[Assessment of seawater quality along the Asinara Gulf. Note 1: preliminary results of seawater monitoring using Dicentrarchus labrax and Sparus aurata as bioindicators]. / Valutazione della qualità delle acque di mare del Golfo dell'asinara. Nota 1: Risultati preliminari del monitoraggio mediante l'utilizzo dei bioindicatori dicentrarchus labrax e Sparus aurata.

In recent years, physical-chemical, chemical and microbiological testing systems to water's control was matched by the use of "biomarkers" such as algae, nematodes, Anellidi, Porifera, molluscs and arthropods (crustaceans), although these are phylogenetically distant from humans and they differ in methods of recruitment, toxico-kinetics and metabolism of xenobiotics. That is why today the predatory fishes (tuna, mackerel, sea bream, sea bass and swordfish) are among the most widely used in biomonitoring studies. In particular Sparus aurata and Dicentrarchus labrax (sea bream and sea bass) are appropriate in warning of environmental pollution. Moreover since the two species are precious and particularly present in food, they could represent a potential vehicle for the transport of contaminants to humans. To this end, the aim of this note, part of a complex research project launched in line with the provisions of the ministry for the environment, land and sea, is to evaluate the quality of coastal waters by using of Sparus aurata and Dicentrarchus labrax. The results obtained show that the area concerned, at present, is not affected by serious pollution processes, as the human pressure is highlighted by the presence of phenols in sea water and heavy metals (Cd and Hg) in the bioindicators. The detection of these toxic elements in fish species, could also not be directly attributable to any condition of impairment of the environment. However given the accumulation of these contaminants in the parts are edible, the consumption of fish could be a source of exposure particularly for those most exposed to health risks (children, elderly, sick and pregnant women).

Open repair for ruptured abdominal aortic aneurysm: is it possible to predict survival?

The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAAA) and to assess the accuracy of the Glasgow Aneurysm Score (GAS) and the Acute Physiology Chronic Health Evaluation II (APACHE-II). From January 1998 to July 2006, 103 patients underwent operations for RAAA. For each patient, 44 variables were retrospectively recorded in a database. Data were analyzed with univariate and multivariate methods. In the univariate analysis significant predictors of death were hypotension (p=0.001), preexisting peripheral vascular disease (p<0.001), renal insufficiency (p=0.037), chronic obstructive pulmonary disease (p=0.028), level of HCO(3)(-) (p<0.001), intraperitoneal rupture (p=0.001), blood transfused (p<0.001), cardiac complications (p<0.001), and APACHE-II score (p=0.001). Multivariate analysis confirmed statistical significance for coexisting peripheral vascular disease (p<0.001), diastolic blood pressure at admission <60 mm Hg (p=0.039), APACHE-II score >18.5 (p=0.025), HCO(3)(-) <21 mg/dL (p<0.001), and intraperitoneal rupture of the aneurysm (p=0.011) as predictors of death. Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. APACHE-II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAAA.

[Thermal comfort in perioperatory risk's evaluation]. / Il comfort termico indicatore del rischio perioperatorio.

Studies till now conducted about operating rooms' microclimate have been focused mainly on operators' thermal comfort, considering that uneasiness conditions may compromise their working performance. In last years, nevertheless, the anesthesiologic community recalled attention on patients' risks determined by perioperatory variations of normothermia, underlining the necessity of orientating studies to individuate microclimate characteristics act to guarantee thermal comfort of the patient too. Looking at these considerations, a study has been conducted in the operating rooms of the hospital-university Firm and the n.1 USL of Sassari, finalized, on one hand, to determinate microclimate characteristics of the operating blocks and to evaluate operators' and patients' thermal comfort, on the other to individuate, through a software simulation, microclimate conditions that ensure contemporarily thermal comfort for both the categories. Results confirm the existence of a thermal "gap" among operators and patients, these last constantly submitted to "cold-stress", sometimes very accentuated. So, we underline microclimate's importance in operating rooms, because there are particular situations that can condition perioperatory risks. Moreover it can be useful to integrate risk's classes of the American Society of Anestesiology (ASA) with a score attributed to the PMV/PPD variation, reaching more real operatory risk indicators.

