Radiofrequency minimally invasive endovascular treatment of lower limbs varicose veins: clinical experience and literature review

AIM

Varicose veins of the legs are a common condition affecting 10-15% of men and 20-25% of women in the western world. This high prevalence is responsible of high medical and social costs. Most primary varices are associated with greater saphenous vein (GSV) incompetence. A new method, radiofrequency (RF) endovenous obliteration (VNUS-Closure'' procedure), recently has been described as a less invasive and cost-saving alternative to stripping for the treatment of refluxing GSV.

METHODS

Twenty-four patients with varicose veins underwent endovenous obliteration of the above knee GSV by VNUS Closure'' procedure. The vein diameters were from 5 to 10 mm. The RF catheter was inserted via percutaneous puncture or through a small skin incision. All operations were performed in local, tumescent anesthesia, under ultrasound guidance. All patients were discharged 2 h after operation. Clinical and ultrasound follow-up was performed at 1 week, and at 1, 6, 12, 24 months.

RESULTS

The complete or partial occlusion of the treated segment of the GSV has been achieved in 23 cases. In only one patient persisting patency of the GSV was immediately detected after the procedure. That was successfully treated by ultrasound guided foam sclerotherapy. All patients could resume all normal activities within 3-5 days. Every patient had reduction of varicosities, leg pain, fatigue and oedema. Adverse sequelae were minimal: 2 patients had transient thigh paresthesias. We didn't report deep venous thrombosis or pulmonary embolism (mean follow-up 26.7 months, range 15-33 months).

CONCLUSION

A literature review and the authors'experience reveal that, in absence of significant complications, such as deep vein thrombosis and pulmonary embolism, there are significant advantages in the RF endovascular obliteration of the GSV. In effect, the Closure'' procedure, in selected patients, offers reduced postoperative pain, shorter sick leaves, faster return to normal activities compared with vein stripping, and it appears to be cost-saving for society. The mid-term (36 months) recurrence rates after RF obliteration seem to be similar to the results of the conventional surgical management.

FDG-PET study of the bilateral subthalamic nucleus stimulation effects on the regional cerebral metabolism in advanced Parkinson disease

The aim of the study was to evaluate the changes in regional cerebral metabolic rate of glucose (rCMRGlu) induced by bilateral subthalamic nucleurs (STN) stimulation in advanced Parkinson's disease (PD). 18F-Fluorodeoxyglucose (FDG) PET data obtained before and one month after stimulation were analyzed with statistical parametric mapping (SPM). As a result of clinically effective bilateral STN stimulation, rCMRGlu increased in lateral globus pallidus (GP), upper brain stem, dorsolateral prefrontal cortex (DLPFC) and posterior parietal-occipital cortex, and decreased in the orbital frontal cortex and parahippocampus gyrus (p < 0.001). We conclude that the alleviation of clinical symptoms in advanced PD by bilateral STN stimulation may be the result of activation of both ascending and descending pathways from STN and of restoration of the impaired higher-order cortex functions.

A case of carotid bifurcation anomaly discovered during a thyroidectomy operation

The anatomic anomalies of the supra-aortic trunks and their branches are comparatively frequent observations. They often remain asymptomatic throughout life although in some cases, especially if nothing is known of them, they may complicate surgical interventions involving that anatomical region. The case of a female patient who, during thyroidectomy, suffered the ligature of her external carotid artery which was taken mistakenly for the thyroid, is reported. Dissection of the area made it possible to identify an anomaly of the vascular structures with a carotid bifurcation which turned out to be very low, a very deep internal carotid artery on the prevertebral fascia and an absent lower thyroid artery. In the postoperative period, the patient was subjected to MR of the neck. This showed an anatomical anomaly of the left carotid bifurcation which was much lower than normal. An attempt was made to reconstruct the external carotid artery with a saphenous vein but unsuccessfully. The incident did not have serious complications for the patient but it might be asked whether, given the low cost and the absolute non-invasiveness of the examination, it might not be worth while to carry out a duplex scan of the supra-aortic trunks before going ahead with any operation in the cervical region, in consideration above all of the dangerous nature of these vascular structures and of the usefulness of studying pathologies that often remain silent until the occurrence of an event which might well be catastrophic.

