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ABSTRACT: The aim of the study was to demonstrate the utility of endovascular stent-graft repair for emergency management of aorto-iliac surgery complications. Between 1997 and 2004, in our institute, 201 patients underwent transluminal endovascular graft placement. In 3 patients (1.4%), previously submitted to conventional aortic surgery, endovascular treatment was carried out due to the occurrence of late complications: 1 secondary aortocaval fistula, 1 impending rupture of aortic pseudoaneurysm and 1 secondary aorto-enteric fistula. All candidates were high surgical risk patients (ASA III-IV) suitable for endoprosthesis positioning by endovascular stent-graft implantation presenting with severe worsening conditions in an emergency situation. The patients were treated under local anesthesia and mild sedation. After treatment there was complete resolution of the clinical presentation and an improvement of general conditions in all 3 patients. In the 1(st) patient legs edema disappeared and in the 2(nd) patient mesogastric pain is absent, respectively at 30 and 8 months. The 3(rd) patient, with secondary aorto-enteric fistula, was submitted 2 months later to aortic graft removal and axillo-bifemoral bypass because of infection development. For the treatment of abdominal aortic surgery complications in high risk patients, particularly in emergency situations, endovascular approach is a feasible and safe alternative to conventional open repair. Further evaluation of this technique and longer follow-up will determine its exact role in the management of these life-threatening complications.
The Journal of cardiovascular surgery 07/2007; 48(3):315-21. · 1.56 Impact Factor
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ABSTRACT: A review of the literature on the surgical treatment of abdominal aortic aneurysms (AAAs) reveals that aortofemoral bypass (AFB) is used frequently in some centers. The latter series are characterized by higher rates of graft-related complications than in those in which AFB is used less frequently. The aim of our study was to evaluate the relative frequency and outcome of different types of bypass grafts in the surgical treatment of AAAs with iliac involvement, in our center and in others.
Between 1994 and 2004, 190 AAA patients with involvement of the iliac axes underwent elective repair in our department. Surgery was performed via median transperitoneal access.
The AAAs extended to the common iliac artery (CIA) in 90.5% of patients. The remaining 9.5% extended to the external iliac artery (EIA). Aorto bi-iliac grafts were used in 159 cases, straight tube grafts in 13, aorto EIA grafts in 15, and AFBs in 3. Overall 30-day morbidity and mortality rates were 12.1% and 2.6%, respectively. At follow-up (mean: 5.6 years), one distal limb infection of an AFB and 4 CIA/EIA aneurysmal enlargements occurred and were repaired accordingly. Secondary patency and 5-year cumulative survival rate were 100% and 80%, respectively.
In this series of AAAs extending to the iliac axes, AFB was used selectively (1.6%), even when the AAA extended to the EIA. This allowed us to maintain direct vascularization of the hypogastric arteries and eliminate the risk of complications associated with inguinal access. We feel, therefore, that for the repair of aortoiliac aneurysms, AFB is rarely indicated.
The Journal of cardiovascular surgery 05/2007; 48(2):187-92. · 1.56 Impact Factor
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ABSTRACT: The purpose of this study was to review our experience with popliteal artery aneurysms (PAAS) and to identify the major factors associated with thromboembolism of PAAS and failure of grafts after surgical repair.
The medical records of 38 patients with 42 PAA, who presented in a university medical center between March 1985 and September 2000, were retrospectively reviewed. Data were collected on clinical presentation, risk factors, type of reconstructions, early and late morbidity, limb loss and mortality. Duplex scan, as well as computed tomography, was performed in 33 (78.6%) cases, and preoperative angiography in 38 (90.5%). Thrombolysis was performed prior to surgical reconstruction (16.07+/-21.97 months) in 4 cases presented with acute ischemia. All patients underwent synthetic (23, 54.8%) or autogenous (19, 45.2%), below-the-knee (39, 92.9%) or above-the-knee (3, 7.1%) femoropopliteal bypass graft. The proximal and distal anastomoses were end-to-end both in both cases in 30 bypasses (71.4%). Thirty-six (86%) aneurysms were surgically treated by one vascular surgeon. Postoperative anticoagulants were given in 8 cases (19%). Long-term follow-up (mean: 57.59+/-37.77 months) was available for 35 patients (92.1%). Multivariate analysis was used to assess association between risk factors and outcome.