Role of the genetic study in the management of carotid body tumor in paraganglioma syndrome.

Diagnosis of carotid body tumor (CBT) was made in a 36 years old woman. The pre-operative examination included genetic analysis of the succinate dehydrogenase that showed a mutation in his subunit D responsible of multiple paraganglioma at slow growth. Subsequently a thoraco-abdominal CT and indium(111) octreotide body scan were performed and another paraganglioma was detected in the anterior mediastinum. CBT was surgically removed; differently the thoracic lesion due to his benign genetic profile was not treated. During a 3-years follow-up the thoracic paraganglioma as expected, didn't increase. Genetic analysis of succinate dehydrogenase, should be performed in the management of CBT.

[A possible cause of misdiagnosis in tumors of the axilla: schwannoma of the brachial plexus]. / Una possibile causa di errore nella diagnosi differenziale delle formazioni ascellari: lo schwannoma asintomatico dei tronchi del plesso brachiale.

The Authors report a rare case of a 57 years old man affected by a left radial nerve schwannoma that occurred as an asymptomatic lesion of the axilla. At clinical examination the lump was undistinguishable from the most common axillary lymphadenopathy. A lymphoadenopathy was erroneously diagnosed with ultrasonography (US). This mistake was due to the low specificity of the instrumental methodology and to the rarity of an asymptomatic schwannoma of the infraclavicular brachial plexus. The neoplasia was excised without using the microscope. In the early post-operative follow up, a "falling" attitude of the wrist, the hand and the fingers appeared, peculiar for a lesion of the radial nerve. Furthermore a hypoaesthesia of the skin of first finger and of the first interosseus space was associated. The sensitive and motor electromyography showed a radial nerve suffering. The "stupor" of the nerve trunk was treated with steroid therapy for 7 days and the patient underwent to some series of neuro-rehabilitative physical therapy for 12 weeks. The postoperative total body CT, showed that the lesion was unique: therefore it was possible to exclude the diagnosis of neurofibromatosis. After 28 months electromyography and axillary US were performed showing the complete resolution of the motor and sensitive deficit and the absence of local recurrence.

Endovascular treatment of asymptomatic popliteal aneurysms: 8-year concurrent comparison with open repair.

AIM: The aim of this prospective comparative study was to compare the results of 8-years experience of endovascular treatment (ET) of popliteal aneurysms (PAs) using the Hemobahn/Viabahn endograft with those achieved with open repair (OR). Endpoints were primary and secondary patency rate. METHODS: The study was a prospective randomized clinical trial from January 1999 to December 2003 and a prospective comparative study from January 2004 to December 2006. Patients with an asymptomatic aneurismal lesion in the popliteal artery 2 cm at angio-computed tomography were included in the study. Indication for ET was PA (proximal and distal neck length >1 cm); contraindications were: 1) age <50 years; 2) poor distal run-off; 3) contraindication to antiplatelet, anticoagulant or thrombolytic therapy. RESULTS: Between January 1999 and December 2006, of a total of 42 patients with 48 PA, 27 were treated with OR (group A) and 21 with ET (group B). The primary patency rate was 100% in group A and 80.9% in group B at 12 months and 71.4% and 88.1%, respectively, at 72 months; the secondary patency rate at 72 months was 88.15% and 85.9% in groups A and B, respectively. No statistical differences were observed at the log-rank test. During the entire study period, 3 (14.3%) patients in group B required conversion to open surgery because of endograft occlusion. CONCLUSION: Within the power limitations of this study, ET for asymptomatic PA in patients with suitable anatomy can be considered safe, with long-term results comparable with those of OR.

Do hypertension and diabetes mellitus influence the site of atherosclerotic plaques?

