Francesco G. Calio

The effects of sulodexide on both clinical and molecular parameters in patients with mixed arterial and venous ulcers of lower limbs

Background Mixed venous and arterial ulcers account for approximately 15%–30% of all venous leg ulcerations. Several studies have shown that matrix metalloproteinases (MMPs) and neutrophil gelatinase-associated lipocalin (NGAL) play a central role in the pathophysiology of venous and arterial diseases. Some studies have shown the efficacy of glycosaminoglycans, such as sulodexide (SDX), in treating patients with leg ulcers. The aim of this study was to evaluate clinical effects of SDX and its correlation with MMPs and NGAL expression in patients with mixed arterial and venous leg ulcers. Methods Patients eligible for this study were of both sexes, older than 20 years, and with a clinical and instrumental diagnosis of mixed ulcer. Results Fifty-three patients of both sexes were enrolled and divided into two groups by means of randomization tables. Group A (treated group) comprised 18 females and ten males (median age: 68.7 years) treated with standard treatment (compression therapy and surgery) + SDX (600 lipoprotein lipase-releasing units/day intramuscularly) for 15 days followed by SDX 250 lipase-releasing units every 12 hours day orally for 6 months as adjunctive treatment. Group B (control group) comprised 17 females and eight males (median age: 64.2 years) treated with standard treatment only (compression therapy and surgery). The type of surgery was chosen according to anatomical level of vein incompetence: superficial venous open surgery and/or subfascial endoscopic perforating surgery. In all enrolled patients, blood samples were collected in order to evaluate the plasma levels of MMPs and NGAL through enzyme-linked immunosorbent assay. These results were compared to another control group (Group C) of healthy individuals. Moreover, biopsies of ulcers were taken to evaluate the tissue expression of MMPs and NGAL through Western blot analysis. Our results revealed that SDX treatment is able to reduce both plasma levels and tissue expression of MMPs improving the clinical conditions in patients with mixed ulcers. Conclusion Inhibition of MMPs could represent a possible therapeutic intervention to limit the progression of leg ulceration. In particular, our findings demonstrate the efficacy of SDX in patients with mixed arterial and venous chronic ulcers of the lower limbs.

Short-term results of a randomized trial examining timing of carotid endarterectomy in patients with severe asymptomatic unilateral carotid stenosis undergoing coronary artery bypass grafting

OBJECTIVE This study evaluated the timing of carotid endarterectomy (CEA) in the prevention of stroke in patients with asymptomatic carotid stenosis >70% receiving a coronary artery bypass graft (CABG). METHODS From January 2004 to December 2009, 185 patients with unilateral asymptomatic carotid artery stenosis >70%, candidates for CABG, were randomized into two groups. In group A, 94 patients received a CABG with previous or simultaneous CEA. In group B, 91 patients underwent CABG, followed by CEA. All patients underwent preoperative helical computed tomography scans, excluding significant atheroma of the ascending aorta or aortic arch. Baseline characteristics of the patients, type of coronary artery lesion, and preoperative myocardial function were comparable in the two groups. In group A, all patients underwent CEA under general anesthesia with the systematic use of a carotid shunt, and 79 patients had a combined procedure and 15 underwent CEA a few days before CABG. In group B, all patients underwent CEA, 1 to 3 months after CABG, also under general anesthesia and with systematic carotid shunting. RESULTS Two patients (one in each group) died of cardiac failure in the postoperative period. Operative mortality was 1.0% in group A and 1.1% in group B (P = .98). No strokes occurred in group A vs seven ipsilateral ischemic strokes in group B, including three immediate postoperative strokes and four late strokes, at 39, 50, 58, and 66 days, after CABG. These late strokes occurred in patients for whom CEA was further delayed due to an incomplete sternal wound healing or because of completion of a cardiac rehabilitation program. The 90-day stroke and death rate was 1.0% (one of 94) in group A and 8.8% (eight of 91) in group B (odds ratio [OR], 0.11; 95% confidence interval [CI], 0.01-0.91; P = .02). Logistic regression analysis showed that only delayed CEA (OR, 14.2; 95% CI, 1.32-152.0; P = .03) and duration of cardiopulmonary bypass (OR, 1.06; 95% CI, 1.02-1.11; P = .004) reliably predicted stroke or death at 90 days. CONCLUSIONS This study suggests that previous or simultaneous CEA in patients with unilateral severe asymptomatic carotid stenosis undergoing CABG could prevent stroke better than delayed CEA, without increasing the overall surgical risk.

Effects of a new nutraceutical substance on clinical and molecular parameters in patients with chronic venous ulceration.

Pathophysiological events involved in the onset of chronic venous ulceration (CVU) are inflammation, activation of polymorphonucleates (PMNs) and secretion of proteases such as matrix metalloproteinases (MMPs), which degrade extracellular matrix (ECM) that is a support for vascular and tissutal wall. MMPs, neutrophil gelatinase‐associated lipocalin (NGAL) and inflammatory cytokines are overexpressed in CVUs and they could play a central role in pathophysiological mechanisms of skin lesion and delayed wound healing. Bioflavonoids, such as diosmin and other compounds, appear to have several provessel function activities including anti‐inflammatory, antioxidant and phlebotonic effects and are widely used in the treatment of chronic venous disease (CVD)‐related problems.

