An update in varicose vein pathology after ten years of endovenous laser therapy (EVLT) with a 980 nm diode laser: clinical experience of a single center

AIM

To show our experience in the surgical treatment of superficial vein insufficiency of the lower limbs.

SUBJECTS AND METHODS

Since 2002 we have performed 659 procedures of endovascular laser therapy (EVLT) (group A) in the treatment of chronic venous insufficiency of the great saphenous vein using a 980 nm diode laser. A closely matched group of 100 patients (50 Group A, 50 Group B) with homogeneous clinical findings (CEAP classification) was controlled with a mean follow-up of 18 months in our more recent experience (3 years). Most patients operated on in this period were lost to follow-up.

RESULTS

The Final results showed that EVLT can be used only in a specific selected group of cases based on anatomy and hemodynamics and while 980 nm EVLT could not be selected as the best treatment for this pathology, it could be placed side by side with conventional therapy.

CONCLUSIONS

In our one year's more recent experience, we observed an increased number of patients treated with conventional therapy. The development of new laser tools (new wavelengths and continuous radial laser) and the improvement of clinical follow up may lead us to a more correct application of EVLT in the absence of randomized trials because of widespread clinical findings and poor pathological follow-up of this approach to superficial venous insufficiency.

Penile duplex pharmaco-ultrasonography of cavernous arteries in men with erectile dysfunction and generalized atherosclerosis

Assessment of cavernosal perfusion in men with erectile dysfunction (ED) relies on Doppler spectrum analysis of pharmachologically stimulated peak systolic velocity (sPSV) in cavernous arteries but its accuracy in identifying men affected by a cavernosal perfusion disorder correlated with atherosclerosis remains undefined. We estimated by B-mode ultrasound, the accuracy of sPSV of cavernous arteries to identify ED with an expected cavernosal perfusion disorder. This was predicted by an elevated intima-media thickness (IMT) of common carotid arteries, a reference methodology to estimate the degree of generalized atherosclerosis, in men exposed to vascular risk factors (VRFs). sPSV and IMT were evaluated in 269 men with ED, 49 had no VRFs, 100 were overweight with/or without hyperlipidaemia, 120 were affected by type 2 diabetes and/or essential hypertension. sPSV was significantly lower (p<0.05) in patients with VRFs associated with atherosclerosis (IMT>or=1 mm) (n=39) than in men with no VRFs and no atherosclerosis (n=49). sPSV correlated negatively with age (p<0.0001), with serum% of glycated haemoglobin (p=0.010) and with carotid artery IMT (p=0.013). An sPSV<or=30 cm/sec, the cut-off value which showed at receiver operating characteristic curve analysis the combined highest value of sensitivity and specificity, correctly identified only 57% of men in whom a cavernosal perfusion disorder was expected based on the presence of carotid artery IMT>or=1 mm combined to the exposure to VRFs. The ultrasonographic evaluation of sPSV had a very limited accuracy in discriminating ED with an expected cavernosal perfusion disorder, based on the presence of a generalized atherosclerosis in men with VRFs.

INTIMA-MEDIA THICKENING OF COMMON CAROTID ARTERIES IS A RISK FACTOR FOR SEVERE ERECTILE DYSFUNCTION IN MEN WITH VASCULAR RISK FACTORS BUT NO CLINICAL EVIDENCE OF ATHEROSCLEROSIS

PURPOSE

The association of erectile dysfunction (ED) with vascular damage in men without clinical atherosclerosis is unknown. By B-mode ultrasound we evaluated intima-media thickness (IMT) of common carotid arteries, a measure of vascular damage, in men reporting ED with or without vascular risk factors (VRFs) but no clinical atherosclerosis.

MATERIALS AND METHODS

IMT of common carotid arteries was evaluated in 270 men with ED. A total of 50 men (mean age +/- SD 39.84 +/- 12.5 years) had no VRFs, 100 (mean age 47.92 +/- 10.94 years) were overweight and/or had hyperlipidemia, and 120 (mean age 53.95 +/- 9.73 years) were affected by type 2 diabetes and/or essential arterial hypertension.

