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Compelling evidence support an involvement of oxidative stress and intestinal inflammation as early events in the predisposition and development of obesity and its related comorbidities. Here, we show that deficiency of the major mitochondrial antioxidant enzyme superoxide dismutase 2 (SOD2) in the gastrointestinal tract drives spontaneous obesity. Intestinal epithelium-specific Sod2 ablation in mice induced adiposity and inflammation via phospholipase A2 (PLA2) activation and increased release of omega-6 polyunsaturated fatty acid arachidonic acid. Remarkably, this obese phenotype was rescued when fed an essential fatty acid-deficient diet, which abrogates de novo biosynthesis of arachidonic acid. Data from clinical samples revealed that the negative correlation between intestinal Sod2 mRNA levels and obesity features appears to be conserved between mice and humans. Collectively, our findings suggest a role of intestinal Sod2 levels, PLA2 activity, and arachidonic acid in obesity presenting new potential targets of therapeutic interest in the context of this metabolic disorder.

The contribution which Prof. Edmondo Malan gave to the world of surgery is matched only by the number of disciples that are working every day in his memory. Yet, the heritage of the Master is not limited to mere surgical teaching. Because of his willpower, many surgical departments have been inaugurated, many teaching schools have been founded, the boundaries of general surgery and many specialties have been crossed; in his memory, vascular research went far beyond expectations, reaching a level of excellence he could have only dreamed of. His heirs, once more, have perpetuated his lessons in surgery, keeping alive the true spirit of medicine, which is our foundation: the art of teaching and learning, as a never-ending process. Professor Edmondo Malan is not vanished. His name is not buried in history books. He is constantly alive, every day, a vivid presence in every surgical skill that reminds the audacity and the dedication of a man, not only a doctor, focused on caring and healing, from the bottom of his heart

BACKGROUND: Case and single center reports have documented the feasibility and suggested the effectiveness of endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (RAAAs), but the role and value of such treatment remain controversial. OBJECTIVE: To clarify these we examined a collected experience with use of EVAR for RAAA treatment from 49 centers. METHODS: Data were obtained by questionnaires from these centers, updated from 13 centers committed to EVAR treatment whenever possible and included treatment details from a single center and information on 1037 patients treated by EVAR and 763 patients treated by open repair (OR). RESULTS: Overall 30-day mortality after EVAR in 1037 patients was 21.2%. Centers performing EVAR for RAAAs whenever possible did so in 28% to 79% (mean 49.1%) of their patients, had a 30-day mortality of 19.7% (range: 0%-32%) for 680 EVAR patients and 36.3% (range: 8%-53%) for 763 OR patients (P < 0.0001). Supraceliac aortic balloon control was obtained in 19.1% +/- 12.0% (+/-SD) of 680 EVAR patients. Abdominal compartment syndrome was treated by some form of decompression in 12.2% +/- 8.3% (+/-SD) of these EVAR patients. CONCLUSION: These results indicate that EVAR has a lower procedural mortality at 30 days than OR in at least some patients and that EVAR is better than OR for treating RAAA patients provided they have favorable anatomy; adequate skills, facilities, and protocols are available; and optimal strategies, techniques, and adjuncts are employed.

