Search

Liver metastases that disappear after chemotherapy are called vanishing or disappearing liver metastases. These metastases represent a diagnostic and clinical challenge as their biological behaviour is hardly predictable and their treatment is not completely standardized. In this case report, we present an interesting solution to treat disappearing liver metastases using percutaneous microwave ablation and US/MRI fusion guidance employing pre-chemotherapy MRI as reference imaging.

Summary: NMDA receptor (NMDAR) subunit composition plays a pivotal role in synaptic plasticity at excitatory synapses. Still, the mechanisms responsible for the synaptic retention of NMDARs following induction of plasticity need to be fully elucidated. Rabphilin3A (Rph3A) is involved in the stabilization of NMDARs at synapses through the formation of a complex with GluN2A and PSD-95. Here we used different protocols to induce synaptic plasticity in the presence or absence of agents modulating Rph3A function. The use of Forskolin/Rolipram/Picrotoxin cocktail to induce chemical LTP led to synaptic accumulation of Rph3A and formation of synaptic GluN2A/Rph3A complex. Notably, Rph3A silencing or use of peptides interfering with the GluN2A/Rph3A complex blocked LTP induction. Moreover, in vivo disruption of GluN2A/Rph3A complex led to a profound alteration of spatial memory. Overall, our results demonstrate a molecular mechanism needed for NMDAR stabilization at synapses after plasticity induction and to trigger downstream signaling events necessary for cognitive behavior. : Molecular Interaction; Neuroscience; Molecular Neuroscience Subject Areas: Molecular Interaction, Neuroscience, Molecular Neuroscience

Early-life stress involved in the programming of stress-related illnesses can have a toxic influence on the functioning of the nigrostriatal motor system during aging. We examined the effects of perinatal stress (PRS) on the neurochemical, electrophysiological, histological, neuroimaging, and behavioral correlates of striatal motor function in adult (4 months of age) and old (21 months of age) male rats. Adult PRS offspring rats showed reduced dopamine (DA) release in the striatum associated with reductions in tyrosine hydroxylase-positive (TH+) cells and DA transporter (DAT) levels, with no loss of striatal dopaminergic terminals as assessed by positron emission tomography analysis with fluorine-18-l-dihydroxyphenylalanine. Striatal levels of DA and its metabolites were increased in PRS rats. In contrast, D2 DA receptor signaling was reduced and A2A adenosine receptor signaling was increased in the striatum of adult PRS rats. This indicated enhanced activity of the indirect pathway of the basal ganglia motor circuit. Adult PRS rats also showed poorer performance in the grip strength test and motor learning tasks. The aged PRS rats also showed a persistent reduction in striatal DA release and defective motor skills in the pasta matrix and ladder rung walking tests. In addition, the old rats showed large increases in the levels of SNAP-25 and synaptophysin, which are synaptic vesicle-related proteins in the striatum, and in the PRS group only, reductions in Syntaxin-1 and Rab3a protein levels were observed. Our findings indicated that the age-dependent threshold for motor dysfunction was lowered in PRS rats. This area of research is underdeveloped, and our study suggests that early-life stress can contribute to an increased understanding of how aging diseases are programmed in early-life.

Background: There is increasing recognition of a prothrombotic state in COVID-19. Post-mortem examination can provide important mechanistic insights. Methods: We present a COVID-19 autopsy series including findings in lungs, heart, kidneys, liver, and bone, from a New York academic medical center. Findings: In seven patients (four female), regardless of anticoagulation status, all autopsies demonstrated platelet-rich thrombi in the pulmonary, hepatic, renal, and cardiac microvasculature. Megakaryocytes were seen in higher than usual numbers in the lungs and heart. Two cases had thrombi in the large pulmonary arteries, where casts conformed to the anatomic location. Thrombi in the IVC were not found, but the deep leg veins were not dissected. Two cases had cardiac venous thrombosis with one case exhibiting septal myocardial infarction associated with intramyocardial venous thrombosis, without atherosclerosis. One case had focal acute lymphocyte-predominant inflammation in the myocardium with no virions found in cardiomyocytes. Otherwise, cardiac histopathological changes were limited to minimal epicardial inflammation (n = 1), early ischemic injury (n = 3), and mural fibrin thrombi (n = 2). Platelet-rich peri‑tubular fibrin microthrombi were a prominent renal feature. Acute tubular necrosis, and red blood cell and granular casts were seen in multiple cases. Significant glomerular pathology was notably absent. Numerous platelet-fibrin microthrombi were identified in hepatic sinusoids. All lungs exhibited diffuse alveolar damage (DAD) with a spectrum of exudative and proliferative phases including hyaline membranes, and pneumocyte hyperplasia, with viral inclusions in epithelial cells and macrophages. Three cases had superimposed acute bronchopneumonia, focally necrotizing. Interpretation: In this series of seven COVID-19 autopsies, thrombosis was a prominent feature in multiple organs, in some cases despite full anticoagulation and regardless of timing of the disease course, suggesting that thrombosis plays a role very early in the disease process. The finding of megakaryocytes and platelet-rich thrombi in the lungs, heart and kidneys suggests a role in thrombosis. Funding: None.

