Ruptured aneurysm of the internal iliac artery.

The aneurysms of the internal iliac artery are rare and very often asymptomatic. Because of the anatomic location of this artery, it can be difficult to diagnose this kind of aneurysm, when isolated. Frequently it is diagnosed in consequence of aneurysmatic complication, such as rupture and/or impending rupture. In this work we report our experience concerning 6 cases of ruptured aneurysm of the internal iliac artery, observed in 5 patients. In three of these cases the lesion was isolated. In two cases the patients had already been operated on for abdominal aortic aneurysm, 4 and 6 years before. All the five patients were operated on. In 5 cases we ligated the aneurysm, without using any vascular graft. In one case where the external iliac artery was involved, we used a vascular graft between the common iliac and common femoral artery, in order to repair the vascular axis. One case of mortality was observed and a rare complication occurred in one case. An 83-year-old man treated in emergency for ruptured aneurysm of the left internal iliac artery, with regular post-operative course, was hospitalized again 24 days later with sepsis and pain in the left lower abdomen. A CT scan and a following urography showed a urinary fistula probably due to an ischemic necrosis of a segment of the ureter. A percutaneous nephrostomy has been performed and the patient successfully discharged.

Ruptured abdominal aortic aneurysms: factors affecting the early postoperative outcome.

BACKGROUND: In spite of the progress in diagnosis and treatment of ruptured abdominal aortic aneurysms (RAAA) the mortality rate still remains very high (varying from 15% to 50% according to various experiences). This study is aimed at analyzing the relative contribution of preoperative hemodynamic conditions and of operative and postoperative factors to outcome of patients operated on for ruptured abdominal aortic aneurysms. METHODS: For this purpose a retrospective case series involving 152 patients operated on in emergency for RAAA, during the period 1990-1994, has been reviewed. In this group we examined the site of rupture, the size of the aneurysms, the presence or not of a shock condition at admission, the existence of inflammatory aspects, the adopted type of prosthesis. RESULTS: The mortality rate was 24.3% (37 patients). In 10 patients (27%) the cause of death was an irreversible hemorrhagic shock. Eight patients (21.6%) died for an intestinal infarction. In 7 patients the fatal outcome was due to the development of an acute renal failure. Five patients (13.5%) underwent an acute myocardial infarction and other five a multiorgan failure. Two patients (5.5%) eventually died for respiratory insufficiency. CONCLUSIONS: The results of our study seem to confirm that the outcome of patients affected by rupture of abdominal aortic aneurysms depends not only on the preoperative hemodynamic condition but also on the expertise of the surgical team.

Indications and role of isolated profundaplasty in patients affected by limb ischemia.

The deep femoral artery is the primary source of blood supply to the lower extremity in presence of superficial and/or popliteal occlusion. The atherosclerotic involvement of the profunda femoris artery is relatively less frequent and generally is localized in the initial segment of the artery. The profundaplasty employed to relieve limb threatening ischemia is infrequently used as an isolated procedure. However many authors demonstrated that restoration of flow through this vessel alone, in patients without significative lesions of the aorto-femoral district, will effectively relieve ischemia when the superficial femoral artery is also occluded. Our experience gained in the last eight years concerns 24 patients (21 male, 3 female). All the patients had severe ischemia of the lower limb with invalidating claudication (13), rest pain (9) and gangrene (2). On the basis of our results, we think that the operation is recommended, whenever possible, in patients with critical ischemia when the possibilities of more extensive revascularizing procedures are absent.

The association between abdominal aortic aneurysms and chronic leg ischaemia. Prevalence in 125 consecutive patients.

A study was carried out to see if in patients with atherosclerotic lesions of the lower limbs the percentage of abdominal aneurysms is higher than in the general population. One hundred twenty five consecutive patients were studied in two different hospitals and compared with a control group. In the two groups with peripheral vascular diseases the patients had a prevalence of aneurysms of 12%, while in the control group the prevalence was of 3%. All patients were operated on successfully except two of them who are now in follow up with regular ultrasound assessment, one with an aortic aneurysm of 3.2 cm and the other with an aortic diameter of 4 cm and moderate liver failure.

Non specific aorto-arteritis. Clinical picture, diagnosis and therapy.

