Fracture and migration in right atrium of a permanent venous central access system in a elderly patient: case report and literature review.

Abstract: Catheter dislocation and fracture with migration of central venous lines have been reported in the International literature. Catheter fracture with consequent migration has been observed in 0.5-3.0% and may either be consequent to catheter removal or it can occur spontane-ously. Our case report concerns the migration of a Hickman catheter connected to a venous port to the right atrium in a 61-year old patient. A literature up-to-date has been performed to assess the risk of port-a-cath positioning. The position of catheter tip is considered critical for the risk of migration, that is greater as higher the tip localization respect to the carina. The aim of our study is to underline the critical role of X-ray to visualize the exact location of the catheter tip, regard-less of the approach used for catheter positioning.

The role of self-expanding vascular stent in superior vena cava syndrome for advanced tumours.

INTRODUCTION: Superior vena cava (SVC) syndrome (SVCS) is a life-threatening occurrence that necessitates prompt treatment. At present, endovascular stenting is proposed as a first-line treatment to relieve symptoms. We assessed the effectiveness, safety and outcome of SVC stent positioning in patients affected with advanced cancer. METHODS: Forty-two patients undergoing stent positioning in the SVC for neoplasms from January 2002 to December 2018 form the basis of this retrospective study. Demographic data, risk factors, associated diseases, symptoms at presentation according to the score proposed by Kishi and the type of SVCS according to Sanford and Doty were collected. Minor and major complications were recorded. Suspected stent occlusion was confirmed by means of recurrence of symptoms followed by a confirmatory computed tomography (CT). RESULTS: Thirty-four (81%) patients had a nonresectable lung tumour invading or compressing the SVC. Five (12%) patients had a non-Hodgkin's lymphoma, and three (7%) had metastatic lymphadenopathies. Nitinol stents (Memotherm®) were employed in 19 (45%) patients, and steel stents (Wallstent™) in the remaining 23 (55%) patients. Thirty-five (85%) patients died during follow up for disease progression and the overall survival rate at 24 months was 11% (standard error (SE)=0.058). Thirteen patients (32%) had a recurrence of SVCS because of stent thrombosis in three (23%) and extrinsic compression from uncontrolled cancer progression in ten (77%). The overall symptom-free interval at 24 months was 57% (SE=0.095). CONCLUSIONS: We recommend the use of the endovascular procedure as a first-line treatment in locally advanced or metastatic tumour in the presence of SVCS.

Treatment of lower limb arterial disease by Dardik graft: It takes one to know one.

OBJECTIVE: To perform a comprehensive literature review on outcomes achieved with the historical Dardik graft, illustrated with a case report of a patient with 13-years primary patency and limb salvage. METHODS: A comprehensive literature review was performed through MedLine (PubMed.gov, U.S. National Library of Medicine, National Institute of Health) from 1976 to 2018 using search terms (Umbilical Vein Graft), (Dardik graft), (Glutaraldehyde stabilized human umbilical vein [HUV]) and (HUV) to collected data on clinical use of HUV. Only papers in English and reporting adequate information about indication for surgery, short- and long-term patency and complication rate were included. RESULTS: Data about a total of 899 patients (977 limbs) were available. Overall, 45% of patients (438 limbs) underwent HUV implantation for critical limb ischemia (rest pain or tissue loss) or for disabling claudication in 12.2% of cases (120 limbs). Others indication for surgery were acute onset limb ischemia, popliteal aneurysms or aneurysmal degeneration of a previously implanted synthetic graft. At a mean follow-up of 4.3 years (range 3-6 years), primary patency and secondary patency were 61.3% and 61%, respectively. Aneurisms formation was detected in 3% of cases (21 limbs), graft's infection in 24.4% of cases (31 limbs) and graft's thrombosis in 25.5% of cases (193 limbs). CONCLUSION: This article provide a historical review of the use, outcomes and complications of HUV. Even though it is no longer commercially available, the knowledge of this type of substitute still remains inspirational for the development of innovative vascular conduits and fundamental for the new generations of physician both in diagnostics and in the management of complications.