Deleterious mutations in the glutamate receptor metabotropic 1 gene (GRM1) cause a recessive form of cerebellar ataxia, SCAR13. GRM1 and GRM5 code for the metabotropic glutamate type 1 (mGlu1) and type 5 (mGlu5) receptors, respectively. Their different expression profiles suggest they could have distinct functional roles. In a previous study, homozygous mice lacking mGlu1 receptors (Grm1crv4/crv4) and exhibiting ataxia presented cerebellar overexpression of mGlu5 receptors, that was proposed to contribute to the mouse phenotype. To test this hypothesis, we here crossed Grm1crv4 and Grm5ko mice to generate double mutants (Grm1crv4/crv4Grm5ko/ko) lacking both mGlu1 and mGlu5 receptors. Double mutants and control mice were analyzed for spontaneous behavior and for motor activity by rotarod and footprint analyses. In the same mice, the release of glutamate from cerebellar nerve endings (synaptosomes) elicited by 12mM KCl or by α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) was also evaluated. Motor coordination resulted improved in double mutants when compared to Grm1crv4/crv4 mice. Furthermore, in in vitro studies, glutamate release elicited by both KCl depolarization and activation of AMPA autoreceptors resulted reduced in Grm1crv4/crv4 mice compared to wild type mice, while it presented normal levels in double mutants. Moreover, we found that Grm1crv4/crv4 mice showed reduced expression of GluA2/3 AMPA receptor subunits in cerebellar synaptosomes, while it resulted restored to wild type level in double mutants. To conclude, blocking of mGlu5 receptor reduced the dysregulation of glutamate transmission and improved motor coordination in the Grm1crv4 mouse model of SCAR13, thus suggesting the possible usefulness of pharmacological therapies based on modulation of mGlu5 receptor activity for the treatment of this type of ataxia.

Abstract: Gray zone lymphoma (GZL) is described as sharing features with classical Hodgkin lymphoma (cHL) and diffuse large B-cell lymphoma (DLBCL). However, there remains complexity in establishing diagnosis, delineating prognosis, and determining optimum therapy. Sixty-eight cases diagnosed as GZL across 15 North American academic centers were evaluated by central pathology review to achieve consensus. Of these, only 26 (38%) were confirmed as GZL. Morphology was critical to GZL consensus diagnosis (eg, tumor cell richness); immunohistochemistry showed universal B-cell derivation, frequent CD30 expression, and rare Epstein-Barr virus (EBV) positivity (CD20+, 83%; PAX5+, 100%; BCL6+, 20%; MUM1+, 100%; CD30+, 92%; EBV+, 4%). Forty-two cases were reclassified: nodular sclerosis (NS) cHL, n = 27 (including n = 10 NS grade 2); lymphocyte predominant HL, n = 4; DLBCL, n = 4; EBV+ DLBCL, n = 3; primary mediastinal large BCL n = 2; lymphocyte-rich cHL and BCL–not otherwise specified, n = 1 each. GZL consensus-confirmed vs reclassified cases, respectively, more often had mediastinal disease (69% vs 41%; P = .038) and less likely more than 1 extranodal site (0% vs 25%; P = .019). With a 44-month median follow-up, 3-year progression-free survival (PFS) and overall survival for patients with confirmed GZL were 39% and 95%, respectively, vs 58% and 85%, respectively, for reclassified cases (P = .19 and P = .15, respectively). Interestingly, NS grade 2 reclassified patients had similar PFS as GZL consensus-confirmed cases. For prognostication of GZL cases, hypoalbuminemia was a negative factor (3-year PFS, 12% vs 64%; P = .01), whereas frontline cyclophosphamide, doxorubicin, vincristine, and prednisone ± rituximab (CHOP±R) was associated with improved 3-year PFS (70% vs 20%; P = .03); both factors remained significant on multivariate analysis. Altogether, accurate diagnosis of GZL remains challenging, and improved therapeutic strategies are needed.

