Treatment of true superficial femoral artery aneurysms: the 15-year experience of a single centre.

OBJECTIVE: True superficial femoral artery aneurysms (SFAAs) are rare and traditionally treated by open repair. However, the endovascular approach excluding the aneurysm sac with a covered stent may be an alternative. This study aimed to compare the outcomes of the open and endovascular repair of SFAAs. METHODS: This is a retrospective, observational, monocentric study. The main endpoints were: technical success, limb salvage and primary patency rate, and hospitalisation time. RESULTS: We identified 49 SFAAs in 40 patients; the mean age was 73.3±10.1 years, the mean diameter of SFAAs was 5.41±3.64cm, and 61.2% were symptomatic for ischaemic or compression-related signs. The indication for open repair was given mainly for complex SFAAs involving the distal third of the superficial femoral artery and with an ipsilateral popliteal aneurysm. Among the 36 open-repair patients, 33 underwent ligation and revascularisation via bypass or graft interposition, and 3 patients underwent simple ligation without revascularisation. The endovascular approach was adopted mainly for aneurysms located in the medial third of the SFAA, which underwent covered stenting in 12 patients and coil embolisation in 1 patient. The technical success was 100% in all cases. There were no statistical differences in terms of primary patency and limb salvage rate between groups at two and four years. The mean hospitalisation time was 10±4 and 3±1 days after open and endovascular treatment, respectively. CONCLUSIONS: The endovascular approach may be a valid alternative for isolating SFAAs offering good results and shorter hospitalisation. Open repair remains a valid approach, particularly in complex aneurysms.

Open repair with resection and reimplantation for popliteal artery aneurysm.

Popliteal artery aneurysms are the most frequent type of peripheral arterial aneurysm and can be repaired by either open or endovascular techniques. An 81-year-old man presented with leg swelling and during duplex ultrasound examination was diagnosed a popliteal aneurysm. The transverse diameter was 3.6 × 4.5cm, length 2.8cm, one run-off vessel patent. The popliteal aneurysm was asymptomatic for clinical signs of limb ischaemia. We opted for an open surgical repair through a posterior approach. During dissection of the popliteal artery above and below the aneurysm, the two non-diseased popliteal extremities appeared to be very close, leading to the decision to perform an end-to-end anastomosis between the two arterial extremities. The patient was discharged after three days with no adverse events. Follow-up consisted of duplex ultrasound examination at one, three and six months, and then annually. At the six-month follow-up there was no restenosis at the anastomosis.

Revascularisation through the obturator foramen of lower limbs with a compromised ipsilateral groin due to infection.

INTRODUCTION: Infra-inguinal vascular reconstruction with active groin infection is a concerning issue. Using resistant grafts to infection is the most adopted approach. However, in absence of these materials in acute situations, the trans-obturator approach allows for limb revascularisation avoiding the infected site. We evaluated the effectiveness of this approach in patients who needed lower limb revascularisation with an ipsilateral groin infection. MATERIALS AND METHODS: A retrospective study was conducted over a four-year period. RESULTS: Over this period, 13 patients underwent trans-obturator reconstructions (13 external iliac-popliteal above-knee and one aortobipopliteal above-knee bypass). Seven patients had been previously revascularised and were admitted for graft infection (six infra-inguinal bypasses, one axillo-bifemoral bypass). Four presented with acute limb ischaemia, three with groin haematoma and one with a groin abscess. The remaining cases consisted of drug-addicted patients with injury of femoral vessels due to self-injection of drugs. The patients underwent reconstructions with autologous grafts which complicated early with groin haematoma. After transobturator revascularisation, the groin underwent debridement with applying vacuum-assisted wound closure device. CONCLUSION: The transobturator approach could be considered as a chance for lower limb revascularisation in case of ipsilateral groin infection. Moreover, avoiding the infected site allowed us to focus separately and safely on the treatment of the inguinal wound.

The CEAP-L classification for lymphedemas of the limbs: the Italian experience.