Obiettivo; In letteratura è riportato che solo il 50% dei pazienti con aneurisma toracico rotto raggiunge l’Ospedale ancora in vita, ed il 75% di questi muore nelle 24 ore successive. L’elevata percentuale di mortalità e paraplegia, in seguito a trattamento chirurgico di un aneurisma dell’aorta toracico rotto, limita di molto tale procedura. Il trattamento endovascolare offre un’alternativa meno invasiva alla chirurgia tradizionale, in quanto evita la toracotomia, la terapia anticoagulante e il clampaggio aortico. In questo lavoro riportiamo la nostra iniziale esperienza riguardante il trattamento endovascolare in urgenza dell’aneurisma dell’aorta toracico rotto. Metodi: La nostra esperienza è iniziata nel maggio 2004, da allora abbiamo trattato 11 pazienti con rottura franca di aneurisma dell’aorta toracica (10 aneurismi toracici rotti ed un caso di aneurisma dissecante rotto). I pazienti trattati presentavano un’età media di 76.2 anni (min. 69, max 88), 10 maschi ed una femmina. Tutti i casi, tranne uno, si sono presentati in Pronto Soccorso in condizioni emodinamicamente stabili (PA>70mmHg) e sono stati sottoposti ad un esame Angio TC dell’aorta toracica, addominale e degli assi iliaco femorali. Le condizioni cliniche e la valutazione strumentale hanno evidenziato la possibilità di un trattamento endovascolare. In un solo caso, presentandosi in shock emorragico, la diagnosi e la fattibilità endovascolare è stata fatta direttamente in sala operatoria, dopo un accurato studio angiografico e con IVUS (Intavascular Ultrasound). Risultati: Tutti i pazienti sono stati trattati entro 12 ore dall’arrivo in Ospedale e tutte le procedure sono state eseguite in sala operatoria e in anestesia generale. Le endoprotesi utilizzate sono state in 9 casi Endofit/Endomed, in un caso Talent/Medtronic ed in un altro Zenith/Cook, con un accesso femorale chirurgico ed uno percutaneo. Solo in un caso è stato necessario coprire l’arteria succlavia sinistra, mentre in un altro cas, Objective; In literature it is reported that only 50% of patients with ruptured thoracic aneurysm reaches the hospital alive, and 75% of these die within 24 hours. The high percentage of mortality and paraplegia after surgical treatment of a ruptured thoracic aortic aneurysm, limits indications to this procedure. Endovascular treatment offers a less invasive alternative to traditional surgery, as it avoids thoracotomy, anticoagulant therapy and aortic clamping. In this paper we report our initial experience regarding the endovascular treatment in emergency of broken thoracic aortic aneurysm. Methods: Our experience began in May 2004, since then we have treated 11 patients with frank rupture of the thoracic aortic aneurysm (10 aneurysms and a case of dissecting aneurysm). These patients had a mean age of 76.2 years (min. 69, max 88), 10 males and one female. All cases except one, were presented to the emergency department under hemodynamically stable (BP> 70 mm Hg) and were subjected to CT angiography of the thoracic aorta, abdominal aorta and iliac femoral axis. The clinical and instrumental evaluation have shown the possibility of endovascular treatment. In one case, presenting in hemorrhagic shock, the endovascular feasibility was made in the operating theater, after a careful study with angiography and IVUS (Intavascular Ultrasound). Results: All patients were treated within 12 hours of arrival in hospital and all procedures were performed in the operating room under general anesthesia. The endoprostheses used were in 9 cases Endofit / Endomed, in a case Talent / Medtronic and in another Zenith / Cook, with a surgical femoral access and percutaneous one. Only in one case it was necessary to cover the left subclavian artery, while in another case it was necessary to cover the origin of the subclavian artery and left common carotid artery after carotid-carotid bypass. The technical success was 100%, in two cases the presence of endoleaks on type 1 has necessitated

L’ulcera penetrante dell’aorta (PAU) è lesione rara, localizzata prevalentemente nell’aorta toracica, il più spesso asintomatica e benigna, tendendo nella maggioranza dei casi alla stabilizzazione, od anche alla regressione. In alcuni casi però la PAU ha tendenza evolutiva, verso l’ematoma periaortico, lo pseudoaneurisma e la rottura dell’aorta, o la dissecazione, con imminente pericolo di vita (Sindrome Aortica Acuta). Il rilievo di una PAU alla TC od RM richiede dunque un attento controllo e, nel caso compaiano sintomatologia o segni d’evoluzione, deve essere urgentemente trattata, con sostituzione chirurgica, o, preferibilmente, con esclusione mediante endoprotesi., Penetrating Aortic Ulcers – Clinical Relevance and Therapeutic Indications _ Penetrating aortic ulcer (PAU) is a rare pathology, affecting more frequently the thoracic aorta. Mostly benign and asymptomatic, PAU frequently tends to stabilize or even regress. In some cases, on the contrary, it evolves into peri-aortic ematoma and aortic rupture or dissection, with absolute mortality (Acute Aortic Syndrome). A diagnosis of PAU at TC or RM requests therefore careful observation and repeated examinations. In case of symptomatology and evolution, PAU has to be treated in emergency, by means of surgical repair or, more likely, by endovascular exclusion.

