Endovascular treatment of multiple anomalous splenic artery aneurysms in a Jehovah witness.

PURPOSE: The present report describes a full endovascular treatment of a multiple anomalous (Splenic artery aneurysms) SAA with combination of coils embolization and proximal occlusion of the splenic artery with the Amplatzer vascular plug. CASE REPORT: A 53-year-old Jehovah witness woman presented with multiple aneurysms arising from an anomalous splenic artery. An endovascular treatment was performed by implantation of multiple coils and an Amplatzer Vascular Plug. A CT scan 2 months after the procedure showed complete thrombosis of the aneurysms. DISCUSSION: Aneurysms involving an anomalous or aberrant splenic artery are rarely reported in the literature. Their surgical treatment involves potential difficulties as a consequence of anatomical position and vascular anomalies. A fully endovascular technique can be much more attractive compared to any surgical management, providing an effective and minimally invasive option.

Early results of synchronous carotid endarterectomy and off-pump coronary revascularization.

AIM: This study reports results of synchronous carotid endarterectomy (CEA) and off-pump coronary artery bypass grafting (CABG) in further support of the hypothesis that carotid and coronary artery revascularization can be safely performed in most patients. METHODS: The series includes 74 consecutive patients underwent synchronous CEA and off-pump CABG (group A) compared with 50 patients undergoing synchronous CEA and on-pump CABG (group B). Primary endpoint of this study are death, stroke, perioperative myocardial infarction and need for repeated revascularization within 30 days of the procedures. The secondary endpoint includes local and systemic complications. RESULTS: No stroke was observed in group A. Ipsilateral minor stroke occurred in two patients of group B (4%). Two deaths within 30 days were observed in group A (2.7%) compared with 4 deaths in group B (8%). Combined stroke/death rate at 30 days was 2.7% in group A compared with 12% in group B (P< 0.05). No significant differences in myocardial infarction, local and systemic complications were observed. CONCLUSION: Synchronous CEA and off-pump CABG may reduce the high surgical risk of patients who actually require combined carotid and coronary revascularization. This opinion has to be substantiated by larger studies and randomized trial.

Emergency endovascular treatment of a ruptured internal iliac artery aneurysm long after abdominal aortic aneurysm surgical repair.

The purpose of this report is to describe the endovascular exclusion of an internal iliac artery (IIA) aneurysm in emergency setting, long after abdominal aortic aneurysm surgical repair. An 85-year-old male presented with a contained rupture of a huge IIA aneurysm, ten years after aortoiliac bifurcated grafting. Because of poor clinical conditions an emergency endovascular treatment was planned. A stent-graft was positioned from the proximal right branch of the bifurcated surgical prosthesis to the distal external iliac artery, covering the hypogastric aneurysm neck. One month after the procedure, CT scan demonstrated the complete exclusion of the aneurysm. Endovascular treatment of IIA aneurysms is an excellent option to reduce perioperative morbidity and mortality in high risk patients, particularly in an emergency setting.

Surgical treatment of femoral artery pseudoaneurysms after cardiac catheterization.

AIM: To report a clinical experience about surgical treatment of iatrogenic peripheral artery pseudoaneurysms (FPA). METHODS: This is a retrospective review of 90 consecutive patients (46 males, 44 females, mean age 66.2 years, range 33-86) with FPA complicating coronary angiography or angioplasty, observed between October 1990 through June 2006. RESULTS: A 3 cm pseudoaneurysm or larger was confirmed by duplex ultrasound scanning in 90 out of 21 454 cardiac patients (0.42%), occurring more frequently in interventional (59/3 983) rather than diagnostic (31/17 471) procedures (1.48% vs 0.17%). The surgical treatment consisted in direct closure with polypropilene suture and occasionally, patch angioplasty or bypass. No limb loss occurred. There were 4 wound complications (4.4%), one pulmonary embolism (1.1%), 3 deaths (3.3%). CONCLUSION: Classical results reported in literature demonstrate that the surgical repair of femoral pseudoaneurysms following cardiac catheterization is safe, effective and durable. In these series, although low major morbidity (1.1%) and no cases of limb loss were reported, the authors observed 3 death (4.4%), resulting from the severity of cardiac disease in 2 cases and from the vascular repair itself in one case (femoral endoarteritis). These results substantiate the common observation that patients who actually require invasive coronary diagnosis and treatment are often affected by advanced cardiovascular disease and suffer the occurrence of complications, having a high risk of death. Therefore, any surgical treatment should be performed with strict adherence to sound vascular surgical principles.

