Continuous air tonometry of the sigmoid colon during abdominal aortic surgery.

BACKGROUND: The aim of this study was to record the changes in the mucosal intracellular (pHi) of the sigmoid colon during operations of the abdominal aorta, using the air tonometry method. METHODS: Patients with abdominal aortic aneurysm (AAA), and with aortoiliac occlusive disease (AIOD) were included in the study. The tonometric catheter was placed in the sigmoid colon under colonoscopy, and its position was confirmed during operation. The pHi records were divided into certain phases: 1) beginning; 2) clamping; 3) declamping; 4) Intensive Care Unit (ICU); 5) 1st day in the ICU; 6) 2nd day in the ICU. RESULTS: A total of 30 male patients (15 with AAA, 15 with AIOD) were enrolled in the study. Dyslipidemia, arterial hypertension and coronary heart disease were present in the majority of the patients in both groups. In the AAA group, a significant difference (P=0.004) was present between at least two time phases regarding the pHi time course. A comparison of the difference between regional pH and arterial pH (pH(r-a)) in both groups of patients showed a statistically significant result (P=0.008). As for the difference between partial pressure of regional CO2 (PCO2) and partial pressure of arterial CO2 (PaCO2) (P(r-a)CO2), a statistically significant difference in the P(r-a)CO2 course from one time phase to another in both groups was noticed (P<0.001). CONCLUSIONS: Air tonometry (Tonocap monitor, Datex-Ohmeda, GE Healthcare, Little Chalfont, England, UK) is an effective and easily applicable method, allowing the surgeon to be better informed of the tissue oxygenation of the intestinal wall, for the prevention of colon ischemia complications and to take the appropriate measures.

Chronic contained abdominal aortic aneurysm rupture after suprarenal fixation fatigue fracture.

Chronic contained rupture (CCR) of an abdominal aortic aneurysm is a rare condition, and differential diagnosis might be difficult. We present a clinical case of a hemodynamically stable octogenarian who presented with intermittent pain in the left lower abdomen. The patient had a history of diverticulitis, and 6 years ago, he had undergone endovascular abdominal aortic aneurysm repair (EVAR) with a Talent bifurcated prosthesis. Additionally, 20 days before his admission to our hospital, he had undergone a secondary iliac limb extension for treatment of post-EVAR rupture. On admission, abdominal plain radiography identified suprarenal fixation fracture as a possible reason for CCR, but computed tomographic angiography failed to confirm any endoleak or "active" bleeding and rupture. The patient received medication treatment for possible diverticulitis and was kept under close monitoring for suspected failure of recently performed secondary endovascular procedure and CCR. A day later, the abdominal pain symptoms worsened, and a new computed tomographic angiography confirmed the suspected CCR. The patient was treated successfully by "open" repair using a Y prosthesis. To our knowledge, this is the first reported case of post-EVAR CCR due to suprarenal fixation fatigue fracture. Lifelong post-EVAR follow-up with high level of both clinical and imaging diagnostic accuracy is essential for the early recognition and proper treatment of EVAR pitfalls.

The role of simple renal cysts, abdominal wall hernia, and chronic obstructive pulmonary disease as predictive factors for aortoiliac aneurysmatic disease.

BACKGROUND: This study was designed to investigate the possible predictive value of simple renal cysts (SRCs), abdominal wall hernia (AWH), and chronic obstructive pulmonary disease (COPD) for the presence of abdominal aortoiliac aneurysms (AAA). METHODS: Between January 2006 and January 2011, we treated 170 consecutive patients with aortoiliac pathology. Patients' data were prospectively collected and were retrospectively analyzed. Of these patients, 110 (study group) had AAA (group 1) and 60 (control group) had aortoiliac occlusive disease (AOD; group 2). Moreover, patients of group 1 were subdivided, according to aneurysm's diameter to subgroup 1A (aortic aneurysm diameter >55 mm and/or common iliac diameter >22 mm; n = 62) and subgroup 1B (aortic aneurysm diameter ≤ 55 mm and/or common iliac diameter ≤ 22 mm; n = 48). All patients underwent a computed tomographic angiography, and datasets were analyzed for aortoiliac and SRCs' anatomical data. Additionally collected data were atherosclerotic risk factors, history of previous or current AWH, and COPD. RESULTS: The two groups as well as the two AAA subgroups were homogenous regarding demographics and atherosclerotic risk factors. Univariate analysis showed that incidence of SRCs, AWH, and COPD were significant predictive factors for presence of AAA. Multivariate analysis identified SRCs and AWH as independent predictive factors for the presence of AAA. In association with the aneurysm's size, multivariate analysis failed to show any predictive value of SRCs, AWH, or COPD. CONCLUSIONS: Results of our study showed a positive predictive value of SRCs and AWH for presence of AAA and a strong relationship but not with predictive value between COPD and AAA. These data might be helpful for the early recognition of patients at risk for an aortoiliac aneurysm formation and for establishment of AAAs population-based screening. Further research of pathophysiological commonalities between the four studied entities may be extremely helpful for designing future preventive and treatment strategy of AAAs.