Introduzione e Scopo del Lavoro - Le osservazioni di aneurismi dell’arteria splenica sono aumentate negli anni più recenti, per l’uso più frequente di metodiche diagnostiche quali Ecografia, Ecodoppler, Tomografia Computerizzata (TC) e Risonanza Magnetica (RM), ponendo quindi spesso il quesito sulla miglior condotta terapeutica da tenere nei confronti di questi. Materiali e Metodi - Partendo da alcune osservazioni personali, rivedendo quindi i dati riportati nella recente letteratura, i vantaggi e le complicanze delle diverse metodiche utilizzabili: chirurgia tradizionale “aperta”, embolizzazione, esclusione con stent graft, chirurgia laparoscopica, con o senza splenectomia associata, vogliamo definire quale sia l’indicazione terapeutica più opportuna. Discussione - Gli aneurismi dell’arteria splenica sono lesioni rare, con incidenze riportate dallo 0,1 al 10%, essi costituiscono la più frequente localizzazione degli aneurismi viscerali, terzo tipo d’arteria addominale colpita, dopo aorta ed iliache, in soggetti adulti, intorno ai 60 anni. Sono molto più frequenti nel sesso femminile, presentano associazione significativa con gravidanza, ipertensione arteriosa, ipertensione portale. Sono spesso di natura fibrodisplastica, anche se le alterazioni più frequentemente rilevate sono di natura arteriosclerotica e calcifica, la morfologia è tipicamente sacculare. Le possibili complicanze dell’aneurisma splenico sono il progressivo aumento di volume, la trombosi, l’embolizzazione ed ovviamente la rottura, con emorragie gravi e mortali, anche se la maggioranza dei casi diagnosticati sono di aneurismi asintomatici. L’indicazione terapeutica è al trattamento chirurgico, se la lesione supera i 2 centimetri di diametro, mostra tendenza evolutiva o presenta una sintomatologia. La chirurgia tradizionale prevede la legatura dell’arteria splenica, con o senza asportazione dell’aneurisma, o la sua ricostruzione. L’abbondante perfusione collaterale permette nella maggior parte

Il trattamento chirurgico tradizionale degli aneurismi rotti dell’aorta addominale è tuttora gravato da un’alta mortalità post-operatoria. Le recenti metodiche endovascolari consentono l’esclusione rapida della sacca aneurismatica rotta e la rivascolarizzazione periferica, per mezzo di un’endoprotesi introdotta attraverso un accesso femorale. L’esclusione endovascolare degli aneurismi aortici rotti ha un decorso post-operatorio meno impegnativo per il paziente, con relativa diminuzione delle complicanze ad esso correlate. Per considerare la procedura è necessario che il paziente giunga in Pronto Soccorso in uno stato di relativa stabilità, onde poter effettuare un’Angio-TAC, confermare la diagnosi e studiare se la morfologia dell’aneurisma permetta di praticare con sicurezza la tecnica endovascolare. L’esperienza della nostra equipe e degli specialisti che ci affiancano all’Ospedale Bassini ci ha consentito di iniziare con successo questo trattamento degli aneurismi rotti, motivandone la sua prosecuzione e, se possibile la sua estensione., EMERGENCY ENDOVASCULAR TREATMENT of RUPTURED ABDOMINAL AORTIC ANEURYSMS A high post-operative mortality (50%) is still related to conventional surgical repair of ruptured AAA. Newer Endovascular Techniques allow fast exclusion of ruptured aneurismal sac by means of aorto-iliac endoprosthesis trough a femoral access. EVAR in ruptured AAA is associated with shorter post-operative recovery and less related complications. It is mandatory that patients with aortic rupture can reach the Hospital in stable conditions, in order to allow accurate selection of candidates for Endovascular Exclusion through Angio-CT. Multi-disciplinary team with experience in Endovascular procedures is essential. Our good initial outcome using this procedure stimulates to continue and, possibly, extend the application of EVAR in AAA rupture.

