The Role of Physical Exercise as a Therapeutic Tool to Improve Lipedema: A Consensus Statement from the Italian Society of Motor and Sports Sciences (Società Italiana di Scienze Motorie e Sportive, SISMeS) and the Italian Society of Phlebology (Società Italiana di Flebologia, SIF).

PURPOSE OF REVIEW: This consensus statement from the Italian Society of Motor and Sports Sciences (Società Italiana di Scienze Motorie e Sportive, SISMeS) and the Italian Society of Phlebology (Società Italiana di Flebologia, SIF) provides the official view on the role of exercise as a non-pharmacological approach in lipedema. In detail, this consensus statement SISMeS - SIF aims to provide a comprehensive overview of lipedema, focusing, in particular, on the role played by physical exercise (PE) in the management of its clinical features. RECENT FINDINGS: Lipedema is a chronic disease characterized by abnormal fat accumulation. It is often misdiagnosed as obesity, despite presenting distinct pathological mechanisms. Indeed, recent evidence has reported differences in adipose tissue histology, metabolomic profiles, and gene polymorphisms associated with this condition, adding new pieces to the complex puzzle of lipedema pathophysiology. Although by definition lipedema is a condition resistant to diet and PE, the latter emerges for its key role in the management of lipedema, contributing to multiple benefits, including improvements in mitochondrial function, lymphatic drainage, and reduction of inflammation. Various types of exercise, such as aquatic exercises and strength training, have been shown to alleviate symptoms and improve the quality of life of patients with lipedema. However, standardized guidelines for PE prescription and long-term management of patients with lipedema are lacking, highlighting the need for recommendations and further research in this area in order to optimise therapeutic strategies.

Endograft connector technique to treat popliteal artery aneurysm in a morbid obese patient.

Surgical repair of popliteal artery aneurysm in morbid obese patients poses additional challenges. We report a morbid obese patient who had a 59 mm right popliteal artery aneurysm which was successfully treated with the endograft connector technique. This technique was used to perform the distal anastomosis of the below-knee femoro-popliteal bypass. A 10 mm Dacron graft was used as a main graft bypass and an 11 mm/10 cm stentgraft as endograft connector. Following the respective tunnel of the Dacron graft, an end-to-side proximal anastomosis was performed at distal femoral artery. The aneurysm exclusion was obtained through a proximal and a distal ligation. Postoperative duplex showed adequate bypass patency. Knee x-rays demonstrated no signs of stent kinking/fractures. The postoperative course was uneventful and the patient was discharged home on fourth day post operative. The six-month computed tomography scan and the 12-month duplex control showed a patent bypass with no signs of stenosis.

A popliteal artery aneurysm presenting with ab extrinseco popliteal vein occlusion and compartment syndrome: a case report.

INTRODUCTION: Aneurysms of popliteal artery are the most frequently reported aneurysm after abdominal aorta. An unusual presentation is compression to adjacent structure. CASE PRESENTATION: A 67 years old caucasian man presenting deep vein thrombosis signs to the right leg including functional impotence was admitted in emergency setting to Vascular Surgery Unit. A pulsing mass was present in the popliteal cave at inspection. The computed tomography angiography demonstrated a 53.2 mm popliteal artery aneurysm causing an ab extrinseco compression of the popliteal vein and a dislocation of popliteal nerve. A surgical open reconstruction with a reinforced Dacron graft was performed via a posterior approach. Patient was discharged on the fourth postoperative day with no functional impotence. At three and six months Doppler ultrasound followup both popliteal arterial graft and popliteal vein were patent. CONCLUSION: An unusual presentation of a popliteal artery aneurysm can be a popliteal compartment syndrome, especially in large aneurysms. Deep popliteal vein compression and/or popliteal nerve dislocation signs can rarely represent the clinical symptoms. The popliteal artery aneurysm repair is generally required to avoid a distal embolization and rupture. Through a surgical open repair was possible to achieve both popliteal cave decompression and the popliteal artery aneurysm repair.

Inflammatory abdominal aortic aneurysm (IAAA).

PURPOSE: The aim of this study is to report our experience about the inflammatory abdominal aortic aneurysm (IAAA). METHODS: Between January 1999 and January 2008 we treated 8 cases of IAAA. Two patients underwent surgery in emergency. The preoperative diagnostic procedure were ultrasound (US), computed tomography (CT) and intravenous urography (IVU). In 6 elective patients the diagnosis of IAAA was obtained preoperatively. In one case a left hydroureteronephrosis was demonstrated by intravenous urography (IVU). All patients underwent open surgery with midline incision and transperitoneal access. RESULTS: No 30-days mortality occurred. A case of pancreatitis was treated with conservative therapy. All patients had 60-days corticosteroid therapy. CONCLUSIONS: Our datas suggest that because IAAA have the same rate of rupture of AAA, they need the same preventive treatment as non inflammatory abdominal aortic aneurysm (AAA). The kind of approach OPEN-EVAR should be chosen with the same criteria as AAA, even if EVAR treatment doesn't allow us to obtain the biopsy. Furthermore there are no sufficient evidences about regression of retroperitoneal fibrosis after EVAR treatment. Also the premature onset should be considered in the choice of treatment.