Subclavian artery aneurysm due to clavicle fracture.

BACKGROUND: Aneurysms of the subclavian artery (SA) are rare, but they can present with devastating consequences that may lead to loss of the limb. We present a case of symptomatic posttraumatic aneurysm of the left SA in a 67-year-old woman. METHODS: A 67-year-old woman presented to our vascular unit with a history of sudden pain in her left hand, forearm, and shoulder, together with vasomotor changes. A chest radiograph revealed a fracture of the left clavicle because of a car accident that took place 17 years ago, and the digital subtraction angiography revealed presence of an aneurysm of the left SA right below the fracture of the clavicle. Surgical treatment of the aneurysm included excision and ligation of the SA which gave excellent results. CONCLUSION: Thus, an individually tailored treatment is mandatory for the very rare pathology of SA aneurysms.

Acute forearm compressive myopathy syndrome secondary to upper limb entrapment: an unusual cause of renal failure.

Compressive myopathy syndrome (SCM) is a syndrome characterized by the lesion of skeletal muscle resulting in subsequent release of intracellular contents (myoglobin, creatine phosphokinase, potassium, etc.) into the circulatory system, which can cause potentially lethal complications. There are numerous causes that can lead to SCM resulting to acute rhabdomyolysis, and many patients present with multiple causes. The most common potentially lethal complication is acute renal failure. The occurrence of acute rhabdomyolysis should be considered as a possibility in any patient who can remain stationary for long periods, or is in a coma, or is intoxicated in any form. We report the rare case of a 26-year-old patient who developed SCM caused by ischemia reperfusion, with subsequent acute rhabdomyolysis and acute renal failure after prolonged compression of the right upper extremity.

Two-dimensional versus three-dimensional CT angiography in analysis of anatomical suitability for stentgraft repair of abdominal aortic aneurysms.

BACKGROUND: The morphological analysis prior to endovascular abdominal aneurysm repair (EVAR) plays an important role in long-term outcomes. Post-imaging analysis of computed tomographic angiography (CTA) by three-dimensional reconstruction with central lumen line detection (CLL 3D-CTA) enables measurements to be made in orthogonal slices. This might be more precise than equal post-imaging analysis in axial slices by two-dimensional computed tomographic angiography (2D-CTA). PURPOSE: To evaluate the intra- and interobserver variability of CLL 3D-CTA and 2D-CTA post-imaging analysis methods and the agreement between them in pre-EVAR suitability analysis of patients with abdominal aortic aneurysm (AAA). MATERIAL AND METHODS: Anonymized CTA data-sets from 70 patients with AAA were analyzed retrospectively. Length measurements included proximal and distal aortic neck lengths and total distance from the lower renal artery to the higher iliac bifurcation. Width measurements included proximal and distal neck diameters, maximum AAA diameter and common iliac diameters just above the iliac bifurcations. The measurements were performed in random order by two vascular surgeons, twice per method with 1-month interval between readings. In the CLL 3D-CTA method we used semi-automated CLL detection by software and manual measurements on CTA slices perpendicular to CLL. The equal measurements in 2D-CTA were performed manually on axial CTA slices using a DICOM viewer workstation. The intra- and interobserver variability, as well as the agreement between the two methods were assessed by Bland-Altman test and bivariate correlation analysis. RESULTS: The intraobserver variability was significantly higher in 2D-CTA measurements for both readers. The interobserver variability was significant in 2D-CTA measurements of proximal neck dimensions while the agreement in CLL 3D-CTA analysis between the two readers was excellent in all studied parameters. The agreement between the two suitability analysis techniques was poor for both readers, especially in measurements of proximal neck's dimensions and in total aortoiliac length (p = 0.001). CONCLUSION: In pre-EVAR morphological evaluation of AAAs the CLL-3D CTA post-imaging analysis has better intra- and interobserver correlation than 2D-CTA and might represent a useful tool for the proper selection of endograft's type and size.

