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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.

Purpose: In order to assess the current knowledge of carotid angioplasty and stenting, we reviewed the pertinent literature distinguishing two types of reports on angioplasty for atherosclerotic stenosis of the internal carotid artery: case reports and series with less than 10 cases, and series reporting more than 10 cases., Methods: Each series was examined individually followed by a general analysis., Results: The 11 largest series in the literature included a total of 912 patients. The rate of transient ischemic attacks ranged from 6 to 14.8%. Stroke rate varied from 1.5 to 9.1%. Restenosis was reported in 4 to 16% of cases., Conclusion: Based on the data available in the literature, we cannot recommend carotid angioplasty. Carotid endarterectomy is recognised as safe and is generally considered to be the gold standard. In order to assess carotid angioplasty and stenting accurately, prospective randomized studies comparing surgery and angioplasty are necessary.

Objective: To determine the mechanism and the severity of injuries caused by power-driven cultivators., Methods: This retrospective study analyzed the clinical records of 20 patients treated from 1984 to 1996 for a total of 23 lower limb injuries caused by power-driven cultivators (three patients had bilateral injuries) in the Nice University Hospital., Results: A total of 90% of the accidents occurred when the machine was put into reverse and the limb was caught by the rotary blades; the cause of the remaining accidents was unknown. Of the 23 patients, 10 patients (43.5%) suffered posterior dislocation of the knee due to forced hyperextension. Injuries were classed in two groups as a function of their prognosis: group I consisted of osteomuscular lesions without vascular or nerve involvement (11 lower limbs, 11 patients). The mortality rate in this group was 9%, the rate of major amputation was 18%, and the prognosis was favorable in 82% of the cases. Group II corresponded to lower limb injuries with neurovascular involvement (12 lower limb injuries in 10 patients: one patient belonged to both group I and group II). Acute lower limb ischemia was constant in group II; the mortality rate was 20% (two of 10 patients), and the rate of major amputation was 41.6% (five of 12 patients; three emergency amputations and two secondary amputations)., Conclusion: These agricultural machines can cause severe trauma, and the resulting wounds are contaminated by telluric germs in rural areas. Paradoxically, power-driven cultivators are not legally classified as "dangerous machines." Modification of existing legislation in this field would seem advisable.

Purpose: Percutaneous transluminal angioplasty (PTA) has an established and valuable role in the treatment of iliac stenoses and occlusions. The use of stents may improve the results of PTA. The aim of this study is to report our surgical experience of iliac angioplasty over the past 5 years., Patients and Methods: From January 1993 to October 1997, 201 iliac PTA were performed in 175 patients, at the level of the common iliac artery (n = 111) and external iliac artery (n = 90). In 26 cases, two iliac lesions were treated simultaneously. There were 188 stenoses and 13 chronic occlusions. During PTA, 55 stents were used, because of unsatisfactory results (dissection, residual stenosis) or in case of total occlusion, in the common iliac artery in 35 cases and in the external iliac artery in 20 cases. In 15 cases (8.6%), a femoro-popliteal bypass was associated to the iliac PTA, because of multilevel occlusive disease., Results: There were no early deaths. There were seven initial failures. The initial success rate was 96%. The clinical follow-up has been achieved in 163 patients, (range: 3 to 48 months, mean: 28 months). The primary patency rates were 84%, 79% and 63% respectively at 1, 2, and 4 years. The secondary patency rates were 87%, 85% and 73% respectively at 1, 2, and 4 years.

Background: Abdominal aortic aneurysms (AAA) are associated with lower-limb occlusive arterial disease (LLOAD) in 20-40% of patients. Retrospective analysis of 200 elective AAA repairs and comparison with literature data revealed that LLOAD has little influence on standard therapeutic management of AAA., Methods: In this study, only 2.5% of the patients required femoropopliteal bypass along with aneurysm repair. In contrast, aneurysm repair was associated with lumbar sympathectomy in 30% of cases owing to existence of peripheral arterial disease., Results: Concurrent LLOAD did not significantly increase the operative mortality of AAA, but postoperative peripheral arterial complications were more frequent in patients with both aneurysmal and occlusive disease., Conclusions: Although concomitant LLOAD did not adversely affect the long-term survival of patients who underwent surgical repair of AAA, this subgroup of patients was at higher risk of aggravation of their lower extremity arterial lesions.

The authors report a case study of bilateral extracranial atherosclerotic aneurysms of the internal carotid artery, discovered simultaneously in a 58 year-old man. The patient had previously undergone polyarterial surgery for a subrenal abdominal aortic aneurysm 11 years earlier. The operation was performed in two stages with a few days interval, with an identical procedure on each side: under general anesthesia, resectioning of the aneurysm, restauration of the arterial flow by an internal saphenous venous graft between the internal and common carotids, and repositioning the external carotid. The surgical follow-up was uneventful. Extracranial aneurysms of the internal carotid artery are rare, although well-documented. To be found bilaterally, as in our case, is exceptionally unusual. The seriousness and the frequency of complications from internal carotid artery aneurysms indicate that surgical treatment is warranted.