L’indicazione a CEA in elezione è ormai stabilmente accettata e comprende: stenosi carotidee emodinamicamente significative sintomatiche ed asintomatiche; l’indicazione in emergenza è ancora fortemente discussa e si riferisce alla tromboembolia carotidea, entro le prime ore da uno stroke in progresso, senza alterazioni di coscienza. Accanto a questa va a nostro avviso considerata l’indicazione “non differibile” a CEA, basata non tanto sui parametri di sintomatologia neurologica e percentuali di stenosi, anche se importanti, quanto soprattutto sugli aspetti morfologici di “placca carotidea instabile”. Numerosi studi hanno confermato che le placche molli, a core lipidico, emorragico o colliquato, con capsula sottile, con grossolane ulcerazioni, e la presenza di trombo sulla superficie, sono correlate ad un alto rischio d’embolia cerebrale. La dimostrazione di tali aspetti morfologici, accertabile con piena attendibilità con Ecodoppler, indica la necessità di CEA non differibile, confermando l’importanza del terzo parametro: la morfologia della placca, oltre a sintomatologia neurologica e percentuale di stenosi, nell’indicazione chirurgica, Surgery of Carotid Endarterectomy (CEA) has shown, through prospective randomized trials, its undisputed efficacy in the prevention of stroke in elective, hemodynamically significant carotid stenosis in symptomatic, as also in asymptomatic patients, provided that the complication rate correlated to the intervention is limited. Still controversial is the indication for CEA in emergency, in the acute phase of cerebral ischemia, due to the risk of hemorrhagic conversion of ischemic infarct, with a poor prognosis. A growing number of positive experiences reported in the literature seems to authorize the extension of indication for CEA in urgency to subjects with ischemic neurological symptoms, without altered state of consciousness, and within the first hours of the event. But there are also indications to CEA, which "can not be postponed". Those are clinical conditions characterized by repeated ischemic attacks and / or by the presence of unstable carotid plaques. Prospective studies that have looked at the natural history of carotid atherosclerotic plaque, in relation to related cerebral ischemic events, showed some morphological features correlated with a higher percentage of embolic cerebral ischemia. The purpose of this study was to determine, based on personal experience and published studies, which are the morphological characteristics of unstable carotid plaque, that require intervention of CEA in a short time. Some pathological features of the evolutionary process of carotid plaque, defined with good reliability through the Doppler examination, have shown greater correlation with cerebral ischemia. These features are: lower plaque echogenicity as defined by GSM index, the prevalence of "soft core" with a thin capsule surface, intramural hemorrhage, ulceration, aspects of thrombotic appositions in the luminal surface. We must therefore conclude that for indication to surgery, in addition to the usual criteria of percentage of stenosis and carotid related neurolo

