Vascular graft infection is a rare but potentially devastating complication. Even with ameliorating medical and surgical techniques, this complication remains the most serious event after an arterial prosthetic replacement. A careful clinical exam of a patient who received a vascular graft is important because the suspicion of graft infection is always present. A correct imaging and eventual sampling of periprosthetic fluids is mandatory to know the precise identity of the involved bacterium(a). On this finding we can choose the best treatment for each patient. First of all, antibiotic treatment is mandatory when an infection has been recognized before the surgical treatment. The standard approach is the removal of the graft and an autogenous replacement. Because of the aging of the population, treating older or immunologically depressed patients is more common, and so alternative methods to reduce the heavy impact of the intervention have been suggested. Among these, ultrasound debridement of the infected tissues, and also of the graft, is an option for conservative treatment with good results at follow-up.

operatively with suturing of the graft proximally due to poor proximal seal without endoleaks.

Aim. We report our experience with the use of PTFE trilaminate graft Advanta SST (Atrium Maquet (TM)) versus autologous great saphenous vein (AGSV) and composite PTFE trilaminate-vein graft for below-the-knee (BTK) revascularization. Methods. Data of all consecutive patients who underwent either a BTK or a distal femoro-popliteal bypass from January 2004 to March 2013 using Advanta SST, AGSV or composite Advanta SST-vein graft were retrospectively reviewed and outcomes were analyzed. Kaplan-Meier method with Log-rank test was used to estimate survival, limb salvage and patency rates. Chi-square test was used to evaluate risk factors affecting outcomes. P value <0.05 was considered significant. Results. Sixty-one patients (48 males, 78.7%; median age 73 years, IQR 66-80) underwent a BTK/distal revascularization for peripheral artery disease causing critical limb ischemia (52 patients, 85.2%) or disabling claudication (9 patients). Advanta SST graft was used in 17 patients (group A), AGSV in 30 (Group B) and composite Advanta-AGSV graft in the remaining 14 (group C). Patients' demographics and risk factors were similar among the three groups, being hypertension and smoke the most frequent comorbidities. When Advanta SST was employed, the median duration of intervention was significantly lower than using vein or composite grafts (212 minutes, IQR 177-257; 270 minutes, IQR 220-375, P=.02; 327.5 minutes, IQR 252.5-405, P=0.003 respectively). At 30-days, wound complications tended to be significantly higher in Group B (13.3%) and C (11.7%) than in group A (0%), P=0.02. At long term, survival, primary assisted and secondary patency rates did not differ significantly among the three groups. Limb salvage was similar as well among group A, B and C (P=0.29), being 81.2+9.7%, 89.4+5.8% and 67.7+13.5% respectively at 1 year and 81.2+9.7%, 83.4%+7.9% and 54.2%+16.2% respectively at 3 years. Primary patency rate at 1 year was significantly better for group B than for group A and C (71.2+8.6%, 49.6+12.7% and 47.6+14.1% respectively, P=0.02), but after 1 year the patency rate for group B and A was similar (55.5+10.6% and 49.6+12.7% respectively), being for group C significantly worse (19+11.8%). A history of previous or current smoke affected significantly primary patency rate in group A (RR 0.39, 95%CI 0.08-0.95, P=0.03). Conclusion. Long-term results of the use of Advanta SST graft for BTK/distal revascularization seems to be promising, with significant lower duration of the operation and wound complications. At long term, survival, limb salvage, primary assisted and secondary patency rates did not differ significantly among the three groups. The AGSV still remains the best graft in terms of primary patency at 1 year, but after one year primary patency rates using the Advanta SST compare favorably to those of AGSV, while composite bypass grafts have the worst performance. These results need to be increased further.

The popliteal vein is the most frequent site of venous aneurysm. Surgical treatment is indicated above a 2.5 cm diameter to prevent complications, notably deep venous thrombosis and pulmonary embolism (PE). Here we report a case of recurrent episodes of severe PE, leading to cardio-circulatory shock caused by a popliteal vein aneurysm (PVA) despite oral anticoagulant therapy. When surgical correction of the aneurysm was performed, we found an ulcerative lesion in the inner aspect of the vein that was acting as a thrombogenic focus' inside the aneurysm. An accurate inspection of the intimal wall is always important during surgery of PVA, particularly when tangential resection is performed.

