Francesco Stilo

Perioperative Iloprost and Endothelial Progenitor Cells in Uremic Patients With Severe Limb Ischemia Undergoing Peripheral Revascularization

The incidence of severe limb ischemia (SLI) is high among haemodialysis (HD) patients. Limb rescue rate after surgical revascularization is relatively poor compared with patients with normal renal function. Prostanoids are an interesting category as adjuvants to revascularization. New vessel growth develops not exclusively by proliferation of endothelial cells in vascular extremities but also by cells mobilized from the bone marrow (HSC), transformed into endothelial progenitor cells (EPC) contributing to both re-endothelialization and neovascularization. Basal number of HSC and EPC is significantly reduced in HD patients and correlated with a subsequent defective neovascularization. The aim of this study was to evaluate the effects of perioperative treatment with iloprost in uremic patients with acute ischemia of lower limbs, undergoing surgical revascularization, on endothelial progenitor cells, hypothesizing a possible biological mechanism induced by the prostanoids. A search was also made for vascular remodeling processes through the analysis of the concentrations of soluble adhesion molecules (i-CAM, v-CAM, e-selectin), biochemical markers of endothelial activation. Thirty HD patients with SLI undergoing peripheral revascularization were enrolled (15 were treated with iloprost and 15 with a placebo). Iloprost was administered as an intra-arterial bolus of 3000 ng over 1 to 3 min immediately after revascularization and in the same affected artery. Serum samples were taken before revascularization (T0), at 6 (T6) and 24 h (T24) after infusion to measure sICAM-1, sE-selectin, and sVCAM-1, and for quantification of HSC and EPC. Progenitors were identified by specific surface markers CD34+, CD133+ and VEGFR2+. Count was conducted using PROCOUNT performed in a TRUCOUNT tube and with a FACSort flow cytometer. Before revascularization, all patients showed a decreased number of HSC and EPC. After 6 h, HSC augmented significantly compared with T0 in both groups. The iloprost group attained a significant increase compared with the placebo group. HSC levels reduced drastically at T24. EPC augmented significantly compared with basal level after 24 h. In the iloprost group, the increase was considerable compared with the placebo group. A close negative correlation, assessed by Pearson coefficient (r), was found between HSC and EPC at T24 in the iloprost group (R = 0.82 P < 0.01). Adhesion molecules had increased levels at T6 and T24 in both groups. Moreover, a close positive correlation, assessed by Pearson coefficient, was found between EPC and adhesion molecules in both groups but the iloprost group maintained a better statistical association. Revascularization stimulated HSC and EPC release from bone marrow but at a different time: HSC increased suddenly at 6 h and diminished to a minimal amount at T24, conversely, EPC increased significantly only at T24. Iloprost treatment was able to amplify this mechanism validating recent findings (North TE et al., [31]). Adhesion molecules as markers of endothelial activation and vascular development confirmed this tendency.

Involvement of the aorta in brucellosis: the forgotten, life-threatening complication. A systematic review.

Human brucellosis is a disease of protean manifestations, and has been implicated in complications and focal disease in many human organ systems. However, little is collectively known about the background, the course, the clinical characteristics, the diagnostic issues raised, and the short- and long-term therapeutic approaches in patients with aortic involvement as a complication of brucellosis. With the aim to glean from the literature useful information to better understand and manage this complication, a computerized search without language restriction was conducted using PubMed and SCOPUS. An article was considered eligible for inclusion in the systematic review if it reported data on patients with involvement of the aorta due to a Brucella infection. The epidemiologic and clinical characteristics of 44 cases of brucellar aortic involvement found through the systematic review of the literature were analyzed together with those of two new cases that we treated in the recent past. This complication involved the ascending thoracic aorta in 18 cases (in 16 of them as a consequence of brucellar endocarditis), and the descending thoracic aorta or the abdominal aorta in the remaining 30 cases. In the latter it was associated with spondylodiscitis of the lumbar spine in 13 cases. History of or symptoms indicative of brucellosis were not universally present. Brucellar aortic involvement represents a possibly underdiagnosed and underreported complication with major morbidity and mortality potential. Experience with novel invasive therapeutic approaches remains limited. Early suspicion through detailed history and diagnosis, aided by advances in aortic imaging, would allow for better planning of therapeutic interventions.