Criticism of learning curve in laparoscopic adrenalectomy: a systematic review.

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the treatment of choice for benign adrenal lesions. Lateral Transperitoneal Laparoscopic Adrenalectomy (LTLA) is considered the gold standard. The number of LTLAs a surgeon must perform, in order to complete his learning curve, is not well defined in Literature. Moreover, the few papers dealing with the learning curve for LTLAs show controversial results and consider different evaluation parameters. METHODS: The systematic review has been carried out according to PRISMA statement. The literature search included PubMed and Scopus database. Hand searching of reference lists of previous review articles and relevant studies was also performed. The search string was "learning curve AND laparoscopic adrenalectomy". RESULTS: A total of 9 papers met the inclusion criteria out of 94 non duplicate citations. The aim of this systematic review is to provide a multidimensional evaluation by bringing into focus evaluation parameters of surgical performance, (operative time, intraoperative complications, conversion rate and blood loss), factors related to patient's pathology (side, size, adrenal pathology) and surgeon-specific properties. CONCLUSIONS: Operative time, intraoperative bleeding, intraoperative complications and conversion rate are the main parameters that have been considered for the achievement of learning curve, and for each there are discrepancies, mainly due to the relative rarity of adrenal tumors, and so for difficulties in obtaining approper analysis that could establish an effective learning curve. So, further evaluations in larger experience are needed.

MMP and TIMP alterations in asymptomatic and symptomatic severe recurrent carotid artery stenosis.

OBJECTIVES: This study aimed to determine whether the plasma levels of matrix metalloproteinases (MMPs)-2 and -9 and their specific inhibitors (tissue inhibitors of metalloproteinases (TIMPs-1 and -2)) were altered in patients with symptomatic and asymptomatic, severe, recurrent carotid artery stenosis. PATIENTS: Fifty-two patients (out of a total of 621) who had undergone successful carotid artery endarterectomy (CEA) between 1999 and 2003 and developed recurrent carotid artery stenosis (>/=70%) were included in the study. Restenosis was symptomatic in 23 patients and asymptomatic in 29 patients. METHODS: Recurrent carotid artery stenosis was classified based on presentation, and as early-intermediate (6 months to 3 years) or late (>3 years). A detailed clinical history was taken and two blood samples were drawn from each patient to determine plasma levels of MMPs and TIMPs along with other biological parameters. Recurrent stenosis was confirmed with computed tomographic angiography. RESULTS: Patients with symptomatic restenosis had significantly (p<0.001) higher active MMP-2 and -9 plasma values and significantly (p<0.001) lower TIMP-1 and -2 plasma values when compared to patients with asymptomatic restenosis. Plasma concentrations of active MMPs were higher and TIMPs lower in patients affected with late recurrent stenosis as compared to early-intermediate restenosis (p<0.001). No differences were recorded in latent MMP plasma values. Multivariate analysis showed that active MMP-2 and -9 were independent predictors of late recurrent carotid artery stenosis (p<0.03 and p<0.001, respectively). CONCLUSIONS: Higher plasma concentrations of active MMP-2 and -9 were associated with an increased risk of carotid restenosis with plaque recurrence.

Preservation of left colic artery with lymph node dissection of IMA root during laparoscopic surgery for rectosigmoid cancer. Results of a retrospective analysis.

