Chromosomal alterations in atherosclerotic plaques.

Alterations of chromosomes 7 and 11 have been involved in the progression of atherosclerosis. Twenty-three carotid endarterectomy specimens were studied for the presence of alterations in chromosomes 7 and 11, and fibroblastic growth factor-3 (FGF-3) gene amplification. Besides classic histological stainings, immunophenotyping of cellular and vascular components and fluorescence in situ hybridization (FISH) were performed. At the caps, unstable plaques (n=18) showed inflammatory infiltration of macrophages, smooth muscle cells, and T-lymphocytes. Specifically in these regions, the FISH showed varying percentages of trisomy (15/18) and tetrasomy (8/15) of chromosome 7. In four cases polisomy 7 was noted in some nuclei. Monosomy of chromosome 11 and gene amplification of FGF-3 gene was observed. The FISH of the five stable plaques and normal arterial walls showed no chromosome alterations; furthermore, chromosome 3, which is not involved in atherosclerotic progression, presented a normal ploidy of smooth muscle cells in stable and unstable plaques and normal arterial walls. In conclusion, chromosome 7 and 11 alterations and FGF-3 gene amplification are components of unstable plaques, and might contribute to the evolution of stable plaques into complicated plaques.

[Type "A" aortic dissection. Surgical technique, caseload, and follow-up]. / Dissezione aortica di tipo "A". Tecnica chirurgica, casistica e follow-up.

BACKGROUND: The authors analyse the indications for the various surgical strategies through a retrospective study of the morbility and mortality rates in their own series of cases and during follow-up. METHODS: 107 patients were operated for type A aortic dissection between 1978 and 1998: 69 using a technique performed under moderate hypothermia (Group A) and 38 in deep hypothermia (Group B). All patients who survived from 1978 to 1994 underwent an accurate follow-up. RESULTS: The mortality rate in Group A was 21.7% and 26.3% in Group B. 61.9% patients in Group B presented thrombosis of the false lumen, compared to 30.6% in Group A. Patients with a false perfused lumen underwent re-do surgery in 9.5% compared to 3.5% in those with thrombosed false lumen, and 16.6% showed an aortic dilatation rate of over 5 cm compared to 7.1%. CONCLUSIONS: From an analysis of these data, and in line with the data reported in the literature, although it is impossible lo indicate an ideal surgical strategy for this severe pathology, it is extremely important to achieve thrombosis of the false lumen.

[Vascular pathology. A study of some blood parameters indicative of leukocyte activation and platelet dysfunction]. / Patologia vascolare. Studio di alcuni parametri ematici indicativi di attivazione leucocitaria e disfunzione piastrinica.

BACKGROUND: In vascular pathology the endothelial lesions easily reflect on blood cells, inducing a reactive state. In the present study the eventual presence of activation signals in leukocytes and platelets was tested. METHODS: Fifty-eight subjects with major vascular pathology and 14 with lower limbs venous insufficiency were studied, together with a control group of 25 normal subjects. Elastase PMN, superoxide ion, leukocytes and subpopulation count, platelet factor 3, clot retraction, heparin in neutralizing activity (HNA plasmatic and intraplatelet), platelet count and volume were tested. RESULTS: As regards leukocytes, it was observed a significative increase of elastase PMN and monocytes number for both the studied pathologies, of superoxide ion and leukocyte number only for major vascular pathology; for platelets, an inhibition of functionality, revealed by clot retraction test for arterious and venous pathologies and by HNA test only for the venous one. CONCLUSIONS: As regards the leukocyte activation, elastase PMN is particularly responsive to the endothelial lesion both in arterious and in venous districts, while superoxide ion appears to increase in presence of a marked alteration. The level of monocytes is indicative of an inflammatory condition and of leukocytes of an atherosclerotic inflammatory process. As for platelets, the test clot retraction is specifically sensible to the endothelial abnormality in both the arterious and venous pathologies with addition of an abnormal HNA test only in venous insufficiency. This platelet dysfunction is probably due to endothelial release of vasoactive and heparin amplifying substances.