Voluntary termination of pregnancy (VTP), pre-conception and post-partum phases, as well as Occupational Medicine consultation for healthcare workers are opportunities for screening and vaccinating rubella seronegative childbearing women. However, data about vaccination acceptance following these phases is rarely reported.A retrospective study over a 2-year period (2016–2017) was performed, evaluating the prevalence of rubella seronegative women which underwent VTP (wVTP), mothers in early puerperal phase (mEPP) and childbearing healthcare workers (CbHW) aged 15–49 years. Anti-rubella vaccination rates and factors associated with vaccine hesitancy (VH) were investigated.Anti-rubella IgG titres were assessed in 8623 women. Seroprevalence of rubella susceptibility was 7.9% (wVTP 6.4%; mEPP 17.4%; CbHW 9.3%). Anti-rubella vaccination rates were found to be different in the three groups (wVTP 37.1%; mEPP 10.9%; CbHW 25.4%), specifically in 2016 and among women born in Italy. VH rate was higher in 2017, especially among wVTP and CbHW. Anti-rubella vaccination rates in wVTP vs. mEPP was higher in women born in Italy but not in those born abroad. Multivariable analyses demonstrated significantly higher risk of VH for mEPP (OR 8.2; 95% CI: 3.9–16.9) and women reporting history of allergy to drugs, food or environmental agents (OR 2.7; 95% CI: 1.4–5.1).During the analyzed period childbearing women included in this study were not adequately protected against rubella. Anti-rubella vaccination rates were widely unsatisfactory. Being mEPP and reporting allergy were significantly associated to higher rates of VH. Tailored strategies targeting on vaccine safety are needed for retention of these women in immunisation programmes. Keywords: Rubella, Congenital rubella syndrome, Vaccination

Induced pluripotent stem cell (iPSC)-based cell therapies have great potential for regenerative medicine but are also potentially associated with tumorigenic risks. Current rodent models are not optimal predictors of efficiency and safety for clinical application. Therefore, we developed a clinically relevant nonhuman primate model to assess the tumorigenic potential and in vivo efficacy of both undifferentiated and differentiated iPSCs in autologous settings without immunosuppression. Undifferentiated autologous iPSCs indeed form mature teratomas in a dose-dependent manner. However, tumor formation is accompanied by an inflammatory reaction. On the other hand, iPSC-derived mesodermal stromal-like cells form new bone in vivo without any evidence of teratoma formation. We therefore show in a large animal model that closely resembles human physiology that undifferentiated autologous iPSCs form teratomas, and that iPSC-derived progenitor cells can give rise to a functional tissue in vivo.

We recently demonstrated that low frequency, moderate intensity, explosive-type resistance training (EMRT) is highly beneficial in elderly subjects towards muscle strength and power, with a systemic adaptive response of anti-oxidant and stress-induced markers. In the present study, we aimed to evaluate the impact of EMRT on oxidative stress biomarkers induced in old people (70–75 years) by a single bout of acute, intense exercise. Sixteen subjects randomly assigned to either a control, not exercising group (n=8) or a trained group performing EMRT protocol for 12-weeks (n=8), were submitted to a graded maximal exercise stress test (GXT) at baseline and after the 12-weeks of EMRT protocol, with blood samples collected before, immediately after, 1 and 24 h post-GXT test. Blood glutathione (GSH, GSSG, GSH/GSSG), plasma malonaldehyde (MDA), protein carbonyls and creatine kinase (CK) levels, as well as PBMCs cellular damage (Comet assay, apoptosis) and stress–protein response (Hsp70 and Hsp27 expression) were evaluated. The use of multiple biomarkers allowed us to confirm that EMRT per se neither affected redox homeostasis nor induced any cellular and oxidative damage. Following the GXT, the EMRT group displayed a higher GSH/GSSG ratio and a less pronounced increase in MDA, protein carbonyls and CK levels compared to control group. Moreover, we found that Hsp70 and Hsp27 proteins were induced after GXT only in EMRT group, while any significant modification within 24 h was detected in untrained group. Apoptosis rates and DNA damage did not show any significant variation in relation to EMRT and/or GXT. In conclusion, the adherence to an EMRT protocol is able to induce a cellular adaptation allowing healthy elderly trained subjects to cope with the oxidative stress induced by an acute exercise more effectively than the aged-matched sedentary subjects.