AIM: A method to classificate lymphedema has been needed to gather all the important information on the clinical evolution of the disease using a common language and an easy clinical applicability. METHODS: The proposal for a new classification of the limb lymphedema was inspired by the C.E.A.P. classification for chronic venous insufficiency of the lower limb. The classification adopts the acronym C.E.A.P. by adding the letter L to underline the aspect ''lymphedema'' and is based on clinical data such as extension of lymphedema, presence of lymphangitis, leg ulcers and loss of functionality of the limb and instrumental criteria that permit to confirm and precise diagnosis. The Clinical classification is based on the most objective sign in these patients, the edema which is subdivided into 5 classes depending on the clinical manifestations. The etiological aspect considers 2 types of alterations of the lymphatic system: congenital and acquired. The anatomic is aimed to locate the anatomical structures involved. Pathophysiological conditions are gathered into 5 groups: agenesia or hypoplasia, hyperplasia, reflux, overload, obstruction. RESULTS: The classification has already been appraised after 4 years of activity at the unit of Vascular and Endovascular Surgery of Ferrara, at the S. Giovanni Battista Hospital in Rome, at the Umberto I Ancona Hospital and at the S. Giovanni-Addolorata Hospital in Rome. CONCLUSIONS: The proposal for a new classification of lymphedema C.E.A.P. L was developed in order to categorize patients with definite and objective marks, creating clinical reports with a common vocabulary, clear to all clinicians, permitting to stage the disease, evaluate treatment and finally obtain epidemiological and statistical data.

High output heart failure due to an iatrogenic arterio-venous fistula after lumbar disc surgery.

Vascular injury is a rare but not uncommon complication of spinal surgery and associated with dramatic consequences. Congestive heart failure secondary to a hyperkinetic circulation can occur in systemic diseases and in arterio-venous fistulae. A 57-year-old man was admitted to hospital complaining of dyspnoea and oedema of the left leg. Eight days previously he had undergone a discectomy at L4-L5. On auscultation a systolic-diastolic murmur was noted over the entire abdomen. An echocardiogram demonstrated an enlarged right atrium, severe mitral and tricuspid regurgitation and increased pulmonary artery pressure. An abdominal CT demonstrated irregular dilatation of the left common iliac vein and through a fistula and simultaneous opacification of the right common iliac artery; subsequently, this was also confirmed by angiography. The patient underwent an emergency endovascular stent-graft of the right common iliac artery with normalization of the venous return pressure and quick resolution of the heart failure. It is important for the physician involved in clinical work to keep in mind all the possible post-surgical complications that can occur in symptomatic patients who have recently undergone an intervention.

[Effectiveness of the combination of alpha tocopherol, rutin, melilotus, and centella asiatica in the treatment of patients with chronic venous insufficiency]. / Efficacia clinica di un'asociazione di alfatocoferoli, rutina, meliloto e centella asiatica nel trattamento di pazienti con insufficienza venosa cronica.

BACKGROUND: The aim of this comparative clinical study was to evaluate the efficacy of the association of alphatocopherol, rutin, melilotus officinalis, and centella asiatica with oral administration in patients with chronic venous insufficiency. METHODS: Thirty patients with chronic venous insufficiency have been randomized in two groups of fifteen subjects (control and treatment group). During the period of treatment the patients didn't wear elastocompressive stockings. The therapeutic efficacy and the clinical tolerability of this association have been valued with clinical-instrumental evaluations and by a control after 15 and 30 days. Functional bothers, cramps and the edema have been valued in function presence and of their gravity with a clinical-score between 0 and 4. RESULTS: At the end of the observation period, a significant improvement of the clinical simptomatology was obtained, characterised by a diminution of the sovrafascial edema. CONCLUSIONS: The present study confirms previous clinical experiences regarding the described treatment and suggests its application in chronic venous insufficiency.

Endovenous management of saphenous vein reflux. Endovenous Reflux Management Study Group.

PURPOSE: This study assessed clinical outcomes of two catheter-based endovenous procedures to eliminate or greatly mitigate saphenous vein reflux. MATERIALS AND METHODS: A computer-controlled, dedicated generator and two catheter designs were used to treat 210 patients at 16 private clinic and university centers in Europe. The Closure catheter applied resistive heating over long vein lengths to cause maximum wall contraction for permanent obliteration; the Restore catheter induced a short subvalvular constriction to improve the competence of mobile but nonmeeting leaflets. RESULTS: Closure treatment caused acute obliteration in 141 (93%) of 151 limbs; Restore treatment, shrinking one or more valves, acutely reduced reflux to less than 1 second in 41 (60%) of 68 limbs. Closure treatments were associated with early recanalization (6%), paresthesias (thigh, 9%; leg, 51%; P <.001), 3 skin burns, and 3 deep-vein thrombus extensions, with 1 embolism. Restore treatments were thrombogenic (16%) despite prophylactic anticoagulation, and treated valves enlarged over 6 weeks, becoming less competent. Clinical Efficacy Assessment Project clinical class was significantly improved after both treatments, up to 1 year. At 6 months, 87% of 53 Closure patients were class 0 or 1, 75% were symptom-free, and 96% of 55 treated limbs were completely free of reflux. Fourteen of 31 Restore patients (45%) had no symptoms, but 55% were class 2 or lower and only 19% had less than 1-second reflux. CONCLUSION: Closure treatment is clinically effective, albeit with offsetting complications and early failures; these are being addressed through four procedural modifications. Restore valve shrinking, although conceptually attractive, is too problematic to be competitive with Closure treatment or saphenectomy.

