Carlo Andrea Reale

The “Safari” Technique to Perform Difficult Subintimal Infragenicular Vessels

The purpose of this study was to describe the efficacy of planned combined subintimal arterial flossing with antegrade–retrograde intervention (SAFARI) to obtain the precise recanalization of the patent portion of a distal runoff vessel in critical limb ischemia (CLI) patients presenting long occlusions involving the popliteal trifurcation. Four patients at risk of limb loss due to long occlusions involving the leg vessel tree and not suitable for a surgical bypass were treated by the subintimal antegrade and retrograde (posterior tibial or anterior tibial artery) approach. The patent portion of the runoff vessel was previously assessed by magnetic resonance angiography (MRA) and directly punctured under Doppler ultrasound (US) guidance. A subintimal channel rendezvous was performed to allow snaring of the guidewires. Subsequently, a balloon dilatation was performed without stent deployment. All patients were successfully recanalized and had complete healing of the limb lesions. At the 12-month follow-up all patients showed clinical improvement with no major complications related to the procedure. This combined antegrade and retrograde subintimal approach is currently an excellent endovascular option in patients with long occlusions extending onto the leg vessels trifurcation and at risk of limb loss.

Male varicocele: transcatheter foam sclerotherapy with sodium tetradecyl sulfate--outcome in 244 patients.

PURPOSE To retrospectively evaluate the recurrence rate, resolution of pain, improvement of semen parameters, and achievement of pregnancy after transcatheter foam sclerotherapy (TCFS) in varicocele by using sodium tetradecyl sulfate (STS) foam. MATERIALS AND METHODS The institutional review board approved the study; informed consent was waived. A retrospective study was conducted in 244 consecutive male patients (mean age, 28.2 years; range, 17-42 years) with 280 varicoceles treated with TCFS between January 2000 and January 2004. The gonadal vein was selectively catheterized by using left antecubital transbrachial venous access; a foam of 3% STS and air was injected. Follow-up was performed with physical and Doppler ultrasonographic examinations and by using a questionnaire-based assessment of pain and pregnancy. Semen analysis was performed according to World Health Organization guidelines. Significant differences in semen parameters before and after treatment were determined by using the Wilcoxon signed rank test. RESULTS Technical success rate was 97.1% (272 varicoceles). Complete follow-up results (mean, 40.3 months +/- 19.46 [standard deviation]) in 225 varicoceles (80.4%) revealed eight (3.6%) grade II-III recurrent varicoceles and resolution of pain in 164 (96.5%) of 170 cases. Statistically significant improvement of all semen parameters was achieved in infertile patients after treatment (P < .001). Of 59 patients with pretreatment sperm alterations who desired pregnancy, 23 (39.0%) achieved pregnancy (mean follow-up, 28.6 months +/- 7.77). CONCLUSION TCFS in male varicocele with 3% STS foam was associated with a low recurrence rate, a high rate of pain resolution, and a significant improvement of pretreatment sperm parameter alterations; a substantial increase in pregnancy achievement was obtained for patients with pretreatment sperm alterations who desired pregnancy.

Intra-arterial Thrombectomy versus Standard Intravenous Thrombolysis in Patients with Anterior Circulation Stroke Caused by Intracranial Arterial Occlusions: A Single-center Experience

