Open surgery of infrarenal aortic aneurysms with iliac involvement: repair should be entirely intra-abdominal.

AIM: A review of the literature on the surgical treatment of abdominal aortic aneurysms (AAAs) reveals that aortofemoral bypass (AFB) is used frequently in some centers. The latter series are characterized by higher rates of graft-related complications than in those in which AFB is used less frequently. The aim of our study was to evaluate the relative frequency and outcome of different types of bypass grafts in the surgical treatment of AAAs with iliac involvement, in our center and in others. METHODS: Between 1994 and 2004, 190 AAA patients with involvement of the iliac axes underwent elective repair in our department. Surgery was performed via median transperitoneal access. RESULTS: The AAAs extended to the common iliac artery (CIA) in 90.5% of patients. The remaining 9.5% extended to the external iliac artery (EIA). Aorto bi-iliac grafts were used in 159 cases, straight tube grafts in 13, aorto EIA grafts in 15, and AFBs in 3. Overall 30-day morbidity and mortality rates were 12.1% and 2.6%, respectively. At follow-up (mean: 5.6 years), one distal limb infection of an AFB and 4 CIA/EIA aneurysmal enlargements occurred and were repaired accordingly. Secondary patency and 5-year cumulative survival rate were 100% and 80%, respectively. CONCLUSIONS: In this series of AAAs extending to the iliac axes, AFB was used selectively (1.6%), even when the AAA extended to the EIA. This allowed us to maintain direct vascularization of the hypogastric arteries and eliminate the risk of complications associated with inguinal access. We feel, therefore, that for the repair of aortoiliac aneurysms, AFB is rarely indicated.

The endovascular management of open aortic surgery complications with emergency stent-graft repair in high-risk patients.

The aim of the study was to demonstrate the utility of endovascular stent-graft repair for emergency management of aorto-iliac surgery complications. Between 1997 and 2004, in our institute, 201 patients underwent transluminal endovascular graft placement. In 3 patients (1.4%), previously submitted to conventional aortic surgery, endovascular treatment was carried out due to the occurrence of late complications: 1 secondary aortocaval fistula, 1 impending rupture of aortic pseudoaneurysm and 1 secondary aorto-enteric fistula. All candidates were high surgical risk patients (ASA III-IV) suitable for endoprosthesis positioning by endovascular stent-graft implantation presenting with severe worsening conditions in an emergency situation. The patients were treated under local anesthesia and mild sedation. After treatment there was complete resolution of the clinical presentation and an improvement of general conditions in all 3 patients. In the 1(st) patient legs edema disappeared and in the 2(nd) patient mesogastric pain is absent, respectively at 30 and 8 months. The 3(rd) patient, with secondary aorto-enteric fistula, was submitted 2 months later to aortic graft removal and axillo-bifemoral bypass because of infection development. For the treatment of abdominal aortic surgery complications in high risk patients, particularly in emergency situations, endovascular approach is a feasible and safe alternative to conventional open repair. Further evaluation of this technique and longer follow-up will determine its exact role in the management of these life-threatening complications.

Transcranial Doppler assessment of the functional effects of symptomatic carotid stenosis.

Mean flow velocity changes in the middle cerebral arteries (MCAs) during a 2-minute thumb-to-finger opposition task were measured by means of transcranial Doppler ultrasonography in patients with severe unilateral carotid stenosis and ipsilateral transient ischemic attacks and in control subjects. The increase of flow velocity in the MCA contralateral to the hand performing the task was significantly different (p < 0.001, one-way ANOVA) in controls (+5.52 +/- 2.4 cm/sec) and in patients (+1.76 +/- 1.6 cm/sec, side of stenosis; +3.83 +/- 2.1 cm/sec, normal side). A post hoc least significant difference test revealed a significant difference between controls and patients on the side of stenosis (p < 0.001) and between the normal side and the stenotic side in patients (p < 0.03). One month after carotid endarterectomy, the effect of the motor task produced a significantly different effect on flow velocity in patients (p < 0.01, two-way ANOVA) because the increase of flow velocity during the motor task on the side of stenosis (4.84 +/- 1.9 cm/sec) was similar to that observed on the normal side (4.63 +/- 1.4 cm/sec). These findings suggest that the effect of a simple motor task on flow velocity of MCAs may allow for the evaluation of the functional effects of carotid lesions. Prospective studies are needed to evaluate whether this test constitutes a useful approach for the identification of patients who would benefit from a surgical procedure.