Thirty-five patients were males, 3 were females; mean age was 68.31+/-8.66 years. Risk factors were arterial hypertension (25, 69%), smoking (19, 50%), dyslipidemia (7, 18.4%) and diabetes (5, 13.2%). Thirty PAAS (71.4%) were symptomatic for acute (11, 26.2%) or chronic (7, 16.7%) ischemia, distal embolization (8, 19%), compression of the popliteal fossa (3, 7.1%) and rupture (2, 4.8%, one of which presented with acute ischemia); 12 were asymptomatic. Bilateral PAAS were present in 18 patients (47.4%); 14 (36.8%) also had an abdominal aortic aneurysm (AAA); associated AAAS were twice as common in patients with bilateral PAAS (9/18, 50%) compared to those with unilateral PAAS (5/20, 25%; p=NS). The mean diameter of the PAAS was 3.4 cm; no significant difference was found in the mean diameter of symptomatic and asymptomatic aneurysms. Complete thrombosis of the aneurysmal sac was found in 15 cases (35.7%), severe atherosclerotic femoro-popliteal lesions in 17 (40.5%), arteriomegaly in 11 (26.2%), occlusion of the superficial femoral artery (SFA) in 7 (16.7%). Three leg arteries were present in 17 limbs (40.5%), 2 in 6 (14.3%), 1 in 7 (16.7%), no leg vessels in 12 (28.6%). Occlusion of the SFA and the absence of major leg arteries were independently associated with thrombosis of the aneurysmal sac (p=0.005). Two-thirds of patients with thrombosed PAA (10, 66.7%) presented with acute ischemia, while 1/3 (5, 33.3%; p=NS) had some degree of claudication. Optimal runoff (score=1) was estimated in 23 limbs, while score was between 2-7 in 19 limbs. Thrombolysis was successful in all 4 cases, with no complications. Primary graft patency was 66.1% at 4 years; the only variables independently associated with loss of bypass patency were smoking (p=0.04) and poor leg runoff (p=0.02). Postoperative bypass occlusion occurred in 2 cases presented respectively with acute and chronic ischemia, and in 2 asymptomatic patients; all 4 bypasses were polytetrafluoroethylene grafts. A total of 8 thrombosed, polytetrafluoroethylene, below-the-knee bypass grafts required secondary reconstructions (2 redo + 6 restorative procedures). The secondary patency rate at 3 years was 77.9%. Lower limb amputation had to be performed 2 months after primary reconstruction in 1 case (2.4%) presented with acute ischemia. The estimated limb salvage rate at 10 years was 96%. Mortality was 4.8%. Survival at 6 years was 82.6%.
Our experience indicates that SFA occlusion and poor runoff vessels were independent factors associated with PAA thrombosis. The diameter of asymptomatic PAAs was not significantly different than that of asymptomatic ones. Use of tobacco and poor runoff vessels were independent factors associated with primary bypass patency. In PAAs complicated with acute ischemia, thrombolysis allowed us to regain a good runoff and to perform subsequent bypass procedure, with no amputation. The use of autogenous graft material, when possible, is recommended.
International angiology: a journal of the International Union of Angiology 04/2004; 23(1):54-65. · 1.65 Impact Factor
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La radiologia medica 04/2002; 103(3):274-8. · 1.44 Impact Factor
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ABSTRACT: The purpose of the current study was to identify the possible short- and long-term effects of diabetes on the outcome of carotid endarterectomy.
Medical records were reviewed for 781 carotid endarterectomies (in 734 patients) performed by the same vascular surgeon in a university medical center between January 1994 and December 1998. Patients were divided two groups: those with diabetes (n = 181 patients; 193 operations) and those without diabetes (n = 553; 588 operations). The two groups were similar with respect to mean age, male-female ratio, and contralateral lesions. The only significant differences were a higher prevalence of peripheral vascular disease and dyslipidemia in the diabetic group and a higher prevalence of hemispheric transient ischemic attacks among the nondiabetic patients. Carotid color duplex ultrasound scan had been performed in all patients, and in 56 patients from the diabetic group and 56 patients from the nondiabetic group (matched for age, sex, and contralateral lesions), the distal extension of the lesion from the carotid bifurcation had also been defined. Both of these subgroups were fully representative of their respective groups of origin. Carotid endarterectomy was performed after the induction of general anesthesia; electroencephalographic monitoring was continuous.
