Biomedical subjects
Publications and source records attributed to S Miani.
The Authors report a case of arterio-venous fistula of the left renal pedicle, twenty six years after nephrectomy. The diagnosis was made by clinical signs and confirmed by angiography. Treatment was surgical with complete removal of the fistula.
From 1980 to 1990 a yearly medical-surgical control was carried out on 950 arteriopathic patients hospitalised in the General and Cardiovascular Surgery Institute, Milan University, during the above mentioned period. The operations for surgical reconstruction were mainly for arteriosclerotic lesions involving the abdominal-peripheral district (750 patients, 79%) and the supra aortic trunks (200 patients, 21%). 84% of the patients were males. Among the patients on follow-up, a relatively modest number (100 patients) did not attend the prescribed diet therapies for several reasons, consequently these patients have been considered as a control group. The comparison, between the patients who attended and those who did not attend the diet, has been made on the basis of the following parameters: cholesterolemia (COL), LDL, HDL, triglyceridemia (TG), VLDL, glycemia (GLI), body mass index (BMI) and arterial pressure (PA). The results have shown a decrease in the absolute normal values of cholesterol, LDL and triglycerides, while they have not shown the same significant variations regarding glycemia and body weight. In accordance with the literature, the diet seems to have obtained satisfactory results, especially regarding the values of lipidemia, with a reduction in the atherogenic risk index. Regarding smoke as a risk factor it has been shown that it is present in 80% of the patients at the beginning: 60% of the patients stop smoking at the moment they are hospitalised and the remaining 20% continue smoking. The hygienic-dietetic intervention is confirmed, also in our experience, as a curative, or even more, a preventive tool against the worsening of an already overt arteriosclerosis as well as a necessary support for drug therapies.
The paper reviews 2014 cases of aneurysm of the abdominal aorta treated over the past 10 years at the Institute of General and Cardiovascular Surgery of the University of Milan directed by Prof. Ugo Ruberti, and analyses 38 which showed inflammatory characteristics. In spite of the low frequency of this type of aneurysm (1.8%), preoperative diagnosis is important since surgery entails greater technical difficulties than surgery for an atherosclerotic aneurysm of the abdominal aorta. In this respect the study of preoperative ESR and white blood cell levels is important: the review showed an increased ESR in 71% of cases in which the aneurysm was clearly inflammatory (a percentage which was twice that found in patients with atherosclerotic aneurysms) and increased white blood cells in 32% of cases compared to 2.6% in atherosclerotic aneurysms. Contrary to previous reports, CAT and abdominal echography were not particularly important. However, in those cases where the aneurysm was thought to be inflammatory on the basis of these findings, the Authors chose to operate once the diagnosis had been made without waiting for steroid therapy to reduce the extent of inflammation due to the well-known risk of rupture and the controversial efficacy of medical therapy.
The juxtarenal aortic occlusion is an infrequent but not exceptional condition determining several problems during the corrective procedure. The incidence of this pathological picture is around 10% of the patients affected by steno-obliterative lesions of the subrenal aorta. The danger of this morbid condition derives mainly from the risks threatening the renal function which sometimes is already endangered before surgical intervention. The operation however implies high additional risks because some surgical procedures require suprarenal aortic clamping and because during the surgical manoeuvres embolization could occur in the lumen of renal arteries. This study analyzes 206 patients who underwent surgical intervention for subrenal aortic occlusion during the last 15 years. 11 patients were operated on in emergency because of lower limbs ischaemia. 4 patients presented a complete thrombosis of an aneurysmatic lesion of the subrenal aorta. The study is aimed at analyzing the renal behaviour in the postoperative period, comparing its functionality with the preoperative parameters. A second aspect which will be considered refers to the type of surgical procedure.
In a consecutive series of 640 surgically treated abdominal aortic aneurysms, 4 patients affected by thrombosis of the abdominal aortic aneurysm were observed. All aneurysms were five centimeters in diameter or smaller and all the patients complained of chronic claudication. In spite of the old opinion that considered abdominal aneurysmal thrombosis an useful event, we believe that the angiographic and clinical picture of juxta-renal aortic occlusion points to surgical treatment.
