A new approach for proximal anastomosis in type "A" acute aortic dissection: prosthesis eversion

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

Aneurysms of anomalous splenomesenteric trunk: clinical features and surgical management in two cases

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

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

OBJECTIVE: To evaluate the feasibility, technical effectiveness and limb salvage potential of percutaneous transluminal angioplasty (PTA), particularly infrapopliteal, in diabetic subjects with ischaemic foot ulcer. DESIGN: Intervention study with PTA in consecutive series. SETTING: Six Diabetology Foot Centres and one Cardiovascular Catheterization Laboratory in Italy. SUBJECTS: Two hundred and twenty-one consecutive diabetic subjects hospitalized for ischaemic foot ulcer. INTERVENTION: Peripheral arterial occlusive disease (PAOD) was investigated by means of foot pulses assessment, ankle-brachial-index (ABI), transcutaneous oxygen tension (TcPO2) and duplex scanning. If non-invasive parameters suggested PAOD, angiography was performed and a PTA was carried out during the same session. MAIN OUTCOME MEASURES: PTA feasibility, improvement of ABI and TcPO2, limb salvage rate, clinical recurrence. RESULTS: On angiography, two patients had stenoses which were 50%, even when longer than 10 cm and/or multiple/calcified. In 11 patients (5.8%) PTA was performed in the proximal axis exclusively, in 81 (42.4%) patients in the infrapopliteal axis exclusively and in 99 (51.8%) in both the femoropopliteal and infrapopliteal axis. Both ABI and TcPO2 improved significantly after PTA (P < 0.0001). Clinical recurrence occurred in 14 subjects: 10 of whom underwent a second successful PTA. Of the 191 patients who underwent PTA, 10 (5.2%) underwent an above-the-ankle amputation. CONCLUSIONS: PTA, including infrapopliteal, is feasible in most diabetic subjects with ischaemic foot ulcer and is effective for foot revascularization. Clinical recurrence was infrequent and the procedure could successfully be repeated in most cases. In subjects treated successfully with PTA the above-the-ankle amputation rate was low. PTA should be considered as the revascularization treatment of first choice in all diabetic subjects with foot ulcer and PAOD

"Delirium Day": A nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

Background: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. Methods: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. Results: The mean sample age was 82.0 \ub1 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. Conclusions: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys

Abdominal aortic aneurysms and concomitant neoplastic diseases. EVAR : a new option for surgical timing

Aim. Although the simultaneous occurrence of abdominal aortic aneurysm (AAA) and neoplastic disease is a rare event, the incidence of both increases with age and therefore the continuous growth of life expectancy has raised the prevalence of this association. The introduction of endovascular aneurysm repair (EVAR) in clinical practice has offered new treatment options. The authors report their experience with the introduction of E VAR. Methods. From January 2004 to June 2006, 176 patients affected by AAA were admitted - 29 had an emergent operation for rupture or fissuration, whereas 147 underwent elective surgery. Fifty of them were offered EVAR and a concomitant malignancy was present in 6 patients. In all 6 patients, EVAR was performed first. Results. We had no in-hospital mortality and no early complications. We had only one cancer-related death, 6 months after surgery. Conclusions. The introduction of EVAR has modified surgical timing in our clinical practice. When managing patients with AAA and concomitant malignancies EVAR allows treatment even in case of poor clinical conditions but still it is not the gold standard for AAA repair. Thus, it should be performed only after a thorough selection of patients who are not suitable for the combined intervention

Insufficienza cerebrovascolare da compressione estrinseca della carotide interna ad opera di un aneurisma della carotide comune

Successful dacron prosthetic repair of an extensive common carotid aneurysm responsible for compression of the internal carotid and cerebrovascular insufficiency is reported. A short account of surgical techniques employed for lesions of this kind is also presented