Antonio Rampoldi

Angiographic evaluation of peripheral arterial occlusive disease and its role as a prognostic determinant for major amputation in diabetic subjects with foot ulcers

OBJECTIVE To evaluate in diabetic patients with foot ulcers the angiographic findings of peripheral occlusive arterial disease and their role as a prognostic determinant for major amputation. RESEARCH DESIGN AND METHODS From 1993 to 1995, 104 diabetic inpatients with foot ulcers underwent arteriography on the ulcerated limb. Stenoses in the iliac trunk, the superficial femoral artery, the profunda femoral artery, the popliteal artery, the anterior tibial artery, the posterior tibial artery, and the peroneal artery were scored on the basis of vessel lumen reduction: 0 if stenoses involved a reduction in the vessel lumen of <50%, 1 if stenoses involved 50 to <75% reduction, 2 if stenoses involved 75 to <100% reduction, and 3 if total occlusion was present. The sum of the points assigned to each of these arteries was called the angiographic score. RESULTS Stenoses causing a vessel lumen reduction ≥50% were detected in 103 patients (99%). Stenoses were also detected in subjects with palpable foot pulses, ankle-brachial indexes ≥1, or transcutaneous oxygen tension ≥50 mmHg. The risk of major amputation was increased significantly when total occlusion was present in the popliteal and infrapopliteal arteries (x2 for trend = 50.57, P < 0.001). No major amputation was carried out in patients with angiographic scores <10; major amputation was carried out in all the patients with scores >14. Multivariate analysis indicated a high angiographic score as an independent risk factor for major amputation (odds ratio 2.32, P = 0.001, CI 1.40–3.84). CONCLUSIONS Angiography permits an exact detection of occlusive arterial disease in subjects with normal results for noninvasive vascular procedures. A score that has a relevant prognostic value for major amputation can be obtained from the evaluation of the extent and diffusion of the stenoses.

Change in Major Amputation Rate in a Center Dedicated to Diabetic Foot Care During the 1980s: Prognostic Determinants for Major Amputation

From 1990 to 1993, 115 diabetic patients were consecutively hospitalized in our diabetologic unit for foot ulcer and 27 (23.5%) major amputations were carried out. The major amputation rate of this series of cases was compared with that occurring in diabetic subjects taken into our hospital for foot ulcer in two previous periods: 1979-1981 (17 major amputations in 42 inpatients or 40.5%) and 1986-1989 (26 major amputations in 78 inpatients or 33.3%). The comparison shows a progressive reduction in major amputation rate [Odds ratio 0.66, 95% confidence interval (CI) 0.46-0.96]. Univariate and multivariate analysis, carried out in the population of the 1990-1993 period, in order to detect the independent factors associated with major amputation show the following prognostic determinants of major amputation: Wagner grade (odds ratio 7.69, CI 1.58-37.53), prior stroke (odds ratio 35.05, CI 3.14-390.53), prior major amputation (odds ratio 3.49, CI 1.26-9.38), transcutaneous oxygen level (odds ratio 1.06, CI 1.01-1.12), and ankle-brachial blood pressure index (odds ratio 4.35, CI 1.58-12.05), while an independent protective role was attributed to hyperbaric oxygen treatment (odds ratio 0.15, CI 0.03-0.64). In accordance with other studies, we, therefore, conclude that a comprehensive protocol as well as a multidisciplinary approach in a dedicated center can assure a decrease in major amputation rate. The parameters of limb perfusion were the modifiable prognostic determinants most strongly predictive for amputation.

The role of spontaneous portosystemic shunts in the course of orthotopic liver transplantation

Abstract. Spontaneous portosystemic shunts are commonly found in cirrhotic patients. Not yet established is their role after orthotopic liver transplantation (OLTx), especially when an increase in portal pressure develops, as during early acute rejection. In this study, 34 cirrhotic patients in a series of 70 OLTx are considered. Each patient had preoperative angiographic assessment, and, in 21 (62 %), large spontaneous portosystemic shunts were evident. In 12 cases the shunts were not affected by the surgical procedure and were present during the postoperative period; in 9 the hepatectomy itself involved interruption of the shunts. The patient population was divided into two groups: patients with postoperative shunts (n = 12) and those without (n= 22). The two groups were similar in age, sex. Childs stage, transplantation variables, and number and grade of rejection episodes. However, mean transaminases (AST) values in the first 2 weeks were significantly higher levels in shunt versus nonshunt patients (421 ± 335 vs 183 ± 126; P < 0.025), and this was even more evident when rejection occurred (626 + 375 vs 195 ±129; P < 0.001). Furthermore, during an acute rejection reaction, three cases showed a true “steal phenomenon” through the large reopened shunts with ischemic damage to the grafts. The data indicate a possible detrimental effect of the spontaneous shunts on graft perfusion and suggest the prophylactic surgical interruption of the residual shunts during the transplantation.

