Case report of a successful multidisciplinary approach to a giant scrotal malformation.

INTRODUCTION: Congenital pelvic malformations are rare and represent a difficult therapeutic challenge. Scrotal arteriovenous malformations are quite unusual, with only a few such cases reported in the literature. Only one case of scrotal malformation? due to an arteriovenous fistula resulting in azoospermia has been described. PRESENTATION OF CASE: The two-phase strategy adopted in that case permitted complete treatment of a large-sized malformation that was served by 4 main blood confluences. DISCUSSION: Angio-CT performed using reconstructions with MIP and SSD algorithms provided more detailed data about the extension of the afferents and efferents of the arteriovenous malformation, thus enabling us to plan the endovascular treatment of the lesion. CONCLUSION: A multidisciplinary approach is mandatory to achieve good results in these cases.

EVAR and OPEN treatment of abdominal aortic aneurysm: What is the role of MMP-9 in the follow-up?

INTRODUCTION: The aim of our study is to verify the role of metalloproteinases in endovascular repair (EVAR) and OPEN surgery treatment for abdominal aortic aneurysm (AAA). Postoperatively, these enzymes could represent an important biomarker to adapt diagnostic tests and further investigations during follow-up. MATERIAL AND METHOD: From 2004 to 2008, 55 patients were considered with AAA. Of these, 33 patients (mean age: 70.1 years), (mean AAA diameter: 5.4cm) were treated with OPEN surgery (group A) and 22 (mean age: 74.1 years) (mean AAA diameter: 5.1cm) were treated with EVAR. In 17 of them, there were no signs of endoleak (group B1), while in 5 patients, a presence of endoleak (group B2) was detected. Plasma samples were collected in order to determine MMP-9 activity. Enzyme immunoassay was performed preoperatively at 1, 3, 6 and 12 months. Patients treated conventionally were clinically examined after 1 and 12 months by ultrasound. Patients undergoing EVAR treatment were clinically examined by CT scan after 1, 3, 6 and 12 months. The analysis was done by assessing the interaction over time of the MMP-9 value in B1 and B2 groups. RESULTS: The average values observed for MMP-9 were preoperatively and at 1, 3, 6 and 12 months, respectively: in group A 150.8ng/mL (SD=30.5), 252.5ng/mL (SD=25.2), 315.4ng/mL (SD=22.7), 295.3ng/mL (SD=26.8), 210.7ng/mL (SD=30.2); in group B1 105ng/mL (SD=10.8), 125.6ng/mL (SD=18), 85.8ng/mL (SD=19.9), 95ng/mL (SD=20.2), 80.4ng/mL (SD=15.6); in group B2 149ng/mL (29.2), 375.4ng/mL (SD=40.2), 215ng/mL (SD=35.9), 180ng/mL (SD=20.2), 175ng/mL (SD=33.4). The MMP-9 level was higher in group B2 compared to group B1 (P=0.01), suggesting a correlation with the presence of the endoleak. CONCLUSIONS: This preliminary study shows that MMP-9 may be a biomarker of the presence of endoleak. Other further investigations and larger series are needed to show that metalloproteases could play a role in the follow-up of EVAR treated patients.

The endovascular management of open aortic surgery complications with emergency stent-graft repair in high-risk patients.

The aim of the study was to demonstrate the utility of endovascular stent-graft repair for emergency management of aorto-iliac surgery complications. Between 1997 and 2004, in our institute, 201 patients underwent transluminal endovascular graft placement. In 3 patients (1.4%), previously submitted to conventional aortic surgery, endovascular treatment was carried out due to the occurrence of late complications: 1 secondary aortocaval fistula, 1 impending rupture of aortic pseudoaneurysm and 1 secondary aorto-enteric fistula. All candidates were high surgical risk patients (ASA III-IV) suitable for endoprosthesis positioning by endovascular stent-graft implantation presenting with severe worsening conditions in an emergency situation. The patients were treated under local anesthesia and mild sedation. After treatment there was complete resolution of the clinical presentation and an improvement of general conditions in all 3 patients. In the 1(st) patient legs edema disappeared and in the 2(nd) patient mesogastric pain is absent, respectively at 30 and 8 months. The 3(rd) patient, with secondary aorto-enteric fistula, was submitted 2 months later to aortic graft removal and axillo-bifemoral bypass because of infection development. For the treatment of abdominal aortic surgery complications in high risk patients, particularly in emergency situations, endovascular approach is a feasible and safe alternative to conventional open repair. Further evaluation of this technique and longer follow-up will determine its exact role in the management of these life-threatening complications.

Popliteal artery aneurysms. Factors associated with thromboembolism and graft failure.