HIV-1 associated neurocognitive disorders (HAND) are a major complication of HIV-1 infection. The mechanism(s) underlying HAND are not completely understood but, based on in vitro studies, the HIV-1 Tat protein may play an important role. In this study, the effect of prolonged exposure to endogenously produced Tat in the brain was investigated using a tat-transgenic (TT) mouse model constitutively expressing the HIV-1 tat gene. We found that stimulus-evoked glutamate exocytosis in the hippocampus and cortex was significantly increased in TT as compared with wild-type control (CC) mice, while GABA exocytosis was unchanged in the hippocampus and decreased in the cortex. This suggests that Tat generates a latent hyper-excitability state, which favors the detrimental effects of neurotoxic and/or excitotoxic agents. To challenge this idea, TT mice were tested for susceptibility to kainate-induced seizures and neurodegeneration, and found to exhibit significantly greater responses to the convulsant agent than CC mice. These results support the concept that constitutive expression of tat in the brain generates a latent excitatory state, which may increase the negative effects of damaging insults. These events may play a key role in the development of HAND.

Introducción. Los factores que influyen en la elección de una especialidad son la demanda laboral, la remuneración, el prestigio, el tiempo de formación y la posibilidad de tener un estilo de vida 'controlable'. Sin embargo, la influencia de la cultura podría modificar el peso de estas variables a la hora de elegir una especialidad. Objetivo. Analizar los factores que influían sobre la elección de la especialidad médica por parte de los estudiantes. Sujetos y métodos. Entre marzo y mayo de 2010 se encuestaron 125 estudiantes que cursaban quinto año o el internado. Por medio de una encuesta anónima se recogió información sobre los factores que podrían influir en la elección futura de la especialidad. Resultados. La pediatría fue la especialidad más elegida, pero se la consideró entre las menos lucrativas, con más tiempo de formación y prestigio moderado, aunque con una adecuada demanda laboral. La cirugía fue la segunda más elegida y considerada como la de mayor prestigio y mejor remunerada. La clínica médica requeriría más tiempo de formación, con más oportunidades laborales, pero peor remuneradas. Tanto la clínica médica como la cirugía se eligieron como las de estilo de vida menos 'controlable', hallándose en tercer lugar la pediatría. Conclusión. Las características de remuneración, prestigio, estilo de vida, tiempo de formación y demanda laboral, en general, parecen no haber influido significativamente en la elección de la especialidad.Introduction. Factors associated with medical students' specialty choice are work market opportunities, expected income, prestige, length of training and controllable life style possibility. However, cultural influence may modify the weight of these variables at time of choosing a specialty. Aim. To analyze the factors influencing on medical students' specialty preferences. Subjects and methods. From March to May of 2010, 125 medical students' from 5th and 6th year were surveyed. Information was collected by an anonymous questionnaire about factors influencing on a future specialty choice. Results. Opinions about which specialties were regarded as better remunerate, has most prestige, a controllable life style, need more length of training and/or has a good job market were obtained. Pediatrics was the most selected but it was considered one with the worst payment, with less length of training, moderate prestige, although an adequate job market. Surgery was the second choice and was regarded as the one with most prestige and best remuneration. On the other hand, internal medicine was considered to need more length of training, with better work opportunities, but worse remuneration. Internal medicine as well as surgery, is regarded as having the less controllable life style, being pediatrics on third place. Conclusion. The characteristics of income, prestige, life style, length of training and job market opportunities, in general seem to not significantly relate on specialty selection.

Introducción. Los factores que influyen en la elección de una especialidad son la demanda laboral, la remuneración, el prestigio, el tiempo de formación y la posibilidad de tener un estilo de vida 'controlable'. Sin embargo, la influencia de la cultura podría modificar el peso de estas variables a la hora de elegir una especialidad. Objetivo. Analizar los factores que influían sobre la elección de la especialidad médica por parte de los estudiantes. Sujetos y métodos. Entre marzo y mayo de 2010 se encuestaron 125 estudiantes que cursaban quinto año o el internado. Por medio de una encuesta anónima se recogió información sobre los factores que podrían influir en la elección futura de la especialidad. Resultados. La pediatría fue la especialidad más elegida, pero se la consideró entre las menos lucrativas, con más tiempo de formación y prestigio moderado, aunque con una adecuada demanda laboral. La cirugía fue la segunda más elegida y considerada como la de mayor prestigio y mejor remunerada. La clínica médica requeriría más tiempo de formación, con más oportunidades laborales, pero peor remuneradas. Tanto la clínica médica como la cirugía se eligieron como las de estilo de vida menos 'controlable', hallándose en tercer lugar la pediatría. Conclusión. Las características de remuneración, prestigio, estilo de vida, tiempo de formación y demanda laboral, en general, parecen no haber influido significativamente en la elección de la especialidad.