BACKGROUND: During sigmoid or rectal cancer surgery, dissection of lymph-nodes at the origin of inferior mesenteric artery is mandatory. Nevertheless, ligation of the origin of IMA should compromise blood supply to left colon and affect anastomosis. The aim of this retrospective evaluation is to compare high IMA ligation and low IMA ligation with preservation of LCA and skeletonization of the origin of IMA during laparoscopic colorectal resection. METHODS: All 120 patients included were affected by clinically M-0 sigmoid or rectal cancer. A laparoscopic colorectal resection with low or high ligature of IMA was performed. Low ligation was carried out with lymphadenectomy of the arterial root. Patients were divided in 2 groups according to type of treatment: Group A, high IMA ligation (N=65), Group B, low ligation with lymphadenectomy of IMA root (N=55). RESULTS: Preoperatively 59 patients had stage I, 42 patients had stage II  and 19 patients had stage III tumor. A mean of 20.3 +/- 4.5 lymph nodes were removed in group A patients and 18.9 +/- 9.1 in group B patients, and this difference was not statistically significant. Operative time, intraoperative and postoperative complication rates were not different between the two group. CONCLUSIONS: Low IMA ligation combined with lymph-node dissection at its origin is safe and effective, not time consuming and not associated to increased risk of complications and nerve damage. This technique can be considered as alternative to standard high IMA ligation in selected patients.

The surgical management of acute bowel ischemia in octogenarian patients to avoid Short Bowel Syndrome: a multicenter study.

BACKGROUND: This is a multicenter study performed in two Italian tertiary care centers: General Emergency Surgery Unit at St. Orsola University Teaching Hospital - Bologna and Department of Surgical Sciences at Umberto I University Teaching Hospital - Rome. The aim was to compare the results of different approaches among elderly patients with acute bowel ischemia. METHODS: Sixty-three patients were divided in two groups: 1) DSgroup- 28 patients treated in Vascular Unit and 2) GEgroup- 35 patients treated in Emergency Surgery Unit. RESULTS: Mean age was 80 years, significantly higher for the GEgroup (p<0.001). Gender was predominantly female in both groups, without statistical difference. Pre-operatively, laboratory tests didn't show any difference in white blood cell count, serum lactate levels or serum creatinine among patients, while increase of c-reactive protein was observed in DSgroup with significant difference (p<0.001). The Romamain cause of acute bowel ischemia was embolism in DSgroup (p=0.03) and vascular spasm in GEgroup (p<0.001). On CT scan, bowel loop dilation was present in 58.7% of patients without statistical difference in both groups. The time lapse from diagnosis to operation didn't show significant differences between two groups (mean 349.4 min). Pre-operative heparin therapy was administered in DSgroup more frequently (p< 0.001). Among DS patients, thrombectomy was the most frequent procedure (19 patients) associated with bowel resection in 9 cases. In GEgroup, 22 patients had an explorative laparotomy (p<0.001), 8 had a bowel resection with anastomosis and 5 a bowel resection plus stoma. A second look was required more significantly in DSgroup (p<0.002). Post-operative morbidity affected significantly GEgroup (p=0.02). The 3-day survival was significantly higher in the DSgroup (p< 0.001). At discharge 32 patients (50.8%) were alive, 21 in DSgroup (p< 0.001). Only one patient among both groups (1.6%) developed a short bowel syndrome. CONCLUSIONS: In octogenarian patients with acute bowel ischemia, surgery should be always pursued whenever the interventional radiology is not assessed as a viable option. Both groups of patients showed an excellent outcome in terms of avoiding a short bowel syndrome. A multidisciplinary management by a dedicated team could offer the best results to prevent large intestinal resections.

[Intraoperative neuro-monitoring of the recurrent laryngeal nerve. Experience of 1000 consecutive patients]. / Neuromonitoring intraoperatorio del nervo laringeo ricorrente. Un'esperienza di 1000 pazienti consecutivi.

Intraoperative neuro-monitoring was introduced in thyroid surgery several years ago resulting in a facilitated identification of the recurrent laryngeal nerve and less recurrent laryngeal nerve injuries. Between 1999 and 2005 data of all patients undergoing thyroid resection were recorded and analyzed yearly. The intraoperative identification of recurrent laryngeal nerve succeeded in 99.2% (1768 nerves at risk). The percentage of complete resecting surgical procedures raised from 17% to 84%. Minimal vocal cord dysfunction, associated with hematoma and edema in most cases, was diagnosed laryngoscopically in 2.9%. The permanent palsy rate of 0.8% in the first year decreased down to 0.32%. Routinely introduction of intraoperative neuro-monitoring in thyroid surgery is associated with a demonstrable decreased palsy rate. Anyway, the rate of minimal vocal cord movement disorders and transient recurrent laryngeal nerve palsies is not changed.