RESULTS

IMT was significantly lower in men with no VRFs compared to men with VRFs (p <0.05), and correlated with the severity of ED evaluated through the Sexual Health Inventory for Men (p = 0.0008). Of men with VRFs 17.7% (39 of 220) showed an IMT score indicative of vascular damage (1.00 mm or greater), while only 1 man with no VRFs had a high IMT. Men with VRFs and a high carotid IMT score demonstrated more severe ED, were older and had a higher serum level of C-reactive protein compared to men with VRFs and an IMT of less than 1.00 mm (p <0.05). A high IMT score but not an increased measure for each VRF, including aging, significantly increased the risk of severe ED (odds ratio 2.6, confidence interval 1.1 to 5.9) even after controlling for smoking and drugs associated with ED.

CONCLUSIONS

ED in men with VRFs was the only clinical correlate of unrecognized atherosclerosis of common carotid arteries.

Endothelial cell activation in men with erectile dysfunction without cardiovascular risk factors and overt vascular damage

PURPOSE

Endothelial cell activation (ECA) is an initiating event in atherosclerosis. Biochemical measures of ECA were evaluated in patients with erectile dysfunction (ED) associated or not associated with cardiovascular risk factors (VRFs) to assess whether ED is a sentinel of atherosclerosis.

MATERIALS AND METHODS

Circulating soluble P-selectin, intercellular adhesion molecule-1, vascular cell adhesion molecule-1 and endothelin-1 concentrations were assessed in 45 men with ED but no VRFs, 45 men with ED associated with VRFs and 25 healthy men. Ultrasound intima-media thickness of carotid arteries and pharmacologically stimulated peak systolic velocity of cavernous arteries were used to assess vascular damage.

RESULTS

Measures of ECA were higher in men with ED but no VRFs than in controls (p <0.01) and all were comparable among groups of men with ED. Levels of endothelin-1 in men with ED and no VRFs versus healthy men of the same age resulted in the best independent predictor for ED after adjusting for the confounding effect of increased body mass index and smoking (OR 5.37, 95% CI 2.12 to 19.70). Intima-media thickness of carotid arteries was comparable in controls and in men with ED but no VRFs, and ruled out the bias of overt damage of large arteries in the latter. Peak systolic velocity of cavernous arteries excluded vasculogenic ED in the majority of patients with no VRFs.

CONCLUSIONS

Increased biochemical measures of ECA were associated with ED independent of coexisting VRFs and overt vascular damage, suggesting that ED is a sentinel of early atherosclerosis.

Abdominal aortic intramural hematoma related to penetrating ulcer: an inappropriate indication for endovascular repair?

PURPOSE

To present a rare case of abdominal aortic intramural hematoma with penetrating ulcer.

CASE REPORT

A 68-year-old hypertensive lady was admitted with chest pain. An echo Doppler abdominal study showed a 2.5-cm-diameter abdominal aorta with periaortic blood flow. Urgent computed tomography documented a 4-cm aneurysmal dilatation, 4 cm long, at the infrarenal level of the inferior mesenteric artery origin, which appeared on the angiogram as a very short lateral bleb. At elective open laparotomy, no true abdominal atherosclerotic aneurysm was found in the retroperitoneal space, but rather, an intramural hematoma with ulcer. An aortobi-iliac graft was inserted, and the patient was discharged with a good outcome. Histological examination of the explanted tissue confirmed adventitial calcifications, organized thrombus in the hematoma, and intimal neovascularization.

CONCLUSIONS

Considering the pathology, this case was more appropriately treated with open surgery, although endovascular repair was not excluded as an option.

Endovascular treatment of a postlaminectomy arteriovenous fistula. A case report

We report a case of iliac arteriovenous fistula (AVF) following disk surgery. A 51-year-old woman underwent hemilaminectomy for a slipped disk. Two weeks after surgery the patient experienced dyspnea and oedema of the lower limbs. Presence of a systolic murmur on the cardiac floor and on the abdomen was detected and abdomen CT scan which evidenced a AVF between the right common iliac artery and vein. The lesion, confirmed by angiography, was successfully treated with the endovascular technique. The endovascular technique appears to be a valid alternative to the traditional surgical treatment of postlaminectomy AVF.