[Infection prophylaxis in cardiovascular surgery]. / La profilassi delle infezioni in chirurgia cardiovascolare.

MATERIALS AND METHODS: In the period 1986-1994, 2950 patients with cardiovascular diseases were surgically treated. In 2104 cases we placed biological or synthetic grafts to maintain vascular continuity. The most common has turned out to be abdominal aortic aneurysm. We treated 783 cases in emergency conditions. Staging and localization of infection has been the first aim in patients with synthetic vascular grafts. We studied signs and symptoms related to infections. In all cases we discovered the microorganism responsible of infection we started antibiotic therapy. RESULTS: Surgical infection incidence is 4.9% (154 cases). Series analysis has evidenced a decrease in infection incidence in the period 1986-1994. The most frequent infections are: the urinary tract infection (59 cases, 38.5%) followed by surgical wound infection (37 cases, 24.1%), respiratory tract infection (27 cases, 17.5%), vascular graft infection (23 cases, 14.4%). All patients underwent a preoperative antibiotic prophylaxis with 2 degrees-3 degrees generation cephalosporines. We noted a higher graft infection incidence in patients treated with aortobifemoral reconstruction. We handled surgical infection following two main directions: 1-antibiotic therapy, 2-surgical treatment and antibiotic therapy. CONCLUSIONS: We noted surgical technique improvement and correct application of an antibiotic prophylaxis form has turned out to be the "gold standard" in order to reduce cardiovascular surgical infections. To reduce sepsis or graft infection we can work on either of the following: 1) antibiotic therapy; 2) operative time reduction; 3) try to limit vascular surgery in case of concomitant gastrointestinal surgical disease; 4) using alloplastic vascular grafts with high biological compliance; 5) patency time reduction of invasive diagnostic technique.

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.

[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.

[Acute occlusion of the abdominal aorta]. / L'occlusione acuta dell'aorta addominale.

Acute aortic occlusion is a rare event, usually related to atherosclerotic lesions, cardiac embolism or traumatic events. During the last twelve years, we observed 25 acute aortic occlusions: 12 patients (48%) were affected by aortic bifurcation embolism, and 13 patients (52%) by acute aortic thrombosis. There were 18 men (72%) and 7 women (28%) with a median age of 63 years. Severe cardiopathy was observed in 15 patients (60%). Twenty-four patients (96%) underwent surgical treatment: involvement of the renal arteries was found in only 2 cases (8%). We performed 14 aorto-femoral by-passes (58%). Operative mortality was 20%. Death was due to acute kidney failure in 2 cases and to heart infarction in 3 cases.

Idiopathic varicocele: a comparison between types of surgery based on the results of spermiogenesis.

Varicocele must be regarded of the utmost importance in determinating male infertility. Surgical indications should be considered of primary interest in order to achieve a qualitative and quantitative improvement in spermiogram parameters in the majority of the cases. Recent reports showed that it is not the severity of the lesions to determine the alterations in seminal parameters but the length of time of the varicocele. In our report we consider the results achieved on the spermiogram parameters in two groups of 25 patients surgical treated with different techniques. The first group was treated, in others Centers, by means of the traditional technique of ligature of the spermatic vein (Ivanissevich, Palomo). We treated all the patients of the second group (53 patients) with microsurgical technique of anastomosis pampiniform plexus-saphenous vein, and we control the sepermiogram parameters in 25 patients. The first group showed an improvement of the spermiogram parameters after 6 months from the surgical treatment in the 64% of the cases, while in the second group the improvement was of the 92%. Moreover we registered the persistence of this improvement after 12/36 months from the operation time. On the basis of these observations we think that the microsurgical technique leads to the best and longest results on the most invalidating cause of this pathology.

[The surgical treatment of renovascular hypertension in subjects with a single kidney]. / Il trattamento chirurgico dell'ipertensione nefrovascolare in soggetti mononefri.