Effects of oral androstenedione on phospholipid fatty acids, ATP, caspase-3, prostaglandin E(2) and C-reactive protein in serum and livers of pregnant and non-pregnant female rats.

Androstenedione, a steroidal dietary supplement taken to enhance athletic performance, could affect serum and liver lipid metabolism, induce liver toxicity or alter inflammatory response depending on dose and duration of exposure. Pregnancy could further exaggerate these effects. To examine this, mature female rats were gavaged with 0, 5, 30 or 60 mg/kg/day androstenedione beginning two weeks prior to mating and continuing through gestation day 19. Non-pregnant female rats were gavaged over the same time frame with 0 or 60 mg/kg/day androstenedione. Serum was collected and livers were removed from dams on gestation day 20 and from non-pregnant rats after 5 weeks of treatment. Androstenedione had no effect on serum total cholesterol, triglycerides or HDL-cholesterol, but significantly decreased C-reactive protein in pregnant rats and prostaglandin E(2) in serum of both pregnant and non-pregnant rats. There were treatment related decreases in liver ATP and, to a lesser degree, caspase-3 and no change in alkaline phosphatase of pregnant female rats. Androstenedione decreased docosahexaenoic acid in both serum and liver phospholipids of pregnant female rats. In conclusion, oral androstenedione did not result in overt hepatotoxicity in pregnant female rats, but produced modest changes in lipid metabolism and may impair regeneration of injured hepatic cells or tissue.

The energetics of the interaction of BamHI endonuclease with its recognition site GGATCC.

The interaction of BamHI endonuclease with DNA has been studied crystallographically, but has not been characterized rigorously in solution. The enzyme binds in solution as a homodimer to its recognition site GGATCC. Only six base-pairs are directly recognized, but binding affinity (in the absence of the catalytic cofactor Mg(2+)) increases 5400-fold as oligonucleotide length increases from 10 to 14 bp. Binding is modulated by sequence context outside the recognition site, varying about 30-fold from the bes t (GTG or TAT) to the worst (CGG) flanking triplets. BamHI, EcoRI and EcoRV endonucleases all have different context preferences, suggesting that context affects binding by influencing the free energy levels of the complexes rather than that of the free DNA. Ethylation interference footprinting in the absence of divalent metal shows a localized and symmetrical pattern of phosphate contacts, with strong contacts at NpNpNpGGApTCC. In the presence of Mg(2+), first-order cleavage rate constants are identical in the two GGA half-sites, are the same for the two nicked intermediates and are unaffected by substrate length in the range 10-24 bp. DNA binding is strongly enhanced by mutations D94N, E111A or E113K, by binding of Ca(2+) at the active site, or by deletion of the scissile phosphate GpGATCC, indicating that a cluster of negative charges at the catalytic site contributes at least 3-4 kcal/mol of unfavorable binding free energy. This electrostatic repulsion destabilizes the enzyme-DNA complex and favors metal ion binding and progression to the transition state for cleavage.

Effects of oral androstenedione on steroid metabolism in liver of pregnant and non-pregnant female rats.

It is unknown whether androstenedione, a steroidal dietary supplement taken to enhance athletic performance, can affect physiological hormone levels by altering liver enzyme activities that metabolize steroid hormones. Altered hormone levels could be especially devastating during pregnancy. Mature female rats were gavaged with 0, 5, 30 or 60 mg/kg/day androstenedione beginning two weeks prior to mating and continuing through gestation day 19. Non-pregnant female rats were gavaged over the same time frame with 0 or 60 mg/kg/day androstenedione. Livers were removed from dams on gestation day 20 and from non-pregnant rats after five weeks' treatment. Liver microsomes were incubated with 200 microM testosterone, and the reaction products were isolated and analyzed by HPLC. In pregnant rats, formation of 6alpha-, 15beta-, 7alpha-, 16beta-, and 2beta-hydroxytestosterone was increased significantly vs. control at the highest dose level only. Formation of 6beta-hydroxytestosterone increased significantly at both the 30 and 60 mg/kg/day dose levels. In non-pregnant rats, 60 mg/kg/day androstenedione significantly increased formation of 15beta-, 6beta-, 16beta-, and 2beta-hydroxytestosterone. The data suggest that high oral doses of androstenedione can induce some female rat liver cytochromes P450 that metabolize steroid hormones and that the response to androstenedione does not differ between pregnant and non-pregnant female rats.