Early diagnosis of acute mesenteric ischemia after cardiopulmonary bypass.

BACKGROUND: The aim of this study is to identify significant risk factors and eventual clinical markers associated with acute mesenteric ischemia (AMI) after cardiopulmonary bypass. METHODS: The study was retrospectively performed on a group of 19 patients (group A) undergoing cardiac surgery between January 1991 and December 1999, who developed AMI within 30 days of their hospitalization. A control group of 48 patients (group B) was compared in order to define preoperative and operative risk factors for AMI. RESULTS: At the abdominal operation, a non-occlusive mesenteric ischemia was found in every case. In-hospital mortality was 84.2% (16/19). Compared to the control, there was a significant difference in aortic cross-clamp time (p<0.001) and use of inotropic drugs (p<0.01). Postoperatively, the studied group (group A) had a significantly higher mean value of the enzymatic serum levels at any time. CONCLUSIONS: A high index of suspicion for mesenteric ischemia after cardiopulmonary bypass should be considered in patients with conditions of hypoperfusion. The early laboratory signs of AMI might be searched during the first postoperative hours.

[Thromboembolectomy with a Fogarty catheter. Our clinical experience]. / Tromboembolectomia con catetere di Fogarty. Nostra esperienza clinica.

BACKGROUND: The Fogarty thromboembolectomy (TE) has been considered for a long time the best treatment for acute peripheral arterial occlusion. However, recently new therapeutic options like thrombolytic agents (local or systemic) have been introduced. METHODS: A total of 66 patients who underwent Fogarty TE for acute thromboembolic limb ischemia has been retrospectively studied. Patients with documented atherosclerotic pathology who were treated with other revascularization procedures were excluded. Patients were divided into four groups: 1) upper limb embolism, 2) lower limb embolism, 3) thrombosis on atherosclerotic plaque or on a graft, 4) post-traumatic thrombosis. Twelve patients underwent Fogarty TE for upper limb thromboembolic ischemia and 54 for lower limb; 57.5% of patients had atrial fibrillation. RESULTS: Procedures were successful in 59 patients (89.4%). Further surgical procedures (bypass, arterioplasty, further embolectomy) were performed in 35.1% (19/54) of patients of groups 2 and 3 with acute lower limb ischemia. Results were very good in group 1 and 4. Seven of the 54 patients treated for lower limb ischemia underwent limb amputation (12.9%), while hospital mortality was similar for lower and upper limb (31.4 and 33.3% respectively). CONCLUSIONS: The Fogarty TE is still a good option to revascularize acute ischemic peripheral arteries with good results in a high number of patients and should be particularly used where it is possible to perform additional techniques in case of failure.

Laparoscopic cholecystectomy and the Peter Pan syndrome.