This study is aimed at analyzing clinical features, angiographic findings and evolution of Takayasu's arteritis and the criteria adopted to establish the indication for non-surgical versus operative treatment. Eighteen patients affected by non specific aortarteritis were observed and treated at our Department between 1973 and 1996. All patients met the American College of Rheumatology 1990 criteria of classification of Takayasu's arteritis. Sixteen patients were young females. Two patients were males. Nine patients underwent surgical procedures. One young female underwent a PTA. All eight asymptomatic patients were only medically treated. One patient died some days after an aorto-bicarotid bypass graft due to acute myocardial infarction. Two other patients died two and four years after intervention for renal and cardiac failure respectively. One patient after an aorto bicarotid bypass underwent a left hemiplegia due to thrombosis of the right graft branch. All the other 14 patients either surgically or medically treated are well and are under strict surveillance through rigorous follow-up. The 10 patients who underwent surgical or interventional radiological treatment were certainly the most seriously affected patients and were symptomatic (presented neurological disturbances or a severe hypertensive state). This fact explains, to some extent, the mortality and morbidity rate observed in this group. The seven medically treated patients were completely asymptomatic in spite of a major involvement of various vascular districts.

New diagnostic and screening possibilities in the stenobliterative lesions of the deep visceral vessels.

The evolution and continuous improvement of the ultrasonic diagnostic devices allows an hemodynamic and morphological exploration of the deep abdominal vessels that until now seemed to be precluded to non invasive diagnostic techniques. For example, the angiodynography today advantageously substitutes classical urographic investigation during the initial screening of the hypertensive patients suspected of stenotic lesions of the renal arteries. In fact the ecocolordopplersonography allows not only a morphological evaluation of the parenchyma and of the renal vascular tree, but also supplies a quantitative measurement of the blood flow through the renal artery. Still more important are the possibilities offered by these devices in the study of the acute or chronic intestinal ischemia, in which until now a sure diagnosis was only possible using invasive techniques. Performing a study of the mesenteric vascularization urgently, sometimes is possible a decisive demonstration of an ischemic pathology where the clinical abdominal picture provides only uncertain diagnostic elements.

Abdominal aortic aneurysms surgery in over 75 years old patients. Experience in 142 cases treated between 1980-1989.

The paper describes the Authors' experience of abdominal aortic aneurysm surgery in over 75-year-old patients. One hundred and forty-two cases were operated over a 10-year period (1980-89). Seventy-two patients were treated electively and 70 underwent emergency surgery following rupture of the aneurysm. Operative mortality during elective surgery was comparable to that in younger patients, whereas the mortality rate during emergency surgery was notably higher than that in under 75-year-old patients. Follow-up confirmed that the life expectancy of operated patients is significantly better than that of patients with untreated abdominal aortic aneurysms.

Splanchnic artery aneurysms.

From 1970 to October 1991, 26 patients affected by splanchnic artery aneurysms were observed and treated at the Department of General and Cardiovascular Surgery, University of Milan, Italy. Three splanchnic artery aneurysms were operated on in emergency. Visceral artery aneurysms are often completely silent and are generally detected during diagnostic procedures performed in order to clarify some diagnostic questions. When symptomatic they present a characteristic clinical picture of the involved vascular district. Two patients affected by aneurysmal disease of the proper hepatic artery died after operation. All the other splanchnic aneurysms underwent a successful surgical procedure. This study is aimed at analyzing some characteristic clinical pictures, diagnostic methods, therapeutic procedures and postoperative results.

[Histopathology of the renal artery. Stenosing lesions causing hypertension]. / Istopatologia dell'arteria renale. Lesioni stenosanti ipertensigene.

The Authors describe the anatomopathological background of different types of renal artery lesion, causing renovascular hypertension. Various pathological aspects of dysplastic lesions are examined and compared with the aspects of arteriosclerotic disease. Finally correlations between angiographic and histological reports are considered, discussing when and how a surgical procedure should be advisable.

[The role of penile Doppler sonography in the diagnosis of vascular impotence. Preliminary studies]. / Il ruolo della Doppler sonografia peniena nella diagnosi di impotenza vascolare. Ricerche preliminari.

Normal, potent arteriopathic and impotent arteriopathic subjects have been studied by means of the Doppler method for the determination of penile systolic pressure. A penile systolic pressure value less than 75 mmHg and a penisarm pressure index of than 0.55 were always associated with impotence. If present in the arteriopathic, impotence is not always caused by vascular factors.