Aortoiliofemoral bypass graft in young adults: long-term results in a series of sixty-eight patients.

BACKGROUND: The aim of this study was to investigate surgical indications and the long-term outcomes of aoroiliofemoral reconstructions in adults younger than 45 years. METHODS: Between 1973 and 1990, 1256 patients underwent infrarenal abdominal aortic reconstruction for aortoiliofemoral occlusive disease. Sixty-eight (5.4%) patients (group 1) were less than 45 years old and form the basis of the analysis. They were retrospectively compared with two additional groups of patients 45 years and older selected from the entire series. Patients in group 2 (n = 100) were randomly chosen to determine differences in risk factors, associated diseases, operative indications, preoperative findings, and outcomes. Patients in group 3 (n = 70) were matched with those in group 1 for gender, risk factors, associated diseases, preoperative findings, and operative indications to assess the importance of age in determining the short- and long-term outcomes of aortoiliofemoral reconstructions. RESULTS: Postoperative mortality rates (1.5%, 4%, and 4.3% for groups 1, 2, and 3, respectively) and major complication rates (4.4%, 7%, and 7.1% for groups 1, 2, and 3, respectively) were comparable among the three groups. Ten-year secondary patency rates were 84.6%, 70.6%, and 80.3%, for groups 1, 2, and 3, respectively (p = not significant). Ten-year limb salvage rates were 86.9%, 78.2%, and 80.6%, for groups 1, 2, and 3, respectively (p = not significant). During follow-up a significantly higher percentage of myocardial infarction was recorded in group 1 as compared with group 2 (p < 0.03) and group 3 (p < 0.04). The 10-year survival rate for group 1 was significantly lower than that of group 2 (29.0% versus 46.9%; p < 0.005). CONCLUSIONS: Aortoliofemoral reconstruction in patients younger than 45 years is a safe procedure with low operative risks and good long-term results in patency and limb salvage rates. However, life expectancy is poor because of the high incidence of deaths related to coronary artery disease.

Popliteal artery entrapment syndrome: the role of early diagnosis and treatment.

BACKGROUND: The purpose of this study was to evaluate whether certain factors could influence arterial impairment at presentation for treatment of popliteal artery entrapment syndrome (PAES) and whether its early diagnosis could optimize long-term results. METHODS: Between 1979 and 1995, 30 patients were treated for PAES at our institution. Patients were characterized by age, risk factors, associated diseases, preoperative symptoms, affected side, dominant limb, duration of symptoms, musculotendinous structure causing the compression, arteriographic findings, arterial status at presentation, type of operation, postoperative complications, and long-term follow-up. RESULTS: Twenty-nine (65%) limbs underwent musculotendinous section (MTS), 15 (33%) limbs underwent vascular reconstruction, and 1 (2%) was surgically explored. Patients submitted to MTS were younger (mean, 31 +/- 3 years) than patients who underwent vascular reconstruction (mean, 41 +/- 4 years; p < 0.05). MTS limbs had a greater number of minor symptoms compared with those that underwent vascular reconstruction (62% versus 20%; p < 0.02). Arteriogram showed that MTS limbs had a greater number of normal findings at rest when compared with limbs that underwent conventional reconstruction (85% versus 0%; p < 0.001). No specific factors influenced the arterial status at presentation. During follow-up, treadmill examination revealed that MTS limbs had a better response (96%) than limbs that had undergone vascular procedures (67%; p < 0.02). MTS limbs had a better long-term patency rate (mean, 87 +/- 7 months) compared with limbs that were submitted to vascular reconstruction (mean, 107 +/- 8 months) (95% versus 65%; p < 0.02). CONCLUSIONS: Because PAES is a progressive disease that can create serious vascular obstructive disease and no specific factors seem to influence the degree of vascular impairment, the detection and treatment of PAES at an early stage permit better long-term results.