La rottura costituisce la più temibile complicanza degli aneurismi dell’aorta. Tra i pazienti che riescono a raggiungere l’Ospedale, con aneurisma rotto, solo il 36% è operato, con mortalità del 50-60%. Il trattamento endoprotesico degli aneurismi aortici in elezione si è dimostrato efficace e con minori complicanze, può quindi dare miglior sopravvivenza anche in urgenza negli aneurismi rotti. Abbiamo messo a punto un Protocollo per il trattamento degli aneurismi giunti in Pronto Soccorso in rottura: in condizioni di stabilità emodinamica è praticata AngioTC, per la diagnosi, la sede di rottura, lo studio delle caratteristiche anatomiche dell’aneurisma e la scelta per riparazione endovascolare o tradizionale. In caso d’instabilità emodinamica, dopo rapida conferma diagnostica con EcoDoppler, il paziente è condotto in Sala Operatoria e sotto scopia, per via percutanea transfemorale viene introdotto un pallone aortico (alla 1° vertebra lombare); esso è gonfiato ad occlusione in caso di shock. L’angiografia (ed eventualmente l’IVUS) forniscono le misurazioni per l’endoprotesi. Nell’urgenza preferiamo endoprotesi Uni-iliaca, rispetto alla biforcata, per la più rapida esclusione della sacca aneurismatica rotta, con immediato controllo dell’emorragia; segue l’occlusione dell’iliaca controlaterale ed il by pass femoro-femorale chirurgico. La procedura può essere condotta in anestesia locale, con miglior controllo emodinamico, sino all’esclusione endoprotesica, poi completata in generale. Viene riportata l’esperienza iniziale su 11 casi, con 64% di guarigione chirurgica., Rupture is the most feared complication of aortic aneurysms. Among patients who reach the hospital with ruptured aneurysm, only 36% can undergo surgical repair, with a mortality rate of 50-60%. The endovascular treatment in elective aortic aneurysm has been established as effective and with fewer complications, could then give better survival even in urgency in ruptured aneurysms. We have developed a protocol for the treatment of aneurysms arrived in emergency for rupture: in hemodynamic stable conditions AngioScan is performed for the diagnosis, the seat of rupture, the study of anatomical features of the aneurysm and choice for endovascular or traditional repair. In case of hemodynamic instability, after rapid confirmation of diagnosis with Doppler U.S., the patient is taken to the operating room and under fluoroscopy, transfemoral aortic balloon is introduced percutaneously (at the 1 st lumbar vertebra), and it is inflated to occlusion in case of shock. Angiography (and possibly the IVUS) provide the measurements for the endoprosthesis. In urgency an uni-iliac endoprosthesis is preferred to the bifurcated, for the fastest exclusion of the aneurysm sac, with immediate control of hemorrhage, followed contralateral iliac occlusion and femoro-femoral bypass surgery. The procedure can be performed under local anesthesia, with better hemodynamic monitoring, up to endoprosthetic exclusion, then completed in general. The authors report their initial experience of 11 cases, with 64% of surgical success.

Endovascular exclusion of iliac artery aneurysms after aortic grafting for AAA. Isolated iliac artery aneurysms are quite rare, whereas they are more frequent in association with abdominal aortic aneurysms. Aneurysmal dilatation may also affect iliac arteries in the long-term follow-up after aorto-aortic grafting for abdominal aortic aneurysms. The reported clinical case deals with two large aneurysms of the common and internal right iliac arteries, which were corrected by means of an endograft, adopting a less invasive endovascular approach at a lower risk, with a successful short and mid-term outcome. A brief review of recent literature on the topic confirms the effectiveness of the endovascular treatment.

Abdominal aortic aneurysm (AAA) occurs mostly in patients over the fifth decade of age, in which it is not uncommon to diagnose concurrent diseases. Furthermore an AAA can be found by chance, performing investigations for another illness. The question of the kind of approach to two associated diseases must therefore be resolved. We analyze various abdominal pathologies, whether malignant or benign, and other associated diseases, including frequent coronary heart disease. The interesting new perspectives offered by the endovascular exclusion of AAA, in respect of traditional prosthetic surgical repair, are discussed.