Twenty to forty percent of patients with aneurysms of the abdominal aorta also have obliterated arteries of the lower limbs. We analyzed retrospectively a series of 200 patients undergoing elective surgery for aneurysm of the abdominal aorta and compared the results with data in the literature. Obliteration of the lower limb arteries had little influence on the technique usually employed for surgery. Femoro-popliteal bypass was associated with cure of the aneurysm in only 2.5% of the cases. We also performed sympathectomy of the lumbar branches in 30% of the cases because of peripheral arterial lesions. The presence of obliterations did not significantly increase operative mortality. Inversely, post-operative peripheral arterial complications were more frequent in patients with an obliterated artery of the lower limb than in those free of distal disease. Long-term survival was not unfavourably affected by the presence of obliterated arteries, but such patients have a greater risk of arterial lesions of the lower limbs.

We have studied the possible alterations or damage of spermatozoa in patients treated by ESWL for pelvic ureteral stones. Six patients with right and four with left pelvic ureteral stone underwent semen analysis before and after ESWL with Dornier MH3. The semen analysis was repeated 2-3 and 90 days later. No significative alteration was observed.

Acute hyperparathyroidism occurs infrequently and sometimes represents a diagnostic problem in urological patients. We report a case of acute hyperparathyroidism successfully treated by total parathyroidectomy and parathyroid autotransplantation.

The authors review the experience of total parathyroidectomy with microsurgical autotransplantation with reference to the long-term results. This method--after further control investigations--may be envisaged for making a definitive evaluation of the results.

Thirty patients with chronic granulocytic leukemia (CGL), were given cyclophosphamide 60 mg/kg on each of 2 consecutive days, followed by total body irradiation (TBI) 10 Gy and an HLA-identical bone marrow transplant (BMT). Eleven patients were in the accelerated phase of their disease (CGLacc) or in second/secondary chronic phase (CGL-2CP), with a median age of 33 years: four patients died of transplant related complications, and four of recurrent leukemia; three patients are alive and well 19, 31, 33 months from BMT. The actuarial 33-month survival is 27%. The actuarial relapse rate is 50%. Nineteen patients were in their first chronic phase (1CP), with a median age of 32 years: three died of graft versus host disease (GvHD), two of infection, and two of acute respiratory distress syndrome (ARDS); 12 are alive and well 6 to 29 months post-BMT. The actuarial 29-month survival is 63%. The actuarial survival of patients younger than 30 years is 63%, compared to 62% for patients older than 30 (P = 0.1). The survival of patients grafted within or after 24 months from the onset of CGL is respectively 87% and 45% (P = 0.04). None of the patients grafted in 1CP had a true hematologic-cytogenetic relapse. The Ph' chromosome was detected on one occasion in two patients 12, 13 months post-BMT: they both remain hematologically normal and Ph1-negative 3 to 6 months later, after discontinuation of cyclosporin A. This study confirms that survival exceeding 60% can be obtained in CGL in the first chronic phase, whereas less than 30% of patients will survive if grafted in accelerated, second/secondary chronic phase, mainly because of leukemic relapse. The duration of the disease seems to be relevant to the outcome of the transplant. The effect of post-transplant immunosuppression, in our case cyclosporin A, on the interaction between normal and Ph1-positive hemopoietic cells, may deserve further attention.

For varicocele correction, the occlusion of the internal spermatic vein is commonly performed, leaving the testis without its major pathway. Microsurgery offers the possibility to create a new venous drainage to the testis by anastomosing the internal spermatic vein with the inferior epigastric vein. Both stumps of the epigastric vein can be alternatively used, according to the different pathogenic mechanism of the varicocele. Eight patients with left varicocele were operated on using this new technique, with satisfactory results.

A 28-year-old woman with Bence-Jones multiple myeloma (MM) presented with several osteolytic lesions and a massive bone marrow infiltration with mature plasmocytes. After 6 cycles of chemotherapy with melphalan and prednisone, the patient, in apparent clinical remission, underwent allogeneic bone marrow transplantation (BMT) from her brother. The patient has been followed up for 23 months, showing complete remission by clinical and laboratory criteria. Other cases of MM treated with BMT and reported in the literature are reviewed and discussed.