BACKGROUND: The concomitant occurrence of atherosclerotic plaques in carotid, coronary and peripheral vessels has been described in a number of studies. A few studies were, on the contrary, done for determining the role of hypertension and/or type 2 diabetes mellitus for the occurrence of the atherosclerotic plaques in different anatomical sites. Moreover these studies deal with atherosclerotic lesions that are generally considered, without differentiating their morphology as a function of the underlying disease, territory, and risk factors. Primary aim of this study is, thus, to verify whether the two most common causes for atherosclerotic disease, i.e., hypertension and type 2 diabetes mellitus, may influence the site of appearance of the atherosclerotic plaque. A second aim is to verify if the anatomical site of the plaque influences plaque morphology and vulnerability. PATIENTS AND METHODS: A retrospective study of 244 patients affected with type 2 diabetes mellitus or hypertension was performed; 114 subjects were affected by moderate-severe and drugs-treated hypertension (Group A); 55 were affected by type 2 diabetes mellitus in treatment with oral antidiabetic drugs (Group B); 75 were diagnosed as affected by the association hypertension and diabetes (Group C). The inclusion criteria were: exhaustive images of the cardiovascular system (coronary angiography, colour Doppler ultrasound of lower limb arteries and carotid arteries, transthoracic Doppler echocardiography ) and a serum lipid profile (total serum cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides). Three different anatomical sites: carotid axis, ilio-femoral arteries and coronary district, were considered. In each site a plaque lesion-classification was performed to describe the morphology of the plaque. RESULTS: In patients with hypertension, carotid district seems to be the preferential site of onset of atherosclerotic plaques even if a statistical significant association between the two conditions was not found. Statistical evaluation didn't show significant association between different risk factors and coronary district too. On the opposite, a significant association (p < 0.001) between diabetes and the presence of atherosclerotic plaques into lower limb district was found. A very significant association (p < 0.001) between type 2-diabetes and the presence of non-ulcerative plaques was found too. CONCLUSIONS: Our study underlines the relationship between vessel plaques localization and concomitant risk factors for atherosclerosis and suggests a possible difference in plaque morphology and biological behaviour related to different anatomical site.

Specific cellular features of atheroma associated with development of neointima after carotid endarterectomy: the carotid atherosclerosis and restenosis study.

BACKGROUND: The purpose of this study was to investigate whether some cellular and molecular features of tissue retrieved at carotid endarterectomy are associated with the extent of neointima formation at ultrasound follow-up. METHODS AND RESULTS: One hundred fifty patients were studied. Endarterectomy specimens were tested by immunocytochemistry with the use of (1) monoclonal antibodies that identify smooth muscle cells (SMCs) and fetal-type SMCs on the basis of smooth muscle and nonmuscle myosin content, (2) the anti-macrophage HAM 56, and (3) the anti-lymphocyte CD45RO. The maximum intima-media thickness (M-IMT) of the revascularized vessel was assessed by the use of B-mode ultrasonography 6 months after surgery. The M-IMT values were related positively to the number of SMCs (r=0.534, P<0.0005) and negatively to that of macrophages and lymphocytes (r=-0.428, P<0.0005, and -0.538, P=0.001, respectively). Patients were classified as class 1 (M-IMT 1.3 mm). An abundance of SMCs, mostly of fetal type, was found in the plaque of class 3 patients, whereas lesions from class 1 patients were rich in macrophages and lymphocytes. In the multivariate analysis, factors related to M-IMT were the number of SMCs and the percentage of fetal-type SMCs present in the plaque. CONCLUSIONS: Although the classic risk factors did not play a role, an abundance of SMCs and a scarcity of macrophages characterized the primary lesion of patients in whom neointima developed after surgery. In patients in whom neointima did not develop, lesions were rich in macrophages and lymphocytes. This approach can be useful in defining patients at risk of restenosis.

Is carotid endarterectomy in octogenarians more dangerous than in younger patients?

AIM: The risk for developing stroke increases with the advancing age, peaking over age 80. In elderly patients, carotid endarterectomy may provide prophylaxis against stroke. Aim of our study was to compare patients 80 years or older with patients younger than 80 undergoing carotid endarterectomy. Endpoints were perioperative mortality and morbidity. METHODS: From January 1996 to December 2002, 1 659 patients underwent a 1 733 carotid endarterectomy for a symptomatic or asymptomatic significant carotid lesion. Among them, 125 patients were 80 years or older. We analyzed death and stroke rate from cerebrovascular accidents, TIA as well as non cerebrovascular complications and death rate postoperatively and in the long term follow-up. The Pearson's chi-squared(2) test was used for the statistical analysis on risk factors, morbidity and mortality. The Log rank test was used for cumulative stroke-free and survival rates between the 2 groups (level of confidence p<0.05). RESULTS: Risk factors were similar in both groups. No statistical difference was observed in the stroke, TIA, mortality and stroke free rates between the 2 groups. CONCLUSIONS: The results of our study show that perioperative and postoperative mortality and morbidity as well as the long-term stroke-free rate does not differ significantly in patients 80 years or older compared to patients younger than 80 undergoing carotid endarterectomy.