AIM: The purpose of this study was to review our experience with popliteal artery aneurysms (PAAS) and to identify the major factors associated with thromboembolism of PAAS and failure of grafts after surgical repair. METHODS: The medical records of 38 patients with 42 PAA, who presented in a university medical center between March 1985 and September 2000, were retrospectively reviewed. Data were collected on clinical presentation, risk factors, type of reconstructions, early and late morbidity, limb loss and mortality. Duplex scan, as well as computed tomography, was performed in 33 (78.6%) cases, and preoperative angiography in 38 (90.5%). Thrombolysis was performed prior to surgical reconstruction (16.07+/-21.97 months) in 4 cases presented with acute ischemia. All patients underwent synthetic (23, 54.8%) or autogenous (19, 45.2%), below-the-knee (39, 92.9%) or above-the-knee (3, 7.1%) femoropopliteal bypass graft. The proximal and distal anastomoses were end-to-end both in both cases in 30 bypasses (71.4%). Thirty-six (86%) aneurysms were surgically treated by one vascular surgeon. Postoperative anticoagulants were given in 8 cases (19%). Long-term follow-up (mean: 57.59+/-37.77 months) was available for 35 patients (92.1%). Multivariate analysis was used to assess association between risk factors and outcome. RESULTS: Thirty-five patients were males, 3 were females; mean age was 68.31+/-8.66 years. Risk factors were arterial hypertension (25, 69%), smoking (19, 50%), dyslipidemia (7, 18.4%) and diabetes (5, 13.2%). Thirty PAAS (71.4%) were symptomatic for acute (11, 26.2%) or chronic (7, 16.7%) ischemia, distal embolization (8, 19%), compression of the popliteal fossa (3, 7.1%) and rupture (2, 4.8%, one of which presented with acute ischemia); 12 were asymptomatic. Bilateral PAAS were present in 18 patients (47.4%); 14 (36.8%) also had an abdominal aortic aneurysm (AAA); associated AAAS were twice as common in patients with bilateral PAAS (9/18, 50%) compared to those with unilateral PAAS (5/20, 25%; p=NS). The mean diameter of the PAAS was 3.4 cm; no significant difference was found in the mean diameter of symptomatic and asymptomatic aneurysms. Complete thrombosis of the aneurysmal sac was found in 15 cases (35.7%), severe atherosclerotic femoro-popliteal lesions in 17 (40.5%), arteriomegaly in 11 (26.2%), occlusion of the superficial femoral artery (SFA) in 7 (16.7%). Three leg arteries were present in 17 limbs (40.5%), 2 in 6 (14.3%), 1 in 7 (16.7%), no leg vessels in 12 (28.6%). Occlusion of the SFA and the absence of major leg arteries were independently associated with thrombosis of the aneurysmal sac (p=0.005). Two-thirds of patients with thrombosed PAA (10, 66.7%) presented with acute ischemia, while 1/3 (5, 33.3%; p=NS) had some degree of claudication. Optimal runoff (score=1) was estimated in 23 limbs, while score was between 2-7 in 19 limbs. Thrombolysis was successful in all 4 cases, with no complications. Primary graft patency was 66.1% at 4 years; the only variables independently associated with loss of bypass patency were smoking (p=0.04) and poor leg runoff (p=0.02). Postoperative bypass occlusion occurred in 2 cases presented respectively with acute and chronic ischemia, and in 2 asymptomatic patients; all 4 bypasses were polytetrafluoroethylene grafts. A total of 8 thrombosed, polytetrafluoroethylene, below-the-knee bypass grafts required secondary reconstructions (2 redo + 6 restorative procedures). The secondary patency rate at 3 years was 77.9%. Lower limb amputation had to be performed 2 months after primary reconstruction in 1 case (2.4%) presented with acute ischemia. The estimated limb salvage rate at 10 years was 96%. Mortality was 4.8%. Survival at 6 years was 82.6%. CONCLUSION: Our experience indicates that SFA occlusion and poor runoff vessels were independent factors associated with PAA thrombosis. The diameter of asymptomatic PAAs was not significantly different than that of asymptomatic ones. Use of tobacco and poor runoff vessels were independent factors associated with primary bypass patency. In PAAs complicated with acute ischemia, thrombolysis allowed us to regain a good runoff and to perform subsequent bypass procedure, with no amputation. The use of autogenous graft material, when possible, is recommended.

[Percutaneous transluminal angioplasty in the treatment of iliac stenosis. The authors' new guideline for 100 patients]. / L'angioplastica transluminale percutanea nel trattamento delle stenosi iliache. Nuovo orientamento personale negli ultimi 100 pazienti.

This retrospective study was carried out from January, 1990, to September, 1994, after reviewing a series of 100 patients submitted to 143 percutaneous maneuvers (PTA) for aortoiliac revascularization (PTA, PTA and stenting, PTA and bypass). This study was aimed at conforming as much as possible our patients selection criteria and the analysis of the results to the current standards adopted by the major interventional radiology and vascular surgery departments. The Fontaine and the SCVIR classification methods were used for patients selection. Long-term patency was analyzed with clinical and noninvasive diagnostic exams. The results were studied with the Life-table analysis statistical method. The patients were divided into 3 groups: the patients treated only with PTA, those treated with PTA and stenting and finally those submitted to PTA before or after a surgical bypass. The results were analyzed separately. In 95/100 patients the maneuver was technically successful and immediate clinical success was not achieved only in one of them. At the first follow-up we collected data on 87 patients; at 3 years we followed-up 30 patients, but only 5 of them had to be resubmitted to PTA (3 PTA and stenting and 2 PTA alone) because of restenosis. Secondary patency was obtained in 91% and 84% of patients at 1 year and 3 years, respectively. With the Life-table analysis, the cumulative patency rate was 95.44% at 36 months. Few complications were observed (11/100 patients), especially considering that they were classified as "severe" in 3 cases only. To conclude, our results prove PTA to be a highly effective tool in the aortoiliac arteries, whose low mortality and complication rates suggest the use of this percutaneous procedure.