Endograft repair of spontaneous infrarenal abdominal aortic dissection.
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Aged↗
Biomedical subjects
M Porcellini
Publications and source records attributed to M Porcellini.
Carotid endarterectomy in heart transplant patients.
AIM: The aim of this study was to determine the clinical outcome of carotid endarterectomy in heart transplant recipients and morphologic features of atherosclerotic plaques removed during operation. METHODS: Between April 1993 and October 2001 5 heart transplant patients with symptomatic carotid stenosis >70% underwent carotid endarterectomy with regional anesthesia, including a staged bilateral procedure in one patient. Cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol were evaluated in each patient. The plaques ( n=6) underwent histologic analysis after carotid endarterectomy. Carotid artery duplex imaging was added to the routine postoperative evaluation. RESULTS: Carotid plaques resulted to be echolucent on B-mode ultrasound examination. Cholesterol, triglycerides and LDL-cholesterol levels were found to be increased, while HDL-cholesterol were decreased. All patients underwent successful carotid endarterectomy; there were no perioperative deaths, major neurologic or cardiac events. The mean length of stay was 2.2 days. The mean follow-up was 44 months. In 1 case, an asymptomatic restenosis >50% occurred 9 months later and, in 2 other cases, a contralateral mild stenosis was found 12 and 36 months later. One patient had a progressive contralateral stenosis, requiring operation 18 months later. High lipid content and heterogeneous cellular infiltration were observed, including macrophages, T-lymphocytes, neutrophils, and also eosinophils in the rapidly progressing plaque. CONCLUSIONS: Heart transplant patients receiving immunosuppression may successfully undergo carotid endarterectomy, without increased risk, but progression of atherosclerotic disease in the carotid arteries seems to continue, despite lipid-lowering regimen and antiplatelet therapy.
Aged↗
Lymphoceles complicating arterial reconstructions of the lower limbs: outpatient conservative management.
BACKGROUND: Treatment of lymphoceles complicating vascular procedures is controversial. The purpose of this study was to evaluate the practicability, effectiveness and safety of conservative management on an outpatient basis. METHODS: Medical records were reviewed for 23 postoperative lymphoceles (in 18 patients) seen at our institution between 1986 and 1999. Diagnosis was made by physical examination and needle aspiration of fluid collection; bacterial cultures were obtained in all. Ultrasonography was performed in all patients, lymphoscintigraphy (99mTc HSA) in 11, angio-TC in 2 cases, MRI in 3 large lymphoceles. RESULTS: Twenty-one lymphoceles developed in the groin, 2 in the thigh and were mostly (72.2%) diagnosed after hospital discharge. Imaging techniques detected subcutaneous wound collection; in addition, lymphoscintigraphy showed lymphatic interruption and collateral pathways in patients with limb swelling. Outpatient management consisted of limited ambulation, limb elevation and pressure dressings; no serial aspirations were made. Resolution was obtained in all patients over a mean period of 21 days (range, 12 to 35). No patient required re-hospitalization or developed wound and/or graft infection. No recurrence was noted after a follow-up of all patients for 1 year. CONCLUSIONS: Outpatient treatment of lymphoceles following arterial reconstructive procedures can be performed safely. Significant advantages of this pathway include no re-hospitalization and cost reduction.
Adult↗
Outpatient management of superficial temporal artery aneurysms.
BACKGROUND: To evaluate the feasibility and safety of surgical treatment of the superficial temporal artery aneurysms on an outpatient basis. METHODS: The records of 5 patients seen at our institution from 1983 to 1997 were reviewed retrospectively. Preoperative diagnosis was made by patient s history and physical examination, with no further evaluation. RESULTS: Outpatient ligation and excision of four aneurysms of distal branches of the superficial temporal artery (3 frontal, 1 parietal) and one involving its proximal portion was performed under local anesthesia. Supplementation with minimal intravenous sedation facilitated the treatment in an uncooperative child and in the patient affected with proximal STA aneurysm. All procedures were uneventful. Patients were discharged a few hours after surgical treatment. No patient required hospitalization following discharge. No recurrence was noted during follow-up periods of 2 to 16 years. CONCLUSIONS: Outpatient diagnosis and excision of aneurysm of the superficial temporal artery can be performed safely. Significant advantages of this pathway include no hospital admission and cost reduction.
Adult↗
About management of infected grafts.