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.

From varices to venous ulceration: the story of chronic venous disease described by metalloproteinases.

Chronic venous disease (CVD) and its most frightening complication, chronic venous ulceration (CVU), represent an important socioeconomic burden in the western world. Metalloproteinases have been identified in the pathogenesis of several vascular diseases such as venous problems. The aim of this study was to evaluate a broad range of metalloproteinases, such as matrix metalloproteinases (MMPs), ADAMs (a disintegrin and metalloproteinases) and ADAMTSs (a disintegrin and metalloproteinases with thrombospondin motifs) and their inhibitors, tissue inhibitor of metalloproteinases (TIMPs) and a related protein, neutrophil gelatinase‐associated lipocalin (NGAL), in patients with CVD in order to correlate their serum levels with each stage of the disease. We performed a multicenter open‐label study that comprised the enrolment of 541 patients with CVD of clinical stages C1–C6, (178 males, 363 females; mean age 57·29, median age 53·72, age range 29–81); 29 subjects without CVD were included in this study (9 males and 20 females; mean age 54·44, median age 50, age range 28–84) as the control group. Enzyme‐linked immunosorbent assay (ELISA) was performed for measuring serum levels of proteases and related proteins. The study found that the serum elevation of MMP‐2, ADAMTS‐1 and ADAMTS‐7 appeared to be correlated with the initial stages of CVD, whereas the serum elevation of MMP‐1, MMP‐8, MMP‐9, NGAL, ADAM‐10, ADAM‐17 and ADAMTS‐4 was particularly involved in skin change complications. This study showed that each stage of CVD may be described by particular patterns of metalloproteinases, and this may have therapeutic implications in discovering new targets and new drugs for the treatment of CVD.

Plasma MMP and TIMP evaluation in patients with deep venous thrombosis: could they have a predictive role in the development of post‐thrombotic syndrome?

Post‐thrombotic syndrome (PTS) is a condition that can develop in about half of the patients with deep vein thrombosis (DVT) of lower limbs.

Biomarkers in post‐reperfusion syndrome after acute lower limb ischaemia

Ischaemia reperfusion (I/R) injury refers to tissue damage caused when blood supply returns to the tissue after a period of ischaemia. Matrix metalloproteinases (MMPs), neutrophil gelatinase‐associated lipocalin (NGAL) and cytokines are biomarkers involved in several vascular complications. The aim of this study was to evaluate the role of MMPs, NGAL and inflammatory cytokines in I/R syndrome. We conducted an open label, multicentric, parallel group study, between January 2010 and December 2013. Patients with acute limb ischaemia were enrolled in this study and were divided into two groups: (i) those subjected to fasciotomy and (ii) those not subjected to fasciotomy, according to the onset of compartment syndrome. Plasma and tissue values of MMPs and NGAL as well as plasma cytokines were evaluated. MMPs, NGAL and cytokine levels were higher in patients with compartment syndrome. Biomarkers evaluated in this study may be used in the future as predictors of I/R injury severity and its possible evolution towards post‐reperfusion syndrome.

Prosthetic bypass for restenosis after endarterectomy or stenting of the carotid artery

Objective: The objective of this study was to evaluate the results of prosthetic carotid bypass (PCB) with polytetrafluoroethylene (PTFE) grafts as an alternative to carotid endarterectomy (CEA) in treatment of restenosis after CEA or carotid artery stenting (CAS). Methods: From January 2000 to December 2014, 66 patients (57 men and 9 women; mean age, 71 years) presenting with recurrent carotid artery stenosis ≥70% (North American Symptomatic Carotid Endarterectomy Trial [NASCET] criteria) were enrolled in a prospective study in three centers. The study was approved by an Institutional Review Board. Informed consent was obtained from all patients. During the same period, a total of 4321 CEAs were completed in the three centers. In these 66 patients, the primary treatment of the initial carotid artery stenosis was CEA in 57 patients (86%) and CAS in nine patients (14%). The median delay between primary and redo revascularization was 32 months. Carotid restenosis was symptomatic in 38 patients (58%) with transient ischemic attack (n = 20) or stroke (n = 18). In this series, all patients received statins; 28 patients (42%) received dual antiplatelet therapy, and 38 patients (58%) received single antiplatelet therapy. All PCBs were performed under general anesthesia. No shunt was used in this series. Nasal intubation to improve distal control of the internal carotid artery was performed in 33 patients (50%), including those with intrastent restenosis. A PTFE graft of 6 or 7 mm in diameter was used in 6 and 60 patients, respectively. Distal anastomosis was end to end in 22 patients and end to side with a clip distal to the atherosclerotic lesions in 44 patients. Completion angiography was performed in all cases. The patients were discharged under statin and antiplatelet treatment. After discharge, all of the patients underwent clinical and Doppler ultrasound follow‐up every 6 months. Median length of follow‐up was 5 years. Results: No patient died, sustained a stroke, or presented with a cervical hematoma during the postoperative period. One transient facial nerve palsy and two transient recurrent nerve palsies occurred. Two late strokes in relation to two PCB occlusions occurred at 2 years and 4 years; no other graft stenosis or infection was observed. At 5 years, overall actuarial survival was 81% ± 7%, and the actuarial stroke‐free rate was 93% ± 2%. There were no fatal strokes. Conclusions: PCB with PTFE grafts is a safe and durable alternative to CEA in patients with carotid restenosis after CEA or CAS in situations in which CEA is deemed either hazardous or inadvisable.

