Management of superficial vein thrombosis and thrombophlebitis: status and expert opinion document.

Superficial vein thrombosis is characterized by clotting of superficial veins (ie, following direct trauma) with minimal inflammatory components. Superficial thrombophlebitis is a minimally thrombotic process of superficial veins associated with inflammatory changes and/or infection. Treatments generally include analgesics, elastic compression, anti-inflammatory agents, exercise and ambulation, and, in some cases, local or systemic anticoagulants. It is better to avoid bed rest and reduced mobility. Topical analgesia with nonsteroidal, anti-inflammatory creams applied locally to the superficial vein thrombosis/superficial thrombophlebitis area controls symptoms. Hirudoid cream (heparinoid) shortens the duration of signs/symptoms. Locally acting anticoagulants/antithrombotics (Viatromb, Lipohep, spray Na-heparin) have positive effects on pain and on the reduction in thrombus size. Intravenous catheters should be changed every 24 to 48 hours (depending on venous flow and clinical parameters) to prevent superficial vein thrombosis/superficial thrombophlebitis and removed in case of events. Low molecular weight heparin prophylaxis and nitroglycerin patches distal to peripheral lines may reduce the incidence of superficial vein thrombosis/superficial thrombophlebitis in patients with vein catheters. In case of superficial vein thrombosis/superficial thrombophlebitis, vein lines should be removed. In neoplastic diseases and hematological disorders, anticoagulants may be necessary. Exercise reduces pain and the possibility of deep vein thrombosis. Only in cases in which pain is very severe is bed rest necessary. Deep vein thrombosis prophylaxis should be established in patients with reduced mobility. Antibiotics usually do not have a place in superficial vein thrombosis/superficial thrombophlebitis unless there are documented infections. Prevention of superficial vein thrombosis should be considered on the basis of patient's history and clinical evaluation.

Clinical evaluation of defibrotide in the treatment of arterial and venous vascular disease. A preliminary report.

Defibrotide is a new compound with antithrombotic and profibrinolytic activity. It increases the endogenous fibrinolytic activity by promoting the cellular activator of plasminogen from endothelial cells and by decreasing the concentration of its inhibitors. In this study we evaluated a total of 223 patients for a mean period of 43 days for the following vascular conditions: (a) superficial venous thrombosis; (b) prophylaxis against deep venous thrombosis; (c) peripheral vascular disease (ischaemic foot and intermittent claudication; (d) prophylaxis against TIAs in patients with carotid plaques determining embolization; (e) treatment of venous ulcerations determined by chronic venous incompetence; (f) patients with Raynaud's phenomenon and disease. The tolerability observed was good. No side effects were observed even in more prolonged treatments. The overall efficacy was good for all groups especially in comparison with other treatment already in use for these vascular conditions. In conclusion defibrotide is a particularly useful drug in these vascular diseases and can be used both for acute and chronic treatments.

Prevention of recurrent deep venous thrombosis with sulodexide: the SanVal registry.

The aim of this study was to evaluate the prevention of recurrent deep vein thrombosis (R-DVT) with an oral antithrombotic agent (sulodexide) in moderate to high-risk subjects. A group of 405 patients was included into the multicenter registry. Both compression and an exercise program were used as well as a risk-factors control plan. After diagnosis of DVT, patients were treated with oral anticoagulants for 6 months. At the end of this period a coagulation study was made and patients started treatment with oral sulodexide capsules for a period of 24 months. The femoral, popliteal, tibial, and superficial veins were scanned with high-resolution ultrasound at inclusion;scans were repeated at 6, 12, 18, and 24 months. Of the 405 subjects included into the registry 178 in the control group (mean age 52.2; SD 11; M:F=90:88) and 189 in the treatment group (mean age 53.2; SD 10.3; M:F=93:96) completed the analysis period of 24 months. At 6 and 12 months the incidence of R-DVT was lower (p<0.05) in the treatment group. At 24 months the global incidence of R-DVT was 17.9% in the control group and 7.4% in the sulodexide group (p<0.05), 2.42 times lower than in controls. The 2 groups were comparable for age and sex distribution and for the localization of the thrombi at inclusion. Also the 2 groups of dropouts were comparable. In the control group there were 32 recurrent DVTs and 24 subjects lost to follow-up (total of 56) of 202 included subjects (27.7%) in comparison with 28 failures (14 recurrent DVTs and 14 lost subjects) of 203 subjects (13.8%) in the treatment group. This difference was statistically significant. In this analysis the incidence of DVT in controls was 2.07 times higher than in the treatment group subjects. In conclusion sulodexide was effective in reducing recurrent thrombotic events in high-risk subjects.

[Microsurgery in gynecology. 8 years' clinical activity]. / La microchirurgia in ginecologia. Otto anni di attività clinica.

