Raynaud's phenomenon: primary and secondary causes.

The terms "Raynaud's disease" and "Raynaud's phenomenon" are often used interchangeably, as if they were a single problem. Because prognosis and therapy are different with each of these entities, 86 patients with episodic digit ischemia were evaluated over the past five years. All patients were evaluated similarly with plethysmography, angiography, and other studies for underlying causes of the digital ischemia. From the study, it was concluded that the majority of the patients had an underlying cause for the problem even though they satisfied the commonly accepted criteria for the diagnosis of Raynaud's disease. It is clear that the diagnosis of Raynaud's disease must be one of exclusion, because it is more uncommon than is generally appreciated by the medical community.

Recurrent aortic occlusion due to malignancy.

A 62-year-old male had repeated episodes of aortic bifurcation occlusion by malignant masses of the same histologic type as the previously excised adenocarcinoma of the ascending colon. In spite of an extensive investigation of the lungs, heart and aorta no trace of the origin and the route of dissemination of the carcinomatous masses was found. Severe suspicion arises of massive malignant direct invasion of the aorta from the local recurrence of the tumor of the descending colon excised 3 years previously.

Comparative study of evaluation of digital arterial circulation by doppler ultrasonic tracing and hand arteriography.

The measurement of DBP and the arteriography of the hand have been used for the estimation of digital arterial circulation and for the disclosure of occlusive processes of the digital and palmar arteries in vascular and, mainly, in arterial disorders of the hands. However, both methods have some limitations; the first might give normal values in the presence of occlusion of digital or palmar arteries while the second is an invasive technic, it cannot be repeated and is followed by a low morbidity. The technic that we are introducing namely the digital arterial flow tracing (DAFT) is a non-invasive method which discloses, with a high accuracy, the occlusive processes of the digital arteries and it could replace to some extent especially in the study of Raynaud's syndrome, hand arteriography. Further experience is required for the refinement of the method and for the study of the palmar arteries.

Early surgical results on acute arterial occlusion of the extremities.

Although the earliest possible embolectomy is still correlated with best rates of limb salvage, we consider, as do most other authors, that the only critical criterion for operability must be the viability of the ischemic limb. Even in the presence of gangrene of the foot relief of arterial occlusion is recommended in order to secure a more distal amputation. Arterial embolectomy seems to be a simple surgical procedure; however, in the presence of atherosclerotic arteries or in the cases of acute arterial thrombosis the operative procedure needs considerable experience in vascular surgical techniques to secure a successful outcome. Finally, the prevention and early treatment of the revascularization syndrome together with appropriate cardiopulmonary management in a strict intensive-care unit can improve the mortality significantly in cases of acute arterial occlusion of the extremities.

Secondary aortoduodenal fistulae.

Secondary aortoenteric fistula (SAF) is a rare but fatal complication of reconstructive aortoiliac surgery. The prevention, diagnosis and treatment of this complication remains a challenging problem in everyday practice. Nine cases of secondary aortoduodenal fistulae during the period of 1980 to 1992 are presented. Their main symptom was bleeding of the upper gastrointestinal tract. The mean time interval since the aortic surgical procedure was 32 months. Removal of the old graft and closure of the duodenal defect was the first stage of the operative procedure. One patient underwent replacement of the old graft, with a new graft, while in the remaining three patients extranatomical bypass was not necessary because of satisfactory circulation in the lower extremities. In five patients extranatomical revascularization of the lower limbs was performed postoperatively at various intervals. Three patients died postoperatively. Follow-up of the remaining patients ranged from one month to 8 years. Bleeding of the upper gastrointestinal tract in patients with a history of intrabdominal reconstructive vascular surgery must raise severe suspicion as to the certainty of existance of SAF unless the diagnostic procedure, mainly exploratory laparotomy, excludes this possibility.

Vital capillaroscopy on microcirculation: pharmacodynamic activity of Daflon 500 mg in venous insufficiency.

A group of ten female patients suffering from telengiectasia of the lower limbs was treated with Daflon 500 mg administered orally. The results obtained are presented and discussed.

Panarterial ultrasonography. A non invasive evaluation of the peripheral arterial system.

