Surgical treatment of aorto-enteric fistulas.

BACKGROUND: Our series of secondary aorto prosthetic fistulas (PEF) to identify if and how different surgical treatment affect outcome is reviewed. METHODS: Between 1982 and December 1999, in the authors department, 42 patients were investigated for a secondary PEF. Mean age was 65 years: the mean time interval since the primitive aortic procedure was 49 months. Twenty patients were treated in emergency surgery: 29 presented evidence of gastrointestinal bleeding. The preoperative work-up included esophagogastroduodenoscopy, CT scan, and aortography. The vast majority of PEF were in a duodenal location. Surgical procedure carried out was graft excision, bowel suture or bowel resection, aortic stump closure and axillofemoral (AXF) bypass (11), new in situ revascularization by synthetic prosthesis (5), simple suture (9), graft excision without revascularization (1), in situ revascularization using arterial homograft (13). RESULTS: The mean surgery duration was 4 hours and 53 minutes, the mean blood loss was 1845+/-1132. Two patients died shortly after proximal aortic control was obtained. Early overall mortality was 50%, the early overall bypass occlusion rate was 12.5%, the early overall amputation rate was 10%, and the early new PEF rate was 12.5%. Late overall mortality was 22.5%, the late overall bypass occlusion rate was 20%, the late overall amputation rate was 7.5%, and the late new PEF rate was 10%. CONCLUSIONS: Bleeding of the gastrointestinal tract in patients with a history of intra-abdominal reconstructive vascular surgery must raise severe suspicion as to the certainty of existence of a PEF unless the diagnostic procedure excludes this possibility. All treatment methods resulted in catastrophic failure, related to recurrent PEF or septic complication. Perhaps, in the presence of PEF extra-anatomical bypass associated with aortic ligature remains an interesting surgical solution.

Carotid endarterectomy in an awake patient with contralateral carotid occlusion: influence of selective shunting.

The objectives of this study were to determine whether the presence of a contralateral carotid occlusion increases risk and whether the perioperative results are influenced by a systematic or selective policy of shunting during carotid endarterectomy (CEA) in an awake patient. In a retrospective study we compared patients with and without contralateral carotid occlusion (group I, n = 198 - group II, n = 1068) who required CEA. In 77 patients of group I, a shunt was systematically adopted (subgroup A); in the other 121 patients (subgroup B) and in all patients of group II a selective shunting policy was adopted. The risk for the patients with contralateral carotid occlusion was not significantly higher than that for patients without occlusion. Results were not influenced by systematic/selective shunting policy, and the incidence of signs of cerebral ischemia was higher in patients with contralateral carotid occlusion.

Management of infected peripheral bypass by selective partial graft removal and arterial homograft insertion. Two case reports.

We present two cases of partial graft removal and cryopreserved arterial homograft insertion for treatment of patent axillobifemoral (AXB) polytetrafluoroethylene (PTFE) prosthesis with infection confined only to a part of the graft. In the first patient, infection was confined to the left inguinal site; in the second, there was a cutaneous fistula in the middle prosthetic thoracic tract. Neither patient presented signs of systemic sepsis and radio immunological tests were positive only in a confined tract. After surgery, both patients showed early recovery and currently (mean follow-up 21-month) they are disease-free. Selective partial graft removal appears to give satisfactory results and may reduce the risk of complications compared with total graft removal Moreover, arterial homograft shows greater resistance to infection compared to alloplastic materials, when autologous veins are not available and/or not suitable.

Paraanastomotic aneurysms of the abdominal aorta: a 15-year experience review.

The aim of the study is a retrospective review of clinical presentation and management of paraanastomotic aneurysms of the abdominal aorta (PAAA) surgically treated in our Department. From January 1984 to December 1998, 2183 aortic prosthetic grafts were implanted. During the same period, 24 patients were treated for PAAA, 19 false and five true aneurysms. Symptoms were present in 10 patients. Surgical management included tube grafting interposition (14), aortobifemoral bypass (2), graft removal with extraanatomic bypass (2) and with in situ revascularization by arterial homograft (4). Nine patients died during operation or in the early postoperative period, six died during follow-up. Mortality in symptomatic patients was 70%, while in asymptomatic group was 14% (P=0.01). Rupture of false PAAA was very frequent (47% of cases). PAAA are infrequent complications of proximal aortic graft revascularization and tend to be asymptomatic until rupture occurs. The incidence of mortality is very different in asymptomatic versus symptomatic group; rupture is particularly frequent in false PAAA, which must soon undergo surgery when diagnosed. Since PAAA may develop at any time after surgery, their incidence increase in relationship with the length of postoperative interval: therefore, all patients submitted to abdominal graft revascularization need a lifetime surveillance program.