[Abdominal compartment syndrome (ACS) after abdominal aortic aneurysm (AAA) open repair]. / La Sindrome Compartimentale Addominale (ACS) dopo chirurgia dell'Aneurisma dell'Aorta Addominale (AAA).

INTRODUCTION: The Abdominal Compartment Syndrome (ACS) is a "condition in which increased tissue pressure in a confined anatomic space, causes decreased blood flow leading to ischaemia and organic dysfunction and may lead to permanent impairment of function". MATERIALS AND METHODS: Between June 2007 and June 2008 all patients recovered to our Institution for Abdominal Aortic Aneurysm (AAA) underwent intermittent intra-abdominal pressure monitoring using intra-vescical catheter. Pressure data were registered before abdominal incision, during intervention, at closure of abdominal wall and at 6, 12, 24 and 36 hours in post-operative course. Rise in Intra-Abdominal Pressure (IAP) more then 20 mmHg was considered for surgical decompression. RESULTS: Twenty three cases of AAA were treated surgically Fourteen underwent elective repair and 9 emergency/urgency repair; in the emergency/urgency group, 8 were symptomatic without rupture signs and one case presented TC rupture signs. In the last case we registered preoperatively IAP more than 20 mmHg treated with only skin tension-free suture. No perioperative mortality was registered. DISCUSSION: ACS have been increasingly recognized as causes of significant morbidity and mortality over the last years after AAA surgery. ACS was recently classified from the World Society of the Abdominal Compartment Syndrome (WSACS) as primary, secondary and recurrent. ACS was recognized as major prognostic factor after AAA repair. ACS incidence ranges from 4 to 12%. Even if ACS etiological bases are not well known, principal risk factor for ACS development after AAA repair are massive fluid resuscitation infusion and aortic clamping IAP values, and subsequent possibility of ACS development, are superior after ruptured AAA repair than elective repair. Also in our study, even if limited by small number of cases, we registered differences in IAP value during emergency/urgency repair and elective repair. Patients management with rising IAR or at risk of ACS development, should be mandatory decompressed for IAP higher than 20 mmHg or also with inferior values if in association to organ dysfunction. IAP measurement can be performed directly or indirectly and all these techniques have as objective IAP monitoring before its clinical manifestation in ACS. CONCLUSION: ACS can be considered a reliable predictive factor for aneurysm surgery outcome. Prevention of the ACS, with early recognition of rising IAP and urgent intervention to decompress the tense abdomen can lead to mortality reduction after aneurysm repair. The measurement of IAP is simple and non-invasive, and should be a routine component of physiological monitoring in patients following ruptured aneurysm repair in association with hypotensive hemostasis.

Residual vein thrombosis to establish duration of anticoagulation after a first episode of deep vein thrombosis: the Duration of Anticoagulation based on Compression UltraSonography (DACUS) study.

Residual vein thrombosis (RVT) indicates a prothrombotic state and is useful for evaluating the optimal duration of oral anticoagulant treatment (OAT). Patients with a first episode of deep vein thrombosis, treated with OAT for 3 months, were managed according to RVT findings. Those with RVT were randomized to either stop or continue anticoagulants for 9 additional months, whereas in those without RVT, OAT was stopped. Outcomes were recurrent venous thromboembolism and/or major bleeding. Residual thrombosis was detected in 180 (69.8%) of 258 patients; recurrent events occurred in 27.2% of those who discontinued (25/92; 15.2% person-years) and 19.3% of those who continued OAT (17/88; 10.1% person-years). The relative adjusted hazard ratio (HR) was 1.58 (95% confidence interval [CI], 0.85-2.93; P = .145). Of the 78 (30.2%) patients without RVT, only 1 (1.3%; 0.63% person-years) had a recurrence. The adjusted HR of patients with RVT versus those without was 24.9 (95% CI, 3.4-183.6; P = .002). One major bleeding event (1.1%; 0.53% person-years) occurred in patients who stopped and 2 occurred (2.3%; 1.1% person-years) in those who continued OAT. Absence of RVT identifies a group of patients at very low risk for recurrent thrombosis who can safely stop OAT. This trial was registered at http://www.ClinicalTrials.gov as no. NCT00438230.