BACKGROUND Severely impaired patients with persisting intracranial occlusion despite standard treatment with intravenous (IV) administration of recombinant tissue plasminogen activator (rtPA) or presenting beyond the therapeutic window for IV rtPA may be candidates for interventional neurothrombectomy (NT). The safety and efficacy of NT by the Penumbra System (PS) were compared with standard IV rtPA treatment in patients with severe acute ischemic stroke (AIS) caused by large intracranial vessel occlusion in the anterior circulation. METHODS Consecutive AIS patients underwent a predefined treatment algorithm based on arrival time, stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS) score, and site of arterial occlusion on computed tomographic angiography (CTA). NT was performed either after a standard dose of IV rtPA (bridging therapy [BT]) or as single treatment (stand-alone NT [SAT]). Rates of recanalization, symptomatic intracranial bleeding (SIB), mortality, and functional outcome in NT patients were compared with a historical cohort of IV rtPA treated patients (i.e., controls). Three-month favourable outcome was defined as a modified Rankin Scale (mRS) score ≤2. RESULTS Forty-six AIS patients were treated with NT and 51 with IV rtPA. The 2 groups did not differ with regard to demographics, onset NIHSS score (18.5±4 v 17±5; P=.06), or site of intracranial occlusion. Onset-to-treatment time in the NT and IV rtPA groups was 230 minutes (±78) and 176.5 (±44) minutes, respectively (P=.001). NT patients had significantly higher percentages of major improvement (≥8 points NIHSS score change at 24 hours; 26% v 10%; P=.03) and partial/complete recanalization (93.5% v 45%; P<.0001) compared to controls. Treatment by either SAT or BT similarly improved the chance of early recanalization and early clinical improvement. No significant differences were observed in the rate of SIB (11% v 6%), 3-month mortality (24% v 25%), or favorable outcome (40% v 35%) between NT and IV rtPA patients. CONCLUSIONS Despite significantly delayed time of intervention, NT patients had higher rates of recanalization and early major improvement, with no differences in symptomatic intracranial hemorrhages. Early NIHSS score improvement did not translate into better 3-month mortality or outcome. NT seems a safe and effective adjuvant treatment strategy for selected patients with severe AIS secondary to large intracranial vessel occlusion in the anterior circulation.

Management of Biliary Neoplastic Obstruction with Two Different Metallic Stents Implanted in One Session

The efficacy of the “one-step” technique using two different metallic stents (Wallstent and Ultraflex) and associated rate of complications was studied in 87 patients with jaundice secondary to malignant biliary obstruction, with bilirubin level less than 15 mg/dl and Bismuth type 1 or 2 strictures. The study group, composed of 40 men and 47 women with a mean age of 59.4 years (range 37–81 years), was treated with a “one-step” percutaneous transhepatic implantation of self-expanding stents. The cause of the obstruction was pancreatic carcinoma in 38 patients (44%), lymph node metastasis in 20 patients (23%), gallbladder carcinoma in 13 patients (15%), cholangiocarcinoma in 12 patients (14%) and ampullary carcinoma in four patients (5%). A significant reduction in jaundice was obtained in all but one patient, with a drop of total serum bilirubin level from a mean of 13.7 mg/dl to 4.3 mg/dl within the first 4 days. The mean postprocedural hospitalization period was 5.4 days in the Wallstent group and 6.4 days in the Ultraflex group. Mean survival rate was 7.8 months (Wallstent group) and 7.1 months (Ultraflex group). The use of both stents did not reveal any significant difference in parameters tested. The implantation of these self-expandable stents in one session, in selected patients, is clinically effective, devoid of important complications and cost-effective due to the reduction in hospitalization.

Prevalence study of chronic cerebrospinal venous insufficiency in patients with multiple sclerosis: preliminary data.