We report the case of a patient who experienced hemobilia a few weeks after undergoing laparoscopic cholecystectomy (LC). This condition was due to the rupture of a pseudo-aneurysm of the right hepatic artery in the common bile duct, probably caused by a clip erroneously fired during LC on the lateral right wall of the vessel. It also caused the formation of multiple liver abscesses and the onset of sepsis. This life-threatening complication led to melena, fever, epigastric pain, pancreatitis, liver dysfunction, and severe anemia, requiring urgent hospitalization and operation. In the operating theater, the fistula was closed, the liver abscesses drained, and a Kehr tube inserted. Thereafter, the patient's general condition improved, and she is now well. LC is often considered to be the gold standard for the management of symptomatic cholelithiasis. However, recent data have undermined that opinion. The apparent advantages offered by LC in the short term (less pain, speedier recovery, shorter hospital stay, and lower costs) have been overwhelmed by the complications that occur during long-term follow-up. When the late downward trend in the bile duct and the vascular injury rate are taken into consideration, the learning curve is prolonged. Therefore, LC should be regarded as the surgical equivalent of a modern Peter Pan-i.e., it is like a young adult who should make definitive steps toward becoming an adult but does not succeed in doing so. We report the case of a patient who experienced hemobilia a few weeks after undergoing laparoscopic cholecystectomy. Based on the facts in this case, we argue that the endoscopic procedure still needs to be perfected and cannot yet be considered the gold standard for selected cases of gallstone disease.

[Coronary disease in patients with an abdominal aortic aneurysm]. / La malattia coronarica nei pazienti affetti da aneurisma dell'aorta addominale.

The presence of coronary artery disease (CAD) evaluated with coronary angiography and eventual correction of CAD in abdominal aortic aneurysm (AAA) patients has been considered the main determinant of early and late outcome after AAA repair. This study reports our experience in CAD and AAA patients in terms of diagnosis and therapy of CAD. In a population of 126 patients (122 males, 4 females, mean age 67.5 years, range 37-81) who were candidates to elective repair for AAA with a diameter > or = 5 centimeters, we included coronary arteriography in 1) patients who were symptomatic for angina (15.9%); 2) patients with previous myocardial infarction (33.3%); 3) patients with previous coronary artery bypass (4%). We identified a group of 45 patients (35.7%) with significant CAD who had been treated before AAA surgery by coronary artery bypass grafting (CABG) in 37 cases or percutaneous coronary angioplasty (PTCA) in 8 cases. AAA repair was performed during the same hospital stay or at a later date. We did not report any morbidity and mortality related to cardiac or vascular procedures. We believe that among patients reporting cardiac symptoms (previous myocardial infarction, angina) the incidence of surgically-correctable CAD is not negligible (45/67, 67.2%). Therefore, invasive coronary study is strongly suggested in such cases to reveal and treat an eventual coronary artery stenosis prior to AAA repair. The absence of cardiac morbidity and mortality related to cardiac and vascular procedures supports this approach.

[Neurologic complication of carotid thrombendarterectomy]. / Complicanze neurologiche nella tromboendoarteriectomia carotidea.

BACKGROUND AND AIMS: Carotid endarterectomy (CEA) is often carried out to prevent cerebrovascular strokes. It is obviously important that neurological morbidity of the procedure is contained within acceptable limits (< 2%). METHODS: Between January 1991 and December 1997 a total of 239 CEA were performed in 216 patients (169 males and 47 females, mean age 66.6 +/- 14.2 years; range 43-81). Angioplasty was carried out using a precoagulated Dacron patch, except in cases in which the residual diameter of the internal carotid artery was greater than 5 mm. A Javid shunt was used selectively if stump pressure < 50 mmHg. RESULTS: No major neurological complications were observed. A reversible focal neurological deficit was reported in 3 cases (1.2%). Neurological morbidity correlated to peripheral arterial occlusive disease appears to be correlated mainly with technical reasons or cerebral ischemia following clamping. CONCLUSIONS: The extensive use of angioplasty with patch and the selective use of a protective shunt improve the technical success rate of surgery, significantly helping to limit morbidity.

Hemoperitoneum due to spontaneous rupture of an aneurysm of the left gastroepiploic artery.