Cystic adventitial disease of the popliteal artery. Report of 1 case and review of the literature

Cystic adventitial disease (CAD) of the popliteal artery is a rare but well-known cause of intermittent claudication, especially in young patients. The etiology of the disease is still controversial and the literature reports various hypotheses for its origin. Diagnosis starts with thorough history taking and physical examination; non invasive diagnostic studies comprise color duplex scanner (ECD), computed tomography (CT), better if elicoidal (3D CT) and magnetic resonance imaging (MRI), which can aid in establishing correct recognition of the disease in most cases. A 48-year-old man presented with intermittent right calf claudication that had begun 4 months earlier; the symptom-free interval was about 100 m. MRI and MR angiography of right popliteal fossa revealed the presence of an oval cystic (maximum diameter 45 mm). The caudal aspect of the cyst showed pedicles protruding between the popliteal vein and the popliteal artery that compressed the artery, causing complete occlusion of its lumen. Surgery was performed through the posterior approach using an S-shaped incision; the affected segment of the popliteal artery was successfully excised and replaced with an autogenous external saphenous vein graft. A follow-up is underway, both clinical and with; no cyst recurrence has so far been detected either clinically or by duplex scanner during the 15-month postoperative follow-up period; the graft is patent and the patient is completely symptom free. Severe claudication in young patients, possibly without significant vascular risk factors, should prompt the clinical suspicion of adventitial cystic disease of the popliteal artery. Medical history, clinical examination and non invasive instrumental investigations, such as duplex scanner, elicoidal CT and/or MRI, may aid in establishing the correct diagnosis.

[Therapeutic approach to the unilateral occlusive iliac artery disease. Preliminary results]

BACKGROUND

The different therapeutic approaches to unilateral occlusive iliac artery disease are analyzed.

METHODS

In the period from September 1999 to September 2001, a total of 43 patients (38 males and 5 females) has been treated for unilateral iliac artery occlusive disease. Thirty-four cases (79%) underwent an endovascular procedure, and the remaining 9 cases (21%) had a surgical intervention. Endovascular techniques included 11 cases of percutaneous transluminal angioplasty (PTA) of common iliac artery (25.6% of whole series), 5 PTA of external iliac artery (11.6%), 8 PTA+stenting of common iliac artery (18.6%) and 10 PTA+stenting of external iliac artery (23.2%). In 9 cases a surgical revascularization was performed: 6 patients underwent a femoro-femoral cross-over bypass (14%); 2 cases were treated with aorto-bifemoral reconstruction (4.7%) and one patient was operated with ilio-femoral graft (2.3 %).

RESULTS

The analysis of the follow-up of our series showed, in the group of 34 patients treated with endovascular procedures, successful results were obtained in 79.4% (27 cases); in the 9 patients operated with surgical revascularization the success rate was 88.9% (8 cases ); failure rate was 20.6% for endovascular procedures and 11.1% for surgical interventions.

CONCLUSIONS

The conclusion is drawn that endovascular approach (PTA, stenting) is usually the procedure of choice in the treatment of unilateral well localised lesions of the iliac artery. Conventional surgical intervention is effective for revascularizing an extensive involvement of the iliac segment or in case of bilateral disease.

Recurrent varices after internal saphenectomy. Physiopathological hypothesis and clinical approach

BACKGROUND

This paper analyses the causes and describes the best care of recurrent varicose veins after internal saphenectomy.

METHODS

A series of 19 patients who had previously undergone internal saphenectomy were selected for surgery due to recurrent varices in the lower limbs. Clinical examination and colour duplex sonography were used as the preoperative diagnostic tools in all patients. No patients underwent phlebography. In 17 cases the main source of reflux was an incontinent saphenous stump at the level of the saphenofemoral junction with varicose cross-groin collaterals. In 2 cases recurrence was caused by incontinence of the upper thigh perforating vein. In 1 of these patients the recurrence also involved the district of the small saphenous vein. Groin neovascularisation was detected in 1 patient.