PurposeThis study aimed to evaluate the prevalence of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS).Material and methodsFrom November 2009 to February 2010, 74 participants (40 MS patients and 34 healthy controls) were enrolled in a randomised singleblind prospective study. All participants underwent ultrasonography (US) to detect signs of CCSVI.ResultsCCSVI was detected in 55% of patients in the MS group and 35% in the control group; the difference was not statistically significant (p=0.089).ConclusionsIn our experience, a slight difference exists in the prevalence of CCSVI between MS and healthy controls, but it is not as yet clear which parameters may be most significant. This preliminary study failed to show a statistically significant difference in the prevalence of CCSVI among patients affected by MS. It did, however, reveal a tendency that requires a larger number of patients to achieve statistically significant results.RiassuntoObiettivoScopo del presente lavoro è stato valutare la prevalenza dell’insufficienza venosa cerebrospinale cronica (CCSVI) in soggetti affetti da sclerosi multipla (SM).Materiali e metodiDa novembre 2009 a febbraio 2010 74 soggetti (40 affetti da SM e 34 casi controllo) sono stati arruolati in uno studio prospettico randomizzato a singolo cieco. Tutti i soggetti sono stati sottoposti ad ecografia per la ricerca di segni di CCSVI.RisultatiLo studio ha evidenziato una percentuale di pazienti affetti da CCSVI del 55%, nel gruppo dei pazienti affetti da SM, e del 35% nel gruppo controllo con una differenza statisticamente non significativa (p=0,089).ConclusioniEsiste una lieve differenza di prevalenza di CCSVI tra i soggetti affetti da SM e quelli sani nella nostra valutazione, ma ad oggi non sono stati individuati quali tra i numerosi parametri siano i più significativi. Da questo studio preliminare, non è emersa una differenza statisticamente significativa nella prevalenza della CCSVI in pazienti affetti da SM. Tuttavia i dati indicano una tendenza che richiede un più alto numero di pazienti per ottenere risultati definitivi.Purpose. This study aimed to evaluate the prevalence of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS). Material and methods. From November 2009 to February 2010, 74 participants (40 MS patients and 34 healthy controls) were enrolled in a randomised singleblind prospective study. All participants underwent ultrasonography (US) to detect signs of CCSVI. Results. CCSVI was detected in 55% of patients in the MS group and 35% in the control group; the difference was not statistically significant (p=0.089). Conclusions. In our experience, a slight difference exists in the prevalence of CCSVI between MS and healthy controls, but it is not as yet clear which parameters may be most significant. This preliminary study failed to show a statistically significant difference in the prevalence of CCSVI among patients affected by MS. It did, however, reveal a tendency that requires a larger number of patients to achieve statistically significant results.

Superselective embolization in posttraumatic priapism with glubran 2 acrylic glue.

Two patients with posttraumatic priapism underwent transcatheter embolization using microcoils, resulting in temporary penile detumescence and an apparent resolution of the artero-venous fistula. In both cases, priapism recurred 24 hours after the procedure and was successfully treated through selective transcatheter embolization of the nidus using acrylic glue (Glubran 2). The patients showed complete recovery of sexual activity within 30 days from the procedure and persistent exclusion of the artero-venous fistula after a 12-month follow-up.

