VENOUS ULCER--A NEW THERAPEUTIC APPROACH.

Trophic leg ulcer is a major health problem affecting approximately 1-2% of the population, the incidence being higher in the elderly (70-80 years). It is a multifactorial condition, but the most common cause is chronic venous insufficiency. This can be attributed to reflux in the saphenous system and calf perforator vein incompetence. These were first described by Linton, the first intervention designed to correct perforator vein incompetence bearing his name. Today Linton's operation has been abandoned due to the large unaesthetic incision and great postoperative pain. Also, ulcer healing time is long (2 months) and recurrence rate is high. Currently a series of minimally invasive procedures are used to close these perforator veins, such as ultrasound-guided sclerotherapy. The advantages of these techniques are less discomfort to the patients, low rate of complications, short hospital stay.

SURGICAL TREATMENT OF POSTPARTUM ILIOFEMORAL DEEP VEIN THROMBOSIS--CASE REPORTS.

The writing committee for Antithrombotic Therapy for Venous Thromboembolic Disease of the 2008 ACCP guidelines made the following recommendations for thrombus removal strategies in patients with deep vein thrombosis (DVT): open surgical thrombectomy is recommended in patients with acute iliofemoral DVT to reduce symptoms and post-thrombotic morbidity; whenever available, catheter-directed thrombolysis is preferred to surgical venous thrombectomy, the risk of hemorrhage being diminished; surgical venous thrombectomy is recognized to be efficient in cases where catheter-directed thrombolysis is unavailable or the patients are not suitable candidates for such a procedure. Randomized studies comparing surgical thrombectomy and anticoagulant therapy in patients with iliofemoral DVT (IFDVT) showed that at 6 months, 5 years, and 10 years the patients in the thrombectomy group presented increased permeability, lower venous pressure, less edema, and fewer postthrombotic symptoms compared to the patients receiving anticoagulant therapy. In this article we present 3 cases of IFDVT in postpartum patients diagnosed by Doppler ultrasound of the deep venous system. The 3 patients received anticoagulant therapy prior to surgery. Surgery consisted in thrombectomy of the common, superficial and deep femoral veins, external and internal iliac veins, and femoral-saphenous arteriovenous fistula. The patients received postoperative antithrombotic therapy and were followed-up at 3, 6 and 9 months by Doppler ultrasound of the deep venous system.

Surgical techniques in the treatment of multilevel arterial occlusive disease.

AIM OF THE STUDY: To report the surgical techniques for multilevel arterial lesions of the lower extremities and to evaluate the clinical outcomes. In patients with multilevel arterial disease, the treatment consisting of sequentially surgical intervention on the same vascular axis is one of the methods indicated in order to obtain an adequate inflow and outflow. MATERIAL AND METHODS: we have performed a nonrandomized study during a 44-month period (January 2010-September 2013) in a number of 58 patients treated by classical revascularization techniques. All the patients included in the study have been post-surgically surveyed at well-established intervals (1, 3, 6, 9, 12, 24 and 36 months) by: clinical examination, laboratory tests, Duplex ultrasound, and, as needed, CT Angiography. RESULTS: the 6 months primary patency in each studied group (corresponding to the years of 2010, 2011 and 2012) was 95%, 93.33%, and 91.3%, respectively; the 12 months primarypatency was 85%, 80%, and 82.6%, respectively. Clinical improvement has been noticed in44 patients (75.86%). There have been registered 14 amputations (24.13% of the cases): 7 majors (thigh and below the knee), representing 12.06% of the total number of cases and 7 minors (toe or transmetatarsal), representing 12.06% of the total number of cases. Limb salvage rate for the patients in stage III and IV Leriche-Fontaine was 85.10%. CONCLUSIONS: the surgical techniques are a feasible option for the multilevel arterial disease, with

Clinical and epidemiological assessment concerning hybrid revascularization techniques in the treatment of multilevel arterial occlusive disease.

