Endovascular treatment of transplanted renal artery stenosis with PTA/stenting.

PURPOSE: We evaluated the effectiveness of endovascular treatment with percutaneous transluminal balloon angioplasty (PTA)/stenting of transplanted renal artery stenosis (TRAS). MATERIALS AND METHODS: Between January 2005 and December 2010, 17 patients (4 women, 13 men; mean age 60.9 years) with TRAS underwent PTA/stenting. The parameters analysed were: technical success, pre- and post-treatment serum creatinine (SCr) and blood pressure (BP), average number of antihypertensive drugs administered before and after treatment and vessel patency on colour Doppler ultrasound (CDUS) at 1, 3, 6 and 12 months and once a year thereafter. RESULTS: Technical success was 100%. During a mean follow-up of 28.3±18.7 months, there was a statistically significant reduction in SCr and BP values. In 18 % of cases, moderate (<60%) restenosis was observed on CDUS without renal failure and not requiring new treatment. There was a reduction in antihypertensive drugs from an average of 3.5±0.5 to 1.5±0.5. CONCLUSIONS: Consistent with the literature data, our experience shows that endovascular treatment with PTA/stenting is a safe and effective option for managing TRAS and can thus be considered the method of choice.

Hepatic artery aneurysm treatment with heparin-bonded covered stent: a case report.

The hepatic artery is the second most common site for aneurysms formation within the splanchnic circulation. Most hepatic artery aneurysms (HAA) are diagnosed incidentally by a computed tomography(CT) scan or a Doppler ultrasonography. We present the case of a HAA diagnosed preoperatively in a 82-year old man, who was treated with an endovascular procedure. An abdominal ultrasonography revealed by chance the presence of a HAA. The abdominal CT scan confirmed an aneurysm of the common hepatic artery, specifically at the origin of the gastroduodenal artery. The gastroduodenal artery was embolized using coils then a heparin-bonded covered stent was deployed into the common hepatic artery to exclude the aneurysm. Final arteriogram documented the regular patency of the stent and the complete exclusion of the aneurysm. No complication occurred and the patient was discharged on the second postoperative day. Six months later, a follow-up with a Duplex scan confirmed the regular patency of the stent, and the patient was in good clinical conditions.

Abdominal aortic aneurysm treatment: minimally invasive fast-track surgery and endovascular technique.

In our department we started a program in order to offer a mini-invasive approach to all patients affected by abdominal aortic aneurysms (AAAs), trying to offer this option also to patients not eligible for endovascular aneurysm repair (EVAR) due to unfavorable anatomy, age under 65 years and aorto-iliac occlusive disease, considering nowadays EVAR is the gold-standard for the mini-invasive treatment of AAAs. The aim of this study was to compare endovascular versus fast-track surgical treatment in patients undergoing elective surgery for AAAs. We wanted to verify if it was possible to be totally mini-invasive in the treatment of AAAs. A total of 128 patients were chosen for the study. Ninety-four patients were enrolled in the OPEN group and 34 were enrolled in the EVAR group. This study demonstrates that minimally invasive treatment with the fast-track protocol may be a valid alternative to EVAR.

Psychological aspects of pain.

The patients affected by critical limb ischemia (CLI) are patients generally considered difficult cases, destined to repeated approach to the sanitary structures. They are patients affected by many pathologies since years, that they know to be potentially lethal often have already faced many interventions, with partial and not long-lasting benefits, they go from one specialist to another and sometimes they entrust themselves to alternative medicine. Physicians have to take in charge not the pathology but to take in charge the patient. For the control of the pain it turns out essential, near the block of the perception of the pain, to act with psychological participation, in order to interfere with the perception of the pain and the meant one of the pain, modify the feelings associated to the pain, modify the behavior induced by pain.

Cystic adventitial disease of the popliteal artery. Report of 1 case and review of the literature.

