Ruptured pancreaticoduodenal artery aneurysm. A case report and review of the literature

none4noneP. Buresta; A. Freyrie; O. Paragona; M. D'AddatoP. Buresta; A. Freyrie; O. Paragona; M. D'Addat

Aortocaval fistulae. Clinical and diagnostic aspects and results of 9 cases treated

Background. The rupture of an abdominal aortic aneurysm (AAA) in the inferior vena cava is a rare event, with an incidence of between 0.3 and 10%. However, it is extremely severe and often cannot be diagnosed preoperatively. The aim of this paper is to present our experience regarding the characteristics of its presentation, the methods of treatment and the analysis of perioperative results, comparing them with the main series reported in the literature. Methods. The study included all the cases of aortocaval fistula (ACF) treated by our unit over the past 14 years, evaluating the characteristics of their presentation, the methods of preoperative diagnosis, the diameter of the aneurysm, the type of surgery and the results obtained based on perioperative mortality and morbidity (30 days). This group was also compared with a group of patients treated for ruptured aneurysm and contained ruptured aneurysm. Results. A total of 9 patients with AAA associated with the presence of ACF were operated during this period. Eight patients were symptomatic at the time of observation: right cardiac decompensation was apparent in 3 cases (33 %), abdominaI/lumbar pain and shock were present in 5 cases (55%), symptoms of hepatorenal insufficiency in 2 cases (22 %) and 2 cases of isolated renal insufficiency. There were also 2 cases of lower limb ischemia and 2 of venous stasis. Among the signs of rupture, abdominal bruit was noted in 2 cases (22%). A state of anemia with Hb <12 mg/dl was found in 7 cases (77%). Only 1 patient (11%) was completely asymptomatic. The interval between the onset of symptoms and surgery ranged from a few hours (within 12 hours) to 6 days. Diagnosis was intraoperative in 4 cases (44 %). Preoperative angiography was performed in 3 cases for diagnostic purposes. The mean diameter of the aneurysm was 7.3 cm. In 4 cases, ACF was associated with retroperitoneal rupture. Surgery took the form of aneurysmectomy and prosthetic graft and endoaneurysmatic suture of the caval opening; ligation of the vena cava was only required in 1 case. Perioperative mortality was 1 case (11%): 1 of the 4 patients with ACF associated with ruptured AAA, therefore the mortality in this group was 25%. No deaths occurred in the group with isolated ACF. Two cases of deep vein thrombosis (DVT) and 2 of lower limb ischemia occurred during the postoperative period: of the latter, 1 case was resolved by thrombectomy, while the other required demolitive treatment (amputation at the thigh). Functional parameters returned to normal after surgery in patients with renal and hepatorenal insufficiency. The mortality rate in ruptured aneurysms was 16.6% (8/48) and 8.3% in contained ruptured aneurysms (2/24). Conclusions. The clinical symptoms of ACF are very similar to the fissuration crisis of AAA. In our experience, perioperative mortality was relatively low and was limited to cases with ruptured aneurysm

Hypertension and migraine comorbidity: prevalence and risk of cerebrovascular events: evidence from a large, multicenter, cross-sectional survey in Italy (MIRACLES study)

OBJECTIVES: To estimate the prevalence of hypertension-migraine comorbidity; to determine their demographic and clinical characteristics versus patients with hypertension or migraine alone; and to see whether a history of cerebrovascular events was more common in the comorbidity group. METHODS: The MIRACLES, multicenter, cross-sectional, survey included 2973 patients with a known diagnosis of hypertension or migraine in a general practitioner setting in Italy. RESULTS: Five hundred and seventeen patients (17%) suffered from hypertension-migraine comorbidity, whereas 1271 (43%) suffered from hypertension only, and 1185 (40%) from migraine only. In the comorbidity group, the onset of comorbidity occurred at about 45 years of age, with migraine starting significantly later than in the migraine-only group, and hypertension significantly before than in the hypertension-only group; a familial history of both hypertension and migraine had a significantly higher frequency as compared with the hypertension and migraine group. Compared to hypertension (3.1%) and migraine (0.7%), the comorbidity group had a higher prevalence (4.4%) of history of cerebrovascular events, with an odds ratio of a predicted history of stroke/transient ischemic attack (TIA) of 1.76 [95% confidence interval (CI) 1.01-3.07] compared to the hypertension group. In patients without other recognized risk factors for stroke, stroke/TIA occurred more frequently in the comorbidity group, compared to the hypertension group. In the age range 40-49 years, prevalence of history of stroke/TIA was five-fold greater (4.8% in comorbidity vs. 0.9% in hypertension group). CONCLUSION: This cross-sectional study indicates that the prevalence of comorbidity hypertension-migraine is substantial and that patients with comorbidity have a higher probability of history of cerebrovascular events, compared to hypertensive patient