Prospects of prostanoid therapy. Preliminary results

BACKGROUND

To evaluate the efficacy of treatment with prostaglandins (Iloprost and Alprostadil) in patients with peripheral arterial disease in whom a surgical act or a redo operation is not proposable and to set the role of these drugs in the therapy of arterial diseases.

METHODS

We analyzed the results of 96 treatments in patients with peripheral arterial diseases of different etiology, treated in the Day Hospital in the Division of Vascular Surgery from the 1/1/1993 to the 30/6/1998. The efficacy of the treatment has been evaluated on the basis of the clinical picture (healing or reduction of ulcers, reduction of rest-pain, improvement of the ability to walk).

RESULTS

We had positive results in 60% of the patients who completed the treatment, a good outcome for patients with particularly severe arterial disease. Interruptions induced by the occurrence of uncontrolled side-effects are a few (6.25%). Better results have been found in a special category of disease (arterial diseases not associated with diabetes, not very advanced clinical picture, female gender). Iloprost proved to be superior to Alprostadil.

CONCLUSIONS

Prostaglandins today represent an effective therapeutic solution to be considered. Further studies need to be done to find a category of patients who can have the best benefit from this kind of drug.

Carotid endoarterectomy in the presence of contralateral carotid occlusion

BACKGROUND

The purpose of this study was to define a correct anesthesiological and surgical approach in patient who present a significant carotid stenosis with contralateral carotid occlusion.

METHODS

Between 1996 and 1998 in our Department of Vascular Surgery of the Hospital S. Giovanni Battista has been executed 337 Carotid Endoarterectomies (CEA). Of these, 44 patient (13%) had a contralateral internal carotid occlusion. Forty was male (91%), and 4 female (9%). Echo Doppler, angiography, angioTC or angio-RMN and TCD were performed in all patients. In all cases was executed a traditional CEA.

RESULTS

Because of the presence of a large ischaemic cerebral lesion or clamping intolerance 12 operation were performed under general anesthesia (27%). Shunt was used in 15 patients (34%) and patch was used in 10 cases (23%). In 2 cases (4.5%) there was be a thrombosis of the operated internal carotid artery and one patient died (2.3%).

CONCLUSIONS

The presence of contralateral internal carotid occlusion with carotid stenosis > 70% increase the risk of peroperative stroke because of the difficulty of collateral cerebral blood flow. The execution of echo Doppler, angiography, angioTC or angioRM and TCD and their evaluation permit to choice the best anesthesiological and surgical treatment. The utilization of narcosis with thiopental protection and shunting reducing the rate of perioperative stroke, but the local anesthesia allows the best monitoring of intraoperative cerebral function. This behaviour was correctly when in patient with contralateral internal carotid occlusion there is an insufficient intracranic vascularization or an extensive ischaemic lesion or clamping intolerance.

[Deep venous thrombosis in a patient with superficial thrombophlebitis. Apropos of 2 cases]

Deep vein thrombosis in patient with superficial thrombophlebitis of the leg. Description of two cases. Two clinical cases already observed at our Department of Vascular Surgery, regarding patients with superficial thrombophlebitis (STF) associated with a deep venous thrombosis (DVT) are presented. The diagnosis of DVT was achieved exclusively on the basis of the duplex scanner because the two patients were completely asymptomatic. The chance that symptoms and clinical signs of STF cover a DVT is a possibility that should always be considered. For this reason every STF should be further investigated with duplex scanner in order to exclude that the deep venous circulation get involved at the same time. The DVT in these cases is generally due to the spreading of the thrombosis process from the perforating branches. The chance of a multiple onset of thrombosis in the superficial and deep circulation represents anyway an hypothesis worth of studying.

[Malignant fibrohistiocytoma arising at a femoral dacron vascular prosthesis. Case report and review of the literature]

In a recent publication, reporting the sixth case of aortic angiosarcoma, probably induced by the implantation of a dacron vascular prosthesis, Weiss et al. have done a literature review concerning the association between the presence of vascular prostheses and the onset of mesenchymal neoplasms. Although they consider the incidence of this association very low, they also point out the hypothesis, largely supported by experimental studies, that vascular prostheses can play the role of aetiological co-factor or factor in the onset of these tumors. We consider useful to report a case of malignant fibro histiocytoma arising around a femoral vascular prosthesis in a patient operated on for aneurysm of the femoral artery.