Nicotine induces platelet-derived growth factor release and cytoskeletal alteration in aortic smooth muscle cells.

BACKGROUND: Cigarette smoking is implicated in atherosclerotic plaque formation, but the role of nicotine in this process is not completely understood. The release of platelet-derived growth factor (PDGF) by the bovine aortic smooth muscle cell (SMC) after nicotine administration at a concentration similar to that ingested by active and passive smokers and the role of PDGF in SMC cytoskeletal modification were studied. METHODS: SMC, harvested with enzymatic digestion from calf aorta, were stimulated in a serum-free medium for 72 hours with (-)-nicotine (from 6 x 10(-4) mol/L to 6 x 10(-8) mol/L). The release of PDGF was assessed by inhibition antibody-binding assay and confirmed by Western blotting. Mitogenic activity of nicotine on SMCs was also determined. The SMC cytoskeleton was studied with specific antibodies anti-alpha-actin fibers, anti-vimentin, and anti-beta-tubulin, and the modification induced by PDGF was assessed by blocking PDGF activity with specific antibodies. RESULTS: The greatest PDGF release (1.24 +/- 0.14 ng/10(4) cells vs control 0.43 +/- 0.07 ng/10(4) cells) was noted at a (-)-nicotine concentration of 6 x 10(-7) mol/L (P < .001). The addition of monoclonal antibody anti-PDGF decreased the tritiated thymidine uptake of SMCs exposed to (-)-nicotine compared with the control (29% vs 5%-P < .001). SMCs exposed to (-)-nicotine concentration of 6 x 10(-7) mol/L and 6 x 10(-8) mol/L had a significant alteration in the expression of alpha-actin fibers, vimentin, and beta-tubulin compared with control. The administration of antibody anti-PDGF in the culture medium reversed cytoskeletal alteration. CONCLUSIONS: Nicotine enhanced the release of platelet-derived growth, which in turn caused an alteration in cytoskeletal organization.

Femorofemoral bypass grafts: Factors influencing long-term patency rate and outcome.

BACKGROUND: Crossover femorofemoral bypass graft (CFFBG) was proposed in the early days of modern vascular surgery to treat patients affected with unilateral iliac artery disease who were a high surgical risk. We investigated factors influencing short- and long-term outcomes of CFFBG: METHODS: The study was designed as a retrospective clinical study in a university hospital setting with a base of 228 patients. Of these patients, 154 (67.5%) presented a high surgical risk. The indication for operation was limb-threatening ischemia in 188 (82.5%) patients. All patients underwent CFFBG: The procedure was performed in 150 patients as the primary operation and in 78 patients after previous vascular graft failure or infection, or both. A preoperative percutaneous transluminal angioplasty was performed in 57 patients (25%) to correct donor iliac artery disease. In 127 patients (55.7%), an associated vascular procedure was performed to improve the outflow. Postoperative complications; 5- and 10-year primary, secondary, and limb salvage rates; and factors influencing short- and long-term results were assessed. RESULTS: Thirteen (5.7%) postoperative deaths occurred. Postoperative mortality and morbidity rates were significantly higher in patients aged more than 65 years (7.9% versus 3.5% and 18.6% versus 6.1%, respectively, P <.03). Primary and secondary patency rates at 5 and 10 years were 70.2% and 48.1%, 82.8% and 63.2%, respectively; 5- and 10-year limb salvage and survival rates were 85.5% and 80.1%, 63.3% and 31.0%, respectively. Ten-year primary and secondary patency and limb salvage rates were significantly lower when the procedure was performed after previous vascular graft failures (50.2% versus 26.5%, P <.007; 74.1% versus 44.1%, P <.01; and 84.3% versus 72.5%, P <.03, respectively). Five- and 8-year patency rates of autogenous vein CFFBG (34.3% and 22.8%, respectively, P <.03) were significantly lower than those of expanded polytetrafluoroethylene (71.1% and 59.8%, respectively) and polyester (77.3% and 50.3%, respectively) CFFBG: Moreover, 5- and 10-year primary and secondary patency rates were significantly better when externally supported grafts were used as compared with those without external support (80.1% and 69.9% versus 61.1% and 21.1%, P <.01; 88.8% and 75.9% versus 78.9% and 45.4%, P <.05, respectively). Multivariate analysis showed that the only variable associated with poor primary and secondary patency and limb salvage rates was the operation performed after previous vascular graft failures (P <.04, P <.03 and P<.05, respectively). CONCLUSIONS: CFFBG allows early and long-term results similar to those obtained with reconstructions originating from the aorta when it is performed as a primary operation when an adequate outflow is provided and externally supported prosthetic material is used.

