G.P. Deriu

Visceral artery aneurysms: a single center experience.

BACKGROUND Splanchnic artery areurysm is a rare but clinically relevant disease, showing a high mortality rate in emergency surgery. Reports on splanchnic aneurysms are rare and often anecdotal. The aim of this study is to discuss data obtained from 16 patients in a single vascular surgery center. MATERIALS AND METHODS Between January 1987 and December 2000, 16 patients underwent surgery for splanchnic artery aneurysms. In 13 patients the localization was single (in two associated with an infrarenal abdominal aortic aneurysm) and in 3 patients multiple. The arteries involved were: splenic (8), hepatic (4), celiac (3), superior mesenteric (3), ileocolic (2), and pancreatoduodenal (1). 13 patients were asymptomatic and 3 presentec with abdominal pain. All patients underwent CT scan, and abdominal aortic and selective visceral artery angiography. Before surgery, all patients underwent cerebral MR or cerebral CT scan. 13 patients underwent open vascular surgery; 3 patients (2 splenic and 1 hepatic) underwent endovascular procedure (angioembolization). Histological examination of the aneurysmal wall was obtained in 14 patients. Ultrasound examination was performed after 6 months, then yearly. 14 patients underwent abdominal CT scan during the long-term follow-up. RESULTS Perioperative mortality was absent. 12 cases were classified as displastic, with minor or major secondary atherosclerotic changes, and in many cases severe calcications. 2 cases were classified as atherosclerotic. Cerebral MR did not show any cases of intracerebral displastric aneurismal disease. One patient was lost at follow-up after 9 years. One patient showed a recurrence at 6 years (superior mesenteric artery): the patient underwent a new surgical procedure and died 20 days after surgery for intestinal infarction. All abdominal follow-up CT scans show good results of the vascular reconstruction and escluded other new visceral or aortic aneurysms. CONCLUSIONS Visceral artery aneurysms are an uncommon form of abdominal vascular disease showing a high postoperative mortality rate in emergencies. Surgery, and in selected cases, endovascular treatment, can successfully manage splanchnic artery aneurysms with few complications and low recurrence.

Synchronous carotid endarterectomy and retrograde endovascular treatment of brachiocephalic or common carotid artery stenosis.

OBJECTIVES To retrospectively evaluate the safety and the long-term results of retrograde brachiocephalic and common carotid angioplasty and stenting (AS) performed for >70% stenosis synchronously with the carotid endarterectomy (CEA). PATIENTS Sixteen patients operated between April 1999 and March 2002. RESULTS 14/16 procedures were successful. There was no neurological morbidity or mortality. Per-operative angiography showed the optimal stent positioning and patency of both proximal and distal arteries in all patients. In the follow-up, all patients showed patency of the treated vessels without restenosis and the absence of any cerebrovascular symptoms. CONCLUSION Intra-operative retrograde AS combined with CEA is an effective, safe and durable alternative to conventional surgery when a tandem significant proximal lesion is identified in a patient with an high grade carotid stenosis.

Continuous Intraoperative EEG Monitoring during Carotid Surgery

Continuous intraoperative EEG monitoring and stump pressure measurements were studied during 85 carotid revascularizations performed in 40 symptomatic cerebrovascular patients and in 32 asymptomatic subjects with a cervical bruit. The decision to place a temporary shunt was made on the basis of intraoperative EEG abnormalities regardless of stump pressure values. 11 patients with contralateral carotid lesions showed marked EEG alterations, at the moment of clamping, which returned to normal after the placement of an indwelling shunt. Stump pressure values showed a wide variation and a poor correlation with intraoperative EEG changes. In the early postoperative period there were no deaths; no new neurological deficits were detected. In the follow-up there was only 1 asymptomatic carotid rethrombosis, not revealed by the EEG, which was suspected by Doppler sonography and confirmed by angiography. The authors conclude that EEG gives valuable information about cerebral functions during carotid revascularization and can reduce the intraoperative complications of the procedure. Stump pressure measurement cannot be used alone as a safe indicator of cerebral ischemia during carotid cross-clamping.

Open Repair for Ruptured Abdominal Aortic Aneurysm : Is It Possible to Predict Survival?

The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAAA) and to assess the accuracy of the Glasgow Aneurysm Score (GAS) and the Acute Physiology Chronic Health Evaluation II (APACHE-II). From January 1998 to July 2006, 103 patients underwent operations for RAAA. For each patient, 44 variables were retrospectively recorded in a database. Data were analyzed with univariate and multivariate methods. In the univariate analysis significant predictors of death were hypotension (p=0.001), preexisting peripheral vascular disease (p<0.001), renal insufficiency (p=0.037), chronic obstructive pulmonary disease (p=0.028), level of HCO(3)(-) (p<0.001), intraperitoneal rupture (p=0.001), blood transfused (p<0.001), cardiac complications (p<0.001), and APACHE-II score (p=0.001). Multivariate analysis confirmed statistical significance for coexisting peripheral vascular disease (p<0.001), diastolic blood pressure at admission <60 mm Hg (p=0.039), APACHE-II score >18.5 (p=0.025), HCO(3)(-) <21 mg/dL (p<0.001), and intraperitoneal rupture of the aneurysm (p=0.011) as predictors of death. Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. APACHE-II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAAA.

PREVENTION OF AORTIC STUMP DEHISCENCE AFTER COMPLETE AORTIC PROSTHESIS REMOVAL

Dehiscence of the aortic stump is one of the most common causes of death following aortic prosthetic removal. The reason is easy to understand: the aortoprosthesis anastomosis performed during the original infrarenal aneurysm repair is usually performed only a few centimetres below the renal artery origins. An end-to-side prosthetic graft for obliterative disease requires an arteriotomy which must not include the inferior mesenteric artery origin and therefore usually starts just below the infrarenal clamp. Cases with an end-to-end anastomosis may permit a longer infrarenal aortic tract. As a consequence, when the original operation has been done properly, a disruption of the aortic wall suture line, destroying at least 0.5 cm of the remaining infrarenal aortic wall, often does not result in sufficient tissue below the renal arteries to allow a technically sound suture of the aortic stump. In most cases it is this mechanical defect more than subsequent infection of the suture line which causes the dehiscence of the aortic stump. Manoeuvres like the use of a flap of the anterior spinous ligament, proposed by Fry and Lindenauer, 1 or mobilisation of a segment of omentum 2 can protect the area from infection but do not ensure the mechanical integrity of the stump. In other words, only those cases in which the original revascularisation procedure has left a long segment of aortic wall will permit a mechanically sound stump closure capable of resisting disruption. A stump closure technique which may avoid dehiscence when there is insufficient infrarenal aorta tissue is here described.