Hepatic artery aneurysm: an ever present danger.

Hepatic artery aneurysms are infrequent vascular lesions, difficult to diagnose preoperatively manifesting themselves usually by acute rupture. We report our experience in both diagnosis and surgical treatment of 3 cases. The selective angiograph of the celiac tripod and of superior mesenteric artery, is an indispensable means able, not only to put forward a certain diagnosis, but also to supply precious notions on the possibilities of compensation on the side of the collateral circle and of consequence, to suggest operative tactics. Surgical management may range from the simple binding to the reconstruction of the hepatic arterial axis by means of prosthesis grafts and if possible to the simple excision and termino-terminal regraft.

Neuropathy as the only symptom of common carotid artery spontaneous rupture. Case report.

We describe a case of a false aneurysm of the common carotid artery, caused by spontaneous carotid rupture, with atypical clinical presentation. The patient came to the our Hospital complaining of left shoulder pain and functional impairment of her left arm, during the past 20 days. The diagnostic work-up, color Doppler ultrasound, MR and angiography, evidenced a cervical false aneurysm; the electromyography showed denervation of the deltoid muscle, caused by cervical nerve roots compression. The therapeutic stages were initially an endovascular stent placement; then a surgical stage with evacuation for the hematoma and reconstruction of the carotid artery with saphenous graft.

A multicentre study on LMW-heparin effectiveness in preventing postsurgical thrombosis.

A multicentric study was carried out involving six italian departments of general surgery to assess the efficacy of a low molecular weight (LMW) heparin called Fluxum compared to standard calcium heparin in low doses for prevention of postoperative thromboembolic complications (deep vein thrombosis and pulmonary embolism). 610 patients were treated; 308 (50.5%) of whom were treated with Fluxum at doses of 4,000 or 8,000 I.U. Axa once a day by subcutaneous injection and 302 (49.5%) with heparin calcium at doses of 5,000 I.U. two or three times a day by subcutaneous injection. We observed a total of 29 deep vein thrombosis (4.7%); 10 (3.2%) from the group treated with LMW heparin and 19 (6.3%) from the comparative group. During the study 4 (0.65%) pulmonary embolism were found, 1 (0.32%) in the group treated with LMW heparin and 3 (1%) in the group treated with calcium heparin. None serious hemorrhagic accident was reported during the study. The antithrombotic prophy laxis carried out with Fluxum was on the whole better tolerated than the treatment of the other group, registering a lower frequency of hematomas at the injection and surgical wound sites.

Clinical, electrocardiographic, and echocardiographic features in patients with asymptomatic aortic abdominal aneurysm.

Cardiac involvement in peripheral vascular diseases can present interesting patho-physiological aspects and can influence the prognosis. The authors evaluated the cardiac condition of patients with asymptomatic aortic abdominal aneurysm (AAAA) by using clinical, electrocardiographic, and echocardiographic techniques. Seventy-eight patients were studied, 74 men and 4 women, with ages ranging from fifty-five to eighty-one years (mean 69.5 +/- 6.4). All patients were submitted to a complete clinical examination, usual blood tests, a 12-lead resting electrocardiogram, and an echo-Doppler evaluation. Forty-eight subjects (61.5%) were affected by hypertension, 53 (67.9%) were smokers, 25 (32.1%) were alcohol abusers, 39 (50%) had a history of angina pectoris, 20 (25.6%) had had previous myocardial infarction, and 30 (38.5%) were receiving active cardiovascular treatment. All patients except 2, who had chronic atrial fibrillation, manifested sinus rhythm. Electrocardiographic signs of left ventricular (LV) hypertrophy were present in 20 cases (25.6%), intraventricular conduction disturbances in 19 (24.4%), pathological Q waves in 20 (25.6%), and primary repolarization abnormalities in 25 (32.1%). Echocardiography showed a slight increase in left atrial diameter and intraventricular septum thickness (41.5 +/- 4.3 and 12.3 +/- 2 mm respectively). A clearer increase was found in LV mass index (159 +/- 44 g/m2). In 31 patients one or more LV asynergic segments were found. In our patients with AAAA the prevalence of major risk factors for atherosclerosis and ischemic heart disease including previous myocardial infarction was high. Echo-derived LV myocardial mass index was higher than normal even though electrocardiographic criteria for LV hypertrophy did not match echocardiographic data in all subjects. Finally a moderate prevalence of intraventricular conduction disturbances was recorded.