Cystic adventitial disease (CAD) of the popliteal artery is a rare but well-known cause of intermittent claudication, especially in young patients. The etiology of the disease is still controversial and the literature reports various hypotheses for its origin. Diagnosis starts with thorough history taking and physical examination; non invasive diagnostic studies comprise color duplex scanner (ECD), computed tomography (CT), better if elicoidal (3D CT) and magnetic resonance imaging (MRI), which can aid in establishing correct recognition of the disease in most cases. A 48-year-old man presented with intermittent right calf claudication that had begun 4 months earlier; the symptom-free interval was about 100 m. MRI and MR angiography of right popliteal fossa revealed the presence of an oval cystic (maximum diameter 45 mm). The caudal aspect of the cyst showed pedicles protruding between the popliteal vein and the popliteal artery that compressed the artery, causing complete occlusion of its lumen. Surgery was performed through the posterior approach using an S-shaped incision; the affected segment of the popliteal artery was successfully excised and replaced with an autogenous external saphenous vein graft. A follow-up is underway, both clinical and with; no cyst recurrence has so far been detected either clinically or by duplex scanner during the 15-month postoperative follow-up period; the graft is patent and the patient is completely symptom free. Severe claudication in young patients, possibly without significant vascular risk factors, should prompt the clinical suspicion of adventitial cystic disease of the popliteal artery. Medical history, clinical examination and non invasive instrumental investigations, such as duplex scanner, elicoidal CT and/or MRI, may aid in establishing the correct diagnosis.

[Therapeutic approach to the unilateral occlusive iliac artery disease. Preliminary results]. / Strategie terapeutiche nelle lesioni obliteranti monolaterali dell'asse arterioso iliaco. Risultati preliminari.

BACKGROUND: The different therapeutic approaches to unilateral occlusive iliac artery disease are analyzed. METHODS: In the period from September 1999 to September 2001, a total of 43 patients (38 males and 5 females) has been treated for unilateral iliac artery occlusive disease. Thirty-four cases (79%) underwent an endovascular procedure, and the remaining 9 cases (21%) had a surgical intervention. Endovascular techniques included 11 cases of percutaneous transluminal angioplasty (PTA) of common iliac artery (25.6% of whole series), 5 PTA of external iliac artery (11.6%), 8 PTA+stenting of common iliac artery (18.6%) and 10 PTA+stenting of external iliac artery (23.2%). In 9 cases a surgical revascularization was performed: 6 patients underwent a femoro-femoral cross-over bypass (14%); 2 cases were treated with aorto-bifemoral reconstruction (4.7%) and one patient was operated with ilio-femoral graft (2.3 %). RESULTS: The analysis of the follow-up of our series showed, in the group of 34 patients treated with endovascular procedures, successful results were obtained in 79.4% (27 cases); in the 9 patients operated with surgical revascularization the success rate was 88.9% (8 cases ); failure rate was 20.6% for endovascular procedures and 11.1% for surgical interventions. CONCLUSIONS: The conclusion is drawn that endovascular approach (PTA, stenting) is usually the procedure of choice in the treatment of unilateral well localised lesions of the iliac artery. Conventional surgical intervention is effective for revascularizing an extensive involvement of the iliac segment or in case of bilateral disease.

Recurrent varices after internal saphenectomy. Physiopathological hypothesis and clinical approach.

BACKGROUND: This paper analyses the causes and describes the best care of recurrent varicose veins after internal saphenectomy. METHODS: A series of 19 patients who had previously undergone internal saphenectomy were selected for surgery due to recurrent varices in the lower limbs. Clinical examination and colour duplex sonography were used as the preoperative diagnostic tools in all patients. No patients underwent phlebography. In 17 cases the main source of reflux was an incontinent saphenous stump at the level of the saphenofemoral junction with varicose cross-groin collaterals. In 2 cases recurrence was caused by incontinence of the upper thigh perforating vein. In 1 of these patients the recurrence also involved the district of the small saphenous vein. Groin neovascularisation was detected in 1 patient. RESULTS: All patients underwent groin re-dissections using transversal incisions: in 9 cases, access to the saphenofemoral junction was obtained under or at the same level as the inguinal fold, and in 10 cases using a suprainguinal route. The vertical inguinal incision was never employed. Incompetent perforating veins (thigh or leg) were ligated or sectioned in 11 patients. Ligations and exeresis of communicating veins were executed in all patients. Müller's phlebectomies were performed intra- or postoperatively on collateral varices in practically all cases. Postoperative ambulatory sclerotherapy was necessary in 6 cases. CONCLUSIONS: A correct surgical approach is only assured by diagnostic accuracy coupled with a precise hemodynamic evaluation. Correct management of the postoperative follow-up of varicose vein surgery is also important.