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Aged↗
Intramural hematoma of the thoracic aorta in octogenarians: is non operation justified?
OBJECTIVE: The prognostic factors and treatment options for thoracic aortic intramural hematoma are controversial. The purpose of this study was to determine the most suitable treatment of this condition in very elderly patients. METHODS: In a review of the world literature, eight octogenarians with thoracic aortic intramural hematoma were found; to these the three cases reported here must be added. The descending thoracic aorta was involved in eight cases and the ascending/arch in three. RESULTS: In spite of patients' poor general conditions, the medical treatment group showed survival rates of 85.7% (descending) and 66.6% (ascending/arch), respectively. CONCLUSION: Extensive atherosclerotic changes of the aortic wall in the elderly, combined with control of hypertension, may probably prevent thoracic aortic intramural hematoma from progressing to dissection, with a favourable outcome. An earlier and more accurate preoperative diagnosis by modern diagnostic techniques, including spiral computed tomography (CT), as were performed in our own patients, will allow optimal treatment and increased patient survival.
Aged↗
Arterial homografts in the management of infected axillofemoral prosthetic grafts.
Two lower limb amputees with infected contralateral axillofemoral prosthetic grafts received preserved human arteries after removal of the infected materials. Both grafts grew organisms (Enterococcus species, plus Staphylococcus species in one). Long length arterial conduits were fashioned from freshly harvested (in one patient) and cryopreserved (in another one) cadaveric iliac and femoral arteries. One arterial homograft had ABO-compatibility with the recipient. No immunosuppressive drugs were administered after repeat arterial reconstructions. After 12 and 15 months both grafts are still patent, without parietal changes at ultrasonography; the patients have a viable remaining lower extremity and are free of symptoms or re-infection.
Aged↗
Spontaneous rupture of the iliac vein.
Two unusual cases of iliac vein spontaneous rupture into the retroperitoneum are presented together with 18 cases reported by the literature. In one patient of ours, entrapment of clots in an IVC filter and proximal iliac vein involvement into the scar tissue surrounding the left limb of an aortoiliac bifurcation graft might have caused flow disturbances and subsequent predisposition to rupture of the thrombosed external iliac vein. Inflammatory parietal changes, including infiltration of macrophages, T and B lymphocytes producing elastin degradation by means of cytokines, may have led ultimately to vein disruption. Despite clinical features and CT scan findings, the physician's awareness of this disease remains the most important factor for the early treatment.
Aged↗
Combined vascular injuries and limb fractures.
Blunt arterial injuries secondary to bone fractures are frequently associated with nerve, vein and soft tissue lesions. A delayed diagnosis or treatment is the main cause of high amputation rate. Thirty-four patients presenting acute arterial occlusion (15 cases), false aneurysms (13 cases) or AVFs (6 cases) of the extremity were identified between 1983 and 1995. To repair injured arteries, ligation (3 cases), patch angioplasty (6 cases), autogenous vein (15 patients) or PTFE (4 cases) interposition or bypass grafting were made. Percutaneous embolization by coils was performed in 3 AVFs of small limb arteries. Associated venous lesions were treated in 9 patients. External fixation of long bone fractures was made in 29 patients, before vascular reconstruction, to prevent further injury during orthopedic stabilization. Fasciotomies were made in 6 patients to treat compartmental hypertension. Early reexplorations were necessary to correct technical defects in 4 patients. Hyperbaric oxygen therapy was applied in 7 patients to control bacterial contamination and improve wound healing. Primary (2 cases) or secondary (3 cases) amputations were carried out in unsalvageable limbs. Nerve or extensive muscle damage caused poor functional outcome in 4 patients. A multidisciplinary diagnostic and management strategy is required to improve limb and patient survival.
Adolescent↗
Late arteriovenous fistulas and pseudoaneurysms of the extremity secondary to civilian firearms.