A series of 110 patients given surgical treatment for "mechanical infertility of varying origin in 1980-88 is examined". The classification system proposed for the microsurgical procedures available is based both on personal experience and on the classification of the causes of mechanical infertility in women according to aetiopathogenesis. Clinical results are judged in terms of pregnancies achieved and suggest that while adhesiotomy, salpyngostomy, t-t tubal anastomosis and cornual reimplantation are all useful, fimbrioplasty is less likely to give good results, particularly in the long term. Finally the links between gynaecological microsurgery and F.I.V.E.T. and G.I.F.T. are analysed.

Reversal of sterilization by microsurgical technique.

Tubal sterilization techniques that spare the fimbriae and cause the least amount of tubal destruction offer the best chance for reversal of sterilization. Patients seeking reversal of sterilization should be carefully selected. Surgical technique and equipment are important factors in reversal procedures; microsurgical techniques are shown to be more effective than macroscopic techniques.

PIP: Microsurgical techniques enables successful results in tubal anastomosis for reversal of sterilization. Patients in the study had all been sterilized at the medial isthmic segment. Ideally, in this case, there was no luminal disparity and a relatively thick circular muscle coat. After the pathologic or fibrotic tissue had been removed, a series of 8/0 nylon stitches, which include only the muscular coat, was carried out under microscopy. 6 or 7 stitches usually are sufficient to make a watertight anastomosis. A 2nd layer of 8/0 nylon stitches was used to repair the gap in the mesentery and the serosa overlying the fallopian tube. The patency of the anastomosis was inspected at 1 year from the date of the procedure by celiochromoscopy. The good results obtained are the result of the careful techniques of reconstruction using microscopy and the right instrumentation. In all cases, it is most important to consider the site of sterilization. The isthmo-isthmic site is regarded as the most ideal for microsurgical reversal because it is the easiest site for an anastomosis. Silber maintains that the prospect for a normal pregnancy, after reversal, is directly proportional to the length of the remaining tube which is the only critical factor, as long as there is at least 1 cm of ampulla. The time interval that passes between sterilization and surgical reversals also needs to be considered as an influencing factor in terms of the successful results of the tubal reconstruction.

[Partial resection of the spleen for echinococcus cysts with ultrasonic surgical aspirator]. / Resezione parziale della milza per cisti da echinococco con aspiratore chirurgico ad ultrasuoni.

The superior extremity of the spleen was resected in a 52-year-old male patient due to a calcified echinococcus cyst, using an ultrasonic surgical aspirator (Cavitron). Blood loss was limited and no postoperative morbidity was reported. This method appears to be useful in all cases in which it is possible to avoid splenectomy in order to reduce the risk of uncontrolled postoperative infections.

[Treatment of traumatic lesions of the hepatic artery]. / Il trattamento delle lesioni traumatiche dell'arteria epatica.

Injuries to the porta hepatis, which are difficult to diagnose and require variable treatment, are rare. The mortality for the vascular injuries is directly correlated to the uncontrolled intraabdominal hemorrhage and the treatment requires primarily bleeding control. This paper reports a case of a laceration of the left hepatic artery in a young multi traumatized patient (due to a car accident). The hepatic artery injury was successfully managed by primary closure. Even if the treatment of the extra hepatic injuries of the hepatic artery is still controversial, standardized therapy approaches have been proposed. The repair of the hepatic artery is an occasional option. The simple ligation is the most common option, in fact the oxygen extraction from the portal venous blood increases if the artery is ligated and this is sufficient for a adequate hepatocellular function in a healthy liver. In reality, in literature, damages to the liver due to artery ligatures are described even in the case of a good portal flow. Repairing hepatic artery injuries should always be taken into consideration after having made necessary evaluations on the general conditions of the patient because it is preferable to attempt to bring the patient back to the "status quo ante" and therefore avoid possible complications.

[A case of carcinoma of the cervical esophagus treated with interposition of an intestinal loop revascularized using a microsurgical technique]. / Un caso di carcinoma dell'esofago cervicale trattato con interposizione di ansa intestinale rivascolarizzata con tecnica microchirurgica.

The Authors present a case of hypopharyngeal tumor in which digestive continuity was assured by a jejunal autotransplant. Tumoral exeresis and jejunal preparation were carried out at the same time by two surgical teams. The use of microsurgical techniques assures the revascularization of the neck transplant by implementing the superior thyroid artery and the internal jugular vein. Digestive anastomoses complete the operation.

[Free microvascularized flaps in head and neck lesions: the technics of microsurgical reconstruction]. / Lembi liberi microvascolarizzati nelle lesioni della testa e del collo: tecniche di ricostruzione microchirurgica.

The authors report their experience of microsurgical reconstructive techniques using musculo-cutaneous free flaps after radical operations for head and neck neoplasms.