We report the case of a woman, age 65 years, who was admitted to our hospital for intense abdominal pain. Hemoglobin was 9.7 g/100 ml and computed tomography (CT) confirmed the hemorrhagic state showing intraperitoneal blood. After laparotomy a ruptured aneurysm of the left gastroepiploic artery was diagnosed. Ligation of the artery was performed with good results. This case is reported because the situs of this aneurysm is very rare.

Posttraumatic infrarenal abdominal aortic pseudoaneurysm.

Posttraumatic abdominal aortic pseudoaneurysm is a rare lesion. To date, fewer than 30 cases have been reported in the literature, with most of those cases involving the suprarenal aorta. Infrarenal posttraumatic abdominal aortic pseudoaneurysm following abdominal trauma has been reported in only 6 other cases. We observed such a lesion in a 62-year-old man 15 years after blunt abdominal trauma inflicted in a car accident. Back pain was the presenting symptom. Resection and Dacron graft interposition were performed without postoperative morbidity.

Repair of femoral pseudoaneurysm after cardiac catheterization: utility of extraperitoneal iliac control.

Femoral artery lesions may occur after cardiac catheterization or percutaneous transluminal coronary angioplasty (PTCA). The incidence of pseudoaneurysm following transfemoral catheterization ranges from 0.21 to 6.25%. Among 3162 cardiac catheterization procedures thirteen (0.41%) patients presented a femoral pseudoaneurysm requiring surgical repair. The Authors reported their technical consideration about the utility of extraperitoneal iliac control during surgical repair of femoral artery pseudoaneurysm due to cardiac catheterization.

Risk factors in patients with different clinical and angiographic manifestations of ischemic heart disease.

In patients who present with unheralded myocardial infarction both the severity and the extent of coronary atherosclerosis appear to be less than that in patients with chronic stable angina, thus suggesting that, in the latter, protective factors may prevent or delay the evolution towards acute coronary syndromes. Therefore, risk factors were compared in 88 consecutive patients (73 men; mean age 56 +/- 9 years) with unheralded myocardial infarction and a single, discrete, > 70% stenosis in the proximal right, left circumflex or left anterior descending coronary artery (Group 1) and in 55 consecutive patients (46 men; mean age 58 +/- 9 years with chronic stable angina and multiple, diffuse, > 70% stenoses localized both in the right and left coronary arteries (Group 2). Continuous data are presented as mean value +/- 1 SD, proportions as percentages. In Group 1 mean serum levels of total cholesterol, low-density lipoprotein cholesterol and triglycerides were similar to those in mg/dl, p = 0.93 and 160 +/- 87 vs 155 +/- 76, p = 0.74, respectively) while the mean serum level of high-density lipoprotein cholesterol was higher in Group 2 (49 +/- 4 vs 46 +/- 4 mg/dl, p = 0.005). The prevalence of a positive family history of ischemic heart disease, hypertension and smoking habit were similar in the two groups, while the prevalence of diabetes mellitus was higher in Group 2 (29 vs 6%, p = 0.001). Thus, in patients with otherwise similar coronary risk factors, higher levels of high-density lipoprotein cholesterol and diabetes mellitus appear to be associated with a reduced tendency of coronary atherosclerosis to cause acute coronary syndromes.

Correction of pectus excavatum with a self-retaining seagull wing prosthesis. Long-term follow-up.

Between June 1958 and December 1991, 315 patients (217 male and 98 female, mean age = 17.8 +/- 5.5 years) affected by pectus excavatum (PE) were surgically treated. Most of the patients required operation for aesthetic reasons only (299 patients; 95 percent). The grade of PE (Chin classification) was I in 72 patients, II in 152, and III in the remaining 91. The surgical technique consisted of a double transversal sternotomy at the level of the lowest and highest part of the depression associated with a longitudinal sternotomy. A wedge resection of the ribs was then performed and the sternum was fixed using a stainless steel strut molded into a seagull wing prosthesis. The strut was removed 12 months postoperatively. There were no operative mortalities. Four patients had sternal wound infection that was successfully treated. The mean follow-up was 15.8 years per patient and was 60 percent complete. From the aesthetic point of view, the postoperative results were excellent in 246 patients (78 percent), good in 57 (18 percent), and poor in 12 (4 percent). All subjective symptoms, when present, disappeared after surgery. The seagull wing prosthesis appears to be safe, easy to implant and to remove, and comfortable for the patient. This technique has shown good long-term results independently of type of deformity and patient age.