Renovascular hypertension in subjects with a solitary kidney, though an infrequent condition, requires surgical direct revascularization procedures either to reduce the hypertensive state and, more important, to preserve renal function. This paper reports a series of six surgically treated cases between 1982 and 1990, with at least two years follow-up. Preoperative renal function, as evaluated by BUN and blood creatinine, was reduced in 5 cases, the remaining one being normal. All subjects were hypertensive at admission: in four cases drug therapy was ineffective for restoring normal pressure values. All subjects had previously undergone surgical nephrectomy: in 3 cases for shrunk kidney, in 2 for failure of a previous attempt of renal revascularization, and one for renal tuberculosis. 3 subjects were concomitantly affected with abdominal aortic aneurysm, and one had previously undergone aortobifemoral bypass. Treatment of the concomitant aortic lesion and renal artery revascularization were carried out at the same operation. Operations performed were TEA of residual renal artery in 3 cases, prosthetic reconstruction in 2 and intraoperative transluminal angioplasty by Gruentzig balloon catheter in one. Over a two-year follow-up renal function remained good in 4 cases, while one subject required a second surgical revascularization due to late acute thrombosis of a previous aortorenal saphenous vein graft. Acute early postoperative renal failure occurred in one case and permanent haemodialysis was instituted. No deaths were recorded in this series.

[Major interventions in vascular surgery with and without autotransfusion. Comparison of coagulation and hemodynamic parameters]. / Interventi di chirurgia vascolare maggiore con e senza autotrasfusione. Confronto di parametri coagulativi ed emodinamici.

Twenty out of 32 patients undergoing major vascular surgery received autologous blood transfusion and hemostatic and hematological parameters were evaluated in both transfused and non-transfused groups. Blood and urine samples were also analysed. No acceleration of the hemostatic process was observed during either surgery or the postoperative period; free hemoglobin present in reinfusion sacks (?), even in high doses, was immediately restored to normal values in the patient's circulation. A slight effect was observed at the renal level alone. These findings confirm the good qualitative level of the procedures used to reinfuse blood lost during surgery.

[Profundaplasty as the only revascularization procedure in ischemia of the leg. Clinical contribution]. / La profundoplastica quale unica procedura di rivascolarizzazione nella ischemia dell'arto inferiore. Contributo clinico.

The profunda femoris artery is the primary source of collateral flow to the lower extremity in the presence of superficial femoral and/or popliteal occlusion. The arteriosclerotic disease involvement of this segment is relatively less frequent and in the majority of the cases localized on the ostium and reaches to the first branch. Profundaplasty to relieve limb-threatening ischemia is infrequently employed as an isolated procedure. However many Authors reported their experience on this treatment, in case of critical limb ischemia in patients without significative lesions of the aortofemoral district. Our late four year experience concerns of 22 patients (18 male, 3 female). All the patients had severe ischemia of the lower limbs, with serious symptoms, such as invalidating claudicatio (13), rest pain (7) and gangrene (2). Twenty-two profundaplasty were performed as the only reconstructive procedure. There was no postoperative mortality. Two patients had above knee amputations (15 days and 14 months after the revascularization). All of the other patients improved and follow-up extended to 48 months shows a limb salvage rate of 90%. In conclusion, on the basis of our experience, we think that the operation is recommended, whenever possible, in patients with critical ischemia when the possibilities of more extensive revascularization procedures are considered to be poor.

[Cerebrovascular insufficiency: diagnostic technics compared]. / Insufficienza cerebrovascolare: tecniche diagnostiche a confronto.