Purpose: To corroborate the validity of a computerized methodology for evaluating carotid lesions at risk for stroke based on plaque echogenicity. Methods: The records of 96 carotid endarterectomy patients (59 men; median age 69.5 years, range 52 to 83) with stenoses > 50% were studied retrospectively. Forty-one patients (43%) had been symptomatic preoperatively. All patients had undergone computed tomography (CT) to detect infarction in the carotid territory and a duplex scan to measure carotid stenosis. Plaque echogenicity was analyzed by computer, expressing the echodensity in terms of the gray scale median (GSM). The incidence of CT-documented cerebral infarction was analyzed in relation to symptomatology, percent stenosis, and echodensity. Results: Symptoms correlated well with CT evidence of brain infarction: 32% of symptomatic patients had a positive CT scan versus 16% for asymptomatic plaques (p = 0.076). The mean GSM value was 56 ± 14 for plaques associated with negative CT scans and 38 ± 13 for plaques from patients with positive scans (p < 0.0001). However, there was no difference in the GSM value between plaques with > or < 70% stenosis. Furthermore, the incidence of CT infarction was 40% in the cerebral territory of carotid plaques with a GSM value< 50 and only 9% in those with a GSM > 50 (p < 0.001). Conclusions: Computerized analysis of plaque echogenicity appears to provide clinically useful data that correlates with the incidence of cerebral infarction and symptoms. This method of analyzing plaque echolucency could be used as a screening tool for carotid stent studies to identify high-risk lesions better suited to conventional surgical treatment.

La validità degli screening sulla popolazione per quanto riguarda la patologia aneurismatica dell'aorta addominale é stata comprovata da recenti pubblicazioni. L'affidabilità diagnostica della metodica Eco-Doppler rende possibile la selezione dei pazienti in modo assolutamente non invasivo. La differenza sostanziale di mortalità conseguente ad interventi di aneurismectomia in condizioni di elezione, piuttosto che in emergenza, giustifica pienamente uno studio a carattere preventivo. I risultati preliminari su 738 soggetti di uno screening epidemiologico in corso presso la Divisione di Chirurgia Vascolare dell'Ospedale Bassini vengono riportati, considerando collateralmente l'incidenza di arteriopatie ostruttive e la coesistenza di fattori di rischio per la malattia arteriosclerotica., The validity of population screening for abdominal aortic aneurysmal disease has been confirmed by recent publications. The diagnostic reliability of the Doppler technique makes possible the noninvasive selection of patients. The high different mortality resulting from aneurysmectomy interventions in election, rather than emergency, fully justifies a preventative study. Preliminary results on 738 subjects of an ongoing epidemiological screening in the Division of Vascular Surgery, Bassini Hospital are reported, considering also obstructive arterial disease and risk factors for atherosclerosis.

Lo stripping parziale della vena safena, la sua legatura bassa all'inguine e la non corretta identificazione delle perforanti insufficienti sono gli errori chirurgici più frequentemente alla base della recidiva varicosa. La sola valutazione clinica é spesso incapace di riconoscere anomalie anatomiche spesso presenti nel sistema delle safene. Una completa e corretta informazione preoperatoria non richiede più l'esecuzione di uno studio flebografico; l'introduzione clinica dell'esame Ecocolordoppler, procedura diagnostica non invasiva, é oggi in grado di offrire un'alta affidabilità nella corretta indicazione chirurgica per la malattia varicosa. L'ecocolordoppler permette di riconoscere facilmente le perforanti insufficienti, le varianti anatomiche dell'ostio safeno-femorale ecc. La procedura chirurgica e i risultati dell'intervento si giovano di questi nuova tecnica diagnostica., Partial stripping of the saphenous vein, low interruption at the groin and incorrect identification of the perforating veins are surgical errors most frequently at the base of varicose recurrence. The clinical assessment alone is often unable to recognize anatomical abnormalities, often present in the saphenous system. A complete and accurate preoperative information no longer requires the execution of a phlebographic study, the introduction of Echo-color-doppler clinical examination, noninvasive diagnostic procedure, is now able to offer high reliability in the correct indication for surgery for varicose disease. The Doppler ultrasound allows to easily recognize the insufficient perforators, anatomical variants of saphenous-femoral ostium etc.. The surgical procedure and consequent long-term outcomeare significantly improoved by this new diagnostic technique.

In the last three months approximately 400 patients underwent a supra aortic trunk study with two different Eco-Color-Doppler devices at the Department of Vascular Surgery of the Bassini Hospital. The possibilities that this new diagnostic technique is offering in the study of the carotid plaque and of the pathological and physiological turbolences of the carotid bifurcation and in visualizing flow speed are described. This technique is discussed and compared with alternative invasive procedures.