Blood endothelin-1 levels before and after carotid endoarterectomy for atherosclerotic stenosis

BACKGROUND

Elevated plasma levels of endothelin-1 (ET-1) have been reported in advanced atherosclerosis. Further in vivo demonstration of cause-effect relationship between atherosclerotic lesion and high levels of ET-1 needs to be carried out. The aim of this study was to determine whether circulating levels of ET-1 are influenced by removing haemodynamically significant atherosclerotic stenosis in selected patients with mono or bilateral carotid atherosclerotic stenosis.

METHODS

Cubital venous ET-1-immunoreactive (IR) levels were measured in 20 patients: 11 (mean age+/-S.D. 63.1+/-5.36 years; range 53-70 years) were affected by monolateral, and nine patients (mean age+/-S.D. 64.7+/-9.8 years; range 52-78 years) by bilateral extracranial carotid artery atherosclerotic stenosis. ET-1-IR levels were evaluated before and 7 days after monolateral surgical endoarterectomy. Pre-surgery levels of ET-1-IR were compared with those obtained from 18 healthy younger volunteers (mean age+/-S.D. 27.8+/-2.7 years; range 20-50 years).

FINDINGS

The mean cubital venous levels of ET-1-IR in the atherosclerotic patients before endoarterectomy (mean+/-S.D. 4.50+/-3.35 pg/ml; range 1.28-10.66 pg/ml) were significantly higher than those observed in healthy subjects (mean+/-S.D. 0.641+/-0.137 pg/ml; range 0.36-1.02 pg/ml) (P=0.000). The mean ET-1-IR level decreased significantly after endoarterectomy in the group of patients with monolateral stenosis (pre-surgery: mean+/-S.D. 4.35+/-3.11 pg/ml; range 1.28-10.66 pg/ml; post-surgery: mean+/-S.D. 3.05+/-2.94 pg/ml, range 0.28-8.86 pg/ml) (P=0.005), but not in patients with bilateral extracranial carotid stenosis submitted to monolateral endoarterectomy (pre-surgery: mean+/-S.D. 4.77+/-3.79 pg/ml; range 2.18-10.3 pg/ml; post-surgery: mean+/-S.D. 4.60+/-3.70 pg/ml; range 2.20-11.10 pg/ml).

INTERPRETATION

The removal of a haemodynamically significant atherosclerotic vascular stenosis is associated with a decrease in the circulating ET-1-IR levels 7 days after surgery when haemodynamically significant atherosclerotic lesions are absent.

PYCNOGENOL in chronic venous insufficiency

The aim of out study was to investigate the efficacy of Pycnogenol - a French maritime pine bark extract - in the treatment of chronic venous insufficiency (CVI). The study consisted of a double-blind phase - in which 20 patients were recruited and randomly treated with placebo or Pycnogenol (100 mg 2 3/day for 2 months) - and an open phase - in which other 20 patients were treated with Pycnogenol at the same dose schedule. In total, 40 patients were enrolled; 30 of them were treated with Pycnogenol and 10 with placebo. Pycnogenol significantly improved the legs' heaviness and subcutaneous edema; the venous pressure was also significantly reduced by the Pycnogenol treatment, thus adding further clinical evidence to its therapeutic efficacy in patients with CVI. Pycnogenol was effective, probably by either stabilizing the collagenous subendothelial basal membrane or scavenging the free radicals, or by a combination of these activities. Clinically, capillary leakage, perivascular inflammation and subcutaneous edema were all reduced. The safety of use of Pycnogenol is demonstrated by the lack of side effects or changes in blood biochemistry and hematologic parameters. Pycnogenol can be therefore recommended both for prevention and treatment of CVI and related veno-capillary disturbances.