Aortic dissection after superior mesenteric artery percutaneous stenting. Case report.

We report an unusual case of aortic dissection after superior mesenteric artery percutaneous stenting. A 44-year-old patient, who suffered from back pain and fever, was diagnosed as having an aortic dissection. Aortic dissection, extending from the aortic arch (just after left subclavian artery origin) to the aortic carrefour, was successfully diagnosed by means of Duplex scan and CT scan examination. Two pathogenetic hypotheses, malformative and iatrogenic, were discussed.

Surgical repair of infected peripheral graft and abdominal aortic aneurysm using arterial homograft.

We report a case of combined surgical repair including lower limb revascularization (below-knee bypass) and abdominal aortic aneurysm repair using cryopreserved arterial homograft. The patient experienced lower limb ischemia due to repeated thrombosis of a long-infected polytetrafluoroethylene (PTFE) graft, and was also shown to have a complicating abdominal aortic aneurysm. Infection was eradicated with total graft excision and intravenous antibiotics. Two-year patency of the in situ arterial homograft revascularization was demonstrated with hemodynamic and tomographic controls; no degenerations have been found to date. Benefits of the use of in situ arterial homograft for arterial reconstruction may include improved hemodynamics and greater resistance to infection compared to when alloplastic materials are used. Because of the risk of allograft deterioration, close follow-up of the patient is required.

Osteochondroma of the tibia and popliteal artery stenosis.

In our department, an osteochondroma of the tibia in a young girl with intermittent claudication of the right leg was treated. Many instrumental examinations were performed in order to exclude an arterial disorder. As the patient shows signs of arterial compression, an operative procedure to remove the exostosis was performed.

Popliteal aneurysms: current management and outcome.

BACKGROUND: Peripheral artery aneurysm is the most common peripheral arterial aneurysm. Clinical pictures, perioperative diagnostic evaluations, surgical treatment and results are described. METHODS: From January 1982 to September 1998, 65 popliteal aneurysms in 48 patients were treated in the Department of Vascular Surgery of Busto Arsizio Hospital. The series comprises 44 men (91.7%) and 4 women (8.3%) with mean age 65 years (range 44 to 87 years). At the time of surgery, 38 of the 65 aneurysms (58%) were treated because symptomatic: 31 (82%) for limb ischemia (17 for acute ischemia, 14 for chronic ischemia), 6 (16%) for compression on the adjacent popliteal vein and 1 (2%) for rupture. Forty-seven (72.3%) aneurysms were treated electively: 27 cases were asymptomatic and 20 others had chronic leg ischemia or compression on the popliteal vein. The operations performed are listed as follows: 1 primary limb amputation for irreversible ischemia, 1 lumbar sympathicectomy and 62 leg limb revascularizations with graft interposition (vein or synthetic prosthesis). The patient with aneurysmal rupture underwent leg amputation. RESULTS: Mean follow-up is 6.5 years (ranging from 2 months to 10 years) and revealed important differences between symptomatic versus asymptomatic patients in limb salvage and graft patency: inferential analysis of amputation incidence is significant for p < 0.01 (Fisher exact test). CONCLUSIONS: We think that surgery is the best treatment also for small popliteal aneurysms, because of their frequent complications.

Salmonella mycotic aneurysms: traditional and "alternative" surgical repair with arterial homograft.

Salmonella infection of the abdominal aorta with formation of mycotic aneurysm is rare, but associated with a high mortality and morbidity. Prompt surgical treatment and selective and prolonged antibiotic therapy are required because of its rapid and impredictable evolution in a short period of time, even if an infectivous etiology is only suspected. Methods of revascularization can be different: the traditional two are in situ or extraanatomic bypass using synthetic graft. Both these solutions are subject to complications. An "alternative" method of revascularization with low risk of infection and good patency is the use of arterial homograft in situ. We report two cases of Salmonella mycotic aortic aneurysms successfully treated with revascularization respectively by extraanatomic bypass using synthetic graft and in situ arterial homograft. The reasons for our choice are also discussed.

[Aneurysm of the hepatic artery. Report of a case]. / Aneurisma dell'arteria epatica. Caso clinico.

Hepatic artery aneurysms are considered a rare event even though their report in the literature are becoming more and more frequent. A case of a 50-year-old man with common hepatic artery arterial aneurysm is reported. Initially, aspecific upper abdominal symptoms were found, but the great improvement in the diagnosis of vascular disease allows us to recognize this pathology which has a high risk of rupture so that an aggressive treatment is required.