RESULTS

All patients underwent groin re-dissections using transversal incisions: in 9 cases, access to the saphenofemoral junction was obtained under or at the same level as the inguinal fold, and in 10 cases using a suprainguinal route. The vertical inguinal incision was never employed. Incompetent perforating veins (thigh or leg) were ligated or sectioned in 11 patients. Ligations and exeresis of communicating veins were executed in all patients. Müller's phlebectomies were performed intra- or postoperatively on collateral varices in practically all cases. Postoperative ambulatory sclerotherapy was necessary in 6 cases.

CONCLUSIONS

A correct surgical approach is only assured by diagnostic accuracy coupled with a precise hemodynamic evaluation. Correct management of the postoperative follow-up of varicose vein surgery is also important.

Compliance of geriatric patients subjected to antiplatelet agents with Triflusal in peripheral arteriopathy. Preliminary data

BACKGROUND

Triflusal is an irreversible inhibitor of platelet cyclooxygenase. Triflusal significantly reduced the incidence of nonfatal myocardial infarction in patients with unstable angina. Antithrombotic properties have also been demonstrated in patients with aortocoronary vein grafting, coronary angioplasty, peripheral arteriopathy and cerebrovascular disease. Moreover, in diabetic patients it has a protective effect against retinal microangiopathy, improves renal flow and reduces proteinuria. The drug has a high tolerability and has low incidence of side effects, with prevalence of gastrointestinal and skin disorders. Because of its demonstrated effectiveness and its good handling, we decided to use Triflusal in treatment of geriatric patients with peripheral arteriopathy. Often these patients have a diffused arteriopathic disease which can be associated with chronic diseases. For this reason there are severe problems of compliance due to contemporary administration of several drugs; so the utilization of effective drugs, without side effects, promotes a safer clinical management of patients.

METHODS

Between April 2000 and March 2001, we treated with Triflusal 70 patients, over 65 years old, with peripheral arteriopathy. The group comprises patients who had undergone traditional vascular surgery, or endovascular surgery and patients treated exclusively with drug therapy. During the follow-up we obser-ved the possible clinical development of side effects of the drug reported in the literature (nausea, vomiting, etc.).

RESULTS

One patient, already affected by gastroduodenal disease, suspended the therapy because of severe epigastric burning.

CONCLUSIONS

The follow-up of the patients goes on in order to evaluate the tolerability and handling of Triflusal, observing a larger number of patients.

[Retroperitoneal fibrosis associated with neuritis symptomatology due to external iliac artery stent subadventitial migration]

The occurrence of a neuritis of the ischiatic nerve and the genito-femoral nerve due to the implant of three stents in the iliac artery, is an extremely rare complication, especially if associated with retroperitoneal fibrosis which caused a nevritis symptomatology. A case of stent migration in the subadventitial space which caused 4 years from angioplasty and stents implant, a nevritis symptomatology. Retroperitoneal fibrosis has been considered as a consequence of the stents presence and of their chronic irritational activity, especially for what concerns the stent migrated in the subadventitial space; the procedure personally performed in this case is reported.

[Anomalies of the inferior vena cava in patients treated with surgical vascular procedures in the aorto iliac area. Report of 2 cases and review of the literature]

Two cases of left-sided inferior vena cava observed in a patient affected by Leriche syndrome and the other affected by aortic abdominal aneurysm (AAA) are presented. This very rare congenital malformation (0.2-0.5) was not recognized by the duplex scanner performed preoperatively probably because of the low level of suspicion carried on by an experienced operator. Angio-CT e angio-MR which would have surely showed the anomaly, were not done because in the absence of an aneurysmal disease or other abdominal situations, these investigations were not required before operation. An angio-CT was performed routinely to the patient affected by AAA and so the left-sided vena cava was observed before operation; and then an abdominal arteriography and an ilio-caval venography were required which documented the vena cava anomaly. Surgical interventions didn t have complications. In the case of Leriche syndrome an aorto-bifemoral bypass was performed, and in the case of abdominal AAA an aortic left-iliac right-femoral bypass. Preoperative unrecognizing of this venous malformation is very hazardous mostly in terms of uncontrollable intraoperative hemorrhages. Ultrasonographic diagnosis with duplex scanner has to be very accurate in order to observe not only arterial diseases but also the possible venous anomalies of the abdominal district.