[Magnetic resonance angiography with contrast media bolus in the evaluation of aneurysms of the abdominal aorta]

PURPOSE

To investigate the potentials of 3D breath-hold contrast-enhanced Magnetic Resonance Angiography (MRA) in the diagnosis, follow-up and treatment planning of abdominal aortic aneurysms.

MATERIAL AND METHODS

Twenty-four patients with infrarenal aortic aneurysm underwent MRA. We used a 1.5 T unit (GE Horizon, Echospeed 8.2), a phased array surface coil and 3D Fast SPGR T1-weighted sequences acquired on the coronal plane during patient breath-hold and after contrast agent i.v. administration. A bolus-test was done before angiography to optimize imaging delay time. After 3D MRA a Fast-SPGR T1-weighted sequence was acquired on the axial plane. The 3D MRA source images were processed with the MIP algorithm. Qualitative and quantitative analyses were carried out. Helical CT was performed in 6 cases and DSA in 7 cases. Surgery was the reference standard in 15 patients.

RESULTS

MRA depicted aneurysm thrombosis in 22 cases, carrefour involvement in 18 cases and iliac arteries involvement in 3 cases. Accessory renal arteries were shown in 4 cases; iliac artery stenosis was associated in 5 cases. There was agreement between MR and Helical CT and DSA findings: surgery confirmed MRA results in 15/15 cases.

CONCLUSIONS

3D contrast-enhanced MRA can be considered the method of choice in the follow-up and treatment planning of abdominal aortic aneurysms, because it provides both angiographic and tomographic images: this allows to obtain more information, noninvasively and without the use of ionizing radiations.

Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial

OBJECTIVE

The durability of carotid endarterectomy (CEA) may be affected by carotid restenosis. The data from randomized trials show that the highest incidence of restenosis after CEA occurs from 12 to 18 months after surgery. The optimal CEA technique to reduce perioperative complications and restenosis rates is still undefined. This study examines the long-term clinical outcome and incidence of recurrent stenosis in patients who undergo eversion CEA. Previously published perioperative results of this study did not show statistically significant differences in study endpoints between the eversion and standard techniques.

METHODS

From October 1994 to March 1997, 1353 patients with surgical indications for carotid stenosis were randomly assigned to undergo eversion (n = 678) or standard CEA (n = 675; primary closure, 419; patch, 256). Withdrawal from the assigned treatment occurred in 1.6% of the patients (in 13 assigned to eversion CEA, and in nine assigned to standard CEA). The clinical and duplex scan follow-up examination was 99% complete, and the mean follow-up interval was 33 months (range, 12 to 55 months). The primary outcomes were perioperative and late major stroke and death, carotid restenosis (stenosis >/= 50% of the lumen diameter detected at duplex scanning), and carotid occlusion. The primary evaluation of study outcomes was conducted on the basis of an intention-to-treat analysis.

RESULTS

Restenosis was found at duplex scanning in 56 patients (19 in the eversion group, and 37 in the standard group). Within the standard group, the restenosis rates were 7.9% in the primary closure population and 1.5% in the patched population. Of the patients with restenosis, 36% underwent cerebral angiography that confirmed restenosis in all cases. The cumulative restenosis risk at 4 years was significantly lower in the group that underwent treatment with eversion CEA as compared with the standard group (3.6% vs 9.2%; P =.01), with an absolute risk reduction of 5. 6% and a relative risk reduction of 62%. Eighteen patients would have had to undergo treatment with eversion CEA to prevent one restenosis during the 4-year period. The incidence rate of ipsilateral stroke was 3.3% in the eversion population and 2.2% in the standard group. There were no significant differences in the cumulative risks of ipsilateral stroke (3.9% for eversion, and 2.2% for standard; P =.2) and death (13.1% for eversion, and 12.7% for standard; P =.7)) in the two groups. Of the 18 variables that were examined for their influence on restenosis, eversion CEA (hazard ratio, 0.3; 95% confidence interval, 0.2 to 0.6; P =.0004) and patch CEA (hazard ratio, 0.2; 95% confidence interval, 0.07 to 0.6; P =. 002) were negative independent predictors of restenosis with multivariate Cox proportional hazards regression analysis.