Surgical versus endovascular repair by iliac branch device of aneurysms involving the iliac bifurcation.

OBJECTIVE: To evaluate early and late results of open (OR) and endovascular aneurysm repair by iliac side branch device (EVRISB) for aneurysms involving the iliac bifurcation (AIB). METHODS: Between January 2004 and March 2010, 118 patients were diagnosed with AIBs and underwent OR or EVRISB at two European vascular centers. Particularly, 64 (54.2%) patients were treated by EVRISB and 54 (45.8%) by OR. In one center, 24 consecutive patients were treated by surgery because this was the standard therapeutic approach until January 2005. For the rest of the study period until March 2010, 64 consecutive patients with AIB suitable for EVRISB underwent placement of branched devices. In the other center, 30 consecutive patients with AIBs were treated by OR because advanced endovascular imaging was not available during the study period. RESULTS: No significant differences in demographics, anatomical characteristics, or comorbidities of the patients were recorded between the two groups. Early (30-day) mortality was 0% for EVRISB versus 5.5% for the OR group (P < .001). Major morbidity occurred in 4.6% versus 9.3% of the patient subgroups, respectively (P < .001). Buttock claudication and colonic ischemia were recorded in 5.9% and 2% of OR patients compared with 3.1% and 0% of EVRISB cases (P > .05). Primary patency rates were 98.4% for EVRISB and 100% for OR patients. Primary and secondary endoleak rates of the EVRISB group were 12.5% and 6.3%, respectively. CONCLUSIONS: Endovascular repair by iliac branch device of aneurysms involving the iliac bifurcation can be accomplished with very low morbidity and mortality rates. Especially for young active patients or in cases of contralateral occlusion, the preservation of hypogastric artery seems to be a strong argument for use of EVRISB as a preferable therapy option.

Multiple recurrent dermatofibrosarcoma protuberans of the hand.

We present a rare case of a dermatofibrosarcoma protuberans arising on the dorsum of the hand in a 51-year-old woman, who had experienced four recurrences of the tumour following local excisions. We performed a radical surgical excision of the lesion and covered the defect with a distal ulnar artery skin island flap. Adjuvant radiation therapy followed the surgical treatment. Forty months postoperatively, the patient has a functional hand without signs of recurrence and no evidence of disease. Wide surgical excision with margins of 2.5-3 cm is the optimal treatment for dermatofibrosarcoma protuberans. For selected patients, like those presenting large tumours involving the hand, adequate removal is not easily obtainable, or may result in major functional deficits. An alternative strategy may be the combination of less extensive surgery and radiotherapy, in order to prevent mutilation, decrease the local recurrence rates, and minimize the risk of metastases.

Isolated iliac artery aneurysms: endovascular versus open elective repair.

