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AIM: The aim of this study was to determine the clinical outcome of carotid endarterectomy in heart transplant recipients and morphologic features of atherosclerotic plaques removed during operation. METHODS: Between April 1993 and October 2001 5 heart transplant patients with symptomatic carotid stenosis >70% underwent carotid endarterectomy with regional anesthesia, including a staged bilateral procedure in one patient. Cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol were evaluated in each patient. The plaques ( n=6) underwent histologic analysis after carotid endarterectomy. Carotid artery duplex imaging was added to the routine postoperative evaluation. RESULTS: Carotid plaques resulted to be echolucent on B-mode ultrasound examination. Cholesterol, triglycerides and LDL-cholesterol levels were found to be increased, while HDL-cholesterol were decreased. All patients underwent successful carotid endarterectomy; there were no perioperative deaths, major neurologic or cardiac events. The mean length of stay was 2.2 days. The mean follow-up was 44 months. In 1 case, an asymptomatic restenosis >50% occurred 9 months later and, in 2 other cases, a contralateral mild stenosis was found 12 and 36 months later. One patient had a progressive contralateral stenosis, requiring operation 18 months later. High lipid content and heterogeneous cellular infiltration were observed, including macrophages, T-lymphocytes, neutrophils, and also eosinophils in the rapidly progressing plaque. CONCLUSIONS: Heart transplant patients receiving immunosuppression may successfully undergo carotid endarterectomy, without increased risk, but progression of atherosclerotic disease in the carotid arteries seems to continue, despite lipid-lowering regimen and antiplatelet therapy.

Aim. To eval¬u¬ate the effi¬ca¬cy of ¬intra-arte¬ri¬al throm¬bol¬y¬sis and adjunc¬tive endo¬vas¬cu¬lar pro¬ce¬dures for infra¬in¬gui¬nal ¬native ¬artery chron¬ic occlu¬sions, ¬that ¬result in a ¬recent wors¬en¬ing of symp¬toms ¬because of throm¬bo¬sis super¬im¬posed on under¬ly¬ing path¬o¬log¬ic ¬lesions. Methods. Intra-arte¬ri¬al cath¬e¬ter-direct¬ed throm¬bol¬y¬sis ¬with urok¬i¬nase 300000 IU ¬bolus fol¬lowed by 70000 IU /h for 24-48 ¬hours was admin¬is¬tered to 54 ¬patients affect¬ed ¬with low¬er ¬limb ische¬mia. Twenty-¬three ¬patients (25 ¬limbs) pre¬sent¬ed ¬severe clau¬di¬ca¬tio and 31 -patients (34 ¬limbs) crit¬i¬cal leg ische¬mia; sub¬acute (14 ¬days-3 ¬months) symp¬toms ¬were ¬present in 60.9% and 77.4% , respec¬tive¬ly. After suc¬cess¬ful throm¬bol¬y¬sis, endo¬vas¬cu¬lar pro¬ce¬dures (i.e., angio¬plas¬ty, endo¬lu¬mi¬nal stent¬ing, endo¬pros¬the¬sis place¬ment) ¬were per¬formed in 72% and 67.6%, respec¬tive¬ly. In addi¬tion, infra¬in¬gui¬nal autog¬e¬nous ¬vein recon¬struc¬tion was per¬formed in 5 ¬patients ¬with crit¬i¬cal leg ische¬mia. Results. Initial clin¬i¬cal improve¬ment was ¬seen in 76% of 25 extrem¬ities in ¬group I, ¬with a 30-day pri¬mary paten¬cy and ¬relief of clau¬di¬ca¬tio in 68%. Arterial rec¬a¬nal¬iza¬tion was ¬achieved in 23 (67.6%) and res¬to¬ra¬tion of ¬flow in tar¬get ves¬sels for sub¬se¬quent ¬bypass in 5 (14.7%) of 34 extrem¬ities in ¬group II. The 30-day ¬limb-sal¬vage was 73.5%; ¬limb ¬loss includ¬ed 2 ampu¬ta¬tions (5.9%) as a ¬result of infec¬tion and/or necro¬sis in dia¬bet¬ic ¬patients, ¬despite ana¬tom¬ic paten¬cy at the endo¬vas¬cu¬lar pro¬ce¬dure ¬site. Relief of ische¬mia was ¬achieved in 56% of clau¬di¬cants (¬mean fol¬low-up, 42 ¬months) and ¬limb sal¬vage in 52.9% of ¬patients ¬with crit¬i¬cal ische¬mia (¬mean fol¬low-up, 36 ¬months). Conclusion. Thrombolysis and adjunc¬tive endo¬vas¬cu¬lar pro¬ce¬dures are an accept¬able ther¬a¬peu¬tic ¬option for the treat¬ment of wors¬en¬ing man¬i¬fes¬ta¬tions of chron¬ic occlu¬sive dis¬ease of the femor¬o¬pop¬li¬teal arte¬ri¬al seg¬ment.

BACKGROUND: Treatment of lymphoceles complicating vascular procedures is controversial. The purpose of this study was to evaluate the practicability, effectiveness and safety of conservative management on an outpatient basis. METHODS: Medical records were reviewed for 23 postoperative lymphoceles (in 18 patients) seen at our institution between 1986 and 1999. Diagnosis was made by physical examination and needle aspiration of fluid collection; bacterial cultures were obtained in all. Ultrasonography was performed in all patients, lymphoscintigraphy (99mTc HSA) in 11, angio-TC in 2 cases, MRI in 3 large lymphoceles. RESULTS: Twenty-one lymphoceles developed in the groin, 2 in the thigh and were mostly (72.2%) diagnosed after hospital discharge. Imaging techniques detected subcutaneous wound collection; in addition, lymphoscintigraphy showed lymphatic interruption and collateral pathways in patients with limb swelling. Outpatient management consisted of limited ambulation, limb elevation and pressure dressings; no serial aspirations were made. Resolution was obtained in all patients over a mean period of 21 days (range, 12 to 35). No patient required re-hospitalization or developed wound and/or graft infection. No recurrence was noted after a follow-up of all patients for 1 year. CONCLUSIONS: Outpatient treatment of lymphoceles following arterial reconstructive procedures can be performed safely. Significant advantages of this pathway include no re-hospitalization and cost reduction.

A 69-year-old man with a history of hypertension and severe pulmonary disease had asymptomatic bilateral common iliac and popliteal artery aneurysms. A bifurcated Talent and two Wallgraft stent-grafts were deployed via open femoral arteriotomies to exclude the aneurysms, respectively. The patient had an uncomplicated recovery, with no transfusion need; the hospital stay was 4 days. After a 5-year follow-up, no complication or endoleak has been detected, with patency of endografts and a mean decrease of 15% in aneurysm transverse diameters. Simultaneous endovascular repair should be considered in the treatment of multiple peripheral aneurysms, to avoid sequential conventional or endovascular procedures.

A 69-year-old man with a history of hypertension and severe pulmonary disease had asymptomatic bilateral common iliac and popliteal artery aneurysms. A bifurcated Talent and two Wallgraft stent-grafts were deployed via open femoral arteriotomies to exclude the aneurysms, respectively. The patient had an uncomplicated recovery, with no transfusion need; the hospital stay was 4 days. After a 5-year follow-up, no complication or endoleak has been detected, with patency of endografts and a mean decrease of 15% in aneurysm transverse diameters. Simultaneous endovascular repair should be considered in the treatment of multiple peripheral aneurysms, to avoid sequential conventional or endovascular procedures.