[Intraoperative transesophageal echocardiography in the endovascular treatment of thoracic aortic aneurysms]. / L'utilizzo intraoperatorio dell'ecocardiografia transesofagea nel trattamento endovascolare degli aneurismi dell'aorta toracica.

AIM: Endovascular surgery is an efficacious alternative to conventional surgery in the treatment of descending thoracic aorta aneurysms. However, primary and delayed endoleaks are some endovascular technology's weak points. They are usually detected by angiography or angio CT, but many information may be obtained by transesophageal echocardiography (TEE) both as to endoleaks and to endograft's correct placement. Our purpose is to confirm, on the basis of our experience, the validity of this technique chosen both by us and by other groups with a wider casuistry. METHODS: We positioned endografts for the treatment of degenerative or post-traumatic aneurysms of the descending thoracic aorta using TEE, together with angiography, during surgery in 8 out of 9 patients. TEE was carried out on the same 8 patients also before surgery, and for some patients even in the follow-up together with angio CT, after 6 and 12 months. RESULTS: In the situations where TEE was used we found 5 cases of endoleaks and 1 of these was not detected by angiography because of its small dimensions. All of these endoleaks were immediately corrected with more angioplasty or graft extensions; in a case, where we could not utilize the TEE, the problem solved spontaneously after 30 days as it was confirmed both by angiography and angio TC. The statistical analysis with the Student t test is significant for P < 0.005. CONCLUSIONS: We think that using TEE during the placement of an endograft on the descending thoracic aorta may help to obtain useful information in addition to those that we can obtain with angiography. Therefore, this may lead to improve the technique and to reduce possible both immediate or delayed complications.

Blood flow in the internal carotid and middle cerebral arteries: effects of continuous oral conjugated equine estrogens administration with monthly progestogen supplementation on postmenopausal women.

OBJECTIVE: This study was designed in order to evaluate the effect of conjugated equine estrogens (CEE) on internal carotid and middle cerebral artery blood flow in postmenopausal women. DESIGN: Thirty-four healthy postmenopausal women with intact uteri were randomly divided into two groups of 17 subjects each. The first group was treated for 24 weeks with continuous CEE medication (0.625 mg daily) and cyclical supplementations of 5 mg/day of medrogestone acetate, given on the last 12 days of every 4-week period (Prempak, Wyeth, Italy). The second group received no treatment. The pulsatility indices (PI) of both the internal carotid artery and middle cerebral artery were measured. RESULTS: In the treated group, the PI of the interior carotid artery and MCA was reduced from respectively 0.736 (0.016) and 0.745 (0.009) at baseline, to 0.669 (0.021) and 0.670 (0.011) after 24 weeks (p = 0.01); in the control group, the PI values remained unchanged. The between-group difference for both arteries was significant (p < 0.01). CONCLUSIONS: The administration of CEE with cyclical medrogestone supplementation to postmenopausal women induces a statistically significant reduction in the PI of cerebral arteries.

The effect of tamoxifen and transdermal 17beta-estradiol on cerebral arterial vessels: a randomized controlled study.

OBJECTIVES: Our objective was to study the effects of tamoxifen on cerebral arterial reactivity. STUDY DESIGN: We studied the reactivity of both the internal carotid artery and the middle cerebral artery during a 12-month period of administration of either oral tamoxifen or transdermal estradiol or no treatment. A total of 45 healthy postmenopausal women who had undergone hysterectomy were followed up. Patients were randomly allocated to treatment with either oral tamoxifen 20 mg/day or transdermal estradiol 50 microg/day or nothing (15 patients in each group). They all underwent Doppler examinations of the internal carotid artery and middle cerebral artery at the beginning of the study and after 2, 6, and 12 months of treatment. The pulsatility index was measured. RESULTS: In the women given transdermal estradiol the pulsatility index of both the internal carotid artery and the middle cerebral artery was significantly reduced compared with that in the controls. Tamoxifen did not induce variations of pulsatility index in either artery during all the study period. The difference between the effect of the two drugs on the pulsatility index of both arteries was highly significant. CONCLUSIONS: Our findings demonstrate that tamoxifen does not cause any variation in the pulsatility index of cerebral arteries. The action of transdermal estradiol on the pulsatility index of cerebral arteries in postmenopausal women is the expression of a generalized action of estrogens on arterial vessels, and if this expression plays a role in the protective effect of hormone replacement therapy on risk of cardiovascular disease, tamoxifen treatment in healthy postmenopausal women should be considered with renewed caution.

[Carotid endarterectomy under locoregional anesthesia]. / Endoarteriectomia carotidea in anestesia locoregionale.

The purpose of carotid surgery is to prevent the incidence of stroke in patients with cerebrovascular disease. It's important, therefore, to find the most useful methods of cerebral protection and flow monitorization during carotid endarterectomy. It is well known that patient's clamping tolerance changes according to his anatomical and physiopathological conditions (contralateral carotid patency, stenosis, occlusion), and compensative circles efficiency (Willis). General anaesthesia reduces cerebral metabolic requests and allows a better pressure control, but requires difficult, expensive and complex monitoring techniques. On the contrary loco-regional anaesthesia alone can't assure cerebral protection, but allows to test in real-time patient's reaction at clamping. If an ischaemia occurs, carotid shunting allows to perform endarterectomy, but this method might produce any complication: distal plaque dissection, embolizations. Authors show their 10 years (1986-1996) experience of 624 carotid endarterectomies performed on 580 patients evaluated by: -symptomatic or asymptomatic lesions -mono-bilateral stenosis -general or loco-regional anaesthesia -clamping tolerance -carotid shunting -intra-postoperative complications (temporary or persistent). According to results, authors propose loco-regional anaesthesia in carotid endarterectomy as a simply available and at low costs method to monitorize cerebral functions. In addition it has low rate complications, few contra-indications and may be selected like first-choice anaesthesiological method.

Gonadotropin-releasing hormone agonist-induced hypoestrogenism and blood flows in cerebral arteries.

OBJECTIVE: To evaluate the effect of the hypoestrogenism induced by GnRH agonist (GNRH-a) therapy on cerebral vessel blood flow. DESIGN: Open, controlled study. SETTING: Tertiary care units of the University of Milan, Italy. PATIENTS: Young women scheduled to undergo 6 months of therapy with a GnRH-a; a control group was also enrolled. INTERVENTIONS: In both groups, the pulsatility index of both the internal carotid artery (ICA) and middle cerebral artery (MCA) was measured by means of Doppler ultrasound over a period of 6 months. MAIN OUTCOME MEASURE: The ICA and MCA pulsatility index. RESULTS: No variation in the pulsatility index of either artery was found in either group. CONCLUSIONS: A 6-month period of GnRH-a-induced hypoestrogenism in young women does not lead to any variation in the blood flow of cerebral vessels. This provides some reassurance as to the safety of these drugs in relation to the role that the reactivity of peripheral arteries may play in determining risk of cardiovascular disease. Furthermore, our results show that blood flow in the cerebral vessels of young subjects is under extraestrogenic control and that this may counterbalance estrogen deprivation through mechanisms that probably are no longer active in the perimenopausal years.