Experience of the operative treatment of 45 popliteal aneurysms in 41 patients is reported. The importance of immediate surgical reconstruction whenever a popliteal artery aneurysm has been detected is stressed. In fact, the patency rate of the arterial substitutes which are utilised in the reconstructive technique, and therefore the fate of the affected limbs, is chiefly based on the presence of a sufficient run off. Ischaemic complication due to peripheral embolization or sudden thrombosis of the aneurysmatic sac is very often followed by the irreversible closure not only of the tibioperoneal arteries but also of most collateral vessels.
A case of hypertrophic anterior scalene muscle surgically treated is reported. The patient suffered from upper limb intermittent claudication at any sustained upper extremity activity such as lifting a weight or opening and closing the hand with the arm abducted. Doppler and angiographic study showed significant compression of subclavian artery with hyperabduction and Adson manoeuver. Simple anterior scalenotomy was followed by prompt recovery of symptoms. The results of scalenotomy and other surgical approaches to thoracic outlet syndrome are reviewed in the literature. The most common anomalies of anterior scalene muscle in the TOS are also described. Doppler and arteriographic study in different functional positions are necessary in the evaluation of subclavian artery compression by osseous or muscular structures. In the reported case scalenotomy was at least as effective as 1st rib resection.
The thoracic outlet syndrome (TOS) is caused by compression of the brachial plexus or subclavian artery or vein in the region of the neck and shoulder girdle. The neurovascular bundle may be compressed at multiple sites: costoclavicular space, interscalene triangle, insertion of the pectoralis minor into the coracoid process. More than 90% of the patients present with neurologic symptoms: pain, paraesthesias or arm and hand weakness and 10% also have vascular problems. The diagnosis of TOS is always difficult and depends on careful clinical study of patients. For the neurological type of TOS, electromyograms, arteriograms and venograms are not helpful. The value of Doppler study and of arteriography is demonstrated in the present case of a woman with a five month history of pain and paraesthesias of the arm and hand, who shoved sudden occlusion of left humeral artery. Roentgenograms showed the presence of a well developed left cervical rib. Doppler study and arteriography showed the compression of subclavian artery with the arm abduction manoeuver. After first rib resection and humeral artery thrombectomy there was a complete return of humeral artery flow and of all neurologic functions. Thus the role of first cervical rib or other bone and muscular structures must be emphasyzed both in the brachial and in the subclavian artery or vein compression. Embolization of the axillary or humeral artery should be corrected as soon as possible when the cervical rib is corrected.
A series of 40 femoro-femoral by-pass grafts (FFBG) is presented; these operations were performed from 1978 to 1987 and the follow-up ranged between 6 and 36 months. The subjects were divided retrospectively into two groups, to evaluate the effect of prior iliofemoral reconstructive operations on the long-term patency of the FFBGs. Thirty-four patients (group A) had no previous surgery and 15 (group B) had 23 previous femoral surgical reconstructions. At operation, 34 recipient deep femoral arteries underwent adjunctive TEA (24 out of group A; 10 out of group B) as well as 9 donor limb deep femoral arteries (all out of group A). No donor limb steal phenomenon was recorded in both groups. FFBG occlusion occurred without any statistically significant differences in the groups (A 12%, B 20%) and only in one case a thigh amputation was needed (group B).
Postoperative changes of blood pressure in carotid artery surgery is frequently observed. The Authors, on the base of a review of the literature and examining their own experience related to a consecutive series of 40 cases verify the incidence of this event. Different modality in the onset of postoperative hypertension and hypotension are evaluated. The risks of neurological complications due to the acute hemodynamic modifications are considered.
Five patients suffering from subclavian artery false aneurysms underwent surgery in the last 6 years at the Institute of General and Cardiovascular Surgery University of Milan. The management was considerably different from the treatment of atherosclerotic lesions of this artery, because of the various nature of such traumatic lesion and the variable (stable or unstable) hemodynamic conditions of the patients. Arteriography was extremely useful in the evaluation of site and extension of pseudoaneurysms. When pseudoaneurysm was in the left side (in one case), supraclavicular incision and posterolateral thoracotomy were adopted to allow the control of both proximal and distal portion of subclavian artery. When the pseudoaneurysm was in the right side (in 3 cases) a median sternotomy with extension of the soft tissue incision into the right side of the neck provided the exposure of the proximal and distal right subclavian artery. In the last case, proximal infected false aneurysm (after right axillo-femoral bypass graft) was removed and substituted by contralateral axillo-bifemoral bypass.
