSE: The aim of the study was to investigate surgical indication and long-term outcome of carotid endarterectomy (CE) in young adults. METHODS: Between 1973 and 1990, 1693 patients underwent CE. Forty-nine patients (group T) 35 to 45 years of age who had carotid artery stenosis greater than 70%, formed the basis for the analysis. They were compared with two additional groups of patients older than 45 years of age selected from the entire series. Group 2 was randomly chosen to determine differences in risk factors, associated diseases, operative indications, preoperative findings, and outcome. Group 3 was matched with patients in group 1 for sex, risk factors, associated diseases, preoperative findings, and operative indications to assess the importance of age in determining the short- and long-term outcome of CE. RESULTS: Postoperative mortality, cerebrovascular accidents, and cardiac complications in patients of group 1 (2%, 2%, and 2%, respectively) were similar to those of the other groups (p = NS). During the follow-up (76.7 +/- 3.6 months; range, 1 to 120 months) the incidence of strokes and transient ischemic attacks in group 1 was lower than in group 2 (p < 0.05) but similar to group 3 (p = NS). Ten-year disease-free intervals were 75.7%, 58.7%, and 77.6%, respectively, for groups 1, 2, and 3. Mortality rate unrelated to cerebrovascular disease was similar between group 1 and group 3 (p = NS) but was higher in group 1 than in group 2 (p < 0.02). Ten-year survival rates were 46.1%, 71.7%, and 55.5%, respectively, for groups 1, 2, and 3. CONCLUSIONS: CE in patients younger than 45 years of age is a safe procedure with low operative risks and good disease-free intervals. However, life expectancy is poor because of the high incidence of deaths resulting from complications of atherosclerosis.