Fresh and cryopreserved arterial homografts in the treatment of prosthetic graft infections: experience of the Italian Collaborative Vascular Homograft Group.

Following the experience of cardiac surgeons with homografts in the treatment of infective aortic valve endocarditis, cardiovascular surgeons have investigated in situ revascularization by means of homografts in the management of vascular prosthetic graft infections. Preliminary results are encouraging, but their late fate in long-term follow-up and the influence of preservation techniques are still under investigation. This article reports the experience of the Italian Collaborative Vascular Homograft Group, with the use of fresh and cryopreserved arterial homografts for the treatment of prosthetic graft infections. Between March 1994 and December 1996, 44 patients with prosthetic graft infection were treated with homografts (13 preserved at 4 degrees C, 31 cryopreserved). The mean age of the patients was 65 years. Emergency surgical procedures were performed in eight patients (18%). Sepsis was diagnosed in 11 patients, aortoenteric fistula in 13, and false aneurysms in 10. Staphylococcus was the main cause of infection. The types of vascular reconstruction with homograft were: 32 aortobifemoral, 3 aortoaortic, 2 iliofemoral, 4 peripheral, and 3 axillobifemoral. Human lymphocyte antigen (HLA) and antibody (ABO) blood group system compatibility between donors and recipients was not respected. The mean duration of follow-up was 15 months (range 1-33). Clinical and duplex scanning evaluations were routinely performed. Computed tomography (CT) or magnetic resonance (MR) scanning or arteriography were performed on the basis of duplex scanning results. There were six deaths during the early postoperative period (30 days) with a mortality rate of 13.6%. During the follow-up there were five late deaths with a mortality rate of 11.4%. Eight patients had graft occlusion. Three cases were successfully treated with thrombectomy. Two cases were successfully treated with femoropopliteal bypass with autologous vein. In three cases leg amputation was necessary. The results of fresh and cryopreserved homograft were compared. No significative differences of early postoperative mortality, late mortality, homograft related mortality, and graft occlusion were observed. We have evaluated the actuarial survival of the patients and the actuarial patency of the homografts on the aortoiliac reconstructions. Twelve months after the surgery the actuarial survival of the patients was 73% and the actuarial patency of the homografts was 56%. In our preliminary experience, we have not observed any significant difference in terms of clinical outcome by using fresh rather than cryopreserved homografts. In the near future it will be our policy to employ only cryopreserved homografts. Moreover, we will extend vessel harvesting to nonheart-beating donors, thus maximizing retrieval. The aforementioned solutions will supply the best graft availability to obtain dimensional and ABO compatibility between donors and recipients.

[The use of allografts in the surgical treatment of patients with infected vascular prostheses]. / Ispol'zovanie allotransplantatov v khirurgicheskom lechenii bol'nykh s infitsirovannymi sosudistymi protezami.

The article is devoted to analysis of surgical treatment of patients with such a dangerous complication as infection of the vascular prosthesis. The authors have performed 25 operations for substituting the infected prostheses for allografts. In 18 patients the infected prostheses were located in the aorto-iliac segment, in 5 patients in the femoro-popliteal segment, 1 patient had it in the aorta, and 1 in the subclavian segment. The prostheses were removed and a simultaneous revascularization was made. The authors make a conclusion that it is very expedient to use alloprostheses as a protective measure against persistent or recidivating infections. The allografts have both early and long-term resistance to infection.

The use of arterial allografts in aortic graft infections. A three year experience on eighteen patients.

BACKGROUND: We describe our experience in the treatment of aortic graft infections by replacing them with arterial homografts as suggested by the good results recently described. METHODS: Between March 1994 and March 1997 eighteen patients with infections of the aortofemoral bifurcation segments have been treated. All patients underwent a complete explantation of the infected graft and an in situ revascularization with arterial homograft harvested in multiorgan removal. Eight segments were freshly preserved, 10 were cryopreserved. Four patients were operated as emergencies, of which 3 for aorto-enteric fistulas. All others presented a serious septic state. RESULTS: Three patients died in the early postoperative period: one of acute infarction and two of homograft related causes. In the follow-up there was only one death from acute infarction, a branch occlusion and two allograft enteric fistulas successfully treated by surgery. All surviving patients are submitted to periodical haemodynamic and tomographic control with an average follow-up of 22 months (range 3 months to 3 years) and there has been no allograft degeneration so far. CONCLUSIONS: The use of homologue arterial allografts has shown good results in the treatment of serious aortic graft infections resulting in adequate peripheral vascularization. There have been no significant degenerations to date, either in fresh or cryopreserved allografts.