[Reinterventions for arterial reconstruction in anastomotic aneurysm]. / I reinterventi di ricostruzione arteriosa per aneurismi anastomotici.

We reviewed our experience on the surgical treatment of anastomotic false aneurysms from 1979 through 1990: two groups of patients were identified. Group 1 (31 patients) included patients who had been previously operated on at our Institute and then routinely followed-up with physical examination and ultrasonographic studies. The incidence of anastomotic aneurysm in this group was 4.03%; the interval between insertion of the prosthesis and detection of the false aneurysm varied from 5 to 144 months, with a median interval of 58 month. The surgical treatment of choice (false aneurysm resection and graft interposition) has been successfully performed (97% of cases) without mortality. Group 2 (8 patients) included patients with complications of false aneurysm (emergency operations); in this group radical treatment was not always applicable; mortality and amputations rate were significantly increased (respectively 25% and 37%). We conclude that, after prosthetic reconstructions, only a careful long-term follow-up (also with use of ultrasonic and/or CT-scan studies) may allow reduction in morbidity and improvement in late survival.

[Infected aneurysms of the abdominal aorta. Personal case reports]. / Aneurismi infetti dell'aorta addominale. Casistica personale.

Two cases of infected aneurysms of the subrenal abdominal aorta observed in the last year are reported. In this study some specific aspects of this unusual pathology are analyzed: the high mortality rate, the difficulties involved in the diagnosis and the surgical solutions.

[Consumption coagulopathy associated with a case of an abdominal aortic aneurysm]. / Coagulopatia da consumo in associazione con un caso di aneurisma dell'aorta addominale.

Consumption coagulopathy with clinical symptoms reveals aortic arterial aneurysms in less than 5% of cases. The authors report a case of abdominal aortic aneurysm: surgical repair is able to remove the hemostasis abnormalities for a long time. Implications of the consumption coagulopathy are analyzed: diagnosis, preoperative correction of the coagulopathy, surgical technique.

[Pseudo-occlusions of the internal carotid artery]. / Le pseudo-occlusioni della carotide interna.

The pseudo-occlusion (P.O.) of the internal carotid artery is defined as an atheromatous lesion causing a high-grade stenosis, which describes a peculiar angiographic finding ("string sing" or "slim sign"). The authors report their experience with 6 P.O. (angiographically diagnosed) that had been found in 16 months. In all these cases, whenever there was a clinical e/or B-scan ultrasound suspect, angiographic recommendations for the detection of that lesion have been applied. One of these 6 patients, clinically asymptomatic, refused surgery, remaining asymptomatic for cerebral ischemia during the successive 16 months; angiographic control evidenced an unmodified P.O. The other 5 patients, clinically symptomatic, underwent surgical correction: in one, intraoperative finding was a total carotid occlusion. In the other 4 patients the P.O. was confirmed and an endoarterectomy has been done. No immediate or later complications have been noted (clinical and ultrasonographic average follow-up time was 12 months). The experience described by the authors leeds to some considerations: a) the carotid P.O. is not so rare; specially if adequate angiographic technique has been employed; b) the non-invasive studies could not reliably distinguish a P.O; c) intraoperative findings do not confirm, always, angiographic ones but a fibrous, chronic and totally occluded internal carotid artery; d) the evolution of P.O. in a complete carotid occlusion is very probable but not obligatory, and if this happens it needs long period of time; consequently the surgical correction of P.O. could be justified but not urgently; e) the surgical correction of the P.O. can be done without particular difficulty and its outcome is so similar to those obtained from the routine carotid surgery.

[A subclavian vein lesion due to the positioning of a chest tube via thoracostomy]. / Lesione della vena succlavia da posizionamento di drenaggio endopleurico per via toracotomica.