Long-term outcome after transaxillary approach for thoracic outlet syndrome.

BACKGROUND: Recurrence or persistence of neurologic symptoms after surgical treatment of patients with thoracic outlet syndrome (TOS) are reported to be as high as 25%. To identify factors affecting the long-term outcome of surgical treatment of patients with TOS, we reviewed our 20-year experience. METHODS: One hundred thirty-four transaxillary first rib resections were performed on 118 patients (43 men, 75 women, mean age 38 +/- 13 years). Eighty-three operations (61.9%) were undertaken to relieve symptoms resulting from compression of the lower roots of the brachial plexus, 37 (27.6%) for compression of both lower and upper roots, and 14 (10.5%) for lower root and vascular symptoms. All patients underwent a transaxillary extraperiosteal first rib resection with transection of the scalene muscles. In 73 cases (54.5%) a resection of the anterior scalene muscle was also performed. A cervical rib was removed in 28 cases (20.1%), and anomalous fibrous bands adjacent to the neurovascular bundle were resected in 41 cases (30.6%). RESULTS: No major complications were observed. Of 105 patients (118 procedures) followed up (mean follow-up, 99 +/- 72 months), good to excellent results were obtained in 96 cases (81.4%) and fair to poor results were recorded in 22 cases (18.6%). The presence of a long posterior first rib stump, measured from the chest x ray films, was the strongest determinant of the long-term results among the variables examined (p < 0.0001). Reoperation, consisting of neurolysis and resection of the stump, was performed in 16 patients. The results were excellent in all cases at a mean follow-up of 66 +/- 46 months. Primary and secondary 10-year, actuarial freedom rates from recurrent symptoms were 80.9% and 93.1%, respectively. CONCLUSIONS: Our results suggest that the long-term outcome after surgery for TOS was strongly influenced by the extent of the first rib resection.

Short-term preservation of autogenous vein grafts: effectiveness of University of Wisconsin solution.