Natural history of ascending thrombosis of the abdominal aorta.

During 1980, 30 patients underwent successful operations for ascending thrombosis of the abdominal aorta in its three forms: low (below the inferior mesenteric artery, 11 patients); middle (above the inferior mesenteric artery, 6 patients); and high (at the level of the renal arteries, 13 patients). An angiogram that reveals high ascending thrombosis of the abdominal aorta is paradoxically more favorable than one that reveals middle or low ascending thrombosis of the abdominal aorta. In fact, the patient with a juxtarenal thrombosis has already overcome two of the three phases that constitute the critical moments of potential failure of the collateral circulation. Progressive ascending thrombosis with a poor prognosis and a rapidly downward course can cause acute ischemia with paraplegia of the legs and intestinal infarction. Most patients die suddenly in the emergency or intensive care unit from paraplegia, acute abdomen, or anuria; the latter is due to further progressive thrombosis with obstruction of the orifice of the renal arteries. On the basis of the angiogram only (apart from subjective symptoms), ascending thrombosis of the abdominal aorta constitutes an absolute indication for surgical treatment.

EEG monitoring of carotid endarterectomy with routine patch-graft angioplasty: an experience in a large series.

Four hundred and thirty-nine carotid endarterectomies (CEAs) with routine use of patchgraft angioplasty were performed in 375 patients; the indwelling shunt was used only in patients showing clamp-related EEG abnormalities. Five patients showed EEG abnormalities just after head positioning, which reversed after removal of head hyperextension; three cases suffered EEG flattening due to severe bradycardia or cardiac arrest before carotid clamping, which promptly reversed after treatment. Clamp-related EEG abnormalities appeared in 106 operations (24.2%) and all reversed after the insertion of the indwelling shunt; patients with occlusion of the contralateral internal carotid artery showed a 68.8% rate of EEG clamp-related changes. The short term follow-up (one month after the operation) showed six minor strokes with complete recovery (1.37%), one intraoperative stroke (0.23%), three delayed major strokes (0.69%) and three neurological deaths (0.69%). The long-term follow-up over an average of 42 months showed a 3.7% rate of relevant neurological complications (ie permanent deficits + death) and a 3.16% rate significant restenosis or occlusion of the operated carotid artery. Our results show that the routine use of EEG monitoring and patch-graft angioplasty allow to perform CEAs with a very high degree of safety, improving the clinical course of the disease.

The surgical treatment of atherosclerotic occlusion of the innominate and subclavian arteries. Personal experience with longterm follow-up.

Among 78 patients operated on for occlusive disease of the supraaortic trunks in the period 1970-78, 34 patients who underwent carotid-subclavian bypass (64.7%), aortocarotid bypass (17.6%), endarterectomy of subclavian artery (5.8%) or endarterectomy of innominate artery, had follow-up studies of 3-10 years after surgery. All patients demonstrated originally a differential in systolic blood pressure in the upper extremities. The surgical indications were posed on the basis of neurologic symptoms of vertebrobasilar insufficiency and the angiographic evidence of "subclavian" (79.4%) or "innominate" (20.6%) steal. Carotid-subclavian bypass has been the preferred surgical treatment technique in patients with "subclavian steal". This operation is indicated also in nearly asymptomatic patients in order to prevent the natural history of vertebrobasilar insufficiency. In our experience, operative risk in carotid-subclavian bypass is not present, unless an associated lesion of carotid bifurcation exists, which needs an endarterectomy with patch-graft angioplasty. Longterm results are considered satisfactory in surgically treated patients.

Rationale of the surgical treatment of carotid kinking.