The authors describe an unusual complication of chest tube placement: subclavian vein lesion. After a literature review concerning complications of chest tube placement, the authors conclude that associated risks may be best minimized with a strict adherence to standardized technique and management protocol.

[An unusual case of a double location of arteriosclerotic aneurysms of the ulnar artery and anterior tibial artery]. / Un caso insólito de doble localización de aneurismas arterioscleróticos: arteria ulnar y arteria tibial anterior.

Multiple peripheral arteriosclerotic aneurysms are relatively rare. This is a report of a case of two arteriosclerotic aneurysms in unusual sites: ulnar artery and anterior tibial artery. Surgical treatment was: simple resection for the ulnar aneurysm; resection with restoration of arterial continuity for the tibial aneurysm.

[Transcranial pulsed Doppler in the diagnosis of cerebrovascular pathology: methodology, indications and limitations]. / Il Doppler pulsato transcranico nella diagnostica della patologia cerebro-vascolare: metodologia, indicazioni e limiti.

Doppler analysis of flow in intracranial arteries is now possible using a 2 MHz probe, allowing sufficient penetration of bone to obtain signals noninvasively and to measure rate of flow in middle (MCA), anterior (ACA) and posterior (PCA) cerebral arteries and in basilar trunk. Practical applications of this new method are numerous in cerebrovascular disease and, despite certain limitations due to anatomic factors, transcranial Doppler may identify stenosis of the intracranial arteries and study the value of collateral flow across the anterior circle of Willis in patients with extracranial carotid artery stenosis.

Symptomatic subtotal occlusion of the innominate artery treated with balloon angioplasty and stenting.

PURPOSE: To report the endovascular treatment of a subtotal occlusion of the innominate artery giving rise to subclavian steal syndrome. METHODS AND RESULTS: A 60-year-old man in general good health was admitted to the hospital for sudden onset of amaurosis in the right eye. Thrombosis of the central retinal artery was diagnosed. Physical examination, color flow duplex imaging, and aortic arch angiography showed a subtotal occlusion of the innominate artery with right subclavian steal syndrome. One month later, balloon dilation and stenting of the innominate artery was performed through a right axillary access without cerebral protection. The innominate artery was recanalized with correction of the steal syndrome and restoration of the right radial pulse; no complications occurred. Twelve months later, color flow duplex sonography confirmed innominate stent patency and antegrade flow in the right vertebral artery. CONCLUSIONS: Our experience supports the view that percutaneous endovascular techniques are appropriate and are the preferred treatment for lesions of the supra-aortic vessels. Continued surveillance will determine their long-term durability.

[Recanalization with laser and angioplasty of atherosclerotic lesions of the legs. Personal experience with 31 treated lesions]. / Ricanalizzazione mediante laser ed angioplastica nelle lesioni aterosclerotiche degli arti inferiori. Esperienza personale su 31 lesioni trattate.

From January to November 1989, 31 iliac and femoro-popliteal atherosclerotic lesions were treated in 29 patients (age range: 33-80 years) by means of percutaneous laser-assisted angioplasty. The lesions were 6 iliac tubular stenoses, 6 iliac occlusions and 19 femoro-popliteal occlusions, 2-20 cm long. The laser equipment employed was in 10 cases a Cardiolase 4000 Nd:YAG "hot tip" unit, and in 21 cases a Nd:YAG "sapphire contact probe" unit. Initial success was achieved in 23/31 lesions (74%); the follow-up, by clinical examination, Doppler US, and ankle-arm pressure index performed every 4th month, showed 1-year actuarial patency of 80% for femoro-popliteal occlusion and 100% for iliac lesion, with 87% cumulative patency. Overall complication rate was 22.5%. There were 6 local complications, 4 of which were hematomas at the arterial puncture site, and 2 were performation of the superficial femoral artery, all without any clinical sequelae; one patient developed rethrombosis within 72 hours from treatment, which needed amputation after an emergency bypass. Our preliminary results show no significant improvement when compared with conventional balloon angioplasty results both in immediate success rate and in short-to-midterm patency; furthermore, laser therapy was burdened by a higher complication rate. We believe that laser angioplasty should be employed only in arterial occlusion uncrossable with angiographic guidance alone.