[Hyperplasia of the adrenal medulla]. / L'iperplasia della midollare surrenalica.

A case of arterial hypertension due to suprarenal medulla hyperplasia is reported. Having accepted the existence of this form, the problem of its recognition is stressed, in the presence of catecholamine pathology, even though the type or site of its anatomo-pathological substrate cannot be identified, explorative surgery and possible removal of the suprarenal glands can be indicated.

[Massive pulmonary embolism. Clinical aspects and treatment]. / L'embolia polmonare massiva. Clinica e trattamento.

The frequency of pulmonary embolization seems to be increasing. Venostasis, intimal damage and hypercoagulability of blood are the more recognized causes of pulmonary thromboembolism. It is especially threatening to the elderly, obese, immobilized (for an accident or an operation) patients. Pulmonary isotopic scans or angiograms are most often relied upon to establish the diagnosis. A properly performed pulmonary angiography is necessary to establish or refute the diagnosis in almost every case. With the exception of the patients suddenly dying for a massive pulmonary embolism, the period of time between onset of symptoms and death is usually adequate for substantiating a diagnosis and promptly beginning a fit anticoagulation therapy using continuous intravenous heparin or fibrinolytic agents infusion. Although it is not proper to separate surgical and medical treatment of thromboembolism, the Authors, on the ground of their experience on 5 patients affected by massive pulmonary embolism, in 3 of whom was performed a successful embolectomy, think that heparin anticoagulation treatment is at any rate to apply for treating pulmonary embolism, but in patients in whom the shock is unresponsive to vasopressors or in whom anticoagulation therapy is controindicated, the surgical removal of pulmonary emboly, with the support of a pump oxygenator, is the treatment of choice for the acute massive pulmonary thromboembolism.

[Selective hypogastric arteriography in the diagnosis of vascular impotence]. / L'arteriografia selettiva ipogastrica nella diagnosi di impotenza vascolare.

Clinical employment of selective hypogastric arteriography has been instrumental in the detection of stenosing and obliterating lesions of the pudendal arteries and their penile branches capable of giving rise to impotentia erigendi as the sole symptom. Differentiation of psychogenic and vascular impotence is now possible through non-invasive instrumental examinations such as the nocturnal penile tumescence test, and Doppler ultrasonography of the penile arteries. Arteriography to clinch the diagnosis was only employed when a suspicion was aroused by these two examinations. An account is given of technique employed for selective hypogastric arteriography and the angiographic results obtained.

[The role of penile Doppler sonography in impotent diabetics]. / Il ruolo della doppler-sonografia peniena nel diabetico impotente.

Penile systolic pressure has been evaluated by the Doppler-sonographic method in 15 diabetic patients suffering from erectile impotence. Urodynamic tests have also been carried out in some patients for a diagnosis of neurological impotence. The results obtained show the possibility of a double or sole origin (neurogenic or vascular, or both) in the pathogenesis of this symptom in diabetic subjects.

[Atherosclerotic aneurysm of a branch of the deep femoral artery]. / Un aneurisma aterosclerotico di un ramo dell'arteria femorale profonda.

Peripheral arterial aneurysms present characteristic locations. In the lower limbs, atherosclerotic aneurysms of the deep femoral artery are very rare. Authors report an interesting case of arteriosclerotic aneurysm of a branch of the profunda femoris artery observed in a 80 year-old man, and associated with an abdominal aortic aneurysm. Endo-aneurysmectomy was performed with a dacron patch interposition. Surgical treatment of this rate disease is discussed.

[Inflammatory aneurysms of the subrenal aorta. Histopathological, diagnostic and therapeutic aspects]. / Gli aneurismi infiammatori dell'aorta sottorenale. Aspetti istopatologici, diagnostici e terapeutici.

Inflammatory abdominal aneurysms (AIAA) represent a clearly defined clinical entity with an incidence ranging between 1.2% and 15%. In spite of the increasing number of observations reported in recent years, the etiopatholgenesis and natural history have not been defined. The lesion can present in an acute, subacute or chronic manner and the histopathological studies reveal prevalently two components: an inflammatory infiltrate and a diffuse fibrosis, in varying degree. This study aimed to analyze the more recent imaging procedures in order to correctly diagnose this lesion. In our experience the incidence of AIAA is about 2.5%. On the basis of macro microscopic pictures the authors divided patients into two groups: one constituted by the acute or subacute inflammatory forms, the other by chronic clear inflammatory aneurysms. All patients underwent on operative treatment. The surgical adopted techniques and the obtained results are reported.