Spinal cord stimulation to achieve wound healing in a primary lower limb critical ischaemia referral centre

Critical lower limb ischaemia is a diffuse pathology that could cause claudication, severe ischaemic pain and tissue loss. The common treatment includes modification of risk factors, pharmacological therapy and endovascular or surgical revascularisation of the lower limb to restore a pulsatile flow distally. Spinal cord stimulator is seen as a valid alternative in patients unsuitable for revascularisation after endovascular or surgical revascularisation failure and as adjuvant therapy in the presence of a functioning bypass in patients with extensive tissue loss and gangrene presenting a slow and difficult wound healing. We report our experience on spinal cord stimulation (SCS) indication and implantation in patients with critical lower limb ischaemia, at a high‐volume centre for the treatment of peripheral arterial disease.

A simple technique to achieve bloodless excision of carotid body tumors

We describe a technique for Shamblin II-III carotid body tumor (CBT) resection to reduce bleeding and neurologic complications during surgery. The technique was based on the fact that CBTs are supplied almost exclusively from the external carotid artery. Therefore, we carefully isolated the origin of the external carotid artery and its distal branches outside the tumor and temporarily clamped all of these vessels after heparin administration. This allowed a safe and bloodless resection as the tumor was dissected from the internal carotid artery in the usual subadventitial plane. The internal carotid artery was never clamped, and respect of peripheral nerves was warranted in the clean and bloodless field. From 2007 to 2010, we treated 11 patients with a CBT: six had a Shamblin II and five had a Shamblin III lesion. Neither perioperative neurologic events nor recurrences occurred after a mean follow-up of 42 months.

Femoro-Distal Bypass with Varicose Veins Covered by Prosthetic Mesh

BACKGROUND The great saphenous vein (GSV) is the material of choice in distal bypass for critical limb ischemia (CLI). Varicosities have been reported as the cause of inadequacy of vein in up to 20% of patients. The hypothesis of this study is to consider the external mesh as a technique to use like conduit, in patients with varicose veins and in young patients with ecstatic veins, with results that at least overlap the traditional technique. We report our experience with bypass surgery using autologous varicose vein covered with prosthetic mesh. MATERIALS AND METHODS From May 2005 to July 2008, 249 infrapopliteal bypasses were performed to treat CLI. Twenty-one patients were selected from this group to receive bypass covered by polyester external mesh (ProVena; BBraun, Aesculap, Tuttlingen, Germany). Seventeen patients had varicose veins, four young patients had venous ectasia or previous bypass failure for dilatation. Graft patency was evaluated at 1, 3, 6, and 12 mo, and every 6 mo thereafter. All patients underwent epidural anesthesia with ropivacain 0.75%. RESULTS The mean follow-up time was 32 mo. No dilatation or infection was found in this period. Two early bypass thromboses were recorded and treated immediately. Two lesions were treated at 3 and 8 mo with surgical substitution of the distal portion and PTA of focal intermediate stenosis, respectively. Primary patency at 24 mo was 57.1% (SE ± 3.9), assisted 81% (SE ± 3.2), and had an amputation-free survival rate of 85.7% (SE ± 2.8). In other bypass without mesh, primary patency was 63.8%, secondary 80.5%, and amputation-free survival rate 89.3% at 24 mo. CONCLUSION Polyester external mesh is a valid method to perform bypass with autologous material, as ecstatic or varicose veins. Moreover, in young patients with long-term bypass patency expectancy, it prevents vein dilatation during arterialization process.

Effectiveness of prostaglandin E1 in patients with mixed arterial and venous ulcers of the lower limbs