Aneurysms of the hypogastric artery following surgery of the abdominal aorta. A report of two cases and review of the literature.

Isolated aneurysms of the hypogastric artery are very rare and account for between 0.04% and 0.4% of all intra-abdominal aneurysms. In 85% of cases they are monolateral and are present in association with an aneurysm of the infrarenal abdominal aorta and of the common and external iliac arteries, they make up part of a poly-aneurysmal disease. Unless the patient is an extremely poor condition, surgical treatment is generally indicated for aneurysms greater than 3 cm; close monitoring of those with smaller aneurysms is recommended. Two patients presented with isolated aneurysm of an internal iliac artery which had developed several years after aortoiliac surgery. The one received surgical treatment; the other, who was in poor general conditions and at high risk for surgery, underwent endovascular embolization. Both procedures were successful, with a current follow-up between 15 and 18 months. Endovascular embolization, as performed in the 2(nd) patient, provided an alternative to the surgical procedure. After injection in the aneurysmal sac of the Gianturco spirals, a covered stent was placed in the iliac axis to exclude the inflow of the hypogastric artery. According to our experience of 2 patients, the one treated surgically and the other submitted to a less invasive endovascular procedure, we can state that both methods are practicable. The final choice lies with the vascular surgeon, after weighing the multiple factors that each case involves.

Compliance of geriatric patients subjected to antiplatelet agents with Triflusal in peripheral arteriopathy. Preliminary data.

BACKGROUND: Triflusal is an irreversible inhibitor of platelet cyclooxygenase. Triflusal significantly reduced the incidence of nonfatal myocardial infarction in patients with unstable angina. Antithrombotic properties have also been demonstrated in patients with aortocoronary vein grafting, coronary angioplasty, peripheral arteriopathy and cerebrovascular disease. Moreover, in diabetic patients it has a protective effect against retinal microangiopathy, improves renal flow and reduces proteinuria. The drug has a high tolerability and has low incidence of side effects, with prevalence of gastrointestinal and skin disorders. Because of its demonstrated effectiveness and its good handling, we decided to use Triflusal in treatment of geriatric patients with peripheral arteriopathy. Often these patients have a diffused arteriopathic disease which can be associated with chronic diseases. For this reason there are severe problems of compliance due to contemporary administration of several drugs; so the utilization of effective drugs, without side effects, promotes a safer clinical management of patients. METHODS: Between April 2000 and March 2001, we treated with Triflusal 70 patients, over 65 years old, with peripheral arteriopathy. The group comprises patients who had undergone traditional vascular surgery, or endovascular surgery and patients treated exclusively with drug therapy. During the follow-up we obser-ved the possible clinical development of side effects of the drug reported in the literature (nausea, vomiting, etc.). RESULTS: One patient, already affected by gastroduodenal disease, suspended the therapy because of severe epigastric burning. CONCLUSIONS: The follow-up of the patients goes on in order to evaluate the tolerability and handling of Triflusal, observing a larger number of patients.

Small aorta syndrome: hypothesis or reality?

A syndrome of peripheral obliterating arterial disease characterised by aortoiliac steno-occlusion is reported in the literature under the name small aorta syndrome, occurring in young women of small stature with relatively typical risk factors. Starting from an analysis of the studies reported in the literature and on the basis of our own results, we have attempted to ascertain whether small aorta syndrome represents an independent nosological entity. By analysing studies on the small aorta syndrome and in the light of a recent study made by our group on arterial diameters measured in cadavers, which highlights a significant correlation between aortic diameter and age, it can be affirmed that a pathology of this nature does not respond to absolute criteria for existence. Therefore, the aortoiliac diameter in women suspected of being affected by small aorta syndrome appears to be broadly in proportion to that expected in healthy women of the same age. Small aorta syndrome does not therefore appear to represent a separate nosological entity. It takes the form of a hypoplastic vascular disorder, which is probably congenital, correlated to other arterial districts in the same subject. However, it may encourage the onset of early symptoms in women of small stature.