AIM:Open surgical repair (OSR) and endovascular techniques (ET) are both described in the literature for treating visceral artery aneurysms (VAAs). Aim of this study is to report a two-center experience of patients treated for a VAA using either OSR or ET, analyzing perioperative outcomes.METHODS:Clinical data of 32 VAAs in 32 patients treated between January 2001 and May 2011 were retrospectively reviewed and outcomes analyzed.RESULTS:Eighteen patients were men (56.3%). Median age was 64 years (range 26-79). Sixteen aneurysms were symptomatic: half of them were ruptured causing hemoperitoneum or gastrointestinal bleeding. ET were employed in 19 cases (59%) using covered stents (7 patients), coil embolization (5), plug placement (1), thrombin injection (2) and multiple associated techniques (4). OSR consisted in aneurysmectomy with end to end anastomoses (5 patients) or interposition graft (1), aneurysm ligation (4), splenectomy (2). One patient died during open surgery for hemoperitoneum due to VAA rupture (3%). OSR and ET had similar perioperative complication rates (5.2% vs. 15.3%, P=0.76). OSR had a longer in-hospital stay than ET (8 vs. 4 days, P=0.04). The presence of pancreatitis and alcohol abuse were more frequent in patients who presented with VAAs rupture. Clinical presentation with hemoperitoneum or aneurysm rupture were associated with higher mortality, regardless of the type of treatment.CONCLUSION:Both OSR and ET offered a safe way to treat VAAs in our experience.

A 9.5-cm visceral artery aneurysm was found during a computed tomography (CT) scan performed for abdominal pain. Subsequent selective angiography showed the aneurysm arising from the second branch of the superior mesenteric artery (SMA). The celiac trunk was occluded at its origin and blood supply to the splenic artery was provided through the pancreatic-duodenal arcade. Two injections of 5.000 U of thrombin were delivered transcatheter to produce complete thrombosis. No major complications occurred. After 32 months the aneurysm decreased to 3.7 cm in diameter. Transcatheter thrombin injection seems to be a safe and durable option in the treatment of visceral aneurysms.

One of the crucial aspects of surgical repair of type A aortic dissection is to achieve hemostasis of the anastomosis. Furthermore, the possibility of improving the suture with additional stitches is often technically demanding. We, therefore, describe a new surgical technique for the proximal anastomosis, positioning the prosthesis within the left ventricle. We present our series of 6 patients treated with this new technique. The immediate results confirmed the efficacy, speed, and simplicity of the technique. During long-term follow-up no patient showed significant residual aortic valve incompetence.

Abstract Faglia E, Mantero M, Caminiti M, Caravaggi C, De Giglio R, Pritelli C, Clerici G, Fratino P, De Cata P, Paola LD, Mariani G, Poli M, Settembrini PG, Sciangula L, Morabito A, Graziani L (Internal Medicine Unit, Diabetology Centre, Policlinico Multimedica, Sesto San Giovanni, Milano; Centre for the Study and Treatment of Diabetic Foot Pathology, Abbiategrasso Hospital, Milano; Internal Medicine Unit, IRCCS Salvatore Maugeri Foundation, Pavia; Endocrinology and Metabolism Unit, Diabetic Foot Centre, Villa Berica Hospital, Vicenza Italy; Diabetology Centre and Vascular Surgery Division, S. Carlo Borromeo Hospital, Milano; Diabetology Centre, `Felice Villa' Hospital, Mariano Comense Como; Department of Medicine, Surgery and Dentistry, S. Paolo Hospital, University of Milan, Cardiovascular Catheterization Laboratory, `Città di Brescia' Hospital, Brescia, Italy). Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischaemic diabetic foot ulcers: clinical results of a multicentric study of 221 consecutive diabetic subjects. J Intern Med 2002; 252: 225–232.

