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The traditional criterion of maximum transverse diameter is not sufficient to differentiate the small abdominal aortic aneurysms (AAAs) that are either prone to rupture or prone to enlarge rapidly. Wall stress may be a more reliable indicator with respect to these tasks. We review the importance of geometric features in rupture- or growth-predictive models and stress the need for further evaluation and validation of geometric indices. This study may lead to identifying those small AAAs that could justify early endovascular intervention.

Aneurysms of thoracic veins are rare lesions and their therapeutic management is not clearly determined. We present a 60-year old man with an asymptomatic right innominate vein aneurysm. The patient had been operated on 10 years ago for coronary artery bypass and was under antiplatelet treatment. In a retrospective inspection of his chest X-rays, we found that the aneurysm had been existent for at least 10 years. We suggested conservative treatment and over a 5-year follow-up, the patient has remained asymptomatic. Our patient is alive 15 years with thoracic vein aneurysm and antiplatelet treatment.

Background: Primary soft tissue reconstruction in complex leg injuries is mandatory in order to protect exposed tissues; however, it may be precluded by the patient's clinical status or by local wound conditions. This retrospective study aims to evaluate the use of negative pressure as an adjunct to delayed soft tissue reconstruction in patients with complex lower limb trauma., Material and Methods: Forty-two patients with 49 complex lower limb injuries were treated with Vacuum assisted closure (VAC) 48 hours after bone fixation, vascular repair and surgical debridement. Wound swab cultures were obtained before and after every VAC application. Duration of therapy, wound flora, final reconstructive technique required, outcome and follow-up period were retrieved from medical records., Results: Twenty-four male and eighteen female patients were recruited, with a mean age of 47 years. All were treated with VAC therapy for 15-42 days. Reconstruction was delayed due to the patients' critical condition, advanced age, medical co-morbidities, heavily exuding wounds and questionable viability of soft tissues. Patients were followed up for 90-895 days. Two wounds healed spontaneously, 6 were managed with delayed direct suture, 31 with split thickness skin grafts and 9 required local cutaneous, fasciocutaneous or muscular flaps. One patient died due to fat embolism. Wound bacterial flora progressively decreased in all but one patient. Scar formation was aesthetically acceptable by the patients while function depended on the initial injury., Conclusions: Negative pressure is a safe and effective adjunct to delayed soft tissue reconstruction in high-risk patients with severe lower extremity injuries, minimizing reconstructive requirements and therefore postoperative morbidity.

This case presentation focuses on the hemodynamic alterations due to acute clamping of superior vena cava (SVC) during a right pneumonectomy for lung cancer and on the alternatives for drug administration. In a 71-yr-old female patient without clinical manifestations of SVC syndrome, this large vein was clamped for 22 minutes for patch placement after sudden and unpredictable hemorrhage. The patient became acutely cyanotic and edematous in the face and upper extremities, arterial blood pressure dropped and the venous pressure in the right internal jugular vein was elevated. Drugs for managing the patient were given endobronchially and via an established right atrium line. Postoperatively, no neurologic deficit was noted. This case demonstrates the difficulties for managing patients without superior vena cava syndrome in which acute, non-programmed intra-operative SVC clamping is performed, as this is followed by systemic and brain hemodynamic deteriorations that may lead to bad outcome.

