Edoardo Scarcello

Altered Metalloproteinase-9 Expression as Least Common Denominator between Varicocele, Inguinal Hernia, and Chronic Venous Disorders

BACKGROUND Varicocele, inguinal hernia, and clinical manifestations related to chronic venous disorders are often associated, and collagen metabolism together with metalloproteinases (MMPs) alterations may be implicated. The aim of this study was to analyze the relationship between these factors. METHODS We evaluated tissue and plasma samples from patients with varicocele, inguinal hernia, and great saphenous vein reflux, who underwent surgical treatment for their conditions. We then analyzed and correlated these findings with MMP levels. RESULTS Significantly higher levels of MMP-1, -2, -12, and -13 were found in patients with inguinal hernia. MMP-9 levels were higher in patients with at least two of the conditions indicated. CONCLUSION MMP-9 seems to be the common thread in various clinical conditions and is related to a more general and progressive disorder of collagen metabolism.

Effects of glucocorticoids and tumor necrosis factor-alpha inhibitors on both clinical and molecular parameters in patients with Takayasu arteritis

Objective: To explore the effect of sequential treatment with glucocorticoid and tumor necrosis factor-alpha inhibitors in patients with Takayasu arteritis (TA). Materials and Methods: In five patients with TA, the effects of the sequential treatment with prednisone for 5-7 months and then with adalimumab (ADA) + methotrexate (MTX) or infliximab + MTX, or with ADA only, for 12 months on both clinical and laboratory findings were evaluated. Results: All treatments improved both symptoms and laboratory parameters without the development of side-effects. Conclusions: It was hypothesized that MMP-9 and neutrophil gelatinase-associated lipocalin could be markers of the response to the treatments.

The role of matrix metalloproteinases and neutrophil gelatinase-associated lipocalin in central and peripheral arterial aneurysms.

INTRODUCTION An association between arterial aneurysms and matrix metalloproteinases (MMPs) has been described previously. MMPs regulate extracellular structural proteins and tissue remodeling. Neutrophil gelatinase-associated lipocalin (NGAL) is involved in the regulation of MMP activity. The aim of this work was to study the relationship between the levels of MMPs and NGAL and arterial aneurysms. METHODS In a multicenter, open-label, parallel groups, prospective study, patients with aneurysmal disease were divided into 2 groups: Group I (with ruptured aneurysm) and group II (with nonruptured aneurysm). Healthy volunteer patients were also enrolled and represented the control group (group III). RESULTS We enrolled 307 patients (107 in group I and 200 in group II) with arterial aneurysm: 49 popliteal, 31 common femoral, 2 superficial femoral, 29 common iliac artery, 3 common carotid, and 193 abdominal aorta. Finally, 11 healthy volunteer patients (9 males and 2 females; age range, 40-70 years; median 56) were enrolled in group III. Enzyme-linked immunosorbent assay and Western blot analysis revealed greater levels of immunoreactive MMP-9 and NGAL in all patients with ruptured aneurysms, both central and peripheral aneurysms, and in the aneurismal vessels. CONCLUSION These results provide potentially important insights to the understanding of the natural history of arterial aneurysms. MMPs and NGAL play a role in development of arterial aneurysms and may represent molecular markers for the prevention of aneurysmal rupture.

Angiosome-targeted revascularisation in diabetic foot ulcers.

Peripheral vascular disease is a common complication of type 2 diabetes and is often more severe and diffuse than in non‐diabetic individuals with a higher risk of major amputations in the lower limbs. Diabetic foot revascularisation using both traditional bypass surgery and endovascular therapy are often burdened by the failure and the inevitable subsequent massive amputation. In this study, we examined the clinical response of diabetic patients with critical limb ischaemia and extended ischaemic wounds, treated with a new angiosome‐based revascularisation technique. In a 3‐year period, nine diabetic patients with imminent amputation threatening and foot ulcers with no feasible arterial revascularisation options were treated by the angiosome‐based surgical technique by means of deep vein arterialisation. The postoperative tcPO2 evaluation showed a mean increase in the cutaneous oxygen tension in all patients treated. The overall survival rates were 88·88%, 88·88% and 77·77% at 12, 24 and 36 months, respectively. Limb salvage was 100% at 1 year and steady at 88·88% thereafter. Surgical deep venous arterialisation might be considered as an extreme alternative to attempt tissue preservation in limbs unfit for conventional arterial revascularisations. This technique would give advantages to the patients in terms of better compliance to the minor amputations and thus avoiding major limb amputations.

Different expressivity of two adjacent mutations of the APC gene.