Is percutaneous radiofrequency thermal ablation of hepatocellular carcinoma a safe procedure

Aim To assess the safety and efficacy of percutaneous radiofrequency thermal ablation (RFA) in the treatment of nonsurgical hepatocellular carcinoma (HCC) in daily practice. Methods A total of 63 consecutive patients with HCC (solitary nodule ≤5 cm or 2 nodules ≤3 cm) and cirrhosis were treated with RFA. Majority of the patients had a compensated liver disease (73% Child A) and an early tumor stage (87% CLIP 0 or 1). Indications for treatment were primary HCC therapy (30 patients), adjuvant therapy before liver transplantation (15 patients) or palliation in the remaining 18 patients with progression of HCC despite previous antitumoral treatments. RFA was performed by a 100 kW electrical generator connected to an expandable 10-hook electrode. Results Seventy-one lesions were treated in 80 sessions. Sixteen patients required adjuvant chemoembolization. Mean follow-up was 18±12 months. An objective response was achieved in 87% of patients who underwent primary/adjuvant treatment. Complete histological necrosis was found in 38% of patients who underwent liver transplantation. One, 2 and 3-year survival rates were 95, 76 and 72%, respectively in patients who underwent primary/adjuvant therapy and 82, 68 and 51%, respectively in patients who underwent palliative therapy. Major complications (hemoperitoneum, pleuritis, pneumothorax and sepsis) were observed in 6.3% of the patients. Notably, rapid neoplastic progression was observed in two patients within 2 months after a single RFA session (neoplastic portal thrombosis and plurifocal HCC in one patient and cutaneous seeding and lung metastases in another patient). Conclusions Majority of the HCC patients treated by percutaneous RFA can achieve local control of the tumor in HCCs less than or equal to 3 cm. As the procedure can be associated with major complications and cases of rapid neoplastic dissemination may occur, a more accurate selection of candidates to RFA treatment is advisable.

Feasibility and Effectiveness of Peripheral Percutaneous Transluminal Balloon Angioplasty in Diabetic Subjects With Foot Ulcers

OBJECTIVE The aim of this study was to evaluate the feasibility and effectiveness of this vascular procedure in diabetic inpatients with foot ulcers. RESEARCH DESIGN AND METHODS In 80 consecutive inpatient diabetic subjects with a foot ulcer, an angiographic study of the lower limbs was carried out to evaluate the necessity and possibility of performing vascular procedures. In 22 subjects, vascular procedure was not necessary; in 26 subjects, peripheral transluminal angioplasty was carried out; in 10 subjects, angioplasty was considered impossible and a peripheral bypass graft was performed; and in 22 subjects, no vascular procedure was considered possible. RESULTS Of the 26 angioplasties, 8 were performed in iliac or femoral arteries and 18 were performed in the popliteal artery and its branches. The angioplasty was considered unsuccessful in 4 subjects and successful in 22. After angioplasty, on discharge, parameters of limb perfusion improved significantly: transcutaneous oxygen tension was 27.0 ± 14 mm/Hg on admission and 44.6 ± 14 mm/Hg on discharge (P < 0.001); ankle-brachial index was 0.61 ± 0.23 on admission and 0.77 ± 0.20 on discharge (P = 0.018). Of 22 subjects who underwent successful angioplasty, 21 ended the follow-up of 12 months: during this period, they showed no relapses in the salvaged limb, and their parameters of limb perfusion did not significantly vary. CONCLUSIONS Angioplasty is feasible in a large percentage of diabetic subjects with peripheral occlusive arterial disease and foot ulcer and is often also practicable in the popliteal artery and its branches. In these subjects, angioplasty significantly improves the parameters of limb perfusion. Angioplasty is therefore an important therapeutic tool in ulcerated diabetic foot care.

A caval homograft for Budd-Chiari syndrome due to inferior vena cava obstruction

Transjugular intrahepatic portosystemic shunt (TIPS) is the standard treatment of Budd-Chiari syndrome (BCS) non responsive to medical therapy. However, patients with inferior vena cava (IVC) obstruction proximal to the atrium do not benefit from TIPS and a surgical approach is mandatory. We report the case of BCS due to intrapericardial IVC obstruction. We describe a novel surgical approach using a fresh caval homograft. An attempt to balloon dilatation of the IVC obstruction was complicated by right atrial disruption with tamponade and ventricular fibrillation. Lately, the patient successfully underwent a reconstruction of the cavo-atrial continuity by the interposition of a fresh caval homograft, a novel surgical approach never described before for BCS. Further follow-up revealed progressive reduction and resolution of ascites, and overall clinical improvement. IVC obstruction near to the atrium can be surgically approached with a new technique consisting in inferior vena cava resection and replacement with a caval homograft.