Leucocyte rheological properties are altered in patients with diffuse atherosclerosis.

To evaluate whether atherosclerosis may be associated with altered leucocyte rheology, we assessed leucocyte count (by Coulter counter), aggregation (by means of the leukergy test) and expression of adhesion molecules integrin LFA-1 and CD 44 (by means of immunofluorescence staining and flow cytometry) in 9 patients with carotid plus lower limb artery atherosclerosis (group A), 14 patients with carotid atherosclerosis only (group B) and 23 controls without atherosclerosis (group C). The level of LFA-1 (calculated as mean fluorescence channels-MFCs) on neutrophils, lymphocytes and monocytes was significantly higher (p < 0.05) in group A and B patients than in controls (group A-mean +/- SE: 383.77 +/- 9.42 vs 295.45 +/- 5.76; 474.22 +/- 8.86 vs 388.35 +/- 7.84; 457.66 +/- 12.03 vs 396.25 +/- 4.37. Group B: 322.42 +/- 6.36 vs 295.45 +/- 5.76; 421.42 +/- 7.21 vs 388.35 +/- 7.84; 415.71 +/- 7.73 vs 396.25 +/- 4.37, respectively); furthermore, the MFC of LFA-1 on neutrophils was significantly different (p < 0.05) between group A and B patients. The percentage of aggregated leucocytes was significantly higher (p < 0.05) in group A patients (4.46 +/- 1.07) than those in groups B (1.75 +/- 0.38) and C (1.43 +/- 0.25), whereas no significant difference was detected between groups B and C. Leucocyte number and expression of CD44 were not significantly different among the 3 groups. In conclusion, changes in leucocyte rheology are present in patients with atherosclerosis and may contribute to chronic ischaemia.

Criteria for prognostic evaluation of the results of lumbar sympathectomy: clinical, haemodynamic and angiographic findings.

Lumbar sympathectomy still has an important role in the surgical treatment of occlusive peripheral arterial diseases of the lower limbs located below the inguinal ligament, when the presence of peripheral lesions makes revascularization difficult. A consecutive series of 143 patients who underwent lumbar sympathectomy was considered, and the clinical, angiographic and haemodynamic findings evaluated. Haemodynamic studies on these patients showed a relation between the clinical improvement and the pressure index, measured at the ankle before lumbar sympathectomy. The patients with pressure index values above 0.5 had a symptomatic improvement whereas the patients with a pressure index below 0.3 gave less good results. It is therefore believed that lumbar sympathectomy showed not be considered a second operative choice but an elective operation, especially in patients affected by lesion of the superficial femoral artery, the popliteal artery and its branches, with pressure indices above 0.5 where revascularization is not possible.

Antithrombotic treatment during acute inflammatory complications of patients affected by postphlebitic syndrome: LMW-heparin versus standard heparin.

Seventy seven patients affected by postphlebitic syndrome (PPS) during acute inflammatory and/or obstructive complications were controlled. Thirty nine patients were treated with a new low molecular weight heparin (Fluxum), 16,000 I.U. AXa/day subcutaneously for 10 days and, subsequently, 8,000 I.U. AXa/day subcutaneously for up to 50 days. Thirty eight patients were treated with 20,000 I.U./day i.v. for 10 days of sodium heparin and, subsequently, with 12,500 I.U./day of calcium heparin by subcutaneous injection for up to 50 days. Clinical symptoms (pain, oedema, hyperemia, rashes, itching, dermatitis, ulceration) and instrumental patterns (Doppler) were recorded. Fluxum had an evident effect on the improvement of patient's clinical performance during acute complications of PPS.

Popliteal artery aneurysms. Factors associated with thromboembolism and graft failure.