AIM: Elongation and tortuosity of the internal carotid artery (ICAET) is a common angiographic, angioMR or Duplex scanning finding: it can be "pure" and, in a great majority of cases, it is not correlated to neurological symptoms. It can be associated with atherosclerotic bifurcation plaque, therefore in this case, indications to surgery follow that of carotid stenosis. On the other hand in some patients ICAET seems potentially correlated to hemispheric or non hemispheric symptoms: ICAET may show as kinking with a wide or narrow acute angle, single (< shaped) or double (Z shaped), or less frequently as a coiling (S,U, or C shaped). Surgical indications are controversial. In the author's opinion, surgery may represent the safest tool in the prevention of a stroke due to carotid occlusion, in selected patients. The aim of this study is to describe the author's experience in the surgical treatment of carotid kinking not associated with significant atherosclerotic lesions. METHODS: From March 1994 to March 2001, 29 patients (11 male, 18 female) with a pure ICAET underwent surgery. Patients presented hemispheric symptoms (24.13%), non hemispheric symptoms (41.3%) or both (27.5 %). Two asymptomatic patients (6.9%) underwent surgery because of contralateral carotid occlusion. RESULTS: The postoperative (within 30 days from operation) results, no mortality was observed, 1 patient presented a stroke (3.4%), and 1 patient had a TIA at awakening (negative cerebral CT scan). All patients with hemispheric symptoms (15 patients) had complete remission, whereas only 6 out of 12 patients (50%) presenting non-hemispheric symptoms had remission (1 patient underwent a controlateral ICAET correction). CONCLUSIONS: The natural history of symptomatic and asymptomatic ICAET is practically unknown, but in some cases selected indication to surgery is justified. Surgery was indicated for patients with transient ischaemic attacks ( hemispheric symptoms); in asymptomatic patients presenting a kinking with an angle inferior to 30 degrees, and a contralateral carotid artery occlusion; in patients with non hemispheric symptoms, after a screening to exclude all other possible neurological or non-neurological causes with duplex scan positive for significant increase of flow velocity in ICA and positive cerebral CT scan or MR scan for ischaemic lesions in the homolateral hemisphere, and/or a flow inversion in anterior cerebral artery or flow reduction in the middle cerebral artery, according to different head positions (rotation and flex-extension).

Surgical management of extracranial vertebral artery occlusive disease.

Thirty-seven consecutive patients underwent vertebral artery (VA) reconstruction over a 6 years period (1983-1989). Detailed neurologic, medical, and angiographic information was obtained for all patients. Indications for surgery were as follows: (1) stenosis of VA with symptoms of vertebrobasilar insufficiency; (2) very tight stenosis (greater than 75%) of the dominant VA with stenosis or occlusion of the contralateral VA; (3) very tight stenosis of VA with bilateral occlusion of the internal carotid artery (ICA); (4) very tight stenosis of VA with homolateral ICA lesion eligible for simultaneous repair; (5) very tight stenosis of VA and very tight stenosis of the homo or contralateral carotid siphon. There were 15 isolated vertebral lesions (group I), and 22 were VA lesions associated with lesions of the supraaortic trunks which were simultaneously treated (group II). The reconstructions of the first portion of the VA were 30 (12 of group I and 18 of group II) and reimplantation of the VA into the common carotid artery was the procedure of choice. There were 7 revascularizations of the third portion of the VA at C1-C2 level (3 of group I and 4 of group II): carotid-vertebral bypass, using an autogenous vein graft, was the procedure of choice. Three patients in group II died in the immediate postoperative period from myocardial infarction but no patient presented immediate postoperative neurologic deficits. All symptomatic patients but one were relieved of their symptoms in a median follow-up of 31 months. No postoperative complications were observed. Long-term results were satisfactory in all the 28 patients at their last follow-up visit.(ABSTRACT TRUNCATED AT 250 WORDS)

Clamping ischemia, threshold ischemia and delayed insertion of the shunt during carotid endarterectomy with patch.