[Aorto-mesenteric compression syndrome. Description of clinical case and critical review of the literature]. / La sindrome del compasso aorto-mesenterico. Descrizione di un caso clinico e revisione critica della letteratura.

Aorto-mesenteric duodenal compression syndrome is a rare disease in which superior mesenteric artery causes a substenosis of the duodenum. Pathogenesis of this syndrome is due to congenital or acquired factors. Symptomatology is usually non specific and intermittent. Diagnosis is given by selective superior mesenteric artery angiography. Therapy is only surgery.

[Cutaneous mechanical staplers. Our experience]. / Le suturatrici meccaniche cutanee. Nostra esperienza.

This paper reports the results of a trial, comparing the use of disposable skin staplers with conventional nylon or silk sutures in skin closure. This study began in 1986; 7274 patients undergoing elective and emergency operations were controlled during the postoperative period, 3 and 6 months after surgery. It was shown that skin clips instead of sutures decrease the operative time, produce wound healing with a good cosmetic results, and above all a significant lowering of the wound infection rate.

Reparative surgery of valves in the treatment of superficial venous insufficiency. External banding valvuloplasty versus high ligation or disconnection. A prospective multicentric trial.

OBJECTIVE: A prospective study was performed in order to compare results obtained in the treatment of early and/or limited primary varicose veins of the lower limbs using two different procedures: external valvuloplasty and high ligation or disconnection of the sapheno-femoral junction. MATERIALS AND METHODS: 116 limbs (113 patients) were selected. 57 with normal cusps in dilated valves were subjected to external valvuloplasty with Silicone prosthesis under Doppler control (intraoperative angioscopy in 16 cases); 59 limbs were subjected to high ligation or disconnection of the junction; 57 limbs out of 116 were subjected to complementary procedures. Duplex and photoplethysmographic examinations were performed before and after the surgical procedures in all patients. Doppler venous pressures were measured in 36 limbs and invasive pressures in 40 limbs. Patients were postoperatively followed up every 4 months until the 12th month. RESULTS: Indications for valvuloplasty were found in 8.2% of cases and in 66.3% of the early varices. Clinical results were slightly superior in the reparative surgery group. Thrombotic occlusion of the proximal long saphenous vein was significantly higher in the ligation-disconnection group. Results from photoplethysmography and venous pressure measurements indicated that both operations are equally effective in the elimination of reflux in the junction.

[Surgical treatment of cervical fistula after esophagogastroplasty (EGP)]. / La terapia chirurgica della fistola cervicale dopo esofagogastroplastica (EGP).

The authors report their experience on cervical anastomosis dehiscence in patients who had total esophagectomy and esophagogastroplasty for esophageal neoplasms. They describe, accurately and step by step, the plastic reconstructive technique (by using a vascularized transposed cutaneous flap), used to treat a symptomatic cervical fistula which occurred in 3 of the 24 patients who had esophagectomy and cervical-esophagogastroplasty. This kind of treatment led to complete healing of the fistulas, without clinical and radiological signs of fistula recurrence in all the patients treated.

["Simulated walking" in the duplex evaluation of the venous system. The clinical and instrumental correlations]. / La "deambulazione simulata" nella valutazione del sistema venoso con duplex. Correlazioni clinico-strumentali.