UNLABELLED: Aim of the study was to report a novel hybrid technique for multilevel arterial lesions of the lower extremities and to evaluate the clinical outcomes. In patients with multilevel arterial disease, the combined (hybrid) treatment, consisting of endovascular intervention and classical surgical intervention on the same vascular axis seems to be the most indicated treatment in order to obtain an adequate inflow and outflow. MATERIAL AND METHODS: We have performed a non-randomized study during a 44-month period (January 2010 - September 2013) in a number of 94 patients treated by hybrid revascularization techniques. All the patients included in the study have been post-surgically surveyed at well established intervals (1, 3, 6, 9, 12, 24 and 36 months) by: clinical examination, laboratory tests, Duplex ultrasound, and, as needed, CT or MR Angiography. RESULTS: The 6 months primary patency in each studied group (corresponding to the years of 2010, 2011 and 2012) was 58.69%, 68.42%, and 62.06%, respectively; the 12 months primary patency was 45.65%, 57.89%, and 34.48%, respectively. Clinical improvement has been noticed in 83 patients (88.29%). There have been registered 19 amputations (20.21% of the cases): 11 majors (thigh and below the knee), representing 11.7% of the total number of cases and 8 minors (toe or transmetatarsal), representing 8.51% of the total number of cases. The amputation-free survival period ranged between 7 days and 24 months, with an average of 7.66 months. CONCLUSIONS: The hybrid techniques are a feasible option for the multilevel arterial disease, with favorable patency and limb salvage rates.

Paraganglioma of the carotid body: case report.

With an incidence of 0.03% of all tumors, carotid body tumors (CBTs) are extremely rare. We present the case of a 63 year old female patient with an asymptomatic right sided neck mass of 3 cm diameter. Doppler ultrasound and contrast-enhanced CT confirmed the clinical suspicion of carotid body tumor. The patient underwent complete surgical excision of the Shamblin group II tumor and an adjacent lymph node, without preoperative embolization. The histopathological examination diagnosed a benign CBT. There were no postoperative complications at 1 and 6 months follow-ups.

Surgical revascularization in chronic mesenteric ischemia.

Chronic mesenteric ischemia (CMI) is a disease causing death either by starvation or enteromesenteric infarction. Diagnosis is often delayed before the patient is referred to a vascular surgery unit. Atherosclerosis is the main cause of CMI. Arteriography is essential in diagnosing CMI and delineating the atherosclerotic lesions. The revascularization procedure consists in an aortomesenteric bypass reconstructing 1-3 visceral arteries. This paper presents two consecutive CMI cases treated at the Vascular Surgery Unit of the Iasi "Sf Spiridon" Hospital during 2010. Both patients had symptoms suggestive of mesenteric and aortoiliac diseases. CT angiography revealed specific lesions both for aortoiliac disease and stenotic or occlusive lesions in the celiac trunk and mesenteric arteries. Both cases benefited from aortobifemural bypass surgery using a synthetic graft associated with aortic-superior mesenteric artery bypass with reversed vein graft (in the first case both mesenteric arteries were revascularized). Immediate and remote results were favorable, with remission of intestinal symptoms and weight gain. Bypass patency was followed-up by CT angiography and Doppler ultrasound. CMI is a diagnostic and therapeutic challenge. Open surgery provides symptom remission in 90% of cases. Permeability at 5 years is 80-90% for open surgery, higher than by endovascular therapy. Average permeability of the two types of intervention is 70% at 5 years, similar to the infraaortic bypasses.

Complex utrasound study of the atherosclerotic plaque.