BACKGROUND: Shunt insertion during carotid endarterectomy (CEA) is mandatory to avoid neurological damage due to clamping ischemia; however shunt insertion before plaque removal has many inconveniences (atheroembolism, intimal dissection, difficulty of endarterectomy). The aim of this study is to verify whether and how long shunt insertion may be safely delayed to permit plaque removal and ensure cerebral perfusion during the further time consuming manoeuvres of CEA (peeling, patch angioplasty). METHODS: From July 1990 to February 1996 383 patients underwent 411 CEAs under general anesthesia with EEG continuous monitoring and PTFE patch angioplasty. A Pruitt-Inahara shunt was routinely inserted only after atherosclerotic plaque removal. In 316 CEAs (76.9%) without EEG signs of cerebral ischemia (Group A) the mean clamping time was 10 min +/-4.8 (range 2-37 min). In 95 CEAs (23.1%) with EEG signs of cerebral ischemia (Group B) it was 7.3 min +/-3.5 (range 3-20 min). All patients had normal EEG signals after delayed shunt insertion and reperfusion (mean 21 min, range 5-45 min). RESULTS: In the short term results (within 30 days) there was a relevant neurological complication rate of 0.96% (2 major stroke and 2 lethal stroke); at awakening we observed 5 RINDs (1.21% of total) 1 in a patient of Group A (0.31%) and the other 4 in patients of Group B (4.21%). CONCLUSIONS: These data confirm the rationale of a delayed insertion of the shunt: actually the cerebral parenchyma may tolerate under general anesthesia a sufferance due to carotid clamping, EEG detectable, without neurological deficits for at least 7.3 min. This time is sufficient to perform the most difficult steps of CEA (plaque removal, distal intima checking) allowing shunt insertion in a clean operatory field, without inconveniences. Finally the shunt allows complementary time consuming steps, as patch angioplasty, with improvement of both short- and long-term results.

Prospective comparative study of two cerebral protection devices in carotid angioplasty and stenting.

BACKGROUND: The aim of the study was to compare two of the available cerebral protection devices (CPD) PercuSurge, balloon type (group A) and Angioguard, filter type (group B) used in carotid stenting and angioplasty (CAS). METHODS: From September 1999 to February 2001, 26 consecutive patients undergoing CAS were alternatively assigned to group A and B. Postoperative disabling stroke and neurological mortality, nondisabling stroke, TIA and non-neurological mortality were examined. CPD features included time required, ease of handling, device rupture or malfunctioning, radiopaque markers evidence, abnormal major mobility of the opened system. RESULTS: RNCR was 0 and TIAs were not observed in either group. Four patients (3 in group A and 1 in group B) showed drowsiness in the immediate postoperative period. Perioperative carotid occlusion and surgical conversion were observed in 1 case of group A. Average time calculated from the beginning of set-up to complete removal was 46 min in group A versus 31 min in group B. Abnormal major mobility of the opened system was very often observed during endovascular maneuvers with both devices. CONCLUSIONS: CAS may protect against postoperative procedure-related neurological events. Common and specific disadvantages were observed in both systems showing they were not close enough to the ideal device.

EEG monitoring, selective shunting and patch graft angioplasty in carotid endarterectomy. Early and longterm results.

From March 1980 to July 1986 at the Department of Vascular Surgery of the University of Padua, 182 patients underwent 210 carotid revascularizations for atherosclerotic stenosis involving the carotid bifurcation (28 operations were bilateral). Carotid endarterectomies (CE) and patch graft angioplasty totalled 192 (166 patients); an enlarging patch graft angioplasty of the internal carotid artery (ICA) without CE was performed in 14 cases (13 patients); in the remaining four surgical procedures (3 patients), for technical reasons prohibiting CE, the operation consisted of a great saphenous vein bypass between a donor vessel and the ICA distal to the lesion. The preoperative symptoms in 182 patients were as follows: TIAs (98 cases, 54%), non-hemispheric symptoms (21 cases (12%) and fixed stroke or TIAIR (10 cases, 5%). Fifty-three patients (29%) were asymptomatic. In all cases, continuous EEG monitoring was employed. The operation was performed without a temporary intraluminal shunt in the patients showing tolerance to carotid clamping. The protection of the shunt was required only in patients with EEG changes (47 cases). The arteriotomy was routinely closed with a PTFE patch graft angioplasty. Early results of the operation were excellent: none of the patients presented permanent or transient neurological deficits in the immediate postoperative period and none of them died. All patients were reassessed with C.W. Doppler sonography and Duplex scanning in the postoperative period. In all cases, the success of the operation was demonstrated. Longterm follow-up (6-72 months, mean follow-up: 35 months) was done in 121 patients (142 operations): 107 patients were completely asymptomatic, 5 remained stable or slightly improved the preoperative status. Five patients had a new or recurrent TIAs, 3 suffered a stroke, one showed a recurrence of non-hemispheric symptoms. With the exception of two patients suffering a stroke, all had a second arteriography but none of these patients showed extracranial lesions. Two patients presented an asymptomatic restenosis of the ICA. Eight patients (8.8%) revealed a significant evolution of the disease of the contralateral unoperated ICA.(ABSTRACT TRUNCATED AT 400 WORDS)