Based on the concept of the generalized character of atherosclerosis which tends to assume characteristic patterns that may be classified by a predominant site of distribution of the disease within five major categories according to DeBakey, we have developed the examination of the whole arterial system, except the coronary arteries, by using ultrasonic technics which have coined panarterial ultrasonography (PU). This includes a series of ultrasonic examinations by using the Doppler ultrasonic and B-mode duplex or triplex scan apparatus with various probes for the detection of arterial flow and imaging of the various arterial segments. During the last years 716 patients were submitted to PU. The indications for and the findings resulting from the application of PU are presented.

Ruptured abdominal aortic aneurysms. Clinical and surgical considerations.

Rupture of abdominal aortic aneurysms (AAA) is a life-threatening condition and a leading cause of death in various countries. In spite of increased awareness of most physicians for an early diagnosis of the rupture, the performance of surgery in an early stage and special care in the Intensive Care Unit, postoperative mortality is still high in most medical centers as well as in our Clinic. Two series of patients operated in our Clinic during the last 17 years are analysed. The applied surgical technics are presented and morbidity and mortality are analysed. A distinction between the general mortality was made based on all the inhospital deaths and the postoperative mortality rate including only the deaths after the operation during the postoperative period. Among the other conclusions it is also stressed that a real improvement in the mortality rate depends on elective surgery of all the disclosed AAA larger than 4 cm in diameter.

Is cerebral arteriography necessary for decision making in carotid endarterectomy?

The development of ultrasonic diagnostic imaging technics has recently been a competitive diagnostic method in cerebral arteriography. Many vascular surgeons, based on the high specificity and sensitivity of the ultrasonic imaging technics in carotid artery disease, have been performing carotid endarterectomy without arteriography with satisfactory results. In the last four years we have performed in our Department 62 carotid endarterectomies on 57 patients without using cerebral arteriography. In this paper diagnostic ultrasonic imaging and transcranial Doppler technics are presented and the immediate results of carotid endarterectomy in the above series of patients are reported. From our and other authors' experience it is concluded that carotid endarterectomy in patients with carotid artery disease is a safe procedure. Larger series of patients are needed with a longer follow-up in order that carotid endarterectomy without arteriography be accepted by the medical profession as a safe procedure.

Emergency thrombectomy of the inferior vena cava and total colectomy in a patient with ulcerative colitis.

Patients with chronic inflammatory bowel disease, particularly ulcerative colitis, have a greater thrombotic tendency. An effective management of a patient with established ulcerative colitis complicated with acute arterial occlusion of the right lower extremity and inferior vena cava thrombosis is presented. The episodes of thrombosis usually occur in the active phase of the disease. It is suggested that in patients with diseases such as UC, predisposing to thrombosis, the identification of abnormalities in the coagulation profile may predict those particularly at risk.

Mesenteric venous thrombosis due to coagulation deficiencies - a case report.

Mesenteric venous thrombosis is a rather rare condition posing diagnostic problems and very often with an obscure etiology. Recently, various coagulation deficiencies were found as the main etiologic factor. A case of a 75-year-old man with acute abdomen is presented. Exploratory laparotomy revealed a 250 cm necrosis of the small intestine. Patient was successfully treated by resecting the entire involved segment of the bowel. After a complete coagulation profile examination, deficiencies of protein C and anti-thrombin III were found and were considered as the main cause of the disease. In cases with known coagulation deficiencies the presence of an acute abdomen should raise suspicion of mesenteric venous thrombosis.

Surgical treatment of spontaneous internal carotid dissection.

Spontaneous dissection of the internal carotid artery is rarely submitted to surgery. We report a case successfully operated on with complete restoration of the cerebral blood flow. A 43-year-old male was admitted to our hospital 10 days after an episode of amaurosis fugax of the left eye, left sided headache and paresis of the right arm of a few hours duration. A diagnosis of dissection of the left internal carotid artery was made by duplex and triplex ultrasound examination and was confirmed by cerebral arteriography in contrast to magnetic resonance angiography which was misleading. Due to the slow arterial flow from the right to the left cerebral hemisphere through only the posterior communicating arteries we envisaged the possibility of a cerebral infarction if the dissection were to be extended. For this reason a surgical procedure was performed by excising the dissected segment and inserting a venous graft for the re-establishment of the arterial flow. Surgical treatment of spontaneous internal carotid dissection should be considered very carefully when the clinical and laboratory findings suggest the possibility of an impending stroke.

Multi-aneurysmatic degeneration of an autogenous venous graft inserted as femoro-popliteal by-pass.