[Buerger disease. Report of an case, unusual for its site and clinical manifestations]

The diagnosis of Buerger's disease, like that of all arteritis, especially in the onset phase, can be difficult. The general criteria proposed by several authors, with the aim of codifying the verification of the disease, are sometimes too schematic and this collides with the existence of very variegated and polymorphous clinical situations, as well as totally atypical and unusual clinical patterns. On this subject we consider useful to report a case of Buerger's disease that presented some peculiar characteristics, the most important of which was the existence of an aneurysm of the left superficial temporal artery.

Venous and arteriovenous vascular malformations: diagnostic and therapeutic considerations regarding 239 patients observed in the 1978-1991 period

The Authors report their experience in the treatment of venous and arteriovenous malformations, which in this paper are divided into two subgroups, pure venous malformations (VMs) and arteriovenous malformations (AVMs). A pure surgical indication was evident in less than 50% of cases (48.1%), while more conservative treatments were performed in remaining patients. Considering the particular characteristics of the disease, a complete surgical radicality isn't always possible, so surgery must be considered in selected cases.

[Intraoperative microbiological monitoring in abdominal aortic aneurysms in elective surgery. A review of the literature and the authors' personal experience]

Thirty-one patients, ranging in age from 57 to 78 years (mean 66), with the exclusion of cases with doubtful possible results, underwent abdominal aortic aneurysmectomy for asymptomatic AAA and had cultures from the aneurysmal wall and endovascular thrombus to identify possible microbiological source of future graft infection; 5 (16%) of 31 cultures yielded bacterial growth and the most common organism isolated was staphylococcus epidermidis. During an average follow-up of 15.4 months no graft infection was noted in patients with positive or negative aortic cultured. A literature review stresses the same disparity between positive cultures obtained at the aneurysmectomy and subsequent low graft-infection rate. It is concluded that the aneurysm wall itself does not represent an important source of early or late graft infection and it's suggested that the bacterial presence both in the wall and thrombus could be explained by an exogenous contamination at the operation time.

[The clinical and socioeconomic aspects of cerebrovascular diseases in Europe (a study in Turin on patients during 12 years of hospitalization)]

During the period 1976-1987, 295,718 patients affected by vascular diseases have been admitted into all the public and private hospitals of Piemonte (Italy): 172,483 patients were affected by arteriopathies. 95,231 (55.2%) have been admitted because of cerebrovascular diseases: 73,511 (42.6%) were affected by diffuse form (T), 18,258 (26.5%) by TIA and 3,462 (2%) by precerebral stenosis and occlusions. (TSA). These data have been compared to the incidence of cerebrovascular disease in Europe and risk factors, sex, age, department of hospitalizations, kind of therapy and results have been investigated. In Piemonte cerebrovascular diseases show not only the highest incidence among all the vascular diseases, but they seem to be the highest cause of morbidity among all the patients admitted into the hospitals.

[Incidence of aortic aneurysms in Piedmont]

A retrospective clinico-epidemiological study of the incidence of all arteriopathy hospitalization in the Region of Piemonte over a twelve year period (1976-1987) has been performed: among all the cases, patients affected by aortic aneurysm show an average of hospitalization of 0.8 cases per 24 hours. The prevalence of the sex has been pointed out for males (75.5% versus 24.3% of females): the men showed a higher rate independently from the age. The most involved age groups are for population between 70 and 74 years, but, from 1976 up to 1987 we have observed a more homogeneous distribution than in the first considered cases when it was mainly for patients aged more than 70 years. We have to stress a curious and not under standable datum regarding the kind of therapy: patients were treated medically in 69.4% of cases, while surgery was carried out only in 27.9%, but, fortunately, since 1976, we have noticed a continuous increase of surgery up to 40% in 1987. Hospitalizations have regarded the wards of Internal medicine in 24% of cases, while both General Surgery and Vascular Surgery showed rates of 23% and 25%. The average hospitalization time has been lower if compared to that of all the arteriopathies: 14.4 days versus 22.5. Furthermore we have to point out a decrease in average days of hospitalization for aneurysms of the aorta and a decrease in the costs for this pathology. Mortality is still high, also if referred to the non-operated patients: in fact the mean is 25.5% with a low rate of necropsies (mean 29%).