Mixed arterial and venous ulcers of the lower limbs are present in around 15–30% of patients with chronic venous ulcers (CVUs) and are considered difficult‐to‐heal wounds. The aim of this study was to evaluate the results of the treatment of mixed arterial and venous ulcers of the lower limbs with prostaglandin E1 (PGE1) infusion. This study was carried out in 48 consecutive patients. Patients who showed intolerability to PGE1, and patients with peripheral neuropathy, blood or systemic diseases, malignancy and acute wound infections or necrotic tissue on the wound bed were excluded. The patients were separated at random into two main groups: group I (25 patients) received standard treatment and PGE1 infusion. Group II (23 patients) received only standard treatment. Pre‐treatment data indicated the area of ulceration. The number of healed ulcers and the variation in the area of ulceration were considered as endpoints. The endpoints were noticed after 120 days from the beginning of treatment. Healing occurred in 80% of limbs of group I and in 52·2% of limbs of group II patients. The average reduction in area was 92% versus 60% in patients of group I and II, respectively. During the whole treatment period, the incidence of adverse events was 8% in group I: there was one case of headache and one case of headache and hypotension combined. No side effects were recorded in patients of group II. In conclusion, PGE1 infusion is a determinant in the reduction of the healing time of mixed ulcers of the lower limbs.

Endo First Is Not Appropriate in Some Patients with Critical Limb Ischemia because “Bridges Are Burned”

BACKGROUND The aims of this study were to determine the effect of failed prior endovascular treatment (EV) on early and midterm outcomes of subsequent lower extremity open surgical (OS) bypass. METHODS Patients undergoing infrainguinal bypass for critical limb ischemia (CLI) from January 2008 to December 2011 were retrospectively reviewed. The results after first-line bypass and bypass after failure of EV treatment were compared. A total of 213 patients (65.25% men; average age, 73.30 years) underwent bypass. OS patients were then divided into 2 groups: group 1 consisted of 138 patients who underwent primary OS for CLI without prior EV (control group) and group 2 consisted of 75 patients who had OS after a failed attempt at elective EV for peripheral vascular disease. Of the 213 bypass performed, 34% had a prior infrainguinal failed EV. The primary study end points were early and 1-year major amputations and graft occlusion. The secondary outcomes included early and 1-year mortality and the level of distal revascularization. RESULTS Secondary patency and limb salvage rates were significantly better in group 1 up to 1 year (99% vs. 86%; P < 0.001 at 1 month and 95% vs. 76%, P < 0.05 at 12 months, respectively). CONCLUSIONS Previous failed EV should be predictive of poor outcome in patients undergoing distal OS for CLI.

Endovascular repair of aortic rupture due to Brucella aortitis.

Brucellosis is a zoonosis, caused by bacteria belonging to the genus Brucella. Aortic involvement is a rare complication, often following embolization from infective endocarditis. However, contiguous propagation from vertebral involvement may occur. We report the case of an 81 year old patient abruptly presenting with aortic rupture due to Brucella melitensis infection. The diagnosis of aortic rupture was made by CT. The patient underwent urgent endovascular treatment using endoprosthesis deployment in the abdominal aorta and iliac arteries. Long term antibiotic treatment was given. Resolution of the acute event was obtained without further surgical treatment. 18 months after endovascular treatment, the patient remains in good health.

Surgical repair of a giant aneurysm of the right subclavian artery.

Giant isolated subclavian aneurysm is a rare disease. We report a case of a 66-year-old lady, with a proximal intrathoracic true aneurysm of the right subclavian artery. Due to the absence of a proximal neck, and for the relevant tortuosity of the vessels, we decided to approach the aneurysm through a median sternotomy. The aneurysm was excluded and opened. Then, we performed a direct subclavian-carotid transposition. The postoperative course was uneventful.

Thrombectomy and Surgical Reconstruction for Extensive Iliocaval Thrombosis in a Patient With Agenesis of the Retrohepatic Vena Cava and Atresia of the Left Renal Vein

In 80% of the patients presenting with deep-venous thrombosis (DVT), a risk factor can be identified. An absent or hypoplastic infrarenal vena cava is a rare risk factor for DVT in young adults. In these cases, the prevalence of congenital anomalies of the inferior vena cava (IVC) is estimated at 0.5% of the general population, up to 5% in young people. The association with coagulopathy increases the risk of DVT. We report a case of a young man who presented with a massive caval and iliofemoral-popliteal thrombosis in presence of the agenesis of retrohepatic inferior vena cava and atresia of the left renal vein. Open thrombectomy and caval reconstruction with a polytetrafluoroethylene graft were performed. Surgical option with vein reconstruction was preferred to prevent new episodes of thrombosis and the risk of acute renal failure.