Kinking of internal carotid artery: is it a risk factor for cerebro-vascular damage in patients undergoing cardiac surgery?

The incidence of carotid artery kinking is reported from 4% to 25% in different studies. During cardiopulmonary by-pass (CPB) in cardiac surgery the hemodynamic effects related to the kinking could produce hypoperfusion especially if associated with atherosclerotic lesions of the carotid arteries. We report our experience of 653 patients (538 males, 115 females, mean age 58.3 years) studied by coronaroangiography and internal carotid artery duplex scanning during the period January 1991-December 1992. Thirty-seven patients (22 males, 15 females, mean age 64.9 years), revealed anomalies of the internal carotid artery classificated as tortuosity (9 patients; 24.4%), and kinking (28 patients; 75.6%). All but 4 patients underwent cardiac surgery isolated or associated with carotid thrombo-endarterectomy (TEA) with Dacron patch arterioplasty. Three patients died (8.1%), one of them from cerebrovascular accident. He was a patient who had thromboembolism from the ascending aorta but without associated atherosclerotic lesions of carotid arteries. Asymptomatic isolated internal carotid artery kinking does not seem to be a risk factor for neurological complications during CPB. If carotid kinking is symptomatic and associated with atherosclerotic plaque producing internal carotid artery stenosis greater than 75%, we strongly suggest surgical treatment before cardiac operation.

[The long-term results in multiple procedures on the heart valves]. / Risultati a lungo termine nelle procedure multiple sulle valvole cardiache.

In the period 1972-1988, 209 patients (81 males, 128 females, mean age 42.4 +/- 11.9, range 20-71 years) underwent surgery for multiple valve repair (MVR) at the Italian Institution of Cardiac Surgery. Ninety-five patients had previously undergone mitral commissurotomy (MC). NTHA function class was III-IV in 89% of the patients. The procedures were: aortic valve replacement (AVR) + MC (63 patients; 30.2%), mitral valve replacement (MVR) + tricuspid valvuloplasty (TRVPL) (57 patients; 27.4%), AVR + MVR (50 patients; 24%), AVR + MVR+TRVPL (22 patients; 10.5%), AVR + CM + TRVPL (6 patients; 2.8%), AVR + mitral valvuloplasty (6 patients; 2.8%), AVR-TRVPL (2 patients; 0.9%), AVR + MVR + tricuspid valve replacement (2 patients; 0.9%), AVR + MVR + TRVPL + ventriculoplasty (1 patients; 0.5%). The inserted valves were mostly (147/209) Bjork-Shiley tilting disc type. The mean cardiopulmonary bypass (CPB) time was 119.6 +/- 53.9 and the mean aortic clamp time was 69.2 +/- 31.6. A complete follow-up was possible in 158/209 patients (75%) with a mean observation time of 8.11 +/- 4.92 years (total of 778 patients years). Thromboembolism was defined as the cause of any new focal neurologic deficit. All cases of peripheral embolisation were considered to be valve-related. The valve related early and late complication are as follow: fifteen patients in NYHA class III-IV, died perioperatively (7%). We had a thrombotic encapsulation of valve in one patient who required a redo operation after 8.25 years, 6 cases of thromboembolism in patients who interrupted anticoagulants (2 deaths), 4 cases of prosthetic leak, 8 cases of prosthetic valve endocarditis (1 death) 9 cases of anticoagulant-related hemorrhage (2 deaths).(ABSTRACT TRUNCATED AT 250 WORDS)