[Vascular pathology of surgical interest in drug addicts]

The incidence of vascular complications due to drug abuse is at present increasing due to new types of drugs and to the different ways of intake of such substances. The vascular complications related to drug abuse may affect venous, arterious and lymphatic districts and in particular: ischemia following intra-arterial injections, arterious and venous pseudoaneurysm, vasculitis, aneurysms, aortic dissections, abscesses complicated by erosions of vessels, arteriovenous fistulas, compartment syndrome, superficial and deep venous thrombosis, septic trombophlebitis, puffy hand syndrome. The scientific knowledge in this matter is incomplete because of the new pathological cases and the lack of information regarding the efficacy of different treatments. The authors report four patients affected by vascular pathologies due to drug abuse. In one case, a heroin addict has undergone multiple fasciotomies for compartimental syndrome arising because the patient maintained an innatural posture for several hours during an overdose coma. In a second case, a segmental right subclavear deep venous thrombosis has been treated by pharmacological therapy with satisfactory functional recovery of the arm. A third patient has been successfully submitted to intra-arterial pharmacological vasodilatation for generalised lower limbs vasospasm caused by drug abuse. In the last case, the voluntary swallowing of a great dose of cocaine caused the patient's death after multiple ischemic and hemorrhagic cerebral episodes. After the description of these cases, a review of the recent literature and some observations on this topic are presented. A better knowledge of vascular complications due to drug abuse should improve the therapeutical approach of these patients.

[Outcome of patients treated with intra-peritoneal immunochemotherapy for ovarian cancer]

OBJECTIVE

The aim of this study is to show that i.p. chemotherapy improves the evolution of the patients with an ovarian cancer, as the risk of a small number of complications due to this route of administration.

METHODS

85 patients (11 stage Ic, 4 IIc and 70 stage III) were treated from 1980 to 1993 (median of follow up > 77 months) by a cisplatin based immunochemotherapy administered intraperitoneally, by a needle.

RESULTS

Median overall survival exceeds, 72 months (60 months for stage III). Out of 41 relapses, 11 took place after 48 months of follow up. Delayed general complications consisted of 2 chronic nephotoxicities due to CDDP and one leukemia. Local complications are dominated by serous adherences (5 cases of plastic peritonitis). Secondary cytoreductions turned out to be beneficial in this series in spite of relapse diagnosis of them being carried out to late.

CONCLUSION

Classic imagery remains disappointing for the exploration of the pelvic abdominal region. Paclitaxel by i.p. way seems very promising, which should launch once again interest in secondary debulking surgery.

[HIV infection in truck drivers in Burkina Faso: a seroprevalence survey]

Truck drivers are a well recognized high risk population for sexually transmitted diseases. Prior to start-up of a health care program and an information/education campaign, a cross-sectional study using the unlinked, anonymous screening method was carried out to assess seroprevalence of HIV and syphilis infections in truck drivers in Bobo Dioulasso, Burkina Faso. During the month of November 1994, 236 truck drivers were recruited at a cotton-producing factory. The prevalence of HIV infection was 18.6% and the prevalence of syphilis was 9.3%. Multivariate logistic regression analysis showed a statistically significant association between HIV infection and the following factors: age under 30 years, claimed systematic use of condoms, and previous genital ulcers. These findings suggest that truck drivers are highly exposed to the risk of contracting and disseminating HIV infection due to their high mobility and the high incidence of sexually transmitted diseases among their ranks. Prevention of HIV infection in truck drivers in Burkina Faso will require education to promote systematic use of condoms at each sexual contact as well as screening and treatment of sexually transmitted diseases at truck stops.

