L. Claeys

Epidural Spinal Cord Stimulation in the Treatment of Severe Peripheral Arterial Occlusive Disease

Epidural spinal cord stimulation (ESCS) has been suggested to improve microcirculatory blood flow and reduce amputation rates in patients with severe peripheral arterial occlusive disease (PAOD). Pain relief, limb salvage, and skin circulation were studied in 177 patients with ischemic pain caused by nonreconstructible PAOD who were receiving ESCS. Medical or surgical therapy had failed and vascular reconstruction was impossible in all cases. Clinical status was classified as Fontaines stage III (chronic ischemic rest pain) in 114 patients and Fontaines stage IV (ischemic pain and ulcers or dry gangrene) in 63 patients. PAOD was essentially due to arteriosclerosis, but 36 patients also had diabetic vascular disease. After a mean follow-up of 35.6 months, significant pain relief (> 75%) with limb salvage was achieved in 110 patients. In 11 patients with limb salvage, pain alleviation was determined to be between 50% and 70%. ESCS was ineffective in reducing pain, leading to major amputation in 56 patients. The cumulative limb salvage rate was 66% at 4 years. The systolic ankle/brachial blood pressure index did not change under stimulation. TcPo2 was assessed on the dorsum of the foot. Clinical improvement was associated with increased TcPo2, with limb salvage improving from 24.2 to 48.1 mm Hg in stage III (p<0.02) and from 16.4 to 37.2 mm Hg in stage IV (p< 0.03) disease. A TcPo2 increase of more than 50% within the first 3 months after implantation was predictive of success. TcPo2 changes are correlated with the presence of adequate paresthesias in the painful area during the trial period. Lead dislocation and lead breakage occurred in 30 and 12 patients, respectively. Seven patients developed device infection, three patients had skin necrosis over the generator, and two patients had procedural complications related to cerebrospinal fluid fistula. During follow-up causes of death included myocardial infarction in eight patients, pulmonary insufficiency in five, stroke in four, and septic shock in one; the cause remained unknown in three patients. We conclude that in patients with severe nonreconstructible PAOD, ESCS improves skin blood flow, is associated with good pain relief, and considerably improves the quality of life.

F. P. Weber Syrldrome Associated with a Brachial Artery Aneurysm A Case Report

Klippel-Trenaunay syndrome is characterized by the triad of unilateral port-wine heman giomas, varicose veins, and hypertrophy of bone and soft tissue affecting one or more limbs. The rare F. P. Weber syndrome describes the mentioned entity and additional arteriovenous malformations. The association of an arterial aneurysm with the F. P. Weber syndrome has never been described in the current literature. A case of a brachial artery aneurysm in a patient with F. P. Weber syndrome is presented and the etiology of arterial aneurysm combined with congenital vascular abnormalities is discussed.

Significance of radiological diagnosis for detection and staging of inflammatory abdominal aortic aneurysm

Operative morbidity and mortality are elevated in patients with inflammatory abdominal aortic aneurysm. Preoperative identification of inflammatory abdominal aortic aneurysm. the detection of the proximal level and of adhesions to adjacent structures are important for surgical management. The sensitivity and specificity of ultrasonography and computed tomography (CT) for identification and staging in 13 patients with inflammatory abdominal aortic aneurysm were studied. Preoperative radiological diagnoses were validated by intraoperative findings. Correct identification of inflammatory abdominal aortic aneurysm could be achieved in 85% by the use of CT and in 62% by ultrasonography. The proximal level of inflammatory abdominal aortic aneurysm was correctly determined by CT in all patients and by ultrasonography in 62%. Using a transperitoneal approach, the condition was considered inoperable in two patients as a result of the suprarenal extent of the aneurysm and because of unremovable adhesions in two other cases. In the latter pair, it was impossible to predict inoperability by radiological findings. Sensitivity (85%) and specificity (100%) of standard radiological techniques to identify inflammatory changes are high. Inoperability caused by suprarenal extent could be detected correctly by routine radiological procedures. However, identification of dense adhesions appears uncertain.

Lethal Heparin-Associated Pulmonary Embolism Case Reports

Thrombocytopenia is a known adverse reaction occurring in some patients receiving heparin. Two different types of heparin-induced thrombocytopenia have been described. Heparin- induced thrombocytopenia type I is a mild thrombocytopenia after 1 to 4 days of heparin therapy, attributed to a direct interaction between heparin and circulating platelets. No specific treatment is necessary. Heparin-induced thrombocytopenia type II is a severe thrombocy topenia mediated by an immunologic mechanism. Type II generally develops after 5 to 10 days of heparin therapy and can be associated with potentially devastating thromboembolic compli cations. The incidence of heparin-induced thrombocytopenia type II is below 3%. Thrombo embolic events are always accompanied by a decrease in the platelet count, however, compli cations in the absence of absolute thrombocytopenia have been reported. Diagnosis of HIT type II is based on clinical features and laboratory studies for the heparin-dependent platelet antibody. Immediate cessation of heparin administration is essential. Several alternative anti coagulant therapies have been studied and have shown promising results when used for this purpose. Two patients undergoing coronary artery bypass surgery are presented in whom pulmonary embolism developed due to heparin-induced thrombocytopenia type II. In both cases, platelet counts were within the subnormal range at the time of the first thromboembolic complication. The clinical, therapeutic, and prognostic implications are discussed.

Treatment of severe peripheral arterial and vasospastic disease of the upper extremity by spinal cord stimulation

Spinal cord stimulation (SCS) has been successfully introduced for treatment of severe peripheral arterial disease of the lower limbs. However, the effect of SCