Spontaneous recanalization of occluded internal carotid artery after minor stroke. The role of surgical treatment.

Late spontaneous recanalization of internal carotid artery is a very rare event. We describe three cases which came to our observation in which the occlusion was demonstrated both by angiography and Doppler ultrasound. Two of them had surgical treatment and the histological exam of the plaque showed multiple recanalization foci. Our experience confirmed the possibility of a successful surgical treatment that offers a good patency in the short and medium term.

Management of superficial vein thrombosis and thrombophlebitis: status and expert opinion document.

Superficial vein thrombosis is characterized by clotting of superficial veins (ie, following direct trauma) with minimal inflammatory components. Superficial thrombophlebitis is a minimally thrombotic process of superficial veins associated with inflammatory changes and/or infection. Treatments generally include analgesics, elastic compression, anti-inflammatory agents, exercise and ambulation, and, in some cases, local or systemic anticoagulants. It is better to avoid bed rest and reduced mobility. Topical analgesia with nonsteroidal, anti-inflammatory creams applied locally to the superficial vein thrombosis/superficial thrombophlebitis area controls symptoms. Hirudoid cream (heparinoid) shortens the duration of signs/symptoms. Locally acting anticoagulants/antithrombotics (Viatromb, Lipohep, spray Na-heparin) have positive effects on pain and on the reduction in thrombus size. Intravenous catheters should be changed every 24 to 48 hours (depending on venous flow and clinical parameters) to prevent superficial vein thrombosis/superficial thrombophlebitis and removed in case of events. Low molecular weight heparin prophylaxis and nitroglycerin patches distal to peripheral lines may reduce the incidence of superficial vein thrombosis/superficial thrombophlebitis in patients with vein catheters. In case of superficial vein thrombosis/superficial thrombophlebitis, vein lines should be removed. In neoplastic diseases and hematological disorders, anticoagulants may be necessary. Exercise reduces pain and the possibility of deep vein thrombosis. Only in cases in which pain is very severe is bed rest necessary. Deep vein thrombosis prophylaxis should be established in patients with reduced mobility. Antibiotics usually do not have a place in superficial vein thrombosis/superficial thrombophlebitis unless there are documented infections. Prevention of superficial vein thrombosis should be considered on the basis of patient's history and clinical evaluation.

Endovascular treatment of endoleaks after endovascular abdominal aortic aneurysm repair: personal experience.

PURPOSE: This paper describes the different endovascular treatments (cuffs, endografts and embolisation) available for types I, II and III endoleaks occurring after endovascular abdominal aortic aneurysm repair (EVAR). MATERIALS AND METHODS: From January 2000 to June 2006, 134 patients (118 men, 16 women; mean age 75.1 years) underwent EVAR. Ten patients (7%) developed significant endoleaks requiring endovascular treatment. RESULTS: Five endoleaks were type I, two were type II and three were type III. Of the five type I endoleaks, four were proximal and one was distal. The proximal endoleaks were treated by cuff deployment, whereas the distal endoleak was treated with a bifurcated graft. Of the two patients with type II endoleak, one was treated by translumbar puncture and coil embolisation, and the other was treated by superselective embolisation of the lumbar feeding vessel with nonresorbable particles. Of the three patients with type III endoleak, two were treated by deploying an aortouniiliac endograft inside the bifurcated graft and the other by implanting a cuff to restore continuity between the graft body and the contralateral limb. Endovascular treatment was successful in 6/10 cases, whereas three cases required surgical conversion. One patient did not undergo surgery owing to poor general condition. CONCLUSIONS: The reported incidence of endoleaks after EVAR is 10%-20%. Significant endoleaks should be treated promptly. Endovascular treatment can be done with different techniques, but success in not constant due to adverse anatomical conditions and technical difficulties.

Prevention of edema and flight microangiopathy with Venoruton (HR), (0-[beta-hydroxyethyl]-rutosides) in patients with varicose veins.

The aim of this open study was the evaluation of the effects of HR (Venoruton) at a dose of 1 g/day on the prevention and control of flight microangiopathy and edema in subjects with varicose veins and moderate chronic venous insufficiency flying for more than 11 hours. Patients with varicose veins, edema, but without initial skin alterations or complications, were included. Measurements of skin laser Doppler (LDF) resting flux (RF) venoarteriolar response (VAR), ankle swelling (RAS), and edema were made within 12 hours before and within 3 hours after the flights. The resulting edema after the flights was evaluated with a composite edema score (analogue scale line). A group of 20 subjects was treated with HR (1 g/day, starting 2 days before the flight and 1 g for every 12 hours on day of travel). Another group of 18 subjects formed the control group. The length of the flights was between 11 and 13 hours; all seats were in coach class. Fifty patients were enrolled and 38 patients were evaluable at the end of the trial. The 2 groups (treatment and control) were comparable for age and sex distribution. The decrease in RF was significant in both groups with a higher flux at the end of the flight in the HR group (p < 0.05). The venoarteriolar response was decreased at the end of the flights; the decrease was lower in the HR group (p < 0.05). The increase in RAS and the edema score were significantly lower in the HR group. In conclusion HR is useful for reducing the level of microangiopathy and the increased capillary filtration and in controlling edema in patients with venous disease in long flights. The higher level of flux and VAR and the reduction in edema indicate a positive effect of HR on the microcirculation. This study confirms that HR prophylaxis is effective to control flight microangiopathy associated with edema.

An unusual complication of open aortic surgery: hemorrhage due to the iatrogenic rupture of a renal cyst.

The authors describe a clinical case of a retroperitoneal hemorrhage due to rupture of a voluminous renal cyst during a conventional open aortic surgery. Intraoperative trauma is to be considered the cause of bleeding. In most cases the clinical evolution of the patient is benign and conservative treatment is sufficient. Considering the incidence of renal cysts in patients ungergoing conventional aortic surgery, we want to emphasize this possible complication, that has only rarely been dealt with in the literature. We recommend evaluation of such patients in view of preoperative drainage of large cyst including injection of sclerosing agents.

Middle aortic syndrome: an atypical case--a case report.

This case concerns a 61-year-old woman presenting with middle aortic syndrome treated by an aortoaortic thoracoabdominal polytetrafluoroethylene bypass and a right renal Dacron bypass. The case was atypical because of the patient's advanced age at the time of clinical presentation.

[The subclavian-carotid bypass as a method for treating obstruction of the common carotid]. / Il by-pass succlavio-carotideo quale metodica di trattamento dell'ostruzione della carotide comune.

Common carotid artery occlusion is a relatively uncommon lesion (0.5-5% of patients with cerebral ischaemia). Cerebral revascularization is possible only in case of patent carotid bifurcation, three patients, all of them symptomatic (2 TIA's and 1 amaurosis fugax) with a complete common carotid artery occlusion have been treated with a subclavian-carotid artery by-pass (2 PTFE, 1 reversed saphenous vein). Among the patients one death occurred in the fourth postoperative day by bronchopneumonia, no stroke was detected, in the remaining two, the by-pass was patent one year and respectively three years post-operatively. In case of common carotid artery occlusion, visualization of bifurcation is usually better obtained through a color-duplex than arteriography. Several operations have been proposed in these patients (retrograde thrombectomy, carotid to carotid by-pass, carotid-subclavian reimplantation), but subclavian to carotid by-pass is the most safe and common used procedure.

[Ischemic heart disease and postoperative mortality in major vascular surgery. An up-to-date diagnostic approach]. / Cardiopatia ischemica e mortalità operatoria in chirurgia vascolare maggiore. Un moderno approccio diagnostico.

BACKGROUND: The aim of this study is to evaluate the efficacy the dobutamine stress echocardiography in predicting the perioperative cardiac risk of patients undergoing major vascular surgery. METHODS: Seventy-seven consecutive and not selected patients, undergoing a surgical treatment requiring aortic cross clamping, were assessed also with a transthoracic dobutamine stress echocardiography. With electrocardiographic and echocardiographic monitoring ventricular ischemia or wall motion abnormalities, 5 micrograms/kg per min of chlorhydrate dobutamine for 5 minutes were infused, followed by other 10 micrograms/kg per min increased up to 40 micrograms/kg per min. During the last 4 minutes 0.25 mg of atropin were infused increasingly up to 1 mg. RESULTS: Of all these patients, 26 had a stress ischemia but only 4 cases underwent a coronary angiography and only 2 of these underwent a preventive myocardial revascularization. Due to poor cardiac conditions pointed out with the dobutamine stress, 3 patients were not treated surgically. With an aggressive intra- and perioperative monitoring 73 patients underwent a surgical treatment: they were 28 aorto-bifemoral, 3 aorto-aortic grafts, 1 aorto-bisiliac thoraco-abdominal interposition graft, and 20 aorto-bifemoral, 4 aorto-femoral, 1 aorto-aortic thoraco-abdominal, 1 aorto-renal by-pass and 7 aorto-iliac-femoral thromboendoarterectomies. In the postoperative period 4 cardiac ischemic complications and 2 deaths (2.5%) were observed. CONCLUSIONS: According to our personal opinion, stress echocardiography can be considered a test with a excellent feasibility and safety rate, not expensive and with a good reproducibility and reliability. It allowed to predict the cardiac risk in our patients suggesting not only the surgical but also the anesthesiologic and the perioperative therapeutic management.

Arterial injury of the axilla: an unusual case after blunt trauma of the shoulder.

The lesion of an axillary artery after a shoulder dislocation without bone fractures is very rare. The most common lesion is the subtotal transection of the vessel. Vascular injuries may be associated with nervous lesions whose incidence ranges from 27 to 44%. The nervous lesions are highly invalidating. The symptoms which recur most frequently are motor and sensitive deficiencies and a distal ischemia which, in some cases, may not be noted owing to the extensive collateral network. Whenever these symptoms are covered or absent, as in this case report, an angiography of the upper limb becomes essential for correct diagnosis and treatment.

