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Primary aortoduodenal fistula is a serious and rare complication of abdominal aortic aneurysms. This life-threatening disease results most commonly from an abdominal aortic aneurysm, with the fistula forming between the aorta and the third or the fourth portions of the duodenum. Diagnosis is often difficult and urgent adequate surgical treatment as soon as possible is the only therapeutic option to save the lives of these patients. In this paper we report the case of a 76-year-old female admitted to our institution for massive haematemesis, melaena, severe hypotension and violent back pain. The urgent diagnostic work-up revealed an abdominal aortic aneurysm with a strong suspicion of duodenal fistulisation. The diagnosis was confirmed in the operating room, where the patient was immediately submitted to closure of the fistula and in situ aortic reconstruction using an aortic homograft. The postoperative course was uneventful and after 6 months the patient is doing well without any recurrence of infection.

The association between abdominal aortic aneurysms (AAA) and cancer is becoming more and more frequent, giving rise to several questions regarding the therapeutic and surgical management strategies for both diseases. Endovascular aneurysm repair (EVAR) is the treatment of choice for complex and high-risk patients. In this study we reviewed our experience with patients concomitantly affected by any type of cancer and AAA treated by EVAR at our institution over the last six years. From April 2001 to July 2007, 497 AAA patients underwent open or endografting repair in the 1st Division of General Surgery--Service of Vascular Surgery of the University of Verona. In 53 cases (10.6%) an association with a solid neoplasm was found and 27 of these patients (50.9%) were treated by EVAR. Twenty patients underwent a two-stage approach, with EVAR performed first, while in 5 cases a one-stage approach was preferred on the basis of the general condition of the patients, the site of the tumour to be resected, the logistic possibilities and increased experience of the operators with EVAR. Two patients received chemotherapy after EVAR. There was no in-hospital mortality and four perioperative complications (14.8%) were registered. During a mean follow-up of 25.7 months (range: 2-64 months) 5 deaths occurred, 2 in the short term and 3 in the long term, none of which were related to AAA treatment. Three type-2 endoleaks occurred that sealed spontaneously and 62.9% of the treated aneurysms had a mean 20% decrease in diameter while the others presented no variations. In our experience, EVAR was a safe and effective treatment of AAA patients with concomitant malignancies with a relatively low procedure-related morbidity and no mortality. A simultaneous surgical approach can be achieved safely, performing EVAR as the first step without significant risks. Simultaneous treatment has the advantage of avoiding a second major procedure and eliminates the risk of aortic aneurysm rupture in the postoperative period or during chemotherapy in patients who are usually in poor general condition. Care must be taken with regard to the choice of the device to be used and the possible vascular complications of the visceral circulation. In our opinion, EVAR should be considered the treatment of choice in these patients, taking into account, however, that this treatment is not always feasible in all cases and that in patients with a normal life-expectancy (tumour-cured) it may not always be the right choice. Thus, a multidisciplinary approach is necessary in the individual evaluation of these challenging patients in order to make the right decisions.

Humeral neck fracture is rarely associated with injury of the nearby axillary artery and in the English literature only 29 such cases have been reported. An injury of the distal axillary artery secondary to reduction and fixation of a humeral neck fracture is a very rare and unusual complication, to the best of our knowledge has never been reported in literature. In this paper we report the case of entrapment of the distal axillary artery in the humerus rhyme fracture in a 9-year-old child who suffered a nighttime car-accident with her father. At admission, the child presented a left humeral neck fracture with no other lesions and no neurologic problems in her limb; peripheral pulses present in her left hand at palpation. After closed reduction and pinning of the fracture with 2 K-wires, the left upper limb became ischemic and pulseless and the child was transferred at our Institution for diagnosis and treatment. In this paper we discuss the treatment to be adopted in this very unusual situation.

Treatment of femoral artery pseudoaneurysms includes US-guided compression, endovascular coil embolisation or stenting, thrombin injection and open surgical repair. Thrombin injection is currently the standard approach to all non-complicated pseudoaneurysms of the peripheral arteries. Between January 2001 and December 2004, 59 pseudoaneurysms of the femoral artery were submitted to percutaneous US-guided thrombin injection in our surgery division. Complicated pseudoaneurysms, patients in whom percutaneous treatment failed, and chronic pseudoaneurysms with large necks were excluded from this kind of treatment and underwent surgical repair. Eighteen patients were on therapeutic anticoagulation (30.5%) and none of the pseudoaneurysms had an associated arteriovenous fistula. All patients were submitted to clinical and ultrasound follow-up at 24 hours and at 1, 6 and 12 months, and thereafter at yearly intervals for evaluation of recurrences. The thrombin injection was successful in 57/59 patients (96.6%) while two patients (3.4%) were submitted to surgical treatment after failure of the procedure. In 1 patient (1.7%) an additional injection was necessary to achieve complete thrombosis of the pseudoaneurysm. No complications occurred; none of the patients reported discomfort and there was no request for sedation. No recurrences were seen at follow-up. Nowadays US-guided percutaneous thrombin injection is the treatment of choice for femoral artery pseudoaneurysms. Surgical treatment is reserved to rare selected cases. More studies are necessary to evaluate further indications for treatment of visceral or small distal artery pseudoaneurysms.

At present, the standard management of subclavian artery aneurysms is surgical repair. Endovascular treatment of these aneurysms with implantation of a covered stent graft is a relatively new technique that appears to be both feasible and safe. We present the case of a large true aneurysm of the left intrathoracic subclavian artery that was successfully treated with two stent grafts on March 2001. A one-year follow-up CT scan revealed a type 1 secondary endoleak that was successfully treated with a third stent graft. The patient was closely monitored with CT scans that 32 months later confirmed both the patency of the graft and the complete exclusion of the aneurysm, which had decreased in size. At this moment, this is the only case reported in the literature with such a long follow-up but further long-term clinical results will be necessary to fully define the effectiveness of this technique.

Acute cholecystitis is one of the most frequent causes of admissions to surgical departments. The development of liver abscesses is an uncommon and underrated complication of acute cholecystitis. In this study we report on our experience with the treatment of 5 cases of liver abscesses secondary to acute cholecystitis. All 5 cases were characterised by a lengthy period between the onset of acute cholecystitis symptoms and the subsequent diagnosis of a secondary liver abscess. In 4 out of 5 patients, admission for liver abscess occurred 12, 30, 50 and 120 days, respectively, after the acute cholecystitis episode. The liver abscesses were successfully treated with percutaneous drainage under US guidance (4 cases) and 4 patients underwent percutaneous cholecystostomy to treat the acute cholecystitis. After resolution of the acute phase, an elective cholecystectomy was performed in 4 out of 5 cases. Failure to diagnose acute cholecystitis at onset or inappropriate treatment of the condition could lead to the development of liver abscesses.