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The characteristics and prognosis of patients with cystic medial necrosis of the aorta were reviewed. Subjects were 46 patients who underwent aortic and/or aortic valve surgery between August 1965 and October 1994. All had histologically documented cystic medial necrosis including 22 Marfan patients. The patients with Marfan syndrome were substantially younger (median age, 32 vs 50 years; p < 0.05), and experienced annulo-aortic ectasia more frequently {81% (17/22) vs 46% (11/24); p < 0.05} than those without the syndrome. Sixty-eight percent (15/22) of the Marfan patients and 63% (15/24) of the non-Marfan patients experienced complications with aortic dissection, although not to a significant degree. The hospital mortality rate was 14% (3/22) in the Marfan group and 21% (5/24) in the non-Marfan group, which was also not significant. Of the 38 survivors, developments in the health of 37 were completely followed-up until October 1997. The cardiovascular event-free rate for Marfan patients at 10 years (28%) was lower than that for non-Marfan patients (68%, p = 0.057), whereas the actuarial survival rates at 10 years were nearly equal (72% for the Marfan patients and 74% for the non-Marfan patients). Reoperation was the first cardiovascular event in 77% (10/13) of the Marfan patients and in 14% (1/7) of the non-Marfan patients (p < 0.05). Cardiovascular event was the main cause of late death both for Marfan patients (80%; 4/5) and for non-Marfan patients (86%; 6/7). In conclusion, independent of the presence of Marfan syndrome, careful follow-up is necessary for patients with cystic medial necrosis of the aorta to eliminate serious late complications.

We have performed a retrospective review of our experience with the intraaortic balloon counterpulsation pump (IABP) during the last decade, to identify aspects of risk factors, complications, and management that affect peripheral vascular morbidity and mortality. Data from 472 patients who had the IABP inserted during the ten-year period from December 1985 to December 1995 were retrospectively reviewed. Risk factors, implantation techniques, complications, and significant variables were evaluated. One hundred forty-five vascular complications needed surgical therapy in 116 patients. Mean age was 62.2 +/- 12.9 years. There were 84 (72.5%) men and 32 (27.5%) women. Mortality rate was 28.3% (n = 181). The mortality for patients with ischemic vascular complications was significantly higher than in patients who did not suffer any vascular complication (59.6% vs 30.1%, p = 0.0001). Complications included acute limb arterial occlusion in 99 cases (68.3%), compartment syndrome in 27 (18.6%), groin hematoma in 15 (10.3%), and persistent lymph fistula in 4 (2.8%). Of these, 97 (76.9%) occurred during IABP therapy and 29 (23.1%) after IABP explantation. Thromboembolectomy was required for 61 (42.2%) of the ischemic limbs. Associated procedures were 24 (16.5%) profundaplasties, 10 (7%) infrainguinal bypasses (5 (3.4%) femoropopliteal supragenicular, 3 (2.2%) femoropopliteal infragenicular, and 2 (1.4%) infrapopliteal), 26 (17.9%) fasciotomies, and 5 (3.4%) amputations. A history of peripheral vascular disease (31 patients [43.6%] with vs 95 [23.6%] without, p < 0.05) and the presence of diabetes mellitus (70 patients [49.2%] with vs 56 [16.9%] without) increased the risk of limb ischemia significantly. Female sex, insertion of IABP by percutaneous technique, and direct removal with groin compression were associated with higher ischemic complication rates, the differences however were not significant. Itis concluded that 1. Limb ischemia remains the primary complication after IABP insertion; 2. Femoral artery thromboembolectomy is usually sufficient for revascularisation; 3. Adequate implantation and surgical explantation techniques are essential to reduce the IABP-related morbidity; 4. Identification of subclinical disease may aid in the management of subsequent acute limb ischemia; 5. The presence of peripheral vascular disease and diabetes mellitus are associated with higher ischemic complication rates.

Aneurysms of the gluteal arteries are rare and mostly are caused by pelvic fractures or penetrating injuries. As such these aneurysms are pseudoaneurysms. As an absolute rarity we report the case of a 43-year-old man with a histologically verified 5 cm-diameter, true saccular aneurysm of the left superior gluteal artery. The patient was admitted with 6-weeks ongoing sciatic pain without previous trauma. He was scheduled for surgery because an initial attempt of transcatheter embolization failed. By dividing the origin of the gluteus maximus muscle from the iliac crest, the aneurysm was exposed at the pelvic outlet by an extrapelvic approach and was excluded by endoaneurysmorrhaphy. Uncontrolled bleeding was prevented by temporary occlusion of the left iliac artery by a percutaneously inserted balloon catheter, thus avoiding an additional retroperitoneal approach. The postoperative course was uneventful, and sciatic pain had resolved completely. The chosen strategy provides safe and successful surgical management of gluteal artery aneurysms.

Conversion from azathioprine to MMF with consecutive reduction of CsA in heart transplant recipients with CsA-impaired renal function improves renal function as evidenced by lower serum creatinine, urea nitrogen, uric acid, and higher creatinine clearance.

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One-stage surgery is a possible approach to highly symptomatic patients with severe multivascular disease and has acceptable early morbidity and mortality. Patients with severely impaired left ventricular function and unstable CAD carry a high risk of left heart failure and/or myocardial infarction during abdominal aortic surgery. Extracorporeal circulation protects the heart from the hemodynamic changes after aortic clamping or declamping during abdominal aortic surgery. The present study demonstrates that one-stage procedure is a reasonable option for this patient subgroup.