OBJECTIVES:although the mechanism of arterial dilation and aneurysm development has not been clarified, the degradation of elastin and collagen plays undoubtedly a critical role. We evaluated the elastin and collagen content through the detection of their cross-links in aneurysmal and non-aneurysmal abdominal aortic walls.MATERIALS AND METHODS:in 26 human abdominal aortic aneurysm specimens obtained during surgery and in 24 autopsy control samples of non-aneurysmal abdominal aorta the tissue content of elastin and collagen cross-links were measured by HPLC. Collagen was also detected by evaluating two characteristic amino acids, 4-hydroxyproline (4-hypro) with a colorimetric method and 5-hydroxylysine (5-hylys) by gas chromatography.RESULTS:significantly fewer elastin cross-links were found in aneurysm samples compared to controls (desmosines and isodesmosines: 90% reduction; p<0.01). The opposite was true for pyridinoline collagen cross-links (350% increase) and deoxypyridinolines (100% increase, p=0.01). Tissue content of 5-hylys, 4-hypro and total amino acids were reduced significantly by 50% in aneurysmal samples.CONCLUSIONS:beside confirming decreased elastin content in aneurysmal walls, these results show a concurrent increase of collagen cross-links. Since total collagen markers were decreased (decreased 4-hypro and 5-hylys) it is reasonable to suggest that in aneurysmal aortic walls old collagen accumulates cross-links while new collagen biosynthesis is somehow defective.

The differentiation of pseudo-occlusion from complete internal carotid artery occlusion may have important clinical consequences for patients with the former tend not to benefit from reconstructive surgery. The Authors report a case in which color-Doppler duplex-scanner revealed a persisting string-like lumen that was not demonstrated by angiography. The Authors believe that ultrasonography may in future permit the reliable differentiation of pseudo-from complete carotid occlusion, thereby reducing the need for angiography.

The Authors report on two cases of acute aortic occlusion, related to cardiac embolism and thrombosis of aortic aneurysm. The singularity of the etiology adds interest to a pathology which is already, in itself, serious and complex and which requires the intervention of the surgeon, anesthesiologist-reanimator, cardiologist, and nephrologist. The diagnosis is mainly clinical. The use of Doppler and CT scan provide to achieve the diagnosis. Surgical treatment included transfemoral embolectomy, with a Fogarty catheter, in the patient with acute aortic occlusion related to cardiac embolism, and aortobifemoral bypass, in the other patient, affected by thrombosis of aortic aneurysm.

Aneurysms of the splenic artery that anomalously arise from a splenomesenteric trunk are a rarity. Aneurysmal disease of visceral arteries is found in only 0.2% of the general population. The celiac trunk and superior mesenteric artery (SMA) are involved in less than 10% of all visceral aneurysms. Although rupture seems to occur in 20% to 22% of patients, the related mortality rate can rise as high as 100%. Anomalies of the celiac trunk and SMA, more common than previously claimed, include the splenic artery arising from the SMA, which occurs in only 1% of patients. We present two cases of young patients who had 4-cm aneurysms behind the pancreas that involved an anomalous splenic artery. The first patient required dissection of the entire splenopancreatic bloc through a transverse abdominal incision to excise the aneurysm and repair the SMA. The second patient was treated by the classic approach, through a median incision and by entering the mesenteric root. There do not seem to be reports of similar cases, except for two cases of aneurysms involving the celiomesenteric trunk. The cause of these aneurysms can be attributed to mesenchymal alterations during the embryonic formation of aortic collateral branches. A correct surgical approach to splanchnic aneurysms calls for awareness of potential vascular variations of the arteries and their collateral pathways.

Experimental and clinical data suggest that low molecular weight (LMW) heparins not only have an antithrombotic activity but also a profibrinolytic effect. To assess the profibrinolytic effect of the LMW heparin calcium nadroparine (CY216), 20 patients undergoing surgery were enrolled in a randomized study in which CY216 (3075 AXa IU [0.3 ml]/day) subcutaneously 2 hours before surgery and daily for 7 postoperative days was compared with placebo. The coagulation and fibrinolytic profiles of the patients were determined before and after venous stasis in baseline conditions and 1, 4, and 8 days after surgery. The following parameters were evaluated: functional activity of antithrombin III, plasminogen, alpha2-antiplasmin, tissue plasminogen activator (tPA), plasminogen activator inhibitor (PAI), and tPA antigen. During the postoperative period, a significant decrease in plasminogen levels and an increase in alpha2-antiplasmin levels were observed in the patients in the placebo group. In the patients treated with CY216, recovery of the plasminogen levels was evident on postoperative day 4, with a significant, but smaller increase of alpha2-antiplasmin. Venous stasis did not induce any modification of tPA antigen values before surgery; after surgery, a significant increase of tPA antigen was observed only in the CY216 group. The PAI values were similar in both groups before and after surgery. These preliminary data suggest that the LMW heparin CY216 may have a moderate profibrinolytic effect.