BACKGROUND: Suboptimal preservation of autologous veins in storage solutions causes endothelial cell damage that can contribute to graft failure. The purpose of this study was to compare the effects of short-term storage of veins in autologous whole blood (AWB), 0.9% normal saline solution (NS), and University of Wisconsin solution (UWs) on vein structure and function after grafting. METHODS: Autogenous jugular and femoral veins were atraumatically harvested from mongrel dogs. One vein segment was immediately implanted to serve as a control, and the other segments were stored for 45 minutes in AWB, NS, or UWs. The veins were implanted as reversed interposition graft in the carotid or femoral arteries. After 6 weeks light and scanning electron microscopy and isometric tension studies were performed on explanted vein grafts. RESULTS: Morphologic studies revealed an intact endothelium that stained positively for factor VIII. Intimal thickness was similar between controls (48 +/- 12 microns) and veins stored in UWs (53 +/- 8 microns) (p = not significant), but it was significantly increased in veins stored in AWB (151 +/- 29 microns) and NS (149 +/- 18 microns) (p < 0.05). Sensitivity and maximum contraction to norepinephrine were not altered in veins preserved in UWs (6.0 +/- 0.1 mumol/L and 0.19 +/- 0.02 gm/mm2) but were significantly reduced (p < 0.05) in those stored in AWB (7.2 +/- 0.1 mumol/L and 0.08 +/- 0.02 gm/mm2) and NS (7.0 +/- 0.3 mumol/L and 0.09 +/- 0.02 gm/mm2) compared with controls (5.9 +/- 0.2 mumol/L and 0.20 +/- 0.02 gm/mm2). The sensitivity and maximum relaxation to acetylcholine and sodium nitroprusside of veins preserved in AWB, NS, and UWs were similar to controls (p = not significant). CONCLUSIONS: Vein storage in UWs preserves smooth muscle cell function compared with veins stored in NS or AWB. Therefore UWs is a more suitable medium for short-term preservation of veins in cardiovascular operation.

Nicotine-induced smooth muscle cell proliferation is mediated through bFGF and TGF-beta 1.

BACKGROUND: Cigarette smoking influences and enhances the development of atherosclerosis. We investigated if nicotine, an important constituent of cigarette smoking, has a stimulatory effect on bovine smooth muscle cell proliferation in vitro through the mediation of bFGF and TGF-beta 1. METHODS: Bovine aortic smooth muscle cells (SMC) were stimulated with (-)-nicotine at various concentrations ranging from 6 x 10(-4) mol/L to 6 x 10(-8) mol/L. SMC viability and count were assessed. The presence of bFGF and TGF-beta 1 in serum-free conditioned media was determined by the inhibition antibody-binding assay, and the mitogenic activity of (-)-nicotine on SMC was analyzed by the 3H-thymidine uptake. Polymerase chain reaction was used to study the expression of bFGF and TGF-beta 1. RESULTS: The bFGF release after (-)-nicotine stimulation was greater than in the controls, whereas TGF-beta 1 release was lower. The greatest mitogenic activity was found at a (-)-nicotine concentration of 6 x 10(-6) mol/L. The addition of monoclonal antibody anti-bFGF decreased the 3H-thymidine uptake of SMC exposed to (-)-nicotine, whereas the addition of monoclonal antibody anti-TGF-beta 1 increased the 3H-thymidine uptake of stimulated SMC. bFGF mRNA expression was significantly higher in SMC exposed to (-)-nicotine than in the controls, but TGF-beta 1 mRNA expression was significantly lower in SMC exposed to 6 x 10(-6) mol/L (-)-nicotine than in SMC treated with the other concentrations of (-)-nicotine and in controls. CONCLUSIONS: Nicotine is a potent regulator of bFGF and TGF-beta 1 production and release by aortic SMC, and it seems to play an important role in the development and progression of atherosclerosis and neointimal fibrous hyperplasia.

An unusual case of spontaneous rupture of a clinically "silent" phaeochromocytoma.

A case of an adrenal mass which presented as spontaneous rupture contained by its own capsule is described. Clinical symptoms were aspecific and endocrinological examinations were within normal range. CT scan missed the presence of the adrenal tumor and interpreted the mass as a large haematoma arising from the left kidney. The pathological diagnosis was phaeochromocytoma. The management of "silent" phaeochromocytoma and its atypical presentation are discussed. A review of the international literature was also made collecting 29 cases of spontaneous rupture of an adrenal phaeochromocytoma.

Renal carcinoma with a solitary synchronous contralateral adrenal metastasis: a case report.

A case of synchronous contralateral adrenal metastasis of renal cell carcinoma occurring in a 64-year-old male is reported herein. The patient underwent a left transperitoneal nephrectomy for renal cell carcinoma and right adrenalectomy. The postoperative course was uneventful. To our knowledge this is the 14th case of contralateral adrenal metastasis of renal cell carcinoma in the international literature.