Surgical treatment of atherosclerotic lesions of subclavian artery: carotid-subclavian bypass versus subclavian-carotid transposition.

BACKGROUND: The aim of this retrospective study is to analyze the short and long term results of two different surgical treatments in patients with subclavian lesions: common carotid-subclavian artery bypass (CSB) versus transposition of subclavian artery on the common carotid artery (SCT). METHODS: From 1981 until 1995, 40 non randomized patients with symptomatic subclavian steal underwent 20 CSBs and 20 SCTs. Risk factor rates were equally balanced in the two groups. Surgery was carried out routinely under general anesthesia, with electroencephalic continuous monitoring. Patency of revascularization was assessed by physical examination, brachial blood pressure determinations, ultrasound sonography and angiography whenever recurrence of symptoms developed or when the function of repair was in doubt. Patients were examined every year. In Spring 1996 (range 9-189 mos, average 7 years) a general clinical-instrumental follow-up was performed. RESULTS: In the short term (<30 days) mortality was 5%: one death (5%) for pulmonary embolism in a patient with CSB and one for myocardial infarction in a patient with SCT. The early thrombosis rate was 5% (1 CSB and 1 common carotid artery distal to a patent SCT). During follow-up 10 patients (25%) died and 6 were lost. The six-year actuarial patency rate was 100% for SCT and 66% for CSB. Moreover there were 3 thromboses of the vertebral artery homolateral to patent CSBs. CONCLUSIONS: In conclusions SCT should be considered the surgical technical choice for the treatment of proximal subclavian artery lesions.

Diagnosis of high-grade stenosis of innominate artery.

Although pathology of the innominate artery (IA) is not frequent, it causes relevant impairment of extracranial circulation and sometimes cerebrovascular events. Definite differentiation of high-grade stenosis from occlusion of the IA has not been obtained until now with continuous-wave (C.W.) Doppler and duplex system ultrasound, and thus the direct evaluation of IA is not reliable by noninvasive methods. In this study the authors suggest an indirect method of evaluation of IA pathology based on the study of carotid, subclavian, and vertebral arteries (VA) with echo-Doppler-color-flow (EDCF) (with linear--phase array probes of 7.5 and 5 MHz). In the last two years they studied 6 patients with IA pathology (2 with occlusion (occ), 1 with stenosis of 80% and 3 with subocclusive stenosis > 90%). In both patients with occ, right VA flow was inverted, and also the right common carotid (CC) was involved (occ in 1 case and inverted flow in the other); in the 3 subocclusive stenoses a lowered systolic flow in the CC was recorded (48 vs 85 cm/sec, 41 vs 77, and 23 vs 109). In the 80% stenosis, besides the inverted flow in VA, only a reduced diastolic flow in CC was also recorded (19 vs 33 cm/sec measured in the left side). All patients with high grade stenosis were successfully confirmed by an angiographic study, including the different degree of stenosis. Five of the 6 patients underwent surgical correction with a restored flow in the previously involved artery. Only 1 patient with occlusion is waiting for surgical correction.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevention of enteric erosion by vascular prostheses.

Aortoenteric fistula is an uncommon but disastrous complication of aortic reconstruction with a prosthetic graft. Prevention of enteric erosion when using a vascular prosthesis must be a foremost consideration. For these occasions, greater omentum may be used to cover the graft. However, when use of the greater omentum is not possible, the interposition of a prosthetic patch is a means of preventing duodenal erosion. We review the usual procedures for reperitonealization and report on an original method of using a prosthetic patch to prevent erosion.