Carotid artery stenting: findings based on 8 years’ experience

PurposeCarotid artery stenting (CAS) may be an alternative to surgical endarterectomy not only in high-risk patients. Few data are available regarding the long-term clinical efficacy of CAS with the use of cerebral protection devices and the incidence of restenosis. Our experience demonstrates that if certain requirements are fulfilled, CAS can be considered a safe and effective treatment with high short-and long-term success rates.Materials and methodsIn the past 8 years, we treated 1,003 patients (1,096 arteries) affected by internal carotid artery stenosis, 93 with bilateral stenosis. Of these, 567 (51.74%) were symptomatic and 529 (48.26%) asymptomatic lesions. The preprocedural evaluation was performed with Doppler ultrasound (US), magnetic resonance (MR) angiography/computed tomography (CT) angiography and a neurological evaluation. Antiplatelet therapy was administered before and after the procedure.ResultsTechnical success was achieved in 1,092 cases (99.6%), and a cerebral protection device was successfully used in 1,019 procedures (92.9%). The 30-day transient ischaemic attack (TIA)/stroke/death rate was 2.16%: death (0.18%) major stroke (0.45%) and minor stroke/TIA (1.53%). During a follow-up up to 8 years, restenoses occurred in 39 cases (3.57%), of which 28 were post-CAS (2.57%) and 11 post-CAS performed for restenosis after carotid endarterectomy (1%). Only five symptomatic restenoses >80% were treated with a repeated endovascular procedure.ConclusionsA retrospective analysis of our experience suggests that CAS is a safe and effective procedure with better results than endarterectomy. In up to 8 years of follow-up, CAS seems to be effective in preventing stroke, with a low restenosis rate.RiassuntoObiettivoLo stenting carotideo può essere considerato un’alternativa all’endoarterectomia, non solo in pazienti ad alto rischio chirurgico. Attualmente sono pochi i dati disponibili sull’efficacia clinica a lungo termine del CAS con utilizzo del sistema di protezione cerebrale e sull’incidenza di restenosi, ma la nostra esperienza dimostra come, se soddisfatti alcuni presupposti, il CAS può essere considerato un trattamento sicuro ed efficace sia a breve sia a lungo termine.Materiali e metodiNegli ultimi otto anni abbiamo trattato 1003 pazienti (1096 arterie) con stenosi dell’arteria carotide interna, di cui 93 trattati per stenosi bilaterale. Le lesioni sintomatiche sono state 567 (51,74%), le asintomatiche 529 (48,26%). La valutazione diagnostica pre-procedurale è stata effettuata con US doppler, angio-RM/angio-TC ed esame neurologico. La terapia antiaggregante è stata somministrata a tutti i pazienti prima e dopo la procedura.RisultatiIl successo tecnico è stato ottenuto in 1092 casi (99.6 %) ed il sistema di protezione cerebrale è stato impiegato con successo in 1019 procedure (92,9%). L’incidenza a 30 giorni di TIA/stroke e morte è stata del 2,16%, così suddivisa: morte (0,18%), major stroke (0,45%) e minor stroke-TIA (1,53%). Il follow-up fino ad 8 anni ha mostrato una restenosi in 39 casi (3,57%), di queste 28 post-CAS (2,57%) ed 11 post-CAS per restenosi post-TEA (1%). Sono state ritrattate solo 5 restenosi >80% in pazienti sintomatici con nuova procedura endovascolare.ConclusioniNella nostra esperienza, valutata retrospettivamente, il CAS sembra essere un trattamento sicuro ed efficace con risultati migliori rispetto a quanto riportato per l’endoarterectomia. Nel follow-up fino ad 8 anni il CAS appare efficace nella prevenzione dello stroke con bassa incidenza di restenosi.

Prevalence study of chronic cerebrospinal venous insufficiency in patients with multiple sclerosis: preliminary data@@@Studio di prevalenza della insufficienza venosa cerebrospinale cronica nei pazienti affetti da sclerosi multipla: dati preliminari

PurposeThis study aimed to evaluate the prevalence of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS).Material and methodsFrom November 2009 to February 2010, 74 participants (40 MS patients and 34 healthy controls) were enrolled in a randomised singleblind prospective study. All participants underwent ultrasonography (US) to detect signs of CCSVI.ResultsCCSVI was detected in 55% of patients in the MS group and 35% in the control group; the difference was not statistically significant (p=0.089).ConclusionsIn our experience, a slight difference exists in the prevalence of CCSVI between MS and healthy controls, but it is not as yet clear which parameters may be most significant. This preliminary study failed to show a statistically significant difference in the prevalence of CCSVI among patients affected by MS. It did, however, reveal a tendency that requires a larger number of patients to achieve statistically significant results.RiassuntoObiettivoScopo del presente lavoro è stato valutare la prevalenza dell’insufficienza venosa cerebrospinale cronica (CCSVI) in soggetti affetti da sclerosi multipla (SM).Materiali e metodiDa novembre 2009 a febbraio 2010 74 soggetti (40 affetti da SM e 34 casi controllo) sono stati arruolati in uno studio prospettico randomizzato a singolo cieco. Tutti i soggetti sono stati sottoposti ad ecografia per la ricerca di segni di CCSVI.RisultatiLo studio ha evidenziato una percentuale di pazienti affetti da CCSVI del 55%, nel gruppo dei pazienti affetti da SM, e del 35% nel gruppo controllo con una differenza statisticamente non significativa (p=0,089).ConclusioniEsiste una lieve differenza di prevalenza di CCSVI tra i soggetti affetti da SM e quelli sani nella nostra valutazione, ma ad oggi non sono stati individuati quali tra i numerosi parametri siano i più significativi. Da questo studio preliminare, non è emersa una differenza statisticamente significativa nella prevalenza della CCSVI in pazienti affetti da SM. Tuttavia i dati indicano una tendenza che richiede un più alto numero di pazienti per ottenere risultati definitivi.Purpose. This study aimed to evaluate the prevalence of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS). Material and methods. From November 2009 to February 2010, 74 participants (40 MS patients and 34 healthy controls) were enrolled in a randomised singleblind prospective study. All participants underwent ultrasonography (US) to detect signs of CCSVI. Results. CCSVI was detected in 55% of patients in the MS group and 35% in the control group; the difference was not statistically significant (p=0.089). Conclusions. In our experience, a slight difference exists in the prevalence of CCSVI between MS and healthy controls, but it is not as yet clear which parameters may be most significant. This preliminary study failed to show a statistically significant difference in the prevalence of CCSVI among patients affected by MS. It did, however, reveal a tendency that requires a larger number of patients to achieve statistically significant results.