An autogenous great saphenous venous graft inserted as femoro-popliteal by-pass 21 years before, developed multi aneurysmatic degeneration. This complication is very rare.

Obstructive uropathy, following redo aortobifemoral by-pass surgery.

A rare case of obstruction of the right ureter due to encagement between the right iliofemoral and right limb of an aorto-bilateral femoral Dacron graft is described. Patient was managed successfully by ureterolysis, removal of the occluded right iliofemoral graft, omentoplasty and placement of a pig tail catheter along the right ureter.

Superficial venous thrombosis of the lower extremities co-existing with deep venous thrombosis. A phlebographic study on 57 cases.

The incidence of deep venous thrombosis (DVT) coexistent in patients suffering from superficial venous thrombosis (SVT) has not been well documented. In a series of 57 consecutive patients with SVT of the lower extremities treated in our Department in the last five years without any obvious clinical signs of co-existing DVT, an ascending phlebographic study was performed. Co-existent DVT was disclosed in 19.6% of the patients. There was no correlation between the location or the length of thrombus and the co-existence of DVT. Patients in whom SVT developed in existing varicose veins were younger in age and the incidence of co-existence of DVT was lower. Our findings show that SVT does not always have a benign course. The disclosure of a high incidence of co-existing DVT in our series suggests the necessity of the examination of the deep venous system in all the cases of SVT by using ultrasonic technics, triplex and preferably of the ascending phlebography. The disclosure of DVT in those cases makes the application of anticoagulant treatment mandatory.

Abdominal aortic aneurysm and left sided inferior vena cava. A case report.

The co-existence of abnormalities of the inferior vena cava (IVC) and abdominal aortic aneurysm (AAA) is a rare condition but with surgical significance. With the development of various imaging technics and the routine use of computerized tomography for the examination of the abdomen and/or the investigation of AAA these venous abnormalities can be disclosed. A male patient with AAA and left sided IVC is presented.

Arterial aneurysms in Behçet's disease.

Six cases of arterial aneurysms, due to "Behçet's disease" located in various arteries are presented. Surgical reconstruction included: Resection of the lesions and replacement with corresponding grafts with satisfactory results. In spite of the macroscopic similarity of the aneurysms found in "Behçet's disease" as compared to those of mycotic origin, the presence of any microorganism could not be detected in various cultures or pathological specimens. Meticulous diagnosis on the nature of the aneurysm, close follow-up and careful postoperative anticoagulant treatment, is imperative for satisfactory immediate and late results.

Polyarteritis nodosa. An unusual cause of acute abdomen.

Two cases of acute abdomen operated on twice and biopsy specimens confirmed are presented. The diagnosis of a systemic necrotizing vasculitis group of polyarteritis nodosa was established. The syndrome affects predominantly males between the second and forth decade of life. The gastrointestinal tract is involved in approximately 50% of the cases. While a negative laparotomy may be considered as a surgical pit-fall, nevertheless, it is the only way of establishing the diagnosis and treating the complications of the disease in some of the cases.

Carotid endarterectomy and patch angioplasty, utilizing a segment of autogenous endarterectomized superficial femoral artery. A case report.

A case of a male patient, who had undergone a left internal carotid endarterectomy and arterial patch angioplasty is presented. After endarterectomy, arteriotomy was completed with a patch taken from the initial segment of a completely occluded superficial femoral artery, which was properly endarterectomized. The technique of arterial patch endarterectomy preservation is described and special emphasis is given to the advantages of deep endarterectomy on the possible beneficial long-term patency, as well as the availability of this autogenous material, in cases where the SFA artery is completely occluded.

Peripheral occlusive arterial disease in longstanding diabetes mellitus. A population study.

One hundred and seventy-five diabetic patients belonging to the same cohort were investigated. They were all inhabitants of a suburb of Athens and were initially identified during a diabetes detection drive conducted 11 years earlier. The study comprised a full physical examination, answering of a detailed questionnaire--with emphasis on signs of intermittent claudication (IC)--and a 12 lead ECG (analyzed according to the Minnesota code). It was shown that clinical signs of peripheral occlusive arterial disease were significantly associated to male sex, increased duration of diabetes, type of treatment and major ECG signs of coronary heart disease, while increased age, current smoking and existence ease, while increased age, current smoking and existence of hypertension were not significantly associated to POAD.