The ability of angiodynography (or Color Flow Imaging) to achieve accuracy in image resolution of thin details of venous as well as arterial vessels has made continuous wave Doppler and frequency analysis Doppler almost obsolete techniques. Some controversies exist about the effectiveness of color flow imaging versus duplex scanner imaging, but recent progress in ultrasound imaging technology seems to overcome the problem. Angiodynography can effectively substitute X-ray angiography in some specific instances and is able to limit the use of invasive techniques to cases in which surgical procedures are really foreseeable. The non-invasiveness of angiodynography makes it useful to follow-up the asymptomatic lesions, particularly those of the carotid artery, as well as operated patients. Moreover, people for whom contrast angiography is contraindicated can be operated safely on the bases of angiodynography alone. This paper reports the results of one-year activity of Ultrasound Vascular Laboratory with 1982 patients: 923 (48.7%) had their epiaortic arterial vessels examined, with 180 (19.5%) follow-up controls, 297 (39.9%) negative explorations, 234 (31.5%) hemodynamically not significant lesions, 135 (18.2%) subjects affected with moderate (50-70% stenosis) and non ulcerated carotid stenosis, and 77 (10.4%) patients with ulcerated plaques or > 70% stenosis.

[Arteriovenous fistula of the left renal peduncle after nephrectomy. A clinical case]. / Fistola artero-venosa del peduncolo renale sinistro dopo nefrectomia. Caso clinico.

The Authors report a case of arterio-venous fistula of the left renal pedicle, twenty six years after nephrectomy. The diagnosis was made by clinical signs and confirmed by angiography. Treatment was surgical with complete removal of the fistula.

[Paraganglioma of the neck. Analysis of 32 operated cases]. / Paragangliomi del collo. Analisi di 32 casi operati.

Between january 1965 and november 1990, 32 operations for neck paraganglioma were performed: 29 chemodectomas (carotid body tumors) and 3 paragangliomas of the vagus nerve. Seven subjects were affected with bilateral chemodectomas and one of them showed concurrent unilateral vagal paraganglioma. Two paragangliomas were malignant, with invasion of the latero-cervical lymphnodes revealed at operation. Four individuals came to observation from two different families, suggesting familiarity. Preoperative diagnosis was correctly made in 12 of 18 asymptomatic chemodectomas (66.6%), ten of whom observed during the last decade: angiography is the gold standard for diagnosis but CT scan, ultrasound and NMR imaging are going to earn the confidence of physicians for precise evaluation of latero-cervical masses. Surgery is to date the treatment of choice, and the results are dependent on the size of the tumor and the involvement of the neighbouring vascular, nervous and visceral structures. According to the majority of the literature, the 29 chemodectomas were classified in the three groups of Shamblin: I: 4 cases; II: 10; III: 15. Twenty out of the 24 transient or permanent postoperative complications took place in the third group: in five instances some procedures of internal carotid artery reconstruction were needed. Fourteen complications for chemodectomas and 2 for vagal paragangliomas affected the cranial nerves; three transient and one permanent ischemic central neurological deficits occurred in the group III chemodectomas. Not any operative mortality was registered in this series.

[Thrombectomy of the infra- and suprarenal cava to prevent pulmonary embolism in the presence of deep venous thrombosis. Personal experience with 11 surgically-treated cases]. / Trombectomia della cava infra- e soprarenale quale prevenzione dell'embolia polmonare in presenza di TVP. Esperienza personale su 11 casi operati.

DVT is a fairly frequent event and often fails to be recognised. Its main complication, pulmonary embolism, is the third cause of death in Italy with more than 70,000 deaths per annum. In the presence of infra- and suprarenal floating thrombi, cases in which the application of neither intraluminal nor extraluminal filters is indicated, the treatment of choice is thrombectomy with direct surgical access to the cava. Personal experience of 11 patients operated in the past 16 months with excellent surgical success is analysed. The indications and surgical techniques adopted are described.

Surgical treatment of abdominal aortic aneurysm. A ten-year experience (1980-1989) referred to 1725 patients operated on.

The authors' experience of surgical management of abdominal aortic aneurysms (AAA), in 1725 consecutive patients, operated on in a ten years period (1980-1989) is presented. Surgical indications, operative technique, and outcome of elective and emergency procedures are analyzed. A ten years follow-up period is also presented. This shows a significantly better survival rate in surgically treated patients than in nonoperated cases.