Except for the significantly higher prevalence of calcified plaques in the diabetic patients (P <.0001), the characteristics of the carotid disease in the two groups were similar. In the 56-member subgroups, 73.2% of the diabetic and 35.7% of the nondiabetic patients (P <.0001) had lesions extending more than 2 cm beyond the carotid bifurcation. Mean length of plaque beyond the bifurcation was 2.3 +/- 0.09 cm for the diabetic and 1.7 +/- 0.08 cm for the nondiabetic patients (P <.0001). Diabetes was the only factor significantly correlated with plaque length. In the diabetic subgroup, surgery was characterized by significantly longer carotid arteriotomies (P =.03) and clamp times (P <.003). Operative mortality was 1.5% in the diabetic group (2 myocardial infarctions + 1 stroke) and 0.5% in the nondiabetic group (1 myocardial infarction + 2 strokes; P value not significant); stroke rates were 1.5% (3 major strokes) and 0.5% (2 major strokes + 1 minor stroke), respectively (P = not significant). Long-term survival (5 years) was not significantly lower among the diabetic patients.
Diabetes mellitus does not seem to significantly increase the surgical risk for carotid endarterectomy. The presence of more extensive plaques has no significant effect on the results of surgery.
Journal of Vascular Surgery 02/2001; 33(1):148-54. · 3.21 Impact Factor
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ABSTRACT: The aim of this study was to prospectively evaluate the postoperative dilation of two types of knitted polyester arterial prostheses with the use of helical computed tomographic scanning.
Thirty-four patients who underwent aortoiliac or aortofemoral bifurcation grafting were randomized to receive a collagen-sealed warp-knitted polyester graft (n = 16 patients) or a gelatin-sealed Köper-knitted polyester graft (n = 18 patients). Alterations in size of all parts of the grafts were evaluated by helical computed tomographic scanning at postoperative day 8, at 3 months, and at 6 months.
On postoperative day 8, the mean dilation of the Köper-knitted grafts was 18% +/- 8% for the stem and 15% +/- 12% for the limbs. At the same time period, the mean dilation of warp-knitted grafts was 27% +/- 13% for the stem and 33% +/- 18% for the limbs. No increase in graft dilation was observed at 3 and 6 months. Despite the wide range of values among patients with the same graft type, at each time interval, the Köper-knitted grafts dilated significantly less than the warp-knitted grafts (P <. 05).
In this randomized study, helical computed tomographic scanning was an accurate technique with which to assess graft dilation. For a 6-month follow-up interval, the Köper-knitted polyester structure dilated less than the warp-knitted structure. Longer-term serial scans should allow a better understanding of the clinical significance of graft dilation.
Journal of Vascular Surgery 02/2000; 31(1 Pt 1):157-63. · 3.21 Impact Factor
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ABSTRACT: To investigate different clinical applications of gadolinium-enhanced MR angiography (Gd MRA) using three-dimensional breath-hold GE sequences, without bolus time calculation, in patients with vascular diseases.
Forty-seven patients were examined (49 studies in all). Eleven of them had an abdominal aortic aneurysm, 6 surgical bypass, 7 renal artery stenosis, 3 aortoiliac Wallstent, 7 aortic stent-graft; 11 patients had a suspected condition in the thoracic aorta and pulmonary arteries, 1 had subclavian artery stenosis and 1 suspected axillary artery compression. All patients were submitted to breath-hold Gd MRA, after 30-40 mL Gd, with a 1.5 T magnet (Gyroscan ACS-NT, Philips, The Netherlands) and a standard body coil. The GE sequences were acquired with TR = 8.8, TE = 2.7, FA = 60 degrees, matrix = 163 x 512, with 28 seconds acquisition time. Digital subtraction angiography and intraoperative findings were the reference standards to evaluate the results.
Thoracopulmonary district: metastatic compression of axillary vessels was found in 1 breast cancer patient; the true and the false lumens and the intimal flap were identified in 2 patients with chronic aortic dissection (Stanford A), and graft patency and complete resolution of the aortic dissection was seen in the patient operated on for acute aortic dissection (Stanford A). The thrombus, lumen, extent and diameter were studied in 2 patients with thoracic aortic aneurysms. Subclavian artery stenosis was demonstrated in 1 patient, which was treated with transluminal angioplasty and stenting. The other 6 patients had normal findings. Abdominal aortic aneurysms (AAA): as for disease extent, breath-hold Gd MRA had 100% sensitivity and specificity compared with surgical findings. Juxtarenal aneurysm extent, which had been missed at DSA, was detected in 1 patient and then confirmed at surgery. Stenosis: comparing DSA and MRA findings in the whole series of patients we had 97.4% agreement (155/159 arteries), that is 76.4% (13/17) arteries) considering only stenoses > 50%. Breath-hold Gd MRA sensitivity and specificity were 100 and 87.5%, respectively, in our 28 stenoses. Bypass, aortoiliac stent, vascular endograft: patency was demonstrated in all the 6 surgical bypass patients, and there was agreement with color Doppler findings in 5 of 6. Breath-hold Gd MRA seems to have no possible applications in the follow-up of percutaneously implanted iliac stents, but we had excellent findings about patency and position of nichel-titanium endografts used for AAA treatment.
