Crossover iliofemoral bypass graft through tension-free abdominal wall-repair mesh.

INTRODUCTION: In vascular surgery the crossover iliofemoral bypass grafting is a well-known surgical technique. In general surgery the repair of an abdominal defect using a Polypropylene mesh is also a standard procedure. A particular technique is defined by the performance of these 2 separate procedures inside a single operation in which the crossover arterial graft is directed from the retroperitoneal space toward the contra-lateral femoral bifurcation through a Polypropylene mesh which closes the musculoaponeurotic layers of the abdominal wall. We present our experience with the use of this particular surgical technique in patients with critical limb ischemia and with indication for extra-anatomic crossover bypass (high-risk patients with contra-indication for the transperitoneal approach, extensive calcified aortic or iliac wall which contraindicated the direct arterial reconstruction or secondary arterial reconstruction after the occlusion of an aorto- femoral graft). METHODS: In principle, the hernioplasty was performed by using the Lichtenstein tension-free hernia repair technique, followed by the crossover iliofemoral bypass. The main feature of this technique is to pass the vascular graft from the retroperitoneal space above the mesh through a calibrated hole in the mesh RESULTS: The 7 patients with inguinal hernia and l limb-threatening ischemia had favorable evolution, without hernia recurrence, limb-threatening ischemia or any graft complication at 3 years. DISCUSSION: Using this particular surgical technique we treated 2 surgical diseases using a single intervention for highrisk patients who had both inguinal hernia and contra-lateral critical limb ischemia. Being encouraged by the initial satisfactory results, we extended this technique even for the patients with indication of crossover iliofemoral bypass but without inguinal hernia. CONCLUSIONS: The particular surgical technique of the crossover bypass in which the vascular graft crosses a tension-free Polypropylene mesh from the retroperitoneal space toward the Retzius space represents an efficient and short procedure which treats simultaneously 2 different surgical diseases (inguinal hernia and contra-lateral critical limb ischemia) in high-risk patients. The results were satisfactory: we had no hernia recurrence and the limb-threatening ischemia was successfully treated. The preferred vascular graft for this particular technique is the reversed autogenous vein because its resistance to infections and the vein long-term patency is better than of a vascular prosthesis. When a prosthetic graft is required, we prefer to use the classic technique in which the crossover graft is placed in an under-aponeurosis site, in order to diminish the prosthesis infection risk. KEY WORDS: Abdominal wall, Iliofemoral bypass, Vascular surgery.

Multilevel brown tumors of the spine in a patient with severe secondary hyperparathyroidism A case report and review of the literature.

BACKGROUND: The brown tumour is an extreme form of osteitis fibrosa cystica, representing a serious complication of the advanced primary or secondary hyperparathyroidism. It occurs in settings of high levels parathyroid hormone, like in primary or secondary hyperparathyroidism, with a frequency of 3-4% and 1.5-13% respectively, usually affecting young people. CASE REPORT: The authors report a case of a 45 years old woman on long-term hemodialysis, with severe secondary hyperparathyroidism. The main clinical complaints were neck pain, lower thoraco-lumbar back pain, persistent left groin pain, and bilateral lower extremities weakness. The computed tomography scan revealed multiple spine brown tumors affecting the cervical, thoracic and lumbar level. After an initial partial response to the treatment of two years with Cinacalcet, a deterioration of the secondary hyperparathyroidism occurred (hypercalcemia, hyperphosphatemia) and the patient was referred for parathyroidectomy. The patient underwent total parathyroidectomy with auto-transplantation, with a positive postoperative result. CONCLUSIONS: Secondary hyperparathyroidism can lead, during its course, to osteolytic bone lesions called brown tumors. If the medical treatment fails, the surgical removal of the parathyroid glands with autotransplant remains the only treatment of the bone lesions progression. Reviewing the relevant literature in English (until March 2015), we found 24 cases of symptomatic vertebral brown tumors. To the authors' knowledge, this is the first case which describes a multilevel spine involvement (more than two), and the fifth describing a cervical localization. KEY WORDS: Hypocalcaemia, Secondary hyperparathyroidism, Spine brown tumors.