[Association of pheochromocytoma and phakomatosis. Apropos of a clinical case]. / Associazione di feocromocitoma e facomatosi. A proposito di un caso clinico.

Of the multiple endocrine syndromes, the association between pheocromochytoma, medullary thyroid carcinoma (MTC) and parathyroid-hyperplasia (Sipple's syndrome, MEN IIa), and the association of MTC, with multiple monocutaneous neuromas and with a characteristic facial appearance (MEN IIb syndrome) are well known. Furthermore in about 10% of the patients affected by Von Recklinghausen's disease (neurofibromatosis) a pheocromochytoma is present. A new classification of this important (even though rare) chapter of endocrine pathology was developed by Pears in 1968 when he hypothesized a common neuroectodermic origin for groups of cells diffused throughout the body and nested in different organs. The association of such different pathological conditions could be justified by a faulty development of these primitive neuroectodermic cells. This study aim to analyse a recently observed case of pheocromochytoma associated with Von Recklinghausen's disease. The Pathogenetic hypotheses of this rare pathological association, the diagnostic methods and the therapeutic procedures will be review.

[Arterial diseases of surgical importance. Long-term control of diet-related risk factors]. / Arteriopatie di interesse chirurgico. Controllo a distanza di fattori di rischio connessi con la dieta.

From 1980 to 1990 a yearly medical-surgical control was carried out on 950 arteriopathic patients hospitalised in the General and Cardiovascular Surgery Institute, Milan University, during the above mentioned period. The operations for surgical reconstruction were mainly for arteriosclerotic lesions involving the abdominal-peripheral district (750 patients, 79%) and the supra aortic trunks (200 patients, 21%). 84% of the patients were males. Among the patients on follow-up, a relatively modest number (100 patients) did not attend the prescribed diet therapies for several reasons, consequently these patients have been considered as a control group. The comparison, between the patients who attended and those who did not attend the diet, has been made on the basis of the following parameters: cholesterolemia (COL), LDL, HDL, triglyceridemia (TG), VLDL, glycemia (GLI), body mass index (BMI) and arterial pressure (PA). The results have shown a decrease in the absolute normal values of cholesterol, LDL and triglycerides, while they have not shown the same significant variations regarding glycemia and body weight. In accordance with the literature, the diet seems to have obtained satisfactory results, especially regarding the values of lipidemia, with a reduction in the atherogenic risk index. Regarding smoke as a risk factor it has been shown that it is present in 80% of the patients at the beginning: 60% of the patients stop smoking at the moment they are hospitalised and the remaining 20% continue smoking. The hygienic-dietetic intervention is confirmed, also in our experience, as a curative, or even more, a preventive tool against the worsening of an already overt arteriosclerosis as well as a necessary support for drug therapies.

[Functioning extra-adrenal paragangliomas]. / Paragangliomi extrasurrenalici funzionanti.

The diagnosis of extra-adrenal paraganglioma requires the recognition of catecholamine hypertension and the site of the lesion. I-131-MIBG scintigraphy, CAT scan and angiography may localize primitive and metastatic lesions. Six cases of extra-adrenal paraganglioma (5 abdominal, 1 thoracic) surgically treated with complete resolution of the hypertensive state are presented here.

Posttraumatic aneurysm of splanchnic arteries. Report of two cases.

Two cases of posttraumatic aneurysms of splanchnic arteries were referred to Istituto di Chirurgia Generale e Cardiovascolare del-l'Università di Milano (Italy) during 1989, and are the subject of this report. In both the instances a history of blunt abdominal trauma was collected, and histology confirmed the characters of false aneurysms of the lesions. The arteries involved were the middle colic and the splenic, respectively, with a long lasting history of recurrent abdominal pain related with particular physiologic events (e.g. meals or effort) only in the first case. The physiopathology, clinical feature, and problems related to surgical treatment in each cases are discussed in detail.