[Abdominal aortic aneurysm associated with non-neoplastic abdominal disease. Therapeutic approach]

BACKGROUND

Personal experience concerning the treatment of 8 patients with infrarenal aortic aneurysms associated with extravascular non-neoplastic abdominal diseases is presented.

METHODS AND RESULTS

In all 7 cases which underwent combined surgical procedures (aneury-smectomy + cholecystectomy in 4 patients and aneurysmectomy + groin hernia repair in 3 patients) early and late postoperative complications were not recorded.

CONCLUSIONS

The main therapeutic guidelines concerning the pathologic association of infrarenal aortic aneurysms associated with extravascular non-neoplastic abdominal diseases are discussed on the basis of a literature review and of personal experience.

[Prevention and treatment of early and late postoperative complications of prosthetic surgery of the arterial aorto-iliac area]

During a 5-year period, from 1990 to 1994, 61 patients underwent prosthetic reconstruction of aorto-iliac district for aneurysmal (53 cases) or obstructive (8 cases) disease. There was no postoperative mortality; 3 cases of early perianastomotic thrombosis, 2 cases of left colon necrosis, 4 cases of femoral pseudoaneurysm and 5 cases of sexual disfunction were recorded. If accurately performed, the surgery of this arterial district offers very good early and late results.

[Colorectal ischemic necrosis following reconstructive surgery of the abdominal aorta. Report of 2 clinical cases]

The authors report two cases of colorectal ischemic necrosis following surgical reconstruction of abdominal aorta. An intestinal resection according to Hartmann was performed in both cases. The value of prevention based on a careful anamnesis, on a precise angiography study of the abdominal aorta and of splanchnic circle in addition to inferior mesenteric artery reimplantation, when advisable, is underlined as the most effective therapeutic instrument against colorectal ischemic necrosis following surgical reconstruction of the abdominal aorta.

[Indications for the use of somatostatin and octreotide in digestive pathology]

The authors report their experience about the use of somatostatin (SST-14) (47 cases) and its analog octreotide (15 cases) in gastrointestinal diseases. On the basis of own clinical data and literature review, at present they think useful SST-14 employ in the upper gastrointestinal tract bleeding and acute pancreatitis. Out of the emergency, they consider favourable the use of octreotide, above all because of the easy subcutaneous administration's route.

[Extranodal non-Hodgkin's lymphomas. Review and our experience]

The authors report their experience concerning 12 cases of extranodal lymphoma (6 gastric, 1 duodenal, 2 ileal, 1 rectal, 1 splenic, 1 mammary). Extranodal lymphomas are increasing because of the high number of patients with AIDS and new extra-European immigration. Surgery is important not only for diagnosis, but above all for therapy. The great majority of extranodal lymphomas is diffuse rather nodular. Diffuse histiocytic type is the most commun pathologic feature. Prognosis of gastroenteric lymphomas is better than adenocarcinomas of gastrointestinal tract. The surgical techniques are the same as those used for the others tumors, and combined-modality therapy appears superior to local therapy alone for patients with extranodal disease characterized by unfavorable histology, site or stage. The classification is that of Ann Arbor, but for many authors the TNM system was an useful predictor of survival in patients treated with surgery.

One surgical experience in regime of day hospital: considerations on the first one-hundred patients treated

The development of surgery in regime of day hospital proceeds swiftly, especially in Anglo-saxon countries, so that at the beginning of the second millennium it can be foreseen that in USA alone, 75% of all surgery will be carried out in this manner. From March 1st to September 1st 1994, 100 patients were submitted to operations in ODS (One Day Surgery). We had 3 reconversions into ordinary hospitalization (3%), 2 for social-economic reasons and one for headache and vomiting due to intolerance to local anesthetics. As has been seen we have encountered no important complications, all patients were satisfied. From the analysis of our experience we have deducted useful indications that oblige us to partially modify our attitude: we want to transform our service into a free standing center where the patient can undergo preoperative exams, anesthesiologic examinations and surgery on the same day; we are just about to verify the possibility, thanks to an accurate anamnesis, to not request preoperative routine exams in patients with ASA 1 and 2 physical status; to look for a possible asymptomatic crural hernia in patients that undergo inguinal hernioplasty; we do not submit patients to ODS if they do not have assistance at home; or if they live too far from our service.

