Ruptured pancreaticoduodenal artery aneurysm. A case report and review of the literature.

Pancreaticoduodenal artery aneurysms (PDAA) are very rare (2% of the visceral aneurysms) but characterized by a high mortality rate if ruptured. Here a case of ruptured PDAA with an atypical clinical presentation that simulated an acute hepatobiliar syndrome is reported. A 60-year-old female presented with epigastric pain, nausea, gastric vomiting, elevated levels of hepatic enzymes, normal hemoglobin and cholelithiasis on echography. With persistent pain and progressively decreasing hemoglobin, an urgent contrast computed tomography was performed and revealed a large retroperitoneal hematoma that appeared to come from a branch of the superior mesenteric artery (SMA). A selective SMA-angiography showed a small aneurysm of the antero-superior pancreaticoduodenal artery with signs of hemorrhage. The patient underwent surgical ligature of the PDAA, after superselective transcatheter arterial embolization appeared technically impossible. The postoperative period was characterized by a progressive normalization of the hepatic values and hemoglobin and a post-operative angiogram confirmed the total exclusion of the PDAA and the integrity of the posterior pancreaticoduodenal arch. The pre-operative diagnosis of PDAA is usually very difficult. Symptoms can be vague or misleading, as in our case. Angiography is the most accurate diagnostic tool to locate a ruptured PDAA. Moreover, it can be immediately used for urgent endovascular treatment. Post-operative angiography is essential to confirm the total exclusion of the PDAA and demonstrate visceral circulation.

Morbidity and mortality following carotid surgery.

The records of 920 patients who underwent carotid endarterectomy by the same surgeon (M. D'A) between 1976 and 1989 were reviewed. Particular attention was paid to both the neurological and general complications and to how and when the neurological symptoms appeared. Among these patients, a cumulative stroke plus death rate of 3.1% was observed. Complications were classified as clamping ischemia (2.2%), postoperative embolism (1.5%), postoperative thrombosis (2.4%), and cerebral haemorrhage (0.3%). Two patients (0.2%) died from myocardial infarction. In 3.5% of patients, neurological symptoms were transient. The incidence of clamping ischemia was higher when 40 mmHg was considered as the safety limit of the back-pressure; this incidence fell by raising this limit to 50 mmHg, and introducing, in recent years, SEPs monitoring. Intraoperative monitoring of SEPs, in fact, reduced the neurological complications to 1.4%, while intraoperative angiography reduced the need for intraoperative reoperation from 10% to 2%. The use of antiplatelet drugs and an accurate surgical technique are useful steps in the prevention of postoperative embolism or thrombosis.

Intermittent ischemia caused by dissection of the abdominal aorta through myxoid degeneration. Case report.

Acute intermittent ischemia is generally caused by altered vasomotion and rarely by aortic dissection. There is reported a case of dissection of the abdominal aorta which presented a mixoid degeneration of the inner wall. The surgical finding was similar to a medio intimal aortic cylinder obtained generally during endarterectomy. Five years after the operation (endarterectomy of the mixoid cylinder) the patient presents a good patency of the aortoiliac area.

Iatrogenic vascular lesions. Pathogenesis and treatment: an 18 year review.

The records of 304 patients operated on for vascular injuries were reviewed; 76 (25%) of these presented an iatrogenic vascular injury: 13 involved the upper limbs, 49 the lower limbs and 14 the neck and trunk. The lesions were due to a vascular catheterism in 40 patients, to orthopaedic treatment in 27 patients, to general surgery procedure in 3 patients, to urologic surgery in 3 and to otorhinolaryngologic surgery in 3. In vascular catheterism the prevalent complications were thromboses and embolisms; 3 patients needed an amputation after the surgical repair. In orthopaedic surgery, vascular complications were linked prevalently to hip surgery, exchange arthroplasty and upper tibial osteotomy. In urologic, otorhinolaryngologic and general surgery, vascular lesions were prevalently related to haemorrhagic complications, followed by incorrect haemostatic manoeuvres. Retroperitoneal fibrosis or previous surgery increased the risk of vascular injuries. Delay in treatment was responsible for post-operative death or incomplete recovery.

[Thoraco-abdominal aneurysms of type IV]. / Aneurismi toraco-addominali di IV tipo.

AIM OF THE STUDY: Aims of the study were: 1. to evaluate the results of surgical treatment of type IV thoraco-abdominal aneurysms (TAA), with relationship to other types, 2. to evaluate results obtained with an approach different from the traditional thoraco-phreno laparatomy, with specific attention to postoperative respiratory function. MATERIAL AND METHODS: We have retrospectively compared type IV TAA with all other types of thoraco-abdominal aneurysms electively treated between January 1st, 1994 and May 31st, 2003. Data on perioperative mortality, spinal cord ischemia and renal failure (both temporary and permanent) occurring in the first 30 postoperative days were considered. Protection from spinal cord ischemia was accomplished through liquor drainage and prostaglandin E1 (PGE1) infusion. When the aneurysm extension was limited to the celiac axis an extrapleuric access with removal of XI rib was performed. In this subgroup of patients we have considered postoperative recovery time of respiratory function (intubation time, number of days in intensive care unit, postoperative pulmonary complications) postoperative renal failure, perioperative mortality and morbidity. RESULTS: Seventy-eight TAA have been treated in the period of time of the study. Twenty cases were type IV TAA (25.6%) of which 2 due to chronic dissection. Cumulative postoperative mortality has been 19.2%. The single perioperative death in the group of type IV TAA (5%) occurred in post-operative day 15 for multiple organ failure. No spinal cord ischemia occurred in this group. Temporary renal failure occurred in 3 cases (15%) with one case requiring dialysis. In 10 cases (50%) an extrapleuric access with removal of XI rib was performed, with adequate control of the proximal aorta. Postoperative respiratory failure requiring and intubation time longer than 12 hours occurred in 2 cases (20%). In the remaining 8 cases the mean intubation time was 5.3 hours (range 4-8 hrs). Tracheostomy was not necessary in any case. Mean time of intensive care unit stay was 3.5 days (range 0-15 days). CONCLUSION: The appropriate treatment of type IV TAA leads to low mortality and morbidity with results similar to those of pararenal aneurysms rather than those of other TAA forms. Left extrapleuric access when feasible allows faster recovery of a normal respiratory function.

True and false aneurysms in Behçet's disease: case report with ultrastructural observations.

One of the most important aspects of Behçet's disease is aneurysmal arteriopathy. The major problem of this complication is its tendency to develop recurrent false aneurysms at anastomotic and traumatic sites, such as angiographic punctures. We present a clinical case in which five aneurysms, some true, some false, were operated on during a period of 6 years, with the aid of ultrastructural observations of the wall of a true and a false aneurysm. One of the true aneurysms, localized in the aorta, was treated by direct aneurysmorrhaphy, and the 6-year follow-up demonstrated the absence of recurrences. Based on both this experience and the data in the literature, we suggest that the most appropriate surgical approach would, when possible, be direct aneurysmorrhaphy.