Studio di prevalenza della insufficienza venosa cerebrospinale cronica nei pazienti affetti da sclerosi multipla: dati preliminari

PurposeThis study aimed to evaluate the prevalence of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS).Material and methodsFrom November 2009 to February 2010, 74 participants (40 MS patients and 34 healthy controls) were enrolled in a randomised singleblind prospective study. All participants underwent ultrasonography (US) to detect signs of CCSVI.ResultsCCSVI was detected in 55% of patients in the MS group and 35% in the control group; the difference was not statistically significant (p=0.089).ConclusionsIn our experience, a slight difference exists in the prevalence of CCSVI between MS and healthy controls, but it is not as yet clear which parameters may be most significant. This preliminary study failed to show a statistically significant difference in the prevalence of CCSVI among patients affected by MS. It did, however, reveal a tendency that requires a larger number of patients to achieve statistically significant results.RiassuntoObiettivoScopo del presente lavoro è stato valutare la prevalenza dell’insufficienza venosa cerebrospinale cronica (CCSVI) in soggetti affetti da sclerosi multipla (SM).Materiali e metodiDa novembre 2009 a febbraio 2010 74 soggetti (40 affetti da SM e 34 casi controllo) sono stati arruolati in uno studio prospettico randomizzato a singolo cieco. Tutti i soggetti sono stati sottoposti ad ecografia per la ricerca di segni di CCSVI.RisultatiLo studio ha evidenziato una percentuale di pazienti affetti da CCSVI del 55%, nel gruppo dei pazienti affetti da SM, e del 35% nel gruppo controllo con una differenza statisticamente non significativa (p=0,089).ConclusioniEsiste una lieve differenza di prevalenza di CCSVI tra i soggetti affetti da SM e quelli sani nella nostra valutazione, ma ad oggi non sono stati individuati quali tra i numerosi parametri siano i più significativi. Da questo studio preliminare, non è emersa una differenza statisticamente significativa nella prevalenza della CCSVI in pazienti affetti da SM. Tuttavia i dati indicano una tendenza che richiede un più alto numero di pazienti per ottenere risultati definitivi.Purpose. This study aimed to evaluate the prevalence of chronic cerebrospinal venous insufficiency (CCSVI) in patients with multiple sclerosis (MS). Material and methods. From November 2009 to February 2010, 74 participants (40 MS patients and 34 healthy controls) were enrolled in a randomised singleblind prospective study. All participants underwent ultrasonography (US) to detect signs of CCSVI. Results. CCSVI was detected in 55% of patients in the MS group and 35% in the control group; the difference was not statistically significant (p=0.089). Conclusions. In our experience, a slight difference exists in the prevalence of CCSVI between MS and healthy controls, but it is not as yet clear which parameters may be most significant. This preliminary study failed to show a statistically significant difference in the prevalence of CCSVI among patients affected by MS. It did, however, reveal a tendency that requires a larger number of patients to achieve statistically significant results.