High-intensity focused ultrasound (HIFU) for the treatment of hepatocellular carcinoma: is it time to abandon standard ablative percutaneous treatments?

Hepatocellular Carcinoma (HCC) is the leading cause of death in patients with cirrhosis (1). Despite recent advances in early detection programs and the diffusion of surveillance protocols in patients with cirrhosis, only 30% to 40% of patients are diagnosed at an early stage and can benefit from radical therapies (1).

Sustained islet allograft function after peritransplant treatment using exenatide with and without everolimus.

Islet transplantation represents now a feasible therapeutical option for selected patients with brittle type 1 diabetes mellitus. Islet graft function has progressively improved over time with a success rate in some centers similar to that of whole pancreas transplantation. The first phases after transplantation appear to be critical. Transplanted islets are exposed to an inflammatory reaction that, together with glucotoxicity in the case of suboptimal glycemic control results in significant reduction of cellular vitality. For these reasons, different protocols of recipient treatment were proposed, such as anti-inflammatory drugs or long-acting glucagon-like peptide 1 analogues to improve insulin secretion and overall metabolic balance. The mammalian target of rapamycin inhibitors in particular have a significant antiinflammatory effect; in comparison to sirolimus, everolimus proved to have a most potent effect, higher bioavailability, and a shorter half-life. Ten patients affected by type 1 diabetes mellitus (7 with brittle diabetes and 3 already under immunosuppression therapy for a previous kidney transplantation) were treated for 1 month after intrahepatic islet allotransplantation with low-dose exenatide 5 μg twice/day and 6 of them with everolimus 3 mg 12 hours before and 12 to 18 hours after the first islet transplantation, too. The immunosuppression therapy included induction with polyclonal ALG (or Basiliximab in

The Evaluation of Aortic Diameter Changes During Long-Term Follow-Up After Endovascular Treatment of Acute Blunt Traumatic Thoracic Aortic Injuries:

Purpose: To evaluate the variations in aortic diameters and long-term results in patients who underwent thoracic endovascular aortic repair (TEVAR) for acute blunt traumatic thoracic aortic injuries (BTTAIs). Materials and Methods: We retrospectively evaluated 23 patients with a mean age of 39 years (range: 17-74 years) who underwent TEVAR for BTTAI between October 2000 and November 2014. All of the patients underwent computed tomography angiography (CTA) before hospital discharge as a baseline imaging for the subsequent follow-up examinations. The technical success, overall survival, and complications were evaluated. Furthermore, the aortic diameters outside of the stent-graft (1 cm proximal and 1 cm distal to the stent-graft) and the aortic diameters within the stent-graft (2 cm distal to the proximal end and 2 cm proximal to the distal end) were assessed. The diameters at baseline on CTA were compared with those of the latest available follow-up examination. Results: Technical success was 100% with a mean follow-up of 65.4 months (range: 12-171 months). No death was registered, and 2 (8.7%) of 23 endograft-related complications (1 stent-graft distal infolding and 1 endoleak 2 and 4 months after the procedure, respectively) were observed. An increase in aortic diameter either proximal or distal to the stent-graft (mean value 0.7 and 0.5 mm, respectively) or within the stent-graft (mean value of 0.5 mm for both proximal and distal diameters) was registered (mean follow-up at 65.4 months, range: 12-171 months). Conclusion: Aortic dilatation following TEVAR for BTTAI is minimal during long-term follow-up. Endovascular treatment represents a durable and safe option in acute BTTAIs.

Long-term Effect of Islet Transplantation on Glycemic Variability:

Islet transplantation has been reported to restore normoglycemia and the overall metabolic control in type 1 diabetes mellitus (DM). In the most experienced centers, islet transplantation clinical outcome is similar to that of the whole pancreas transplantation. Long-term islet transplantation function remains a very interesting matter worth discussing. A progressive islet function decrease was reported, probably due to islet exhaustion. In 5 islet-transplanted patients with at least 3-yr follow-up and still insulin independent, their glycemic control was characterized by a blinded retrospective continuous glucose monitoring system (CGMS). Islet transplantation restored glycemic control and glucose variability. Data were compared with patients in the waiting list. All the parameters of glycemic variability tested had improved significantly in patients who had islet transplantation compared with those patients who were on the waiting list. In conclusion, islet transplantation is able to maintain a proper glucose control and normalize glycemic variability in selected patients. A blinded retrospective CGMS is a useful method to characterize glucose homeostasis deeply in vivo in islet-transplanted patients.