We optimized breath-hold 3D MRA without bolus transit time calculation and with high-dose Gd in different clinical vascular conditions. In our opinion, 3D GE sequences can replace DSA in selected cases, providing a fast, accurate and noninvasive examination.
La radiologia medica 10/1999; 98(4):275-82. · 1.44 Impact Factor
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Minerva cardioangiologica 10/1998; 46(9):270.
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European Journal of Vascular and Endovascular Surgery 01/1998; 14 Suppl A:47-52. · 2.99 Impact Factor
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A Galante,
A Pietroiusti,
A Magrini,
S Carta,
L Franceschelli,
P Piccolo, G R Pistolese,
E Martelli,
A Mastino,
C Matteucci,
S Grelli,
C Favalli
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ABSTRACT: To evaluate whether atherosclerosis may be associated with altered leucocyte rheology, we assessed leucocyte count (by Coulter counter), aggregation (by means of the leukergy test) and expression of adhesion molecules integrin LFA-1 and CD 44 (by means of immunofluorescence staining and flow cytometry) in 9 patients with carotid plus lower limb artery atherosclerosis (group A), 14 patients with carotid atherosclerosis only (group B) and 23 controls without atherosclerosis (group C). The level of LFA-1 (calculated as mean fluorescence channels-MFCs) on neutrophils, lymphocytes and monocytes was significantly higher (p < 0.05) in group A and B patients than in controls (group A-mean +/- SE: 383.77 +/- 9.42 vs 295.45 +/- 5.76; 474.22 +/- 8.86 vs 388.35 +/- 7.84; 457.66 +/- 12.03 vs 396.25 +/- 4.37. Group B: 322.42 +/- 6.36 vs 295.45 +/- 5.76; 421.42 +/- 7.21 vs 388.35 +/- 7.84; 415.71 +/- 7.73 vs 396.25 +/- 4.37, respectively); furthermore, the MFC of LFA-1 on neutrophils was significantly different (p < 0.05) between group A and B patients. The percentage of aggregated leucocytes was significantly higher (p < 0.05) in group A patients (4.46 +/- 1.07) than those in groups B (1.75 +/- 0.38) and C (1.43 +/- 0.25), whereas no significant difference was detected between groups B and C. Leucocyte number and expression of CD44 were not significantly different among the 3 groups. In conclusion, changes in leucocyte rheology are present in patients with atherosclerosis and may contribute to chronic ischaemia.
Thrombosis and Haemostasis 06/1997; 77(6):1073-6. · 5.04 Impact Factor
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ABSTRACT: This retrospective study was carried out from January, 1990, to September, 1994, after reviewing a series of 100 patients submitted to 143 percutaneous maneuvers (PTA) for aortoiliac revascularization (PTA, PTA and stenting, PTA and bypass). This study was aimed at conforming as much as possible our patients selection criteria and the analysis of the results to the current standards adopted by the major interventional radiology and vascular surgery departments. The Fontaine and the SCVIR classification methods were used for patients selection. Long-term patency was analyzed with clinical and noninvasive diagnostic exams. The results were studied with the Life-table analysis statistical method. The patients were divided into 3 groups: the patients treated only with PTA, those treated with PTA and stenting and finally those submitted to PTA before or after a surgical bypass. The results were analyzed separately. In 95/100 patients the maneuver was technically successful and immediate clinical success was not achieved only in one of them. At the first follow-up we collected data on 87 patients; at 3 years we followed-up 30 patients, but only 5 of them had to be resubmitted to PTA (3 PTA and stenting and 2 PTA alone) because of restenosis. Secondary patency was obtained in 91% and 84% of patients at 1 year and 3 years, respectively. With the Life-table analysis, the cumulative patency rate was 95.44% at 36 months. Few complications were observed (11/100 patients), especially considering that they were classified as "severe" in 3 cases only. To conclude, our results prove PTA to be a highly effective tool in the aortoiliac arteries, whose low mortality and complication rates suggest the use of this percutaneous procedure.