Objectives: To evaluate the effect of phlebectomy on venous reflux and diameter of the great saphenous vein (GSV)., Design: Prospective cohort study., Method: Patients presenting with reflux in the GSV resulting in varicose veins were included in this series. Patients were treated by phlebectomy for dilated and incompetent tributaries of the GSV with conservation of the incompetent GSV. We measured reflux duration (RD), peak reflux velocity (PRV) and the diameter of the GSV using duplex ultrasound imaging at inclusion and 1 month after surgery., Patients: We included 55 limbs in 54 patients (30 women and 24 men) aged from 37 to 83 (mean age 63) years., Results: Following treatment we observed a significant reduction of the mean RD (0.81 s vs. 1.5 s p < 0.01, t-test), mean PRV (120 mm s(-1) vs. 249 mm s(-1)p < 0.01, t-test) and mean diameter of the GSV (SFJ = 5.6 mm vs. 6.7 mm, p < 0.01, sub-terminal valve 4.8 mm vs. 4.4 mm p < 0.05, mid-thigh 5.0 mm vs. 4.2 mm, p < 0.01, knee 4.0 mm vs. 5.3 mm p < 0.01, mid-calf 2.7 mm vs. 4.0 mm, p < 0.01, t-test)., Conclusions: We noted reduced reflux in the GSV after phlebectomy with a significant reduction in RD and PRV. Phlebectomy also led to a significant reduction in GSV diameter. These data suggest that the haemodynamics and the diameter of the SV can be improved by using a treatment focussing on the saphenous tributaries., (Copyright 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Surgical treatment for varicose recurrence (STVR) involves removing all sources of reflux from the deep venous network to the superficial venous network. STVR is usually more complex and aggressive than first-line treatment by stripping, particularly for redo surgery at the groin (RSG). This retrospective study compared traditional STVR and a less aggressive surgical approach focusing on treatment of the varicose reservoir and avoiding RSG if possible., Method: Two successive periods of STVR after great saphenous vein stripping were compared: traditional STVR (T1) and STVR focusing on the varicose reservoir (T2). We reviewed postoperative complications and studied the hemodynamic and clinical results., Results: During T1 and T2, we operated 473 legs in 288 patients (236 women, 52 men) to treat varicose recurrence after great saphenous vein stripping. Mean age was 60.83 years (range, 28-88 years). We operated on 137 patients during T1 and 151 during T2. Patients had similar demographic data, CEAP classification, and Venous Disability Score. Inguinal reflux occurred in 73.9% of T1 patients and in 74.4% of T2 patients. We performed RSG in 66.0% of T1 patients and in 2.2% of T2 patients (P < .05). We did not use echo-guided sclerotherapy in addition to primary STVR. Tumescent local anesthesia was used in 96.2% of STVR in T2 vs 4.0% in T1 (P < .05), and 95.3% of T2 procedures were outpatient vs 13.7% of T1 (P < .05). Outcomes of limbs presenting an inguinal reflux treated with RSG during T1 (group 1) and without RSG during T2 (group 2) were compared. Postoperative complications occurred in 6.7% in group 1 vs 0.5% in group 2 (P < .05), with inguinal complications predominating. The mean cost of the procedure per limb was euro1,195.88 in group 1 vs euro863.08 in group 2 (P < .0001). After 3 years of follow-up, Kaplan-Meier life-table analysis showed group 1 and 2 patients had similar rates of freedom from inguinal reflux (90.8% vs 92.9% survival rate) and from varicose repeat-recurrence (90.8% vs 91.9% survival rate). Group 1 had better results for the Venous Disability Score (0.38 vs 0.58, P = .02) and cosmetic improvement (94.2% vs 84.2%; P = .00032)., Conclusion: STVR focusing on the varicose reservoir and avoiding RSG led to a minimally invasive procedure and a reduction in postoperative complications, with good medium-term clinical and hemodynamic results, particularly for symptoms improvement and cosmetic appearance, with a lower cost vs traditional STVR with RSG., (Copyright (c) 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: A new physiopathologic concept within superficial venous insufficiency (SVI) describes ascending progression from the collaterals to the saphenous veins (SV), leading to a treatment that aims to remove the varicose reservoir and not the SVs. This study reports the midterm results of this therapeutic approach., Methods: This is a retrospective study of patients treated for varices by phlebectomy with conservation of a refluxing SV before July 2004. We evaluated the varicose reservoir by determining the number of zones to be treated (NZT); each lower limb was divided into 32 zones in the preoperative mapping. We performed a clinical and duplex ultrasound examination after 6 months and 1 year, and then once a year until year 4., Results: Amongst 811 lower limbs operated on for first-time varicose veins, 303 in 221 patients (55 men; 166 women), mean age, 52.7 years (range, 20-93 years), were treated by phlebectomy, with conservation of a refluxing SV. All lower limbs operated on presented preoperative SV reflux >0.5 seconds: great SV (GSV), 85.8%; small SV (SSV), 11.9%; and GSV and SSV, 2.3%. The average NZT was 6.05 (range, 2-10). SV reflux was reduced to < 0.5 seconds in 69.6%, 69.2%, 68.7%, 68.0%, and 66.3% of limbs, respectively, after 6 months, 1, 2, 3, and 4 years of follow-up. Symptoms improved or disappeared in 84.2%, 84.2%, 83.4%, 81.4%, and 78.0% of limbs at each annual check-up until year 4. Freedom of varices recurrence was 95.5%, 94.6%, 91.5%, and 88.5%, respectively at 1, 2, 3, and 4 years. When the NZT was >7, the postoperative varicose recurrence was more frequent (odds ratio, 6.82; P = .0001), and the postoperative elimination of SV reflux was more frequent (odds ratio, 4; P = .037) as was symptoms improvement (odds ratio, 2.91; P = .004). When an ostiotruncal SV reflux extended to the malleolus preoperatively, the elimination of the SV reflux was less frequent (47.6% vs 70.3%; P < .05)., Conclusion: Ablation of the varicose reservoir with conservation of a refluxing SV can be an effective treatment in the midterm for the signs and symptoms of SVI and leads to nonsignificant SV reflux in more than two of three cases. The extent of the varicose reservoir ablation is the key factor determining the hemodynamic and clinical efficacy of this more limited surgical approach.

