ICU transfer after elective abdominal aortic aneurysm repair can be succesfully reduced with a modified protocol. A fourteen year experience from a University Hospital.

AIM: To compare different selective criteria for Internal Care Unit (ICU) admission in two different timeframes, after abdominal aortic aneurysm (AAA) repair. A retrospective audit of acquired data was performed. METHODS: During a period of fourteen years (1994-2008), 1152 patients underwent an elective open operation for infrarenal abdominal aortic aneurysm, in our department. Six hundred and two patients (Group A) were treated in the period January 1994-January 2003, and 550 patients (Group B) between January 2003 and August 2008. Postoperatively, all patients were transferred to postanesthesia unit (PAU). After a 2 hours period of close observation, they were transferred either to the ICU or to the surgical ward, according to certain selective criteria (SC). In group A we used SC-A, for admission to an ICU, and in group B we used new, stricter, criteria (SC-B). Thirty-day mortality and morbidity, elective admissions to ICU, rate of subsequent ICU admission, from ward to ICU, and the mean hospital and ICU length of stay, were compared between the two groups. RESULTS: The use of SC-B resulted in a significant reduction of elective admissions to ICU (3.1% vs 8.5%, P<0.001). Nevertheless, the portion of patients, which were transferred with a severe postoperative complication from the ward to ICU, remained similar between the two groups (1.1% vs 0,9%, in group A and B, respectively). All other endpoints were similar in both groups. CONCLUSION: Modifying the protocol of ICU transfer, after elective abdominal aortic aneurysm repair, we can reduce the number of patients requiring ICU, without compromising patients' safety.

Guided remote endarterectomy for superficial femoral artery occlusions: a technical note.

The aim of this paper was to describe a new modification of the remote endarterectomy for the treatment of long superficial femoral artery (SFA) occlusions and to present our preliminary results. Through a subinguinal incision and arteriotomy over the SFA origin, a hydrophilic guidewire was introduced into the subintimal plane of the SFA and advanced distally until reentry into the distal patent popliteal artery. The hydrophilic guidewire is exchanged for an Ablatz wire to provide support for the advancement of the single endarterectomy ring. The MollRing Cutter was introduced in the SFA after the removal of the single endarterectomy ring and it was advanced until the re-entry point. The atherosclerotic core was removed and a nitinol self-expanding stent was placed at the peripheral end of the endarterectomy. Arteriotomy was closed with a patch. Guided subintimally-assisted remote endarterectomy seems to be a successful and safe modification of the traditional technique in the treatment of SFA occlusion, in patients with critical limb ischemia.

Can the diameter of endoluminal shunt influence the risk of hyperperfusion syndrome after carotid endarterectomy?

AIM: The aim of this study was to evaluate if there is a possible relation between the size of endoluminal shunt, in carotid endarterectomy (CEA), and the risk of postoperative hyperperfusion syndrome. METHODS: We retrospectively studied prospectively collected data from 156 patients, who were subjected to CEA using shunting and vein patch angioplasty. One hundred and thirty-eight of the patients had bilateral, high grade (> or = 90%) internal carotid lesions and the remaining 18 had a high-grade stenosis (> or = 90%) and a contralateral internal carotid artery (ICA) occlusion. In 81 patients varying diameters of shunts were used (8-14 Fr) according to the diameter of ICA (group A) and in the other 75 patients (group B) only the smallest shunt was used (8 Fr). Development of hyperperfusion syndrome was evaluated both clinically and radiologically with magnetic resonance imaging. RESULTS: Fifteen patients developed hyperperfusion syndrome (9.6%), between 0 to 6 days postoperatively. Thirteen belonged to group A (86.6%), and 2 (13.3%) belonged to group B (P<0.05). One had an intracerebral hemorrhage (0.6% of the study group) the 3rd postsurgical day. CONCLUSIONS: During CEA in patients with high-grade bilateral lesions, we recommend the use of a shunt with small diameter: this aims at reducing the risk of hyperperfusion syndrome.

Abdominal aortic aneurysm repair in patients with end stage renal disease.

OBJECTIVE: Abdominal aortic aneurysm (AAA) in patients with end stage renal disease (ESRD) represents a challenging therapeutic problem. This study was undertaken to analyze the surgical outcome of AAA repair in patients with ESRD and discuss the optimal peri-operative management of problems that resulted. METHODS: Between January 1995 and January 2005, 11 patients with ESRD underwent abdominal aortic aneurysm repair. All patients were under chronic haemodialysis. Risk factors related to surgical morbidity were evaluated. RESULTS: The average age was 68 years (57-84 years). Nine patients were men: 8 were hypertensive, 6 had diabetes, 4 had coronary artery disease, 3 had suffered a previous stroke, 3 had prior myocardial infarct and 8 were smokers. The duration of haemodialysis was 19 months (range 2 to 46 months). Five of the 11 patients had bilateral common iliac aneurysms in addition to the abdominal aortic aneurysm. The average diameter of infrarenal AAA was 6 cm (4.8-7.5). The mean duration of operation was 191 min. All patients underwent haemodialysis on the day before operation with an average period of 8.5 hours (6-12) and 2 to 20 hours postoperatively. The mean follow-up was 11.5 months (range 1 to 93 months). None of the patients died during the 30-day postoperative period. Two patients died from heart failure 3 and 7 months later. CONCLUSION: Abdominal aortic aneurysm can be repaired in patients with end stage renal disease with good results, despite the increased morbidity and mortality of this population.

Simultaneous venous gangrene in both lower and upper limbs. A case report.

Cancer-related venous gangrene is an extremely rare paraneoplastic syndrome. Here, we present the case of a woman, who suffered from cervical cancer of the uterus and was admitted to our Clinic with venous gangrene in both the right lower and upper limbs. Neither the anticoagulant therapy, nor thrombolysis, succeeded in improving her clinical condition. Cancer is one of the most important causes of venous thromboembolism. Venous gangrene is rarely seen in these patients. Despite adequate therapy, venous gangrene in some very rare occasions may progress to affect further limbs. Mortality in these patients remains very high.

Simultaneous surgical treatment of abdominal aortic aneurysm and bilateral aneurysms of the internal iliac artery.

INTRODUCTION: The purpose of this study is to present our experience in the management of patients with abdominal aortic aneurysms (AAA) and aneurysms in both the internal iliac arteries (IIA) at the same time. METHODS: Between 2000 and 2005, a series of 13 patients with AAA and also aneurysms in both the IIA, were treated in our clinic. They were all men with a mean age of 74 years. The size of the IIA aneurysms (IIAA) ranged from 2.0 to 8.0 cm (mean, 3.4 cm). All patients underwent an aneurysmatectomy of the AAA and placement of a prosthetic bifurcated aorto-biiliac or -bifemoral bypass, by a transperitoneal approach. The management of one of the two IIAA was the aneurysmatectomy and the direct revascularization of the healthy peripheral portion of the remaining IIA with the ipsilateral leg of the aorto-biiliac bypass. The other IIAA was treated with proximal ligation of its neck and aneurysmorraphy. RESULTS: No patient died during the first 30 postoperative days. Morbidity was about 7.7% (one patient suffered from 'trash foot', which was treated successfully with conservative measures). Finally, the mean stay in hospital was 7 days and no patient clinically presented symptoms of pelvic or colonic ischaemia. CONCLUSIONS: Simultaneous treatment of AAA and bilateral IIA aneurysms is a technically difficult, but safe procedure, if it is performed meticulously. Revascularization of at least one internal iliac artery is strongly recommended in order to avoid dangerous complications, such as pelvic or colonic ischaemia.