To evaluate the treatment of late sequelae of penetrating arterial injuries associated with civilian firearms, such as false aneurysms and arteriovenous fistulas (AV-Fs) of the extremities, a retrospective clinical study was carried out. Whenever diagnosis or operative management is delayed because of local fibrosis or morphological and structural vessel changes, primary repair is not feasible and segmental resection is required. Twenty-four patients presenting late false aneurysms (14) and AV-Fs (11) of the extremities, caused by firearms (6 rifle wounds, and 18 pistol wounds), were identified between 1983 and 1995. Twenty-three patients were submitted to resection of pseudoaneurysms (13) or AV-Fs (8), while arterial patch angioplasty was applied in two patients. The venous lesions were repaired by an interposition graft (7) or lateral venorraphy (3). Saphenous vein (15) or PTFE (6) grafts were placed in injured arteries. Percutaneous embolization by coils was performed in two patients. Twenty-three out of 24 patients (95.8%) recovered; one patient (4.1%), affected by aneurysmal AV-Fs of a lower limb dating from 12 years, with enlarged and weakened artery, bled to death. No limb loss occurred. A better evaluation of minimal vascular injuries is required to avoid late sequelae of civilian firearms lesions, with significant blood loss, which need segmental excision of the injured vessels.
Adolescent↗
Popliteal artery entrapment syndrome: diagnosis and management.
A variety of anatomical abnormalities may product an external compression of the popliteal artery, resulting in a thrombotic occlusion. Between 1983 and 1995, 9 patients presented a popliteal artery entrapment syndrome, bilateral in two cases. Ultrasonography, Angio-CT scan and MRI showed the abnormal structures and position of the popliteal artery on popliteal fossa. Arteriography detected an arterial compression in 6 limbs and occlusion in 4 limbs as well as an associated popliteal aneurysm in one patient and distal embolism in four. The abnormal medial head of the gastrocnemius muscle was resected in 8 limbs, while fibrous membranes were resected in 3 limbs. Autogenous vein replacement was performed in 4 cases of popliteal artery occlusion and following resection of a popliteal artery aneurysm in one case. All patients recovered. In the followup period, the occlusion of the arterial reconstruction occurred after 28 months in one patient, with a mild claudication. Noninvasive vascular imaging techniques may allow early diagnosis and management of PAES, avoiding popliteal arterial wall lesions and its occlusion, with a better outcome.
Adolescent↗
Endovascular treatment of late post-irradiation acute leg ischaemia.
A case of acute iliofemoral artery thrombosis occurring 32 years after radiation therapy is reported. Radiological and MRI findings are described; the patient was successfully treated by intra-arterial thrombolysis and PTA-stent.
Acute Disease↗
Intra-abdominal acute diseases simulating rupture of abdominal aortic aneurysms.
OBJECTIVE: To assess preoperative diagnosis of intra-abdominal acute diseases manifesting as a RAAA and determine treatment options. DESIGN: Retrospective review, with a mean follow-up period of 4 years. SETTING: Vascular Department, Medical School, University "Federico II" of Naples, Italy. METHODS: In 12 patients (8.7%) with clinical suggestion of RAAA were found other intra-abdominal acute lesions, associated with asymptomatic aortic aneurysm in 10 of them and absence in one; the remainder had an intact common iliac artery aneurysm. Sonography was performed in the operating room in 5 patients (41.6%) in shock, 4 hemodynamically stable patients (33.3%) had CT scanning or MRI investigations, while 3 (25%) underwent surgery directly. INTERVENTIONS: Three patients were not operated; one half of patients were submitted to emergency laparotomy and in the remaining 3 patients a preoperative preparation was made. Simultaneous aneurysm repair and nonvascular procedures were performed in 4 patients; nonvascular operations alone were carried out in 5 patients. 4 patients underwent a successful later treatment of their aneurysms: two aneurysmectomy and two endoluminal stenting were done within 4 months. RESULTS: Weight loss and fever were found at 58.3% and 50% of patients with concomitant intra-abdominal acute diseases; both were present in 41.6%. Noninvasive imaging techniques detected associate lesions in 6 of 8 patients (75%) and absence of aneurysm in one having a bleeding adrenal mass. There were three in-hospital deaths: one patient died of metastatic disease without operation and two after surgery (22.2%). Two late deaths from cancer cachexia occurred at 11 months and 3.6 years. CONCLUSIONS: Atypical findings, such as weight loss and fever may be suggestive of coincident lesions in patients with suspected RAAA. Noninvasive assessment may identify associated diseases simulating aneurysmal rupture, without a delay in the treatment. A selective policy of medical or operative therapy may be effective to minimize risk of complications and mortality rate.
Abdomen, Acute↗
Popliteal-to-tibial bypass for acute leg ischemia complicating aortic reconstruction.