Background: Radiofrequency and laser vein treatment, which entail preservation of the saphenous confluence, have called into question the dogma of ligation of all tributaries at the sapheno-femoral confluence (SFC), so called "crossectomy". Nevertheless, crossectomy is still done when saphenous vein stripping is chosen for varicose vein treatment. The purpose of this study was to evaluate results after stripping procedures in which the SFC was preserved., Methods: This was a retrospective cohort study for which limbs treated for varicose veins by surgical stripping of the great saphenous vein and preservation of the SFC were studied. All limbs had a preoperative duplex examination and showed SFC and truncal incompetence of the great saphenous vein. Periodic postoperative standing duplex ultrasound and clinical examinations were carried out, and results were recorded and analyzed retrospectively., Results: A total of 195 lower limbs were operated on in 151 patients (128 women and 25 men) aged from 22 to 88 years (mean age 56.8). The preoperative diameter of the SFC ranged from 4.7 to 17 mm (mean 9.5 mm). The preoperative CEAP class distribution was C1 1.5%, C2 82.1%, C3 6.7%, and C4-C6 9.7%. Preoperative symptoms were present in 61.8% of cases. Postoperative thrombosis of the SFC was observed in one case with an extension to the deep femoral vein and pulmonary embolization at 1 month. Recovery was complete. At a mean of 24.4 months postoperatively (median 27.3 months, range 8 to 34.8), persistent SFC reflux was observed in only two cases (1.8%) and a SFC neovascularization in one case (0.9%). Recurrence of varicose veins appeared in seven cases (6.3%) but in conjunction with SFC reflux in only one case. Post treatment 83.9% of limbs were converted to CEAP clinical class 0 to 1 and significant symptom improvement was observed in 91.3% of cases with an aesthetic benefit in 95.5%., Conclusion: Preservation of the SFC during saphenous stripping gave good results with regard to hemodynamics and neovascularization on the SFC, varicose vein recurrence, improvement of symptoms, and aesthetic appearance for legs with a median follow-up of 27.3 months.