Bilateral popliteal artery entrapment syndrome. A case report and clinical considerations

The authors report their experience in the management of a rare case of bilateral popliteal artery entrapment syndrome occurred to their observation. This unusual pathological entity, arising mostly in young subjects and unilaterally, in this case was bilateral and developed in a 51 years old patient. The clinical case is fully documented by multiple Echo-Doppler and arteriographic examinations which clearly demonstrate the peculiar characteristics of the disease. Finally the patient received a two stage surgical treatment with a good global result. The Authors stress the importance of a correct diagnostic approach to this unusual disease to avoid the possibility to misdiagnose it.

[Blood cholesterol in patients with cancer]

Cholesterolaemia values have been investigated in a simple of colon cancer patients and in two control samples consisting of age and sex corresponding subjects suffering respectively from peripheral arteriopathy and minor pathologies (hernias and varices). The study was extended subsequently to a sample of subjects suffering from thyroid neoplasia and two similarly constituted control samples. Cholesterolaemia was significantly lower in colon cancer patients than in the control samples whereas in subjects suffering from thyroid cancer, statistical significance was not attained even though a similar reduction was recorded. The reduction in cholesterol in cancer patients is, in the light of the most recent studies, an effect of cancer on cholesterolaemia, thus giving the lie to the theory that low blood cholesterol is a factor favouring the onset of cancer, and is a finding with by no means indifferent repercussions on the study of the behaviour and physiopathology of cancers.

[Evaluation of pre- and postoperative cerebral hemodynamics in extracranial carotid surgery using transcranial Doppler. Preliminary note]

The Authors report their preliminary experiences concerning the use of transcranial Doppler (TCD) in the pre- and postoperative monitoring of extracranial carotid surgery. TCD is a non invasive method of investigation able to give informations about the distribution of cerebral blood flow and about the mechanisms of compensation of Willis' circle. Furthermore, TCD showed itself to be very useful in the postoperative qualitative evaluation of surgery, pointing out, as a general rule, an increased flow in the middle cerebral artery after thromboendarterectomy of internal carotid artery. This haemodynamic modification, if present, is perceptible since the immediate postoperative period and becomes more evident and definitely stable at a distance of 20-30 days after operation, likewise the definitive stabilization of Willis' circle's haemodynamics.

Renovascular hypertension: a non-invasive Duplex scanning screening

A Duplex-Scanner was used to screen 62 patients with severe hypertension, queried renovascular. Ten results were technically unsatisfactory and in the remaining 52 highlighted flow alterations in the renal arteries of 29 patients were found. Control angiographies confirmed renal artery stenosis in 27 cases. Comparative statistical analyses proved the test to be both highly sensitive and specific, considering other screening methods currently used in diagnosing renovascular hypertension--which include endovenous digital subtraction angiography. Results confirmed the Duplex-Scanner as a reliable renovascular hypertension screener as well as being a non-invasive method with no potentially toxic effects.

[Bandage of the common femoral artery after intervention of disobliteration or aneurysmectomy (considerations on surgical technic apropos of 4 cases)]

The Authors refer their surgical experience in those particular cases in which, after performing an aneurysmectomy or an endarterectomy of common femoral artery, the residual arterial wall appears too thin and weakened. In these not very rare cases, can be indicated, as an additional and prudent manoeuver in order to avoid a possible evolution towards suture disruption or pseudoaneurysm formation, the wrapping or banding of the endarterectomized tract of artery by the mean of dacron prosthesis, sutured around the artery longitudinally. This simple technique, performed in 4 patients, appears easy and safe to perform, offering the advantage to guarantee a biological arterial lumen.

[Exocrine carcinoma of the pancreas in Piemonte (analysis of 3053 hospitalized cases)]

The study concerns 3053 cases of esocrine pancreas carcinoma observed between 1976 and 1981 in Piemonte, Italy. The authors discuss about the principal risk factors associated with that disease (age, sex, geographical distribution), the treatment and the methodological problems in an epidemiologic study concerning pancreatic carcinoma.