Between 1983 and 1995, elective aortic surgery was performed on 1018 patients for aneurysmal (417 cases) or occlusive disease (489 cases), or both (112 cases). Intraoperative acute popliteal occlusion, despite of aortic graft patency, developed in 2 patients due to distal embolization (0.19%) and in 5 patients secondary to acute popliteal trifurcation thrombosis (0.49%). Preoperative ankle index was 0.46 +/- 0.12, but intraoperatively it went down to zero; distal popliteal occlusion was confirmed by intraoperative arteriography. A balloon catheter embolectomy was performed in two patients. Distal bypass from popliteal artery above knee (1) and below knee (3) to the posterior tibial artery was implanted in four patients using reversed autogenous saphenous vein. In one patient, revascularization was not feasible because of diffuse calcified obstructive disease of leg arteries. Reoperations resulted in a satisfactory outcome in 6 out of 7 patients (85.7%). The patient, in which revascularization was not possible, was submitted to major amputation. In the four popliteal-to-tibial bypasses evaluated through a follow up period of 43 months, graft patency was 75% and limb salvage rate was 100%. Instead of amputation, popliteal-to-tibial bypass is a useful treatment for acute in situ thrombosis of popliteal trifurcation following aorto-iliac reconstruction.
Acute Disease↗
[Aneurysms of the external jugular vein].
External jugular vein aneurysms are rare and appear as a soft, compressible mass in the neck. Three cases are herein reported. Ultrasonography is the investigation of choice. Surgical excision is indicated, specially in case of giant and thrombosed venous aneurysm.
Adult↗
Visceral artery aneurysms secondary to collateral circulation.
OBJECTIVE: To evaluate dilatation of visceral arteries secondary to anomalies and collateral circulation. DESIGN: Case report. SETTING: Department of Vascular Surgery, University Hospital. PATIENTS: Two patients with secondary visceral aneurysms were reported. First patient (case 1) had a mid-aortic dysplastic syndrome with multiple aneurysms of the celiac trunk and right renal artery. Other patient (- case 2) presented an inferior pancreaticoduodenal artery aneurysm associated with proximal common hepatic artery occlusion. INTERVENTIONS: The case 1 was submitted to aortic and left renal artery angioplasty (PTFEE), while in the case 2 the resection of aneurysm was performed. RESULTS: Both patients had complete resolution of symptoms and are alive today. CONCLUSIONS: Clinical observations confirmed the development of visceral artery aneurysms secondary to arterial hypertension and collateral circulation.
Adult↗
[Arteriosclerotic aneurysms of the subclavian artery].
OBJECTIVE: To evaluate diagnostic investigations, operative management and long-term outcome of atherosclerotic aneurysms of the subclavian artery. DESIGN: A retrospective clinical study through a follow-up period of 68 months (8 months to 11 years). SETTING: Department of Vascular Surgery, University Hospital. PATIENTS: Between 1983 and 1995, 5 patients with atherosclerotic aneurysms of the extrathoracic subclavian artery were reviewed. All patients presented a pulsatile supraclavicular mass. Ultrasonography and angiography confirmed the diagnosis and were useful in planning the operation. INTERVENTIONS: Four patients were submitted, through a supraclavicular incision, to resection of the aneurysm and replacement of a prosthetic graft (dacron in 2 cases, PTFE in the remaining 2 cases). In one patient, with a small saccular aneurysm, a tangential aneurysmectomy with a patch angioplasty (PTFE) was performed. RESULTS: All patients recovered after a mean hospital-stay of 9 days and had a valid radial pulsation. During the follow-up period, a dacron graft failure occurred 38 months later in one patient: she remains today asymptomatic. CONCLUSIONS: Resection is today recommended for all patients with diagnosed subclavian artery aneurysms. Because of unknown natural history of asymptomatic aneurysms, with an unpredictable risk of complications, more accurate evaluations are required for optimal clinical decision making (early surgery vs watchful waiting?).
Adult↗
Inferior pancreaticoduodenal artery aneurysm associated with common hepatic artery occlusion.
A unique case of true inferior pancreaticoduodenal artery aneurysm (IPDA) associated with occlusion of common hepatic artery is reported. Radiological and MRI findings are described. Because of high risk of visceral ischemia that contraindicated a percutaneous transluminal embolization, a successful tangential resection of aneurysm was performed.
Aneurysm↗