Study Objective: To assess bispectral index (BIS) monitoring on decision making during cardiac surgery with cardiopulmonary bypass (CPB) by measuring the number of preset standardized comments with and without knowing the BIS value and by classifying the interventions following the BIS data., Design: Prospective, randomized study., Setting: University Hospital., Patients: One hundred twenty-one patients scheduled for elective cardiac surgery (89 coronary patients, 24 valve replacement patients, and 8 valve replacement and coronary surgery)., Interventions: Patients were divided into 3 groups. An observing anesthesiologist recorded on a special form ("parallel" anesthesia record) data from the devices of the workstation and the BIS monitor. Conditions in which BIS monitoring was subjectively considered that might have been useful in anesthetic decision making were recorded as "events." In group A (36 patients), the responsible anesthesiologist had continuous access to BIS information. In group B (44 patients), intraoperative anesthetic management was "blinded" to BIS values, whereas in group C (41 patients), the anesthesiologist observing the BIS monitor was free to inform the attending anesthesiologist about the BIS score. The number of events was considered as negatively reflecting the quality of the clinical course of a patient. The reduction of events was considered as improvement in decision making. All patients received the same anesthetic regimen (propofol + remifentanil). Monitoring was equal in all cases. Mild hypothermic CPB was applied in 73 patients. Statistical analysis used 1-way analysis of variance, Student 2-tailed t test, and chi2 analysis., Main Results: Patient demographic data, underlying pathology, operation performed, hypothermia application, times of anesthesia, duration of operation, and CPB were similar in the 3 groups. In group B, the BIS value was considered by the observer as useful to know in 220 events (5.00 +/- 1.58 per patient). In group C, the BIS value was considered by the observer as useful to know in 143 events (3.49 +/- 1.31 per patient, P < 0.001) and, at the same time, the attending anesthesiologist was informed about BIS. In 112 (78.3%) cases, measures were taken. Titration of anesthetic drugs was done in 79 (70.5%) patients, whereas titration of vasoactive drugs was done in 9 (8.0%) patients, titration of both in 13 (11.6%) patients, and other diagnostic or corrective actions in 11 (9.8%) patients. Distributions of BIS values did not differ statistically (39.19 +/- 10.32, 37.38 +/- 10.21, and 38.29 +/- 10.01 in group A, group B, and group C, respectively). "Zenith" and "nadir" BIS values after induction also did not differ statistically. Awakening and extubation times were similar in both groups., Conclusions: Subjectivity, although reduced as much as possible, can play a confining role in the value of our results. The usefulness of BIS monitoring is shown by the fact that BIS data resulted in corrective measures. Attending anesthesiologist's actions, based on BIS information, reduced the events in group C.

A case of a false femoral aneurysm in a young man is reported. The diagnosis was made by MRA and was confirmed by conventional arteriography. MRA was found to be superior to angiography in demonstrating the exact size of the aneurysm. No MRA image of a false aneurysm of the lower extremities has been, to our knowledge, previously reported.

During a 5 year period, 1417 patients with various types of hip fractures were surgically treated. Three cases of iatrogenic arterial injuries occurred during the correction procedures, giving an incidence of 0.21%. In 2 patients the profunda femoral and in one the common femoral artery were involved. The mechanisms of injury were: a protruding screw, beyond the medial border of the femur in the first patient, arterial tear, due to bone speculae in the second and external pressure to the artery from an avulsed lesser trochanter in the third. The clinical findings were false aneurysms in two and distal ischaemia in the third patient. All patients were surgically treated. Early diagnosis of this type of injuries is the cornerstone for a good outcome.

Chronic bilateral ICA occlusion was found in 15 of 3200 patients studied with duplex scanning during a six years period. Ten of these patients had a history of stroke. Mean follow-up was 28.9 months. Six patients died during follow-up, coexisting cardiac ischaemia being the major cause of death. Two patients suffered a stroke (one fatal) resulting in an annual stroke rate of 5.5%, three patients continued to have TIAs and 5 remained asymptomatic. Chronic bilateral ICA occlusion is not always associated with neurological deficit. Coronary ischaemia, more than stroke is the leading cause of death in these patients.

We present a rare case of malignant embolization of the brachial artery from a primary pulmonary tumor. The arterial embolism was the initial event in the clinical course of the disease. A review of the literature revealed forty three cases of malignant peripheral arterial embolism reported, and only two similar cases in which the embolization was the initial event of the disease.

Vasoactive intestinal polypeptide (VIP)-containing nerves were depleted in the penises of 28 impotent men. The extent of the decrease in VIP-containing nerves broadly reflected the severity of erectile dysfunction. VIP-immunoreactive nerves were most depleted in those men with complete erectile impotence, irrespective of the aetiology of the dysfunction, whereas in those men in whom some erectile function persisted, loss of VIP-immunoreactive nerves was more variable and less complete. Conventional histology demonstrated only mild changes (muscle atrophy and occasional thickening of blood vessel walls). VIP levels, measured by radioimmunoassay of tissue extracts, were depleted by more than 80% in penises from impotent diabetics (43.4 +/- 9.9 pmol/g wet weight [mean +/- SEM]), when compared with 6 controls (189.9 +/- 45.9 pmol/g). These findings not only support the contention that VIP may be the principal neurotransmitter involved in penile erection, but also suggest that depletion of this powerful vasodilatory peptide may play a key role in the development of penile impotence.