Centrifugal devices for donor plasmapheresis that collect platelets as a by-product have recently been introduced. The platelet yield ranges from 1.2 to 2 X 10(11) per collection, and the collection time exceeds 50 minutes. An attempt to increase yields and to reduce the procedure time was carried out at our center, taking advantage of the Dideco Eccentriplate (Dideco spa, Mirandola, Italy). Within 30 minutes, 510 ml of plasma were collected along with 3.3 X 10(11) platelets. The shift of donors from whole blood to plasma and platelet donation generated a progressive decrease in red-cell availability. In order to maintain plasma and platelet production without affecting the erythrocyte production, a technique was developed that allows the collection of 3.68 X 10(11) platelets, 250 ml of plasma, and 225 ml of packed red blood cells with a hematocrit of 66.5%. The mean procedure time was 31.6 minutes; 2,671 ml of blood were processed at flow rates of 85-100 ml/minute. The cellular cross contamination of the platelet concentrates was 1.76 X 10(8) (leukocytes) and 2.23 X 10(8) (erythrocytes). Although the procedure was carried out in a selected group of donors, the technical experience has strongly modified our procedure for platelet and plasma collection.

20 patients with acute nonlymphoid leukemia (ANLL) in first remission were given cyclophosphamide, 120 mg/kg, followed by total body irradiation (TBI) and an HLA-identical allogeneic marrow transplant (BMT). TBI was delivered in a single dose (10 Gy on day -1) in 2 patients, or in fractionated doses (3.3 rad/day on days -3, -2, -1) in 18 patients. The median age of patients was 22 years (range 2-44). Median time from remission to BMT was 5 months (range 1-12). 5 patients died of transplant-related toxicity (graft-versus-host disease with or without interstitial pneumonia) and 15 are alive 7-77 months post-BMT (median 20). The actuarial 72 months survival is 73%. There has been one relapse in a 2-year-old child, 4 months post-BMT, in the marrow and in the testis. The 72-month actuarial disease-free survival is 68%. The actuarial probability of relapse is 7%. This study indicates that a high proportion of ANLL patients treated in first remission with fractionated TBI and allogeneic marrow transplantation can become long-term disease-free survivors.

Organ donation is usually limited to solid tissues; paradoxically, organ donors undergoing explant are often transfused in preparation for or during surgery. This practice increases the requirement for blood and adds immunological and infectious risks for both recipients and donors of grafts. We have investigated the possibility of supporting an explant with intraoperative blood salvage and, in the case of a cadaver donor, at the end of the operation, salvaging blood for potential use in the graft recipient. This preliminary report describes the technique and the results obtained in two procedures. The volume of red cells with a hematocrit of 55% obtained from the two donors was 2,090 and 1,180 ml, respectively. These components were employed for the transfusion support of the organ recipients.

Thirty-six children with acute lymphoblastic leukaemia (ALL) in second remission were treated with conventional chemotherapy or with cyclophosphamide and fractionated total-body irradiation followed by an allogeneic bone marrow transplant; the choice of treatment was dictated by the availability of an HLA-identical sibling. The age, sex, clinical data at presentation of the disease and duration of first remission were comparable for the two groups of patients. In the bone marrow transplantation group two patients died of graft-versus-host disease and five of leukaemia. Ten patients survive, nine disease free, 13-53 months from second remission (6-51 months post-bone marrow transplantation). In the chemotherapy group 14 patients died of leukaemia (2-29 months from second remission) and five survive (22-34 months from second remission). The actuarial survival for patients with bone marrow transplantation is 48% at 4 years as compared with 22% for those of the chemotherapy group (P = 0.04); the actuarial probabilities of being in remission are 58 and 18% in the two groups respectively (P = 0.01). This study confirms that allogeneic bone marrow transplantation is superior to chemotherapy in patients in second remission with ALL and should be considered in the presence of an HLA-identical sibling.

This is a retrospective analysis of marrow function in 171 recipients of an HLA-matched bone marrow transplant (BMT). Only patients with detectable hemopoiesis as indicated by leukocyte counts greater than 1.0 x 10(9)/l and platelet counts greater than 25 x 10(9)/l who were alive on day 30 were entered in the study. Poor marrow function was detected in 24 (14%) patients as indicated by a decrease in the peripheral blood counts to less than 40% of the maximal preceding values post-transplant in association with reduced marrow cellularity. Leukopenia (n = 4), thrombocytopenia (n = 3) or a combination of the two (n = 17) occurred 62 +/- 23 (SEM) days post-transplant and was associated with acute graft-versus-host disease (AGVHD) grade II or more and infection (n = 19) in the absence of clear rejection or persistence/recurrence of malignant disease. A multivariate analysis showed that AGVHD was the major risk factor (p = 0.001) for developing poor graft function. In the 24 patients with poor graft function, hemopoietic recovery was strongly associated with resolution of AGVHD and of infections. Their survival (27%) was the same as survival for other patients matched for GVHD who had no pancytopenia. The causes of death were GVHD (n = 13), pneumonia (n = 3) and infections (n = 1). This study draws attention to a particular type of poor graft function following allogeneic BMT that is characterized by (1) normal timing and quality of engraftment, (2) AGVHD of grade II or greater, (3) progressive and severe pancytopenia, and (4) multiple infections with poor clinical condition.(ABSTRACT TRUNCATED AT 250 WORDS)