Takayasu's arteritis in Italian patients.

OBJECTIVE: To evaluate the clinical features, angiographic findings and evolution of Takayasu's arteritis in Italian patients. METHODS: Retrospective analysis of the case records of 27 Italian patients with Takayasu's arteritis, all meeting the 1990 ACR criteria for classification of this vasculitis, with a median disease duration of 9.5 years. RESULTS: The patterns of arterial involvement and the frequencies of systemic and specific symptoms were similar, with some exceptions, to those reported in the literature. In our patients weight loss was rare, the incidence of respiratory symptoms and seizures was low, and no clinical manifestations of intestinal involvement were reported. All of the patients were treated with antiplatelet or anticoagulant medications, and 14 were also treated with corticosteroids and immunosuppressants; a stabilization of the vascular involvement was seen in most of them. Thirteen patients underwent surgery, and 5 had percutaneous transluminal renal angioplasties. Five pregnancies were observed, without complications. Two patients died, one after an angiographic evaluation and one for reasons unrelated to the disease. CONCLUSIONS: Takayasu's arteritis is heterogeneous in presentation, evolution and response to therapy. In our series of patients the disease seems to have showed a more favorable course than that previously reported. This can be attributed to the effectiveness of therapy, but also, at least partially, to the better prognosis that the disease seems to have for Western than for Eastern subjects.

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.

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.

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.

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.

Occlusive arterial disease in young patients.

All the young patients (under 40 years) affected by occlusive arterial disease observed at the Istituto di Clinica Chirurgica II, University of Milan, during the last eleven years have been reviewed. About one third of these patients is affected by a form of arteritis; the others demonstrate the typical pattern of early atherosclerosis or an indeterminate condition which may represent an atherosclerotic complication superimposed on a basic arteritic lesion. The available therapeutic procedures are examined. They show that atherosclerotic disease more frequently permits a surgical reconstruction. The average rate of amputation is about the same in the two considered forms, ranging close to 7-8%. The 10 year follow up of these groups of young patients allowed us to analyze the rate of progression and evolution of these morbid conditions and the influence of the most important risk factors.

Influence of the rupture site of abdominal aortic aneurysms with regard to postoperative survival rate.

This study presents an analysis of the influence of the site of rupture of abdominal aortic aneurysms on the postoperative survival rate. A series of 226 patients, who underwent emergency operations for ruptured aneurysms, is examined. The three most important methods of rupture are: (1) Retroperitoneal rupture: this type is associated with a very high mortality (52.8% in our experience), which reaches almost 75% when the posterior parietal peritoneum tears and massive intraperitoneal bleeding occurs. This mortality is related to the amount of blood loss, hypovolemic shock, the number of transfused blood units and, especially, to increasing renal insufficiency. (2) Rupture into the inferior vena cava: in this event the mortality rate it less severe (38.4% in our experience) and it is mostly related to the occurrence of an high output cardiac failure, as well as to oliguria or anuria following renal venous hypertension. (3) Enteric rupture: this is, in our experience, the most uncommon event. It carries a high mortality rate (50%). The copious bleeding, which is unrestricted in hollow organs, explains the dangerous hypovolemic shock, while massive blood reabsorption from the enteric tract leads to a renal insufficiency.

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.

Critical evaluation of limb salvage concept and indication for infrapopliteal reconstructive surgery.

A large number of surgical procedures aimed at revascularizing the popliteal and infrapopliteal arteries has been reported in patients affected by rest pain or gangrene of the extremities as well as intermittent claudication. In consideration of the high incidence of early and late unsuccessful results following this type of surgery as reported in the literature, we believe that peripheral reconstructions should be restricted to those patients presenting a clinical picture of such severity that major amputation is unavoidable in the short run. In these patients our choice of the appropriate surgical procedure is strictly related to the patency or not of the popliteal artery. The role of the above knee femoropopliteal bypass is discussed. A series of patients that we have operated upon according to these criteria is analyzed. The low number of cases in our group of patients and the high rate of postoperative failures reflect our policy on this matter.

Pathological patterns and surgical treatment of renal artery stenosis in renovascular hypertension.

Atherosclerosis and dysplasia are the most common lesions affecting the renal artery, causing stenosis and renovascular hypertension. Surgical revascularization of the ischemic kidney in properly selected patients has proved to be the treatment of choice. The different pathological characters of dysplastic lesions are examined and compared with the ones of atherosclerotic disease, in surgically treated patients. Correlations between angiographic and histological aspects are also considered. The recognition of these different pathological patterns is important for the selection of the most suitable surgical procedures. The results of a personal technique of arterial reconstruction and angioplasty are reported.

Aneurysms of the renal artery.