[Retroperitoneal fibrosis associated with neuritis symptomatology due to external iliac artery stent subadventitial migration]. / Fibrosi retroperitoneale associata a sintomatologia nevritica dovuta alla migrazione sottoavventiziale di stent dell'arteria iliaca esterna.

The occurrence of a neuritis of the ischiatic nerve and the genito-femoral nerve due to the implant of three stents in the iliac artery, is an extremely rare complication, especially if associated with retroperitoneal fibrosis which caused a nevritis symptomatology. A case of stent migration in the subadventitial space which caused 4 years from angioplasty and stents implant, a nevritis symptomatology. Retroperitoneal fibrosis has been considered as a consequence of the stents presence and of their chronic irritational activity, especially for what concerns the stent migrated in the subadventitial space; the procedure personally performed in this case is reported.

[Anomalies of the inferior vena cava in patients treated with surgical vascular procedures in the aorto iliac area. Report of 2 cases and review of the literature]. / Anomalie della vena cava inferiore in pazienti sottoposti a chirurgia del distretto aorto iliaco. A proposito di due casi operati e revisione della letteratura.

Two cases of left-sided inferior vena cava observed in a patient affected by Leriche syndrome and the other affected by aortic abdominal aneurysm (AAA) are presented. This very rare congenital malformation (0.2-0.5) was not recognized by the duplex scanner performed preoperatively probably because of the low level of suspicion carried on by an experienced operator. Angio-CT e angio-MR which would have surely showed the anomaly, were not done because in the absence of an aneurysmal disease or other abdominal situations, these investigations were not required before operation. An angio-CT was performed routinely to the patient affected by AAA and so the left-sided vena cava was observed before operation; and then an abdominal arteriography and an ilio-caval venography were required which documented the vena cava anomaly. Surgical interventions didn t have complications. In the case of Leriche syndrome an aorto-bifemoral bypass was performed, and in the case of abdominal AAA an aortic left-iliac right-femoral bypass. Preoperative unrecognizing of this venous malformation is very hazardous mostly in terms of uncontrollable intraoperative hemorrhages. Ultrasonographic diagnosis with duplex scanner has to be very accurate in order to observe not only arterial diseases but also the possible venous anomalies of the abdominal district.

Acute lower limb thrombosis caused by a congenital fibrous ring of the superficial femoral artery.

Segmentary isolated stenosis or obstructions of the superficial femoral artery in young people are rarely reported. In patients, most of them women, affected by chronic symptomatology of the lower limbs, the aetiology has been referred to fibromuscular dysplasia with unusual localization. We report a case of acute lower limb thrombosis in a young woman caused by a congenital fibrous ring of the superficial femoral artery and the treatment we performed in this situation including the complication that happened after the percutaneous transluminal angioplasty that we carried out in order to reduce the stenosis of the femoral superficial artery. Histological examination of the lesion demonstrated the nature of the fibrous ring caused by an embryological anomaly, followed by a secondary thrombosis in a woman not using oral contraceptives and without any alteration of the coagulation chain. Fibromuscular dysplasia of the femoral artery is commonly caused by previous thigh injuries, thromboembolic events with recanalization of the artery or arteritis, but in some cases appears to be the consequence of primitive intimal dysplasia. When a fibromuscular dysplasia is suspected, all authors agree on the necessity for a screening of the two preferential localizations of the disease: common carotid artery and renal artery, in the case reported the result was negative.

[Vascular pathology of surgical interest in drug addicts]. / Patologie vascolari di interesse chirurgico nei tossicodipendenti.