[Diagnostic and therapeutic approach to incidentally detected adrenal tumors]

The authors report their experience relative to 12 cases of adrenal "incidentaloma" surgically treated. All masses removed had a main diameter larger than 3 cm. In all patients an anterior median transperitoneal incision was performed. They didn't record postoperative mortality and the postoperative morbidity rate was 15%. In 6 cases a nonfunctioning cortical adenoma was diagnosed. No malignant neoplasm was detected in their series.

[Splenic abscess after angiography. Considerations on a clinical case]

A case of splenic abscess in a diabetic, cardiopathic and arteriopathic 49-year-old man is reported. The abscess developed on a previous splenic infarction caused by an embolus coming from an intraventricular thrombus. The angiographic procedure was the source of bacterial contamination (Staphylococcus aureus). The patient was successfully treated with splenectomy.

[The surgical treatment of strangulated inguinal-crural hernias in geriatric patients]

The authors describe their own experience relative to 79 patients, aged 70 years or older, who underwent, during three years, emergency surgical intervention for inguinal or crural strangulated hernia. They report a postoperative mortality rate of 8.8% and a postoperative morbidity rate of 40%. They stress the need for timely diagnosis and a meticulous surgical treatment. Therefore, they underline the great importance of the anesthesiologic approach and perioperative intensive care.

[Surgical treatment of hepatic hydatidosis. Current trends]

The authors report their experience relative to 33 patients with hepatic hydatidosis surgically treated during the years 1987 through 1993. Various surgical techniques were employed: subtotal (21 cases) and total (5 cases) cystopericystectomy, partial pericystectomy (12 cases), hepatic resection (2 cases). The postoperative rate complication was 30% (4 cases of cholangitis, 4 biliary fistulas, 1 suppuration of residual cavity and 1 colonic fistula). The postoperative morbidity was higher in patients treated with partial pericystectomy. There was no postoperative mortality.

[Intrabiliary rupture of hydatid cysts of the liver. A clinical case]

The authors report a case of intrabiliary rupture of some recurrent hepatic hydatid cysts. The biliary drainage was performed endoscopically during ERCP. The results of treatment were satisfactory. The value of total cystopericystectomy and external biliary drainage on prevention of cyst-biliary fistulas is underlined.

[Indications for reimplantation of the inferior mesenteric artery in the course of prosthetic substitution for the subrenal aorta]

The authors report their experience relative to 8 patients who underwent IMA revascularization during infrarenal AAA repair. The Carrel patch technique was employed in all cases operated. With this procedure no ischemic intestinal complication occurred. Two cases of ischemic colitis were observed in a second group of 40 patients operated for AAA in whom the IMA wasn't reimplanted into the aortic graft. The overall incidence of acute intestinal ischemia was 4%.

[Acute intestinal ischemia. Diagnosis and surgical treatment]

The authors report their experience of 32 patients operated for acute intestinal ischemia. A massive intestinal infarction was diagnosed in 24 cases. The overall postoperative mortality rate was 72%. The postoperative survival rate was 20% after mesenteric infarction and 42% in patients with limited acute intestinal ischemia. The need for early specific diagnosis is stressed, because the therapeutic options vary widely in relation to different types of acute intestinal ischemia. Furthermore, the basic role of parenteral nutrition in postoperative treatment of short bowel syndrome is underlined.

[Surgical treatment of aneurysms of the popliteal artery]

The authors report their experience of two cases of popliteal artery aneurysm. Both patients were treated with aneurysm resection and inverse saphenous vein bypass. Early surgical intervention is the only effective therapeutic tool to avoid serious complications of this pathology.