CONCLUSION

The EVEREST (EVERsion carotid Endarterectomy versus Standard Trial) showed that eversion CEA is safe, effective, and durable. No statistically significant differences were found in late outcome between the eversion and standard techniques at the available follow-up examination.

[Transcranial Doppler sonography in the pre- intra- and post-operative evaluation of 85 patients undergoing carotid endarterectomy]

PURPOSE

To evaluate the usefulness of transcranial Doppler sonography during carotid endarterectomy.

PATIENTS AND METHODS

Pre-, intra-, and postoperative transcranial Doppler was performed in 85 patients who underwent carotid endarterectomy. Intracranial collateral pathways were evaluated preoperatively and continuous monitoring of middle cerebral artery flow velocity was performed during carotid surgery. Transcranial Doppler was repeated in each patient 1 and 7 days thereafter.

RESULTS

Values of residual middle cerebral artery flow velocity during preoperative digital compression of the common carotid artery were significantly correlated (r = 0.56; P < 0.001) with those obtained during cross-clamping. Middle cerebral artery flow velocity was significantly lower during cross-clamping with respect to pre-clamping (P = 0.006), in patients with neurologic symptoms (P = 0.001), EEG alterations (P = 0.001), or defective collateral blood supply through the anterior communicating artery (P = 0.01). Postoperative flow velocity values of the MCA were significantly higher at day-1 examinations (P < 0.0001) with respect to preoperative values, and were no more significantly different at day-7.

CONCLUSIONS

Transcranial Doppler is a useful method to evaluate the risk of cerebral ischemia during carotid endarterectomy cross-clamping, to identify those patients in which shunt insertion is mandatory, and to evaluate the postoperative effect of carotid endarterectomy on cerebral hemodynamics.

A randomized study on eversion versus standard carotid endarterectomy: study design and preliminary results: the Everest Trial

PURPOSE

The EVEREST Trial was designed to determine whether the surgical technique influences the durability and complications of carotid endarterectomy (CEA). The current report focuses on the study design and preliminary results.

METHODS

EVEREST is a randomized multicenter trial. A total of 1353 patients with carotid stenosis requiring surgical treatment were randomly assigned to received standard (n = 675) or eversion (n = 678) CEA. Primary end points included carotid occlusion, major stroke, death, and restenosis rate.

RESULTS

The rate of perioperative major stroke and death (1.3 for each study group) and the incidence of early carotid occlusion (0.6% for eversion vs 0.4% for standard) were similar. No significant differences were found between eversion and standard CEA with respect to incidence of perioperative transient ischemic accident, minor stroke, cranial nerve injuries, neck hematoma, myocardial infarction, or surgical defects as detected with intraoperative quality controls. Clamping time was significantly shorter for eversion CEA compared with patch standard procedures (31.7 +/- 15.9 vs 34.5 +/- 14.4 minutes, p = 0.02). A shunt was inserted in 11% of patients undergoing eversion CEAs and in 16% of patients undergoing standard procedures. Overall 30-day events occurred in 13.3% of the eversion group and in 11.4% of the standard group (p = 0.3). At a mean follow-up of 14.9 months (range, 1 to 38 months), 16 (2.4%) restenoses occurred in the eversion group and 28 (4.1%) occurred in the standard group (odds ratio, 0.56; 95% confidence interval, 0.3 to 1.1; p = 0.08).

CONCLUSION

The preliminary results of the EVEREST Trial suggest that eversion CEA is a safe and rapid procedure with low major complication rates. No significant differences in restenosis rates were observed between eversion and standard CEA at the available follow-up. Longer-term results are necessary to assess whether the eversion technique influences the durability of CEA.