Results of axillofemoral by-passes for aorto-iliac occlusive disease

The purpose of this study was to review our results with axillofemoral by-passes performed for aortoiliac occlusive disease. Fifty patients receiving 51 axillofemoral by-passes from January 1989 to December 1994 were retrospectively reviewed. The 30-day post-operative mortality was 4%. Seven patients (14%) presented graft-related local complications and all but one required reoperation. Five patients were lost to follow-up, the mean length of which was 36 months (16–74 months). Forty-nine per cent of the patients died during the follow-up period. At 36 months, the primary patency rate was 51%, the secondary patency rate was 69%, and limb valvage rate was 87%. A statistical difference was seen in the secondary patency rate between axillobifemoral by-pass (87%) and axillo-unifemoral by-pass (56%) at 36 months (P<0.01), but no difference was seen in the limb salvage rate at 36 months between the two configurations of the by-pass (94% vs 81 %) (P=NS). Twenty patients (40%) operated upon for acute ischemia had a significantly higher post-operative mortality rate (10% vs 0), a significantly higher amputation rate (20% vs 6.6%) and a significantly lower patency rate of by-pass (26% vs 63%) (P<0.01), than the 30 patients (60%) operated on for claudication, rest pain or trophic ulcers. Our findings indicate that the results of axillofemoral by-pass are significantly influenced by the selection of patients for operation, namely the clinical status of ischaemic symptoms, and that since the overall results of axillofemoral by-pass are inferior to those of aortofemoral by-pass, this treatment should be restricted to patients at high risk of aortic clamping.ZusammenfassungEs wurden 51 axillofemorale By-passoperationen aus dem Zeitraum Januar 1989 bis Dezember 1994 retrospektiv analysiert. Die postoperative Mortalitätsrate (nach 30 Tagen) betrug 4%. Bei 7 Patienten (14%) traten am Graft Komplikationen ein, so daß 6 von ihnen reoperiert werden mußten. In die Nachuntersuchung (mittleres Follow-up: 36 Monate, Spanne: 16–74 Monate) konnten 5 Patienten nicht einbezogen werden. Während der Follow-up-Periode verstarben 49% der Patienten. Nach 36 Monaten betrug die primäre Durchflußwiederherstellungsrate 51%, die sekundäre 69%, die Sanierungsrate im betroffenen Glied 87%. Statistisch gab es nach 36 Monaten bei der sekundären Durchflußwiederherstellungsrate einen Unterschied zwischen axillo-bifemoralen (87%) und axillo-uni-femoralem Bypass (56%) (p<0,01), aber hinsichtlich der Heilungsrate gab es zu diesem Zeitpunkt zwischen den beiden Bypass-Arten keinen signifikanten Unterschied (94% vs. 81%). Die postoperative Mortalitätsrate war bei 20 Patienten (40%), die wegen akuter Ischämie operiert worden waren, signifikant höher (10% vs. 0%); ebenso die Amputationsrate (20% vs. 6,6%); signifikant niedriger hingegen war die Durchflußwiederherstellungsrate nach Bypass (26% vs. 63%) (p<0,01) —im Vergleich zu 30 Patienten (60%), die wegen Claudicatio, Ruheschmerz oder trophischen Ulzera operiert worden waren. Nach unseren Untersuchungen sind die Ergebnisse bei axillofemoralen Bypassoperationen entscheidend abhängig von der Auswahl der Patienten gemäß klinischem Zustand und ischämischen Symptomen. Die Gesamtergebnisse nach axillofemoralem Bypass sind schlechter als nach aortofemoralem Bypass, und darum sollte die erstgenannte Operation nur bei Patienten angewendet werden, bei denen die Abklemmung der Aorta ein hohes Risiko darstellen würde.

PredyCLU: a prediction system for chronic leg ulcers based on fuzzy logic; part I - exploring the venous side.

Chronic leg ulcers (CLUs) are a common occurrence in the western population and are associated with a negative impact on the quality of life of patients. They also cause a substantial burden on the health budget. The pathogenesis of leg ulceration is quite heterogeneous, and chronic venous ulceration (CVU) is the most common manifestation representing the main complication of chronic venous disease (CVD). Prevention strategies and early identification of the risk represent the best form of management. Fuzzy logic is a flexible mathematical system that has proved to be a powerful tool for decision‐making systems and pattern classification systems in medicine. In this study, we have elaborated a computerised prediction system for chronic leg ulcers (PredyCLU) based on fuzzy logic, which was retrospectively applied on a multicentre population of 77 patients with CVD. This evaluation system produced reliable risk score patterns and served effectively as a stratification risk tool in patients with CVD who were at the risk of developing CVUs.