[Predictive value of the echo-Doppler test in relation to the development of carotid arteriosclerotic plaques]

The authors report their experience relative to 102 patients evaluated with carotid duplex-scanner. Ultrasonographic data of atherosclerotic carotid changes have been correlated with the outcome of the tested series. In fact, echographic images of vascular changes with high thromboembolic risk (ulcerated plaque) have been associated with cerebrovascular injuries in 25% of the cases. Furthermore, the duplex-scanner showed the need for surgical treatment (TEA) in 32 patients with asymptomatic carotid stenosis. Therefore, this noninvasive diagnostic tool seems to play an essential role in the prevention of cerebrovascular ischemia.

[Synchronous and metachronous carcinomas of the large intestine]

The authors present their experience relative to 5 patients with multiple carcinomas (synchronous and metachronous) of the large bowel. They underline that full examination of the colon before operation in all patients with primary colorectal cancer is necessary, and they propose a lifelong follow-up program after resection for early detection of multiple carcinomas.

[Femoral anastomotic pseudoaneurysms. The etiopathogenetic hypotheses and the therapy]

The authors present two cases of patients with femoral anastomotic aneurysm treated by surgical vascular reconstruction. They underline the role of etiologic factors changing the structure of the arterial wall. The protective action of end to end anastomosis is confirmed. Finally, they recommend an early intervention to avoid life-threatening complications such as rupture and thrombosis.

[The suprainguinal approach in surgery on the internal saphenous vein for varices of the lower limbs]

The authors report their experience relative to 134 patients with lower limb varices surgically treated. An upper inguinal incision of the skin was employed to approach the saphenofemoral junction, obtaining by this means an aesthetic suture, with better asepsis and lower incidence of local complications.

[Major and minor complications in carotid surgery]

The Authors report their experience of major and minor complications in carotid surgery. They analyse the causes and emphasize that a thorough preoperative study and a quick surgical technique are very important in reducing the rate of complications in this essentially preventive form of surgery.

[Mesenteric fibromatosis in Gardner's syndrome]

The paper reports a case of mesenteric fibromatosis with familial polyposis, an association which was diagnosed as Gardner's syndrome, and highlights the complications connected to mesenterial desmoid tumours. In addition, the importance of radical surgical therapy of these neoplasias is underlined. Lastly, it is hypothesised that full screening of patients affected by familial polyposis might show a greater incidence of association between widespread polyposis and pathological changes attributable to Gardner's syndrome.

[Surgical treatment of venous ulcer of the leg]

Personal experience on 53 cases of venous ulcers of the lower limbs is presented. By combining vascular and plastic surgery, in every patient treated, the complete regression of trophic lesions and earlier healing were obtained. Moreover the notable usefulness of other kinds of therapy such as elastic compression and sclerosing treatment is confirmed.

[Diabetes mellitus as a risk factor in vascular surgery]

The paper reports a series of 23 diabetic patients affected by occlusive arterial disease of the lower limbs treated by reconstructive vascular surgery. Revascularisation interventions were performed in 9 patients affected by claudication, with good long-term results. Fourteen patients underwent operations for limb salvage. The major amputation rate was 35%.

[Distal gastric volvulus as a cause of acute occlusion in paraesophageal hernia. Considerations on a clinical case]

A case of distal volvulus of the stomach as a cause of acute intestinal obstruction in a paraesophageal hernia is presented. The patient, an old woman aged 82, had been suffering from abdominal pain and vomiting for about 48 hours. She successfully underwent emergency operation for the reduction of hernia and plasty of the hiatus anterior the esophagus. On the basis of personal experience and review of literature data, stress is laid on the high incidence of paraesophageal hernia complications and the importance of early diagnosis and surgical repair is underlined.

[Popliteal artery entrapment]

The Authors present a case of popliteal artery entrapment syndrome due to an anomalous insertion of medial head of the gastrocnemius muscle. The patient, a 47-year-old man, with calf claudication, was examined with Doppler velocimetry and angiography. He was successfully treated by surgical intervention. A medial approach to the popliteal artery was utilized and the section of anomalous head of gastrocnemius muscle and popliteal thromboendarterectomy were performed. The postoperative course was uncomplicated.