Healing of aortic prosthetic grafts: a study by magnetic resonance imaging

Thirty-six patients with aortoiliac reconstruction were studied by magnetic resonance imaging (MRI) to determine the diameter, baseline signal, and subsequent magnetic signal characteristics of postoperative periprosthetic collection (PPC). Our study confirmed the presence of PCC in most cases (32/36). The diameter was significantly (p < 0.05) correlated with the type of disease being treated, the type of proximal anastomosis created, and whether or not drainage and postoperative transfusion were used. PPC usually disappeared within 3 to 6 months postoperatively. Modifications of magnetic signals T1 and T2 require approximately the same amount of time to diminish. During follow-up investigations in this series, there was one case of prosthetic infection characterized by the persistence of PPC and a strong T2 signal 6 months after surgery, the latter corresponding to incomplete or delayed healing. The MRI aspects of normal healing of aortic grafts were analyzed to correctly interpret the MRI aspects of complications in surgery of the aorta.

Stress MR imaging for evaluation of popliteal artery entrapment

The popliteal artery entrapment (PAE) syndrome has been recognized as a cause of arterial occlusion in young people. It is the result of an anomaly of the relationship between the popliteal artery and the gastrocnemius muscle. Eight young health volunteers (16 legs) and six patients (10 legs) with suspected PAE underwent magnetic resonance (MR) imaging. Gradient-echo images were obtained in axial planes with the leg at rest and during active plantar flexion against resistance. Imaging at rest allowed identification of PAE signs in only one leg, which had an anomalous medial course of the popliteal artery. In the other cases, only the stress technique was able to show signal loss in the popliteal artery due to muscular compression (two legs) or the presence of accessory muscle slip around the vessel (two legs), as confirmed at surgery. MR imaging is therefore a useful technique for the diagnosis of PAE because of its capability of combining information obtainable with other modalities.

Detection of internal carotid artery stenosis. Comparison of 2D-MR angiography, duplex scanning, and arteriography

The purpose of this study was to compare digital subtraction angiography (DSA) and duplex scanning with 2D-Magnetic Resonance Angiography (MRA) to evaluate the accuracy of MRA in determining carotid stenosis. All three methods were applied to 101 carotid arteries in 51 patients. Diameter stenosis of the internal carotid artery was categorized as follows: 0 to 39%, 40% to 59%, 60% to 94%, 95% to 99%, and occlusion (100%). All images were read in blind fashion by different physicians. DSA is still considered the "gold standard" investigation. In 78 arteries the degree of stenosis according to MRA correlated exactly with that of conventional angiography. In the remaining 23, carotid arteries MRA upgraded the stenosis in 13 and downgraded it in 8. The principal problem is the overestimation of the lesion, which was particularly revealing in lesions of more than 60%. Furthermore to date MRA is not able to evaluate the presence of ulceration. For this reason 2D-MRA alone is not a reliable method for evaluating the presence of carotid artery stenosis.

Popliteal artery entrapment: MR findings

A 35-year-old woman with a history of claudication was examined by means of echodoppler, angiography, and MR imaging using gradient rephased sequences, performed at rest and during stress. Magnetic resonance imaging allowed the evaluation of the relationships between the gastrocnemius muscle and the popliteal artery at rest and the evidence of the occlusion during stress. This combined morphological and functional evaluation makes MR a procedure of choice for assessment of young adults with intermittent claudication.

Evaluation of hematoma by MRI in follow-up of aorto-femoral bypass

We selected a population of 20 patients with atherosclerotic disease, submitted to implantation of aorto-femoral bypass graft. These patients were studied by MRI with T1- and T2-weighted sequences (w.s.) using a 0.5 T superconductive magnet. Investigation was performed at 1 wk, 1, 3, and 6 mo after dacron implantation, to evaluate the normal evolution of hematoma and the potential development of complications. At the first week examination, hematoma presented medium signal intensity on T1 w.s. and high signal intensity on T2 w.s.; at 1 mo control the amount of hematoma was slightly reduced and we found persistence of high signal intensity on T2 w.s.; progressive reduction of size and signal intensity on T2 w.s. was noted at 3 mo control, in patients operated for peripheral vascular disease; on the other hand we found persistence of high signal intensity in T2 w.s. in patients treated for abdominal aortic aneurysms; only after 6 mo it was evident in all patients fibrotic evolution of the collection and low signal intensity in both T1 and T2 w.s. Thus, MRI study was useful in the evaluation of patency, morphology, and in detection of intraluminal thrombosis, but also in the characterization of periprosthetic hematoma.