This report describes a case of ruptured internal iliac artery aneurysm into the bladder after repair of an infrarenal abdominal aortic aneurysm. Aortic repair consisted of resection of the aneurysm followed by prosthetic interposition to reestablish arterial continuity. During the postoperative period, the patient had ischemia of left colon, which was successfully treated by the Hartmann procedure. A right internal iliac artery aneurysm measuring 50 mm in diameter was demonstrated by an abdominal CT scan during the initial hospitalization but was considered stable, since ultrasonography showed no change in diameter at 3 months and 1 year. The patient was lost from follow-up until 3 years later when he was hospitalized after rupture of the right iliac artery aneurysm, then measuring 120 mm in diameter, into the bladder. Surgical repair was undertaken. The procedure involved aortobifemoral bypass with suture of the bladder defect and branches of the internal iliac artery by the endoaneurysmal route. Postoperative recovery was uneventful. Upon reexamination 1 month after discharge from the hospital, the patient was asymptomatic. This rare case confirms the gravity of internal iliac artery aneurysm and the importance of therapeutic management to prevent rupture.

We retrospectively reviewed perioperative cardiac complications in a series of 214 patients who underwent surgical treatment for infrarenal aortic aneurysm between 1992 and 1996. There were 192 men and 22 women, with a mean age of 68.3 years. Cardiac risk factors included angina in 28% of patients and previous myocardial infarction in 25%. Resting electrocardiography was normal in 80 patients (37.5%). Depending on clinical findings, thallium-201 scintigraphy was undertaken in 76 patients (35.5%) and led to elective coronary arteriography in 22 patients (10%). Results of coronary arteriography revealed lesions in 14 patients. Aortic reconstruction was performed by the transperitoneal route in all patients. Procedures consisted of aortoaortic bypass (63%), aortobiiliac bypass (27.5%), or aortobifemoral bypass (9.5%). Nine patients (4.2%) died within the first 30 postoperative days. The cause of death was myocardial infarction (MI) in two patients (1%), colonic necrosis in two (1%), acute pancreatitis in one (0.5%), acute renal insufficiency in three (1.4%), and multiple organ failure in one patient (0.5%). Nonfatal cardiac complications were observed in 15 patients (7%). Statistical analysis of risk factors revealed two predictors of perioperative cardiac complications, i.e., history of chronic bronchitis and reoperation. On review of the literature, we cannot propose a routine preoperative work-up. Prospective multicentric studies are needed to determine the predictive value of current preoperative screening methods.

Objectives: This study was undertaken to determine the late survival of patients operated successfully for abdominal aortic aneurysm (AAA) repair, to compare survival data with that of the age- and sex-matched general population, to identify the causes of late death, and to determine the factors influencing late survival., Materials and Methods: A total of 187 consecutive patients underwent elective surgical AAA repair between January 1987 and December 1991. There were 11 postoperative deaths (early mortality rate 5.9%). The remaining 176 patients formed the basis of this cohort-based retrospective study. Six patients (3.4%) were lost to follow-up. Mean follow-up was 71 months., Results: A total of 70 patients (39.8%) died during the study period. Coronary artery disease (CAD) and cancer were the two main causes. The survival rate at five years (71.6%) was lower than that of the sex- and age-matched general population (90.6%). Neither arterial hypertension nor CAD had any influence on late survival. In contrast, age and chronic renal failure were predictive variables of late survival., Conclusions: The life expectancy of patients who undergo successful AAA repair is not as good as that of the age- and sex-matched general population. Late survival depends on the patients' age at the time of surgery and the existence of preoperative chronic renal failure.