OBJECTIVE: To compare endovascular and open repair of isolated or solitary iliac artery aneurysms (SIAAs). METHODS: We present the results of 55 patients with 58 SIAAs that were treated between January 1998 and December 2005 in two European university hospitals. In one center, the standard procedure, if not contraindicated, was endovascular repair, and 32 (58.2%) consecutive patients with 33 SIAAs were treated by using only endovascular techniques (endovascular iliac aneurysm repair; EVIAR). In the second center, 23 (41.8%) consecutive patients with 25 SIAAs were treated by conventional surgical techniques because advanced endovascular skills were not available before late 2005. EVIAR included coil embolization of the hypogastric artery in 13 of the 33 cases with aneurysmal involvement of the internal iliac artery. In the "open" group of patients, midline laparotomy and a transperitoneal approach with bifurcated aortoiliac graft replacement was performed in 4 cases, and a lower lateral abdominal incision with a retroperitoneal approach and iliac replacement was performed in 19 cases. RESULTS: The mean follow-up period was similar in both groups (EVIAR, 35.3 +/- 21.3 months; open, 31.3 +/- 19.9 months). The two groups of patients had similar demographic and clinical characteristics compared with previous reported series, and data analysis revealed a statistically significant difference between the two groups only in hypertension. The early and mid-term outcomes and especially the 3-year primary patency rates were also similar between the two groups (EVIAR, 97%; open, 100%). In the EVIAR group, there was no evidence of endoleaks, kinking, or graft migration, and 26 aneurysms remained stable, whereas in 7 aneurysms a slight decrease in size (>10% in diameter) was observed. Comparison of operative time, intraoperative blood loss, and postoperative hospital stay revealed significant differences (P < .001) in favor of the endovascular group. Secondary intervention was not necessary in any patient in either group during the entire follow-up period. CONCLUSIONS: Elective management with endovascular or open techniques of isolated iliac aneurysms can be accomplished with very low morbidity and mortality rates. Better intraoperative and early postoperative outcomes, as well as the durable mid-term results in our EVIAR-treated patients, indicate that endovascular techniques could be offered as first-line therapy of SIAAs.

Intraluminal intestinal administration of oxygenated perfluorocarbon improves acid-base and cardiopulmonary parameters after acute mesenteric ischemia. An experimental study in rabbits.

PURPOSE: The aim of this study was to evaluate the effects of the intraluminal intestinal administration of oxygenated perfluorocarbon, during experimental acute intestinal ischemia, on the acid-base blood status and the cardiopulmonary parameters. METHODS: Thirty-six rabbits were separated into three groups: (a) Control group (ischemia alone), (b) PFC-O2 group (ischemia plus infusion of oxygenated F-Decalin in intraluminal intestinal administration), and (c) PFC group (ischemia plus infusion of nonoxygenated F-Decalin in intraluminal intestinal administration). An equal number of the animals was then subjected to 8 h of intestinal ischemia by ligation of the superior mesenteric artery (subgroups 1), the mesenteric vein (subgroups 2) or both vessels (subgroups 3). At 0, 2, 4, 6, and 8 h arterial blood samples were taken for acid-base status tests and the vital signs (heart and respiratory rate, pressure of inferior vena cava, and systolic arterial pressure) were noted. The statistical analysis was performed by the nonparametric Kruskal-Wallis test. RESULTS: There were no significant differences in any of the studied parameters (pH, base excess, respiratory gases, pressure of inferior vena cava, systolic arterial pressure, heart and respiratory rate) between animals of the same group and subgroup. In addition, the differences among Control and PFC groups and their equal subgroups were not significant. On the other hand, the measurements of the PFC-O2 animals showed significant differences at 4, 6, and 8 h of ischemia (P < 0.05) in comparison with those from the Control and PFC groups. CONCLUSION: We conclude that the intraluminal intestinal administration of oxygenated perfluorocarbons may thus be a useful adjunctive therapy in the treatment of patients with acute mesenteric ischemia.

Surgical treatment of renal neoplasmatic thrombi extending into the inferior vena cava.

Renal cell carcinoma produces neoplasmatic thrombus that usually invades and progressively grows into the endorenal veins. The thrombus may extend into the ipsilateral renal vein or the inferior vena cava in 15-20% and 8-15% of cases, respectively. These tumors are classified into four categories (I, II, III, and IV) according to the level of cephalad extension of thrombus into the inferior vena cava. The purpose of this study was to assess the surgical strategy for cases of renal tumor thrombus invading the vena cava. We retrospectively reviewed the records of 10 patients with renal cell carcinoma, who underwent in our institution radical nephrectomy and resection of vena cava thrombus between January 1997 and December 2004. Four patients were classified as level I, four were level II, and two were level III. In all cases, the thrombus was removed through a small cavotomy without cardiopulmonary bypass and the cavotomy was closed primarily. Pringle's maneuver was performed in the two level III cases. There were no perioperative pulmonary embolisms or deaths, and the mean hospital stay was 8 +/- 1.1 days. The mean survival was 21.8 +/- 8 months, and the vena cava remained patent for this period. Tumor thrombectomy improves the prognosis and the quality of life of these patients, and in most of cases the surgical technique, although challenging, carries a low morbidity and mortality rate.