La radiologia medica 01/1996; 90(6):772-80. · 1.44 Impact Factor
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ABSTRACT: Mean flow velocity changes in the middle cerebral arteries (MCAs) during a 2-minute thumb-to-finger opposition task were measured by means of transcranial Doppler ultrasonography in patients with severe unilateral carotid stenosis and ipsilateral transient ischemic attacks and in control subjects. The increase of flow velocity in the MCA contralateral to the hand performing the task was significantly different (p < 0.001, one-way ANOVA) in controls (+5.52 +/- 2.4 cm/sec) and in patients (+1.76 +/- 1.6 cm/sec, side of stenosis; +3.83 +/- 2.1 cm/sec, normal side). A post hoc least significant difference test revealed a significant difference between controls and patients on the side of stenosis (p < 0.001) and between the normal side and the stenotic side in patients (p < 0.03). One month after carotid endarterectomy, the effect of the motor task produced a significantly different effect on flow velocity in patients (p < 0.01, two-way ANOVA) because the increase of flow velocity during the motor task on the side of stenosis (4.84 +/- 1.9 cm/sec) was similar to that observed on the normal side (4.63 +/- 1.4 cm/sec). These findings suggest that the effect of a simple motor task on flow velocity of MCAs may allow for the evaluation of the functional effects of carotid lesions. Prospective studies are needed to evaluate whether this test constitutes a useful approach for the identification of patients who would benefit from a surgical procedure.
Neurology 10/1994; 44(10):1910-4. · 8.31 Impact Factor
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European Journal of Vascular Surgery 12/1993; 7(6):604-9.
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ABSTRACT: Carotid artery cross-clamping ischaemia during carotid endarterectomy (CEA) causes 5-30% of perioperative neurological deficits. This study was performed to identify possible clinical situations at higher risk for carotid cross-clamping ischaemia. 606 consecutive patients underwent CEA and were retrospectively studied; they were grouped according to risk factors, presence of associated vascular diseases, clinical pattern, angiographic and CT scan findings. Stump pressure measurement was provided in all patients, perioperative monitoring during CEA was performed by electroencephalogram (EEG) in 469 (77%) and somatosensorial evoked potentials (SEP) in 137 (23%). Local anaesthesia was used in 88 (14.5%) patients. Ischaemic changes during carotid cross-clamping were registered in 118 patients (19.5%). The incidence of cross-clamping ischaemia was then related to different factors; it affected 5.6% of asymptomatics, 25.4% of patients with fixed stroke and 38.5% of those with stenosis and contralateral occlusion. Angiographic and clinical correlation showed that patients with more severe lesions are mostly affected by clamping ischaemia (up to 55% in those with stroke and stenosis with contralateral occlusion). Age, hypertension and diabetes do not significantly affect incidence of ischaemic changes. Positive CT scan increased this risk; statistical relevance was found in regard to patients with unilateral or bilateral stenosis and in those with transient ischaemic attacks. A higher risk can be expected for subjects with more severe clinical and instrumental findings, even if no patients can be considered completely at risk or risk free. Perioperative monitoring is always mandatory and is of great importance in detecting ischaemic changes and preventing cerebral damage using a temporary intraluminal shunt.
European Journal of Vascular Surgery 04/1993; 7 Suppl A:33-8.
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Minerva chirurgica 04/1992; 47(5):229-33. · 0.77 Impact Factor
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Cardiologia (Rome, Italy) 12/1985; 30(11):1031-5.
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Clinical Cardiology 01/1984; 6(12):622-5. · 2.15 Impact Factor
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ABSTRACT: Intermittent claudication of the masticatory muscles is an unusual symptom sometimes described in association with temporal arteritis. We describe here two cases where this symptom was due to insufficient blood supply to the masticatory muscles caused by atherosclerotic changes of carotid vessels. In one of our cases surgical revascularization was followed by the disappearance of this symptom.
The Italian Journal of Neurological Sciences 11/1980; 1(4):271-4.
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Minerva cardioangiologica 11/1979; 27(10):603-16.
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Minerva medica 08/1979; 70(31):2189-92. · 0.90 Impact Factor