Role of magnetic resonance imaging in the evaluation of aortic graft healing, perigraft fluid collection, and graft infection

The authors report their preliminary experience in the use of Magnetic Resonance Imaging (MRI) in ten patients who underwent aortic reconstruction. Examinations were performed 1, 4, 12 and 24 weeks after surgery, to examine the presence, size, magnetic characteristics and evolution of periprosthetic collections. The results have shown that periprosthetic collection can be considered normal after aortic reconstructive surgery, because such a perigraft collection (PFC) was present in 90% of the patients studied 1 week after operation, and had disappeared within 24 weeks in all cases. The magnetic characteristics were evaluated by T1 [repetition time (TR) = 480 msec and echo time (TE) = 20 msec] and T2 weighted spin-echo sequences (TR = 1800 msec and TE = 70/120 msec). Variations in the magnetic characteristics, found in sequential examinations, correlated with modifications of the collection and suggested that it was originally blood. The MRI examination performed 24 weeks after surgery gave a low signal intensity in T1 and T2 weighted sequences (w.s.) suggesting periprosthetic fibrosis. These preliminary observations may constitute a starting point for better evaluation of the normal appearance and evolution of the periprosthetic fluid collections following aortic graft implantation and, may be useful for the early detection of infection especially in asymptomatic patients.

Abdominal aortic aneurysm evaluation: comparison of US, CT, MRI, and angiography

We studied 26 cases of abdominal aortic aneurysm with magnetic resonance imaging (MRI), computed tomography (CT), ultrasonography (US), and angiography. Data acquired were compared to those obtained at surgery. Diameter of the aneurysm was correctly defined in all cases by CT and MRI, while angiography underestimated the diameter of lesions without peripheral calcifications. Involvement of renal arteries was present in four cases and correctly diagnosed with MRI and angiography in all of them. CT did provide this information in three cases and US were not useful. Also, iliac arteries involvement was depicted by CT, MRI, and angiography in 10 out of 10 patients. Coronal sections of MRI provided comparable images to those of angiography. By comparing these different techniques we verified the good reliability of MRI as investigation tool for an accurate evaluation of aneurysms; its only limit lying in the poor capability of detecting calcifications.

[Abdominal aortic aneurysms. Comparison of magnetic resonance, ultrasound, CT x-ray and angiography]

Twenty-four cases of abdominal aortic aneurysm were studied by means of MR Imaging, Computed Tomography (CT), Ultrasound (US) and Angiography. MR Imaging gave detailed information on the site and extension of the aneurysm. The extent of branches involvement, the presence of thrombosis, and the adjacent structures were also demonstrated. Major limitations of angiography were its morbility, and the difficult/impossible demonstration of eventual thrombi, and of the adjacent structures. CT, although extremely valuable in emergency cases and in the detection of calcifications, provided insufficient information on the involvement of the vessels originating from the aorta. US proved useful in the screening of abdominal aortic aneurysms, but lacked both the accuracy and the reliability necessary to a complete preoperative evaluation. MR Imaging proves thus to be a good investigation technique for a complete assessment of aneurysmatic lesions. Its major limitation is its inability to detect calcifications, while its major advantages are the accurate demonstration of both blood flow and eventual thrombi, and the multiplanarity and non-invasiveness of the methodology.