The incidence of vascular complications due to drug abuse is at present increasing due to new types of drugs and to the different ways of intake of such substances. The vascular complications related to drug abuse may affect venous, arterious and lymphatic districts and in particular: ischemia following intra-arterial injections, arterious and venous pseudoaneurysm, vasculitis, aneurysms, aortic dissections, abscesses complicated by erosions of vessels, arteriovenous fistulas, compartment syndrome, superficial and deep venous thrombosis, septic trombophlebitis, puffy hand syndrome. The scientific knowledge in this matter is incomplete because of the new pathological cases and the lack of information regarding the efficacy of different treatments. The authors report four patients affected by vascular pathologies due to drug abuse. In one case, a heroin addict has undergone multiple fasciotomies for compartimental syndrome arising because the patient maintained an innatural posture for several hours during an overdose coma. In a second case, a segmental right subclavear deep venous thrombosis has been treated by pharmacological therapy with satisfactory functional recovery of the arm. A third patient has been successfully submitted to intra-arterial pharmacological vasodilatation for generalised lower limbs vasospasm caused by drug abuse. In the last case, the voluntary swallowing of a great dose of cocaine caused the patient's death after multiple ischemic and hemorrhagic cerebral episodes. After the description of these cases, a review of the recent literature and some observations on this topic are presented. A better knowledge of vascular complications due to drug abuse should improve the therapeutical approach of these patients.

Oral lesions in children born to HIV-1 positive women.

A cohort of 69 children born to HIV-1 positive women was studied to evaluate types, prevalences and relationships to clinical stages of HIV-1-related oral lesions. In addition, relationships among C. albicans biotypes, clinical features of oral candidiasis and HIV-1 disease were investigated. C. albicans biotypes did not correlate with clinical features of oral lesions, disease stages and CD4+ lymphocyte count. Of 8 patients with recurrent oral candidiasis, 4 changed clinical features and 5 changed biotype. Our study pointed out the high frequency (28.9%) of oral lesions, especially caused by fungi and the importance of the examination of the oral cavity in children born to HIV-1 positive women.

[Psychological reactions of medical staff to the patients infected with HIV-1]. / L'atteggiamento psicologico del medico di fronte al paziente sieropositivo per anti-HIV-1.

This paper describes the relationship between medical staff and HIV-1 patients. Important mechanisms can be used by individuals with HIV-1 infection in order to accept their seropositivity to HIV-1. Among them, regression and negation are well-known. These mechanisms are related to countertransference lived by the medical staff. They are various as well as rejected by medical staff to avoid anxious reactions. On the contrary, the medical staff has to accept the experiences of the patients and to be ready to listen to the problems of HIV-1 infected people.

[Acute necrotizing ulcerative gingivitis (ANUG) in HIV antibody-positive subjects]. / Gengivite ulcero-necrotica acuta (GUNA) in soggetti AbHIV positivi.

The paper reports five cases of acute ulcero-necrotic gingivitis in AbHIV-positive subjects and stresses that the frequency of this pathology in the AbHIV-positive population is 0.67% (3.3% if only the homosexual population is taken into consideration) compared to 0.02-0.08% in the normal population. These findings may therefore suggest an association between AUNG and HIV-1 infection.

[The preliminary results of research on salcatonin treatment in the surgical therapy of jaw cysts]. / Risultati preliminari di una ricerca sul trattamento con salcatonina nella terapia chirurgica delle cisti dei mascellari.

The results of research concerning a local and systemic treatment with salcatonin in surgical therapy of maxillary cysts are reported. A reduction in bone recovery time has been noted in the cases studied; this means a reduction in osteolytic area and a roentgenographic opacification of the same.

[Anaerobic bacteria in oral infections of dental origin. The characteristics of Bacteroides species and diagnosis]. / Batteri anaerobi nelle infezioni orali di origine dentale. Caratteristiche di specie e diagnosi per i bacteroides.

Pyogenic orofacial infections are generally the result of a mixed aerobic and anaerobic infection. The aerobic germ, particularly the Bacteroides, have a prevailing role, even though their etiopathogenetic role is not clear yet.