The occurrence of aortoiliac lesions with renal transplantation is an increasingly common combination that causes problems regarding operative strategy and indications for aortoiliac reconstruction and renal transplantation. To gain greater insight into these problems we undertook a retrospective multicenter study based on data from 24 kidney transplantation centers in France. A total of 83 patients who underwent both aortoiliac reconstruction and kidney transplantation were enrolled. Patients were divided into two groups according to the order in which the two procedures were performed. Group I included 36 patients in whom aortoiliac reconstruction was performed before kidney transplantation-either during the same procedure (6 patients) or as separate procedures (30 patients). Group II included 47 patients in whom aortoiliac reconstruction was performed after kidney transplantation. The mean age was 49.9 years. There were 43 abdominal aortic aneurysms (51.8%), 36 occlusive aortoiliac lesions (43.4%), and 4 aortoiliac dissections (4.8%). Prosthetic bypass grafting was performed in 72 cases (86.8%), transluminal angioplasty in 6 cases (7.2%), endarterectomy in 3 cases (3.6%), and arterial autograft bypass in 1 case. Renal transplant protection was used during aortoiliac clamping in only 3 patients in group II (7.3%). One month after the second procedure (i.e., kidney transplantation in group I and aortoiliac reconstruction in group II), creatinemia was <200 micromol/L in 27 patients (87.1%) in group I and in 37 patients (88.1%) in group II. The graft survival rate was 86.1% in group I and 89.3% in group II. The overall postoperative morbidity rate was 36.1% (13 cases) in group I and 36.1% (17 cases) in group II. One year after the second procedure creatinemia was <200 micromol/L in 29 patients (93.5%) in group I and 36 patients (93%) in group II. The graft survival rate was 86.1% in group I and 85.1% in group II. The outcome of kidney transplantation is comparable regardless of whether the procedure is performed alone or in association with aortoiliac reconstruction. This finding indicates that kidney transplantation should be performed in patients presenting indications for prior aortoiliac reconstruction. The outcome of aortoiliac reconstruction without graft protection in kidney transplant patients is comparable to the outcome of conventional aortoiliac reconstruction in patients with native kidneys.

In 1995, a total of 1785 patients underwent elective aortoiliac surgery at 35 centers in France, including 1024 for abdominal aortic aneurysm (57.4%) and 761 for occlusive aortoiliac lesions (42.6%). Direct revascularization of the internal iliac artery was performed in 11.2% of patients with both distal anastomoses located below the iliac bifurcations (18.4% with aneurysm vs. 6.8% with occlusive lesions, p < 0.001). Associated revascularization of the inferior mesenteric artery was performed in 9% of patients (11.5% with aneurysms vs. 5.5% with occlusive lesions, p < 0.001). Postoperative colonic ischemia was observed in 21 patients (1.2%) (1.2% with aneurysms vs. 1.2% with occlusive lesions) and claudication in the gluteal region was observed in 31 patients (1.7%) (1.5% with aneurysms vs. 2.1% with occlusive lesions). Revascularization of the internal iliac artery, regardless of the technique, had no significant effect on the incidence of postoperative colonic ischemia and claudication in the gluteal region-neither after surgery for aneurysm (0.6% vs. 2.1% and 1.2% vs. 1.9%, respectively) nor after surgery for occlusive lesions (0.9% vs. 0.4% and 1.5% vs. 2.6%, respectively). Whether performed routinely or not, revascularization of the mesenteric artery has no significant effect on the incidence of postoperative colonic ischemia (1.1% vs. 1.3%).

The purpose of this retrospective study was to determine the indications and efficacy of direct revascularization of the internal iliac arteries during aortoiliac reconstruction in the prevention of postoperative colonic and pelvic ischemia. This study included 540 patients who underwent aortoiliac reconstruction between January 1987 and December 1996 for nonruptured abdominal aortic aneurysm in 341 cases (63%) and occlusive aortoiliac disease in 199 cases (37%). Mean age was 67.4 years. A tubular aortic prosthetic graft was used in 36 patients and a bifurcated prosthetic graft in the remaining 504 patients. Direct revascularization of the internal iliac artery was performed 102 times in 85 patients (72 with aortic aneurysms and 13 with occlusive aortoiliac disease). The indication for direct revascularization was absence of adequate retrograde flow in 54 cases (53%), absence of anterograde flow in 19 cases (19%), and aneurysmal involvement of the origin of one internal iliac artery in 29 cases (28%). Concomitant revascularization of the inferior mesenteric artery was performed in 14 cases (2.5%). Twenty-two patients (4.1%) died during the immediate postoperative period and two (0.4%) presented nonfatal colonic ischemia. Fatal pelvic ischemia occurred in one patient following treatment of an aortoiliac aneurysm with retrograde revascularization of the internal iliac artery. Postoperative rest pain due to buttock ischemia was observed in three patients (0.6%) in whom direct revascularization of the internal iliac artery was not performed. In the subgroup of patients who underwent direct revascularization of the internal iliac artery, there were 3 deaths (3.5%), 13 nonfatal complications (15.3%), and no colonic ischemia. In this series direct revascularization of the internal iliac artery was performed in a high proportion of cases (15.7%) and did not increase the postoperative morbidity/mortality rate. The incidence of postoperative colonic and pelvic ischemia was low (0.6%). Direct revascularization of the internal iliac artery in selected patients appears to be effective in the prevention of postoperative pelvic and colonic ischemia.