[Carotid endarterectomy using direct suturing]. / L'endoarteriectomi carotidea mediante sutura diretta.

The authors report the surgical technique and their experience in direct suture of arterial wall during carotid endarterectomies, comparing their results with reported data from literature. Selective or routinely utilization of direct suture or patch angioplasty are still a matter of discussion and reports from literature are controversial. In the Vascular Surgery Division of Busto Arsizio Hospital from January 1982 to December 1995, 870 carotid endarterectomies have been performed; direct arterial wall suture has been done in the 95.5% of these. The mean follow-up is 72 months, the restenosis rate is 6.6%, but only the 0.7% of the cases required a new surgical intervention with a patch angioplasty. From these data and according to the reports of international literature, we can assume that the use of a patch or direct arterial wall reconstruction, is a factor of less influence on restenosis rate than systemic or local factors (intimal flaps, surgical mistakes). Carotid endarterectomy has to be performed with great accuracy, in order to avoid surgical mismanagements which could negatively influence on early and late results.

The use of bifurcated and not reversed saphenous vein. Report of two cases.

BACKGROUND: This study was designed to determine the use of bifurcated and not reversed saphenous vein in different cases. CASE DESCRIPTION: We report two cases treated in the department of vascular surgery (Busto Arsizio, Varese, Italy) in which different arterial tracts had to be revascularized at the same time using not reversed autologus greater bifurcated saphenous vein. They are two different clinical situations (infection and very distal revascularization) treated by the same surgical technique. The two patients were subjected to angiographic examination in the pre- and postoperative period. During their follow-up, we carried out noninvasive surveillance (Doppler c.w.). The second were also subjected to bacterial culture and antibiogram to establish an adequate antibiotic therapy. The mean follow-up was 22 months: during this period rest pain disappeared and the trophic lesion recovered. CONCLUSIONS: In our experience, the use of not reversed and bifurcated vein was haemodynamically valid and able to maintain an arterial blood flow on the receiving arteries.

[Our experience in the emergency treatment of secondary aortoenteric fistulae. The preliminary results of the use of aortic homografts]. / La nostra esperienza nel trattamento in urgenza delle fistole aorto-enteriche secondarie. Preliminari sull'uso di homograft aortici.

The digestive prosthetic aortic fistulas are connections between an aortic prosthesis and the duodenum. From January 1988 to January 1994, in the vascular surgery section of Busto Arsizio hospital, 12 patients received emergency treatment for digestive aortic fistulas, with a prosthesis being positioned extra-anatomically. A different treatment was used for three patients who were treated during the period from January 1994 to July 1994. For the second group the old prosthesis was replaced by a homograft. On the first group of 12 patients, 5 had previously been operated on for obstructive arteriopathy of the legs; the other 7 had previously been operated on for an abdominal aortic aneurysm. In 50% of these 12 cases the prosthesis used was a bifemoral aortic prosthesis, in 30% bisiliac aortic, and in 20% an aorto aortic prosthesis. There was an interval, from one month to 20 years depending on the patient, between the first and the second operations. The average age of the patients was 61.2 years. Six of the patients were extreme emergency cases and were operated on immediately on their arrival at the hospital, while the other 6 were operated on 2-3 days after their arrival. Five patients died whilst they were being operated on (3 from haemorrhagic shock, 2 from sepsis and multi-organ failure). None of the patients who were treated from January 1994 to July 1994 died during their operations. The homograft was removed from a multi-organ donor. In treatment such as this, the most important thing is to remove the old prosthesis. The following is a discussion of the techniques used to clamp the aorta and to provide alternative limb vascularization.

[Femoro-distal revascularization with the saphenous vein in critical ischemias. An analysis of the results obtained and the criteria for choosing the most appropriate method]. / Le rivascolarizzazioni femoro-distali in vena safena nelle ischemie critiche. Analisi dei risultati ottenuti e criteri di scelta sul metodo più opportuno.

Critical ischemia is a pathology which requires the collaboration of a number of specialists and is often burdened by high morbidity and mortality rates. There are several possible therapeutic solutions, although each has its limits. The authors present a series of operated cases and compare the results of two different but alternative surgical methods (in situ and reversed saphena by-pass) depending on the patient's conditions. Perioperative and long-term results were comparable in both groups of patients.