AIM: The purpose of this study was to review our experience with popliteal artery aneurysms (PAAS) and to identify the major factors associated with thromboembolism of PAAS and failure of grafts after surgical repair. METHODS: The medical records of 38 patients with 42 PAA, who presented in a university medical center between March 1985 and September 2000, were retrospectively reviewed. Data were collected on clinical presentation, risk factors, type of reconstructions, early and late morbidity, limb loss and mortality. Duplex scan, as well as computed tomography, was performed in 33 (78.6%) cases, and preoperative angiography in 38 (90.5%). Thrombolysis was performed prior to surgical reconstruction (16.07+/-21.97 months) in 4 cases presented with acute ischemia. All patients underwent synthetic (23, 54.8%) or autogenous (19, 45.2%), below-the-knee (39, 92.9%) or above-the-knee (3, 7.1%) femoropopliteal bypass graft. The proximal and distal anastomoses were end-to-end both in both cases in 30 bypasses (71.4%). Thirty-six (86%) aneurysms were surgically treated by one vascular surgeon. Postoperative anticoagulants were given in 8 cases (19%). Long-term follow-up (mean: 57.59+/-37.77 months) was available for 35 patients (92.1%). Multivariate analysis was used to assess association between risk factors and outcome. RESULTS: Thirty-five patients were males, 3 were females; mean age was 68.31+/-8.66 years. Risk factors were arterial hypertension (25, 69%), smoking (19, 50%), dyslipidemia (7, 18.4%) and diabetes (5, 13.2%). Thirty PAAS (71.4%) were symptomatic for acute (11, 26.2%) or chronic (7, 16.7%) ischemia, distal embolization (8, 19%), compression of the popliteal fossa (3, 7.1%) and rupture (2, 4.8%, one of which presented with acute ischemia); 12 were asymptomatic. Bilateral PAAS were present in 18 patients (47.4%); 14 (36.8%) also had an abdominal aortic aneurysm (AAA); associated AAAS were twice as common in patients with bilateral PAAS (9/18, 50%) compared to those with unilateral PAAS (5/20, 25%; p=NS). The mean diameter of the PAAS was 3.4 cm; no significant difference was found in the mean diameter of symptomatic and asymptomatic aneurysms. Complete thrombosis of the aneurysmal sac was found in 15 cases (35.7%), severe atherosclerotic femoro-popliteal lesions in 17 (40.5%), arteriomegaly in 11 (26.2%), occlusion of the superficial femoral artery (SFA) in 7 (16.7%). Three leg arteries were present in 17 limbs (40.5%), 2 in 6 (14.3%), 1 in 7 (16.7%), no leg vessels in 12 (28.6%). Occlusion of the SFA and the absence of major leg arteries were independently associated with thrombosis of the aneurysmal sac (p=0.005). Two-thirds of patients with thrombosed PAA (10, 66.7%) presented with acute ischemia, while 1/3 (5, 33.3%; p=NS) had some degree of claudication. Optimal runoff (score=1) was estimated in 23 limbs, while score was between 2-7 in 19 limbs. Thrombolysis was successful in all 4 cases, with no complications. Primary graft patency was 66.1% at 4 years; the only variables independently associated with loss of bypass patency were smoking (p=0.04) and poor leg runoff (p=0.02). Postoperative bypass occlusion occurred in 2 cases presented respectively with acute and chronic ischemia, and in 2 asymptomatic patients; all 4 bypasses were polytetrafluoroethylene grafts. A total of 8 thrombosed, polytetrafluoroethylene, below-the-knee bypass grafts required secondary reconstructions (2 redo + 6 restorative procedures). The secondary patency rate at 3 years was 77.9%. Lower limb amputation had to be performed 2 months after primary reconstruction in 1 case (2.4%) presented with acute ischemia. The estimated limb salvage rate at 10 years was 96%. Mortality was 4.8%. Survival at 6 years was 82.6%. CONCLUSION: Our experience indicates that SFA occlusion and poor runoff vessels were independent factors associated with PAA thrombosis. The diameter of asymptomatic PAAs was not significantly different than that of asymptomatic ones. Use of tobacco and poor runoff vessels were independent factors associated with primary bypass patency. In PAAs complicated with acute ischemia, thrombolysis allowed us to regain a good runoff and to perform subsequent bypass procedure, with no amputation. The use of autogenous graft material, when possible, is recommended.