[Aneurysm of the popliteal artery. Prognostic and therapeutic criteria]. / Aneurismi dell'arteria poplitea. Criteri prognostici e terapeutici.

Experience of the management of 45 patients affected by popliteal artery aneurysms is reported. All patients, but one, underwent operative treatment. The importance of immediate surgical reconstruction whenever a popliteal artery aneurysm has been detected is stressed. In fact the most frequent complication represented by sudden thrombosis of the aneurysmatic sac and/or by peripheral embolization is generally followed by an irreversible closure of the vascular run off, determining the high rate of failures (28% in our experience) in spite of a prompt surgical reconstructive procedure.

[The role of chronic renal insufficiency in the prognosis of surgical interventions in subrenal abdominal aortic aneurysm]. / Il ruolo dell'insufficienza renale cronica sulla prognosi di interventi di aneurismectomia dell'aorta addominale sottorenale.

Chronic renal insufficiency is one of the most important factors governing the immediate and long-term outcome after aneurysm repair. A total of 484 patients with abdominal aortic aneurysm (A.A.A.) have undergone elective surgical treatment in our Institution during the last 5 years. Of these, we selected 60 patients; 30 with a normal serum creatinine concentration and 30 with preoperative renal insufficiency (serum creatinine concentration greater than 2 mg/dl). In this second group, 23 patients (76.6%) were affected by slight or median renal insufficiency, 5 patients (16.6%) were affected by severe renal insufficiency (creatinine concentration greater than 4.5 mg/dl), and 2 patients (6.6%) had complete renal failure with dialytic treatment from 1.5 and 2 years respectively. We analyzed postoperative renal function in all 60 patients. In the first group, only 6 patients (20%) showed a transient renal insufficiency, without mortality and morbidity. In the second group, postoperative complications and mortality tended to occur more frequently in patients with a severe renal insufficiency than in patients with slight or median insufficiency or complete renal failure. The present data suggest that dialytic treatment might be necessary in patients with severe renal insufficiency before aneurysm repair.

[Prosthetic separation in the retroperitoneum in reconstructive arterial surgery]. / Il distacco protesico in sede retroperitoneale nella chirurgia ricostruttiva arteriosa.

In this assay we take into consideration 3410 retroperitoneal prosthetic reconstructions in aorto-iliac pathology performed in the last 25 years at the General and Cardiovascular Institute of Milan. Thirty-nine retroperitoneal prosthetic dehiscences were observed; 35 of them had been subjected to their first operation in our Institute (1.03%). The incidence of vasculo-enteric fistula and pseudoaneurysm seem to decrease in the last 8 years up to 0.9 (0.9%). Authors consider etiologic factors, diagnostic procedures and technical approaches to this severe complication of vascular surgery.

[The physiopathology, clinical picture and therapy of chronic intestinal ischemia]. / Fisiopatologia, clinica e terapia dell'ischemia intestinale cronica.

Between January 1982 and April 1993, 8 patients suffering from a typical clinical picture of chronic intestinal ischemia, have been observed. All these patients were symptomatic and 7 cases presented stenosing or occlusive lesions of at least 2 of the 3 splanchnic trunks. 5 of these 7 patients underwent a corrective surgical procedure. 2 patients underwent percutaneous transluminal angioplasty. One patient affected by stenosis of the coeliac trunk due to external compression caused by the median arcuate ligament of the diaphragm was not operated because the symptomatology was atypical and the other 2 splanchnic trunks were perfectly patent. Three patients died following the therapeutic procedure: a woman in whom an aorto-mesenteric bypass graft was inserted, underwent, 4 months after, an intestinal infarction due to thrombosis of the graft; another woman, whose coeliac trunk and superior mesenteric artery were thrombosed and whose inferior mesenteric artery was reimplanted on the common iliac artery, died for acute hepatic failure, after 12 months of total parenteral nourishment; a third patient, successfully submitted to PTA of the superior mesenteric artery, died after 4 months due to the occurrence of acute renal insufficiency.