The goals of non-invasive duplex vascular diagnosis of the venous system of the lower limbs are: 1) To make evaluation of the venous system during deambulation feasible under physiological, pathological and post-surgical or elastocompressive conditions. Moreover, any such evaluation must be achieved using a standardized, easy, highly reproducibly method which is inexpensive and utilizes the diagnostic instruments available. 2) To achieve detailed, selective localization of the valvular and parietal dysfunctions at the basis of any reflux pathology. 3) To identify and quantify venous flux and reflux during deambulation. The present work gives the results achieved over the period of one year after a new method simulating deambulation (Walk System 1 patented) was set up for several utilizations, principally correlated to the use of conventional duplex scanning in studying the venous system. The main purpose of the Walk System 1 is step simulation to uncover the location and extent of venous disease. This application test of: a pneumatic pump which compresses the calf to 100-120 mmHg in 0.3 sec thus simulating muscolar pumping during deambulation; standard 40 mmHg compression of the foot in order to rule out any hemodynamic involvement of the foot pump venous system. We can use this pump in the hemodynamic component, a part, during the step simulation, with synchronism with calf pump in TVP prophylaxis or in vascular therapy; an easy-to-use application software able to quickly pulsed Doppler data of flux and reflux by means of the flux and reflux orthodynamic indices or with measures in ml/sec. The study was performed on 80 lower limbs in normal subjects in order to define the normality range and in 380 lower pathologic limbs. The study has yielded a clinical-instrumental correlation between the hemodynamic data observed during inflation-deflation of the calf cuff, positioning the pulsed Doppler sample volume in the saphenous vein in the saphenous-femoral ostium zone and the underlying venous morphology. The results have made it possible to determine physiological S-F reflux and to establish 4 pathological classes of orthodynamic S-F reflux, each class corresponding to a specific range in the orthodynamic reflux index (class 0 = 0 < RI < 0.25; class 1 = 0.25 < RI < 2; class 2 = 2 < RI < 3.5; class 3 = 3.5 < RI < 6; class 4 = RI > 5) and to a particular morphological conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute ischemia of the upper limb. Clinical case and general considerations]. / Ischemia acuta dell'arto superiore. Caso clinico e considerazioni generali.

The authors report a case of acute inveterate right subclavian artery obstruction. The leading role of US vascular investigation and the surgical technique adopted are pointed out. The personal findings are compared with those from the international references.

[Visceral aneurysmal arterial pathology]. / La patologia arteriosa aneurismatica viscerale.

In this paper the Authors report their experience on diagnostic and surgical procedures with respect to aneurysms of the visceral district. The clinical review during the last ten years of surgical activity in the Istituto di Clinica Chirurgica (Università di Ferrara) regards 13 patients with different visceral aneurysms. The study reports the different percentage of localization, the diagnostic approach, the surgical procedure performed and discussion of results obtained. Patients at risk for this disease are pointed out.

A prospective study of local recurrence after resection and low stapled anastomosis in 183 patients with rectal cancer.

Local recurrence is the most serious complication of anterior resection for rectal cancer, usually occurring during the first two years after surgery. Over a five-year period, from 1981 to 1986, 183 patients underwent anterior resection for rectal carcinoma at the Surgery Ward of the University of Ferrara. Patients were followed for two years postoperatively. All operations were performed with staplers and classified according to Dukes, with 43 cases of Dukes' A; 83 cases of Dukes' B; and 57 cases of Dukes' C. In the first 24 months after surgery, the tumor recurred locally in 44 of the 183 patients (24 percent). Dukes' stage, grading distal resection margin, and histopathologic differentiation of the distal rectal ring left in the stapler after anastomosis were assessed to determine a prognostic indicator for the recurrence of the tumor. The stage:recurrence ratio was as follows: A, 1 (2 percent); B, 21 (25 percent); and C, 22 (39 percent). The grading:recurrence ratio was: G1, 13:51 (25 percent); G2, 24:110 (22 percent); and G3, 7:22 (32 percent). The ratio between distal rectal resection margin and recurrence was: 0 to 2 cm, 15:27 (56 percent); 2 to 4 cm, 16:74 (22 percent); and over 4 cm, 13:82 (15 percent). Histopathologic examination of the distal rectal ring was negative for all patients. These data confirm the direct relationship between class and local recurrence and indicate histologic grade and distal resection margin as significant prognostic parameters only when interpreted in the light of staging.

[Effects of therapy with aminaftone on chronic venous and lymphatic stasis]. / Effetti della terapia con aminaftone sulla stasi venosa e linfatica cronica.

Following a short introduction on the physiopathology of the phlebo-lymphatic system, the results of a study carried out on 114 patients suffering from chronic venous insufficiency (CVI) treated at the Department of General Clinical Surgery and Surgical Therapy of the University of Ferrara are reported. These patients were subdivided into two random groups and treated with common phlebotonic drugs and aminaftone, respectively. Both groups were also subjected to those physical and medical measures that are usually adopted for the treatment of such patients. The therapeutic effects were assessed by comparing symptomatology before and after 90 days of treatment, both subjectively (patient's assessment of the symptoms by means of a scoring system) and with objective methods (measurements and echo-Doppler examinations). The differences between the two groups were statistically very significant in favour of patients who had taken aminaftone. Excellent results were obtained in the treatment of CVI as well as in lymphatic-related pathology (lymphedema).