Late thrombosis of inserted prosthetic grafts for arterial reconstructive surgery is one of the most frequent late complication. Its incidence is influenced by many factors: hemodynamic conditions, quality of run-in and run-off, technical aspects of the primary repair. Progressive arteriosclerosis in femoral vessels was the cause of graft limb thrombosis in most instances. When graft occlusion does occur, there is, in a majority of patients, an immediate return of ischemia which often is severe and redo-operation is indicated to restore circulation. A new angiogram is mandatory, especially for the recognition of the inflow to the central anastomosis and for the evaluation of the distal run-off. Several surgical techniques are in use for redo-operation (graft thrombectomy with or without graft prolongation, partial or total replacement of the prosthesis, reconstruction by an extra-anatomical by-pass). Very important is the role of the deep femoral artery: in patients with a multi-level occlusive disease a patent deep femoral artery most often provides an effective inflow repair with a combined use of profundaplasty and lumbar sympathectomy. In this report of 188 late thrombosis, in a twenty year experience, at the Department of General and Cardiovascular Surgery, University of Milan, we made a redo-operation in 83% of the cases, according our preference in surgical procedures, to the partial substitution of the prosthesis with large profundaplasty. An associated lumbar sympathectomy was performed in 25% of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)
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The descent of a cervical goiter below the plain of the thoracic inlet to become substernal in location, is fairly rare, but not exceptional, with an incidence, derived from several large series of operated patients, ranging from 1.7% to 13.1%. The importance of this particular location of the goiter is chiefly due to the fact that the thyroid is growing in a limited space with many surrounding structures, that unavoidably, sooner or later, will be compressed or strained. This provokes respiratory symptoms (such as cough, dyspnea, stridor) or difficulty in swallowing or determines a superior vena cava syndrome with venous stasis in the neck and in the upper thorax, and with facial oedema. The substernal location, that already constitutes a complication of the basic thyropathy, is further aggravated by the incidental malignant transformation of the substernal goiter or by the development of a thyrotoxicosis due to hyper-functioning intra-thoracic thyroid tissue. For all these reasons the presence of a substernal goiter represents in and of itself a precise indication for a surgical treatment. This study is aimed at examining the series of 19 substernal goiters observed at the Institution of General and Cardiovascular Surgery, University of Milan, from 1967 to 1987, particularly analyzing the progresses in the diagnostic procedures, the adopted surgical therapy and the observed complications.
The thyroid nodules represent the most frequent endocrinopathy, because clinically palpable nodules are detectable in 4-5% of the general population. Such pathological condition includes adenomas, carcinoma, intraglandular haematomas or cysts, focal thyroiditis, etc. Fine-needle aspiration cytology allows a correct diagnosis in about 90% of the cases, distinguishing focal thyroiditis from nodular goiter or thyroid malignancies. The new instrumental and cytological studies make the choice for surgical interventions more selective. At the Institution of General and Cardiovascular Surgery, University of Milan, 597 patients underwent surgery from 1966 to January 1988. The observed nodular (toxic or non toxic) thyropathies were 498 (83.4%). Cold nodules represented about a third (34%) of the nodular thyropathies. Thyroid carcinomas were 33 (5.6%). This study is aimed to analyze our surgical attitude with respect to nodular thyropathies, the surgical procedures adopted and the observed complications.
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Clinical employment of selective hypogastric arteriography has been instrumental in the detection of stenosing and obliterating lesions of the pudendal arteries and their penile branches capable of giving rise to impotentia erigendi as the sole symptom. Differentiation of psychogenic and vascular impotence is now possible through non-invasive instrumental examinations such as the nocturnal penile tumescence test, and Doppler ultrasonography of the penile arteries. Arteriography to clinch the diagnosis was only employed when a suspicion was aroused by these two examinations. An account is given of technique employed for selective hypogastric arteriography and the angiographic results obtained.