UNLABELLED: Carotid surgery concept is wining ground both among neurologists who recommend and vascular surgeons who perform an increased number of interventions. Regardless of the technique, we are interested in the tendency of the plaque to grow and determine stenosis. Ultrasound (US) is 91-94% sensitive and 85-99% specific in detecting a significant stenosis of the internal carotid artery. AIM: To establish a correlation between the preoperative US and intraoperative plaque characteristics in order to determine the restenosis rate. MATERIAL AND METHODS: From January 1, 2012 to December 31, 2012, 70 consecutive patients were included in this study. Two groups were formed: 35 patients with stenotic ICA and 35 patients presenting stenosis at the femoral artery bifurcation (control group). The comparison between these two groups started from the premise of a similar pattern for internal carotid artery--deep femoral artery and external carotid artery- superficial femoral artery. US scans were performed on admission in all patients. All images were normalized and Gray Scale Median (GSM) was calculated. RESULTS: Femoral plaque GSM values were higher in relation with hyperechogenicity highlighting the intensely calcified structure. Unstable plaques were more heterogenic, with higher transparency and lower GSM than stable plaques. This was the case of carotid plaques. During follow-up US revealed no restenosis. CONCLUSIONS: Femoral bifurcation plaques are calcified and determine chronic ischemic symptoms, while carotid bifurcation plaques are unstable and determine cerebral symptoms. US remain the gold standard non-invasive technique both for screening and diagnosis and set the therapeutic coordinates.

Epidemiological characteristics of peripheral artery disease: retrospective study.

UNLABELLED: Peripheral artery disease (PAD) is a common condition. Over the past 20 years the risk factors for PAD have changed. AIMS: To identify the regional characteristics of the patients with PAD and the sex- and urban/rural-related differences. MATERIAL AND METHODS: Retrospective study on patients admitted to the Iasi "St. Spiridon' University Hospital in the interval 2007-2012. The dataset was prepared for t student analysis in in view of determining statistical significance. RESULTS: Of the 361,248 patients admitted to the 20 units of the hospital, 2,623 patients were diagnosed with advanced stages of PAD (Leriche--Fontain III and IV). Significant statistical differences were found between men and women, and between rural and urban men (p = 0.001). 20.5% of the patients underwent amputations. CONCLUSIONS: This is one of the first studies that has identified urban/rural differences. The characteristics specific to PAD patients from North-Eastern Romania are presented.

Partial infection of the aorto-uni(bi)femoral graft partial conservation and replacement with autologous material. Is it a reality?

UNLABELLED: The infection of the aorto-uni(bi)femoral graft is a serious complication, associated with high morbidity and mortality rates - severe implications on the vital prognosis (haemorrhage, sepsis) or of the peripheral vascularisation. Frequently, the infections of aorto-uni (bi) femoral grafts first appear at the level of the distal anastomosis, in Scarpa's triangle. MATERIAL AND METHODS: We are going to discuss a number of 6 cases of localised unilateral infection, situated in Scarpa's triangle. The infections appeared either during the first 3 months after the initial implantation of the graft, or later on (2 cases), after 2 and 5 years, respectively. The cases span over a period of 10 years covering a total number of 226 patients with aorto-uni(bi)lateral grafts. Our treatment of choice was to use autologous material, namely the superficial femoral vein, as replacement for the partially infected graft, which was harvested and placed in the iliac position during the same procedure. The surgical intervention was divided into an aseptic time, which involved harvesting the autologous conduit (superficial femoral vein), the proximal anastomosis between the non-contaminated portion of the graft and the venous graft, followed by closure; next, there was a septic time, that included entering the infected wound, extracting the contaminated segment of the graft and distal anastomosis between the femoral vein graft and the receptive artery. In five of the cases the venous conduit was passed through the same anatomical space from where the graft was extracted; in one case it was passed through the obturator channel and anastomosed to the superficial femoral artery at a lower level. The patients received pre- and postoperative intravenous antibiotics in accordance to the cultures taken from the infected wound, up to a period of 2-3 weeks, followed by another 3 weeks of oral antibiotics after discharge. RESULTS: All the patients survived the intervention. Postoperatively oedema of the lower leg and thigh was observed in all of the patients, similar to that appearing in deep venous thrombosis, and required treatment with low molecular weight heparin and long term oral anticoagulation with antivitamin K products.Patients were monitored postoperatively at intervals of one, three and six months followed by two annual check-ups. Biological tests and colour Duplex scans showed no signs of recurrent infection. CONCLUSIONS: Localized partial graft infections are a reality, confirmed by clinical, biological, ultrasound examinations, intra-operative explorations and postoperative results achieved by selective surgical resection. Infectious reoccurrence was not observed during the period of study.