Clinical and therapeutical evaluation of inflammatory aneurysms of the abdominal aorta.

Unexpected anatomical and clinical features of abdominal aortic aneurysm (AAA) may be encountered by the vascular surgeon creating technical problems that increase the normally low mortality rates of this affection. One such variant is the so called inflammatory aneurysm (IA) as a characteristic fibrosis involving the arterial wall and thus surrounding structure scan be observed. In our series of 525 patients affected by AAA the incidence of IA was about 4% (19 cases). Two groups of patients were considered: group A, including all the atherosclerotic patients, and group B 19 patients affected by IA. The latter group referred to a typical painful symptomatology in 84% of the cases: this element is of interest as only 20% of the cases of group A complained of pain. No other significant clinical or laboratory data were recorded which could allow the surgeon to perform a pre-operative differential diagnosis. In all 19 cases that underwent surgical treatment there was a 2-3 cm thick aneurysmal wall with a shiny white surface adhering to the IV portion of the duodenum, vena cava and iliac vessels and in some cases to the ureters. Histological examination of specimens of the aortic wall showed evident signs of atherosclerosis of the media and marked fibrotic thickening of the adventitia with the presence of lymphocyte aggregates: a sign of chronic inflammation. As what concerns indications and surgical treatment, there are no substantial differences. Pre-operative differential diagnosis can be made with CAT scan and ultrasound and the usual operative manoeuvres of aneurysmorrhaphy should be modified.

Emergency carotid surgery.

The authors discuss the indications for emergency carotid endarterectomy, based on their experience between 1956 and 1975 when 15 patients with completed stroke and internal carotid occlusion (Group I) underwent this operation, and after 1975 when emergency revascularization was performed in 22 patients with unstable neurological deficit (Group II) and 21 patients with TIA's associated with preocclusive internal carotid stenosis (Group III). The good early and late results show that surgery was indicated in these cases. An attempt to identify the patients at high risk of acute ischemia on the basis of clinical or anatomical findings is made to ascertain the physiopathologic patterns of cerebral ischemia.

[Update on cerebral monitoring and protective methods]. / Attualità nei metodi di monitoraggio e protezione cerebrale.

Clamping ischaemia is responsible for the 20-30% of the neurological complications during carotid surgery. It is impossible at present to determine preoperatively for certainty the patients who are at risk and the ones who are not at risk for clamping ischemia. Intraoperative monitoring is mandatory in all the cases to point out cerebral ischemia and to prevent neurological deficit with an adequate brain protection. Methods used to predict brain ischaemia include local anesthesia, EEG, SEP, stump pressure measurement, transcranial doppler, regional cerebral blood flow measurement and evaluation of venous blood gases from the internal jugular vein. Local anesthesia is a safe and simple method of assessing cerebral ischemia during carotid clamping but has some limits particularly in case of brain ischaemia for the technical difficulties to install an indwelling shunt in an awake and often troubled patient. Moreover the only possibility of cerebral protection under local anesthesia is an increase in systemic blood pressure with a resulting growth in cardiac morbidity and mortality. For these reasons operation should be performed under general anesthesia to assure a better farmacogical brain protection when preoperative evaluation demonstrates a reduction of cerebral vasoreactivity, with a consequent high risk of clamping ischemia. At present EEG is one of the most used technique of cerebral monitoring under general anesthesia with a sensibility and specificity in the diagnosis of brain ischaemia that is about 90%. The best cerebral protection is obtained with a selective shunting. Burst suppression, with high dose thiopentone, has recently demonstrated its reliability alone or in association with an indwelling shunt in patients at high risk for clamping ischaemia. Of course a systematic cerebral protection together with an accurate control of the blood pressure is necessary in all the patients. This behaviour allowed us to obtain good results in the last 500 patients with a morbidity and mortality respectively of 1% and 1.6% with no significant differences between patients who tolerated carotid clamping and those with clamping ischaemia.