[Endovascular treatment of isolated aneurysms of the hypogastric artery: technical considerations apropos of 2 cases]. / Il trattamento endovascolare degli aneurismi isolati dell'arteria ipogastrica: considerazioni tecniche a proposito di due casi.

Isolated aneurysm of the internal iliac artery is uncommon, with an incidence approaching 0.4%; its diagnosis is difficult; its natural course is progressive expansion and rupture. Two cases of hypogastric aneurysms, promptly treated with embolization, are reported. In selected patients the endovascular technique can represent a good alternative to the traditional surgical treatment that is associated with higher complication and mortality rate.

[Local excision of rectal cancer in early phase as an alternative to major surgery]. / L'escissione locale del cancro del retto in fase "early" quale alternativa agli interventi chirurgici maggiori.

The authors analyse the role of local excision as curative procedure of low rectal early cancer. In their opinion it's very important to select the patients in accordance with some characteristics of the tumor (site, grading, mobility, depth, size, stage, involvement of locoregional nodes, ploidia). Intrarectal ultrasonography is thought be the most important diagnostic tool, both in preoperative diagnosis and in postoperative follow-up; it has a high sensibility to define the parietal invasion of rectal cancer and to recognize metastatic nodes. They review various surgical techniques used to make local excision by several authors (transsacral approach by Kraske, transsphinteric approach by Mason and transanal approach by Bailey), as well as the alternative methods (surgical diathermy by Strauss, endocavitary irradiation by Papillon and cryosurgery by Heberer). The authors point out the technique of Bailey and coll. is getting the major approvals owing to its simplicity, low mortality and morbidity rates, poor incidence of recurrences and good survival. The most recent therapeutic protocols provide only local excision for the lesions limited into mucosa and submucosa (stage T1), also postoperative radio- and chemotherapy for tumors involving muscolaris propria (stage T2). On the other hand, advanced rectal cancer (stage T3) may be managed best by major operations. Recurrences rates (5-22%) and five-years survival rates (78-90%) are obviously conditioned by tumor features. Finally, the authors reaffirm, with their personal experience as well, the importance of local excision as curative operation for low rectal early cancer, provided that a careful case selection is made in accordance with macro- and microscopical features of the tumor.

[Intraoperative iliac angioplasty and distal revascularization: is it an efficacious method in the high-risk patient?]. / Angioplastia ilíaca intraoperatoria y revascularización distal: es un método eficaz en el paciente de alto riesgo?

The fact that iliac femoro-popliteal areas are both simultaneously interested in some high risk patients, frequently is cause of several problems in the indication of the surgical treatment. So, we have decided to practice an iliac Angioplasty peroperatively as a method of iliac revascularization in association with the surgical repairment of the femoro-popliteal area. Results of 20 patients with 23 surgical procedures during a period of two years is reported.

[Dacron-EXS prosthesis in axillo-femoral bypass]. / La protesi di Dacron-EXS nel distretto axillo-femorale.

Twenty-eight axillary by-pass were performed in 27 patients using a dacron externally supported prosthesis. This group of patients has been compared with two other groups in which a dacron knitted (20 p.) or a PTFE (55 p.) prosthesis were implanted. A three years patency has been respectively: 66.6% (EXS), 57.7 (PTFE), 45.5 (Knitted Velour).

Acute thrombosis of renal artery: restoration of renal function after late revascularization.

The authors report a successful surgical revascularization of a solitary kidney after 34 days of anuria in a patient affected by acute thrombosis of the renal artery. Since the renal function can be restored even after prolonged anuria, acute renal artery occlusions should be promptly diagnosed and treated.

Acute thrombosis of the infrarenal aorta. Therapeutic problems.

Acute thrombosis of the infrarenal aorta is a rare event, usually complicating aortic atherosclerotic lesions or aortic aneurysms. During the last twelve years, we treated 10 acute aortic thromboses out of 353 acute ischemias of the lower limbs (2.8%). The high mortality of our series (60%) is related to advanced age (71 years on average), severe underlying cardiopathy, and the frequent involvement of the renal and mesenteric vessels. In our experience Fogarty catheter thrombectomy is usually ineffective, and the surgical approach in high risk patients should be confined to axillobifemoral bypass graft.

Long term results of extra anatomical bypasses.

The authors discuss their own experience with extra anatomical bypasses. It is composed by 214 patients who underwent 224 extra anatomical bypasses: 167 axillofemoral bypasses, 50 femorofemoral bypasses and 7 trans-obturator bypasses. The indications included the presence of infections, or a previously thrombosed aortic prosthesis, or infected aneurysm, in 12.1% of the cases; in 6.2% of the cases the extra anatomical bypass was due to acute ischaemia of limb. In 81.7% it was chosen because of the presence of some general or local contraindication to direct aortoiliac reconstruction. The results are comparable to those reported in the literature. The only unusually high datum is the rate of early infections in femorofemoral bypasses (12%). On the ground of these results, the Authors stress the value of extra-anatomical bypasses as an alternative to direct aortoiliac reconstructions.