Aims and background The phenotypic expression of different APC mutations in familial adenomatous polyposis (FAP) is variable: two to three variants of the disease have been defined based on the severity of colonic manifestations. Age of onset and number of polypectomies per person-year of postsurgical follow-up were compared in two FAP families with very close mutation sites in the APC gene, in order to ascertain mutation-specific variation of expressivity. Families and APC mutations Family A (5 patients) carried a newly characterized mutation, a four bp deletion at codon 843. Family B (5 patients) carried a previously identified mutation at codon 835. Results Mean age of onset was 49.7 years in family A and 30.5 years in family B; number of polypectomies per person-year of follow-up was 1.05 for family A and 10.1 for family B (P <0.001). Conclusions There is significant variation of expressivity (allelic heterogeneity) in FAP between two mutations separated by only eight codons, located at the 5’ extremity of APC gene exon 15.

Aortic banding and endovascular aneurysm repair in a case of juxtarenal aortic aneurysm with unsuitable infrarenal neck

The proximal aortic neck is one of the limiting factors for endovascular aneurysm repair (EVAR) and represents a crucial factor for success or failure of the procedure. In contrast to open surgery, where a clamp can be placed suprarenally but the repair performed infrarenally, EVAR requires a good infrarenal neck for durable fixation and seal. In a high-risk surgical 79-year-old patient with juxtarenal aortic aneurysm with unsuitable infrarenal neck, a hybrid procedure was chosen: juxtarenal aortic banding and EVAR. The banding allowed a successful EVAR by reshaping the juxtarenal aneurysmal aortic segment, hence converting a previously untreatable anatomy into a treatable one.

The US imaging in the management of abdominal aortic aneurysm: perspective

The development of surgical techniques depends on the concomitant development of imaging techniques. Imaging with ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) is evolving at rapid pace. The basic need for treatment is mainly important for the endovascular aortic repair (EVAR) that requires information about many different anatomical aspects regarding aneurysmal neck, renal arteries, and diameter of aneurysmal free lumen, aortic bifurcation, diameter and length of iliac vessels. At present, the development of color-Doppler instruments is surely comparable with that of CT and MR imaging, and an important development has been made also for different types of ultrasonographic contrast medium. The intravascular US (IVUS) mode appears particularly important, that allows real-time detection of a lot of information useful in EVAR. At present, in elective treatment US examination plays a role in different steps: • diagnosis • AAA classification (below, iuxta or suprarenal AAA) • per operative management with IVUS mode [1] • postoperative follow-up. In emergency, the US examination has a place first of all as a bedside exam for patients with a suspected ruptured abdominal aortic aneurysm (rAAA). In haemodinamically stable patients the firtsline US examination appears mandatory during an examination of patients to detect the AAA and to avoid misdiagnosis or, in the opposite case, to abstain from undue X-rays exposition. Actually the physical examination allows the detection of an AAA in about 43% [2] of the patients, and its sensibility results lower for an iliac aneurysm, whereas that of US is up to 99% [3]. In haemodinamically instable patients emergency US exam appears at present the only possible evaluation in the immediately preoperative stage, as the CT exam provides an obligatory and dangerous delay. Moreover in haemodinamically instable patients an emergency IVUS exam could integrate the angiography during endovascular treatment of rAAA to better detect needed information,1 but physicians, nurses, and technicians need to work through a learning curve in order to properly interpret the images generated and maximize the usefulness of the technology. Hypothetically abdominal US through a friendlier learning curve could integrate the angiographic valuation to better define the outer diameter and the parietal features of the aortic neck, as the angiography does not reveal localization and extent of the thrombus and/or calcification.

Endovascular treatment in peripheral arterial disease

Endovascular treatment thirty-three after the first published report on angioplasty, continues to be a rapidly evolving field for the treatment of patients with peripheral arterial disease. A multitude of studies detailing technical improvements and innovative developments have been published. The morphology of a lesion may have an influence on the technical outcome, results at follow up and also risk of treatment. The TASC (TransAtlantic Inter-Society Consensus) document introduced a classification system that categorised lesions with regard to their accessibility to either percutaneus treatment or surgery. It categorised lesions into four types with: type A lesions ideal for endovascular approach; type B lesions where endovascular approach is still the preferred technique; type C lesions where surgical approach is preferred and type D lesions where surgery is the option of choice. Today, endovascular practice, percutaneous transluminal angioplasty (PTA) with or without stenting, is used far more frequently for all types of lower extremity occlusive lesions, reflecting the continuing advances in imaging techniques, angioplasty equipment, and endovascular expertise. The role of endovascular intervention, PTA/ stenting, in the treatment of peripheral arterial disease is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes an attractive alternative to surgery and, as most endovascular interventions are performed on brief hospitalizations, hospital costs are cut considerably. Compared with open surgical procedures, endovascular interventions offer comparable or superior long-term rates of success.