Clinical and therapeutical evaluation of inflammatory aneurysms of the abdominal aorta

Unexpected anatomical and clinical features of abdominal aortic aneurysm (AAA) may be encountered by the vascular surgeon creating technical problems that increase the normally low mortality rates of this affection. One such variant is the so called inflammatory aneurysm (IA) as a characteristic fibrosis involving the arterial wall and thus surrounding structure scan be observed. In our series of 525 patients affected by AAA the incidence of IA was about 4% (19 cases). Two groups of patients were considered: group A, including all the atherosclerotic patients, and group B 19 patients affected by IA. The latter group referred to a typical painful symptomatology in 84% of the cases: this element is of interest as only 20% of the cases of group A complained of pain. No other significant clinical or laboratory data were recorded which could allow the surgeon to perform a pre-operative differential diagnosis. In all 19 cases that underwent surgical treatment there was a 2-3 cm thick aneurysmal wall with a shiny white surface adhering to the IV portion of the duodenum, vena cava and iliac vessels and in some cases to the ureters. Histological examination of specimens of the aortic wall showed evident signs of atherosclerosis of the media and marked fibrotic thickening of the adventitia with the presence of lymphocyte aggregates: a sign of chronic inflammation. As what concerns indications and surgical treatment, there are no substantial differences. Pre-operative differential diagnosis can be made with CAT scan and ultrasound and the usual operative manoeuvres of aneurysmorrhaphy should be modified.

Criteria for prognostic evaluation of the results of lumbar sympathectomy: clinical, haemodynamic and angiographic findings

Lumbar sympathectomy still has an important role in the surgical treatment of occlusive peripheral arterial diseases of the lower limbs located below the inguinal ligament, when the presence of peripheral lesions makes revascularization difficult. A consecutive series of 143 patients who underwent lumbar sympathectomy was considered, and the clinical, angiographic and haemodynamic findings evaluated. Haemodynamic studies on these patients showed a relation between the clinical improvement and the pressure index, measured at the ankle before lumbar sympathectomy. The patients with pressure index values above 0.5 had a symptomatic improvement whereas the patients with a pressure index below 0.3 gave less good results. It is therefore believed that lumbar sympathectomy showed not be considered a second operative choice but an elective operation, especially in patients affected by lesion of the superficial femoral artery, the popliteal artery and its branches, with pressure indices above 0.5 where revascularization is not possible.

Indications for surgical treatment of cerebrovascular insufficiency

197 cases of patients with CVI, subjected to surgery by carotid endarterectomy, are examined. The results were nearly always good and hence the technique is recommended. Particular interest is attached to the risk connected with carotid clamping, through intraoperative study of CBF with 133Xe, such a risk is practically removed.

Cerebral hemispheric "counter-steal" phenomenon during hyperventilation in cerebrovascular diseases

Use of hyperventilation (HV) was recently suggested for the treatment of acute cerebrovascular insufficiency. There is indeed no general agreement on the effectiveness of hyperventilation even though clinical and experimental findings could support its value in clinical use.

During carotid surgery, hyperventilation was used in order to attenuate cerebral ischemia effects during carotid clamping, and a counter-steal phenomenon affecting a whole cerebral hemisphere was demonstrated.

This suggests the role that hyperventilation may play in the treatment of cerebral ischemia.

Assessment of renal function during trimetaphan infusion in prognostic evaluation of surgical management of renovascular hypertension

1. Differential renal function tests and renography were carried out during infusions of trimetaphan camsylate (Arfonad, Roche) in twenty-three patients with renovascular hypertension resulting from unilateral obstructive disease of the main renal artery. Renal plasma flow, glomerular filtration rate, urinary volume and sodium excretion were measured. Peak-time and slope index were assessed on renograms. Ten patients underwent revascularization of the kidney; nephrectomy was done in thirteen.

2. Patients were divided into two groups according to the response of the contralateral kidney during trimetaphan infusion. Patients in whom vasodilatation occurred were cured both by revascularization and by nephrectomy, whereas no patient who failed to show vasodilatation was benefited by nephrectomy.

3. Renal plasma flow measured under basal conditions was not a reliable index of the anatomical condition of the contralateral kidney, whereas its modification during trimetaphan infusion provided an accurate means of predicting surgical results.

4. When renal plasma flow of the contralateral kidney decreases during trimetaphan infusion, revascularization is still advisable, but nephrectomy fails to correct hypertension.