The detection of renal artery aneurysms has greatly increased in the last years with the use of angiographic procedures and nowadays thanks to digital subtraction angiography routinely adopted in the diagnostic evaluation of patients affected by lesions at the renal artery level. This study reports the data of 31 renal artery aneurysms observed in 30 patients admitted to our Institute from 1970 to 1986. All the aneurysms were demonstrated by means of selective renal angiographies. Twenty-two patients out of 30 presented hypertension. In order to establish the possible role of the aneurysm in the genesis of hypertension, in all these cases the PRA was determined. In 27 patients a surgical procedure was adopted. This paper reviews our series of patients, analyzing the diagnostic procedures, the symptomatology presented with particular regard to the presence and the type of the associated hypertensive condition, the adopted therapeutic procedures and the 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.

[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.

[Histological and clinical correlations in thyroid pathology]. / Correlazioni istologico-cliniche in patologia tiroidea.

The cases of 138 patients who underwent, during the last six years, an operation for thyroid affections, have been reviewed in order to compare the definitive histological response with the clinical diagnosis. On the basis of this analysis it was pointed out that, even with the aid of the commonly used diagnostic investigations, it is difficult to get a certain and sure knowledge of the anatomo-pathological picture, before beginning the operation. Furthermore, the definitive histological diagnosis itself may be wrong if it is not based upon the examination of the whole removed tissue, using as many sections as possible.

[Cervico-mediastinal goiter]. / Il gozzo cervico-mediastinico.

The descent of a cervical goiter below the plain of the thoracic inlet to become substernal in location, is fairly rare, but not exceptional, with an incidence, derived from several large series of operated patients, ranging from 1.7% to 13.1%. The importance of this particular location of the goiter is chiefly due to the fact that the thyroid is growing in a limited space with many surrounding structures, that unavoidably, sooner or later, will be compressed or strained. This provokes respiratory symptoms (such as cough, dyspnea, stridor) or difficulty in swallowing or determines a superior vena cava syndrome with venous stasis in the neck and in the upper thorax, and with facial oedema. The substernal location, that already constitutes a complication of the basic thyropathy, is further aggravated by the incidental malignant transformation of the substernal goiter or by the development of a thyrotoxicosis due to hyper-functioning intra-thoracic thyroid tissue. For all these reasons the presence of a substernal goiter represents in and of itself a precise indication for a surgical treatment. This study is aimed at examining the series of 19 substernal goiters observed at the Institution of General and Cardiovascular Surgery, University of Milan, from 1967 to 1987, particularly analyzing the progresses in the diagnostic procedures, the adopted surgical therapy and the observed complications.

[Surgical tactics in the treatment of thyroid nodular pathology]. / Tattica chirurgica nel trattamento della patologia nodulare tiroidea.

The thyroid nodules represent the most frequent endocrinopathy, because clinically palpable nodules are detectable in 4-5% of the general population. Such pathological condition includes adenomas, carcinoma, intraglandular haematomas or cysts, focal thyroiditis, etc. Fine-needle aspiration cytology allows a correct diagnosis in about 90% of the cases, distinguishing focal thyroiditis from nodular goiter or thyroid malignancies. The new instrumental and cytological studies make the choice for surgical interventions more selective. At the Institution of General and Cardiovascular Surgery, University of Milan, 597 patients underwent surgery from 1966 to January 1988. The observed nodular (toxic or non toxic) thyropathies were 498 (83.4%). Cold nodules represented about a third (34%) of the nodular thyropathies. Thyroid carcinomas were 33 (5.6%). This study is aimed to analyze our surgical attitude with respect to nodular thyropathies, the surgical procedures adopted and the observed complications.

[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.

[Physiopathology of venous stasis at the microcirculation level]. / Fisiopatologia della stasi venosa a livello del microcircolo.

The division of the venous circulation in to two sectors, one constituted by the superficial and deep venous trunks (macrocirculation) and the other by the capillaries and precapillary venules (microcirculation), is surely schematical but aids the comprehension of many hemodynamic effects connected to hampered venous return and to the incompetence of the valvular devices. In fact many of the effects of stasis and venous hypertension (oedema, red cell diapedesis, skin dystrophies) cannot be explained merely by hydraulic mechanisms but require a primary alteration of the microvascular wall associated with structural changes of the perivascular connective tissue. The alterations that occur in microcirculation are of the utmost importance in the formation of the venules ulcerations. The passage of fibrinogen through large pores in the venules of the patients affected by venous hypertension derived from venous insufficiency creates a pericapillary fibrin deposition that cannot be removed because of inadequate blood and tissue fibrinolysis. This accumulation acts as a barrier to the diffusion of oxygen and other nutrients, determining a stasis dermatitis that may lead to tissue necrosis and ulceration. The more precise knowledge of the phenomena connected with the venous stasis at the level of microcirculation (pericapillary fibrin deposition, endothelial ischemia, blocked lymphatic drainage) will not only allow a deeper comprehension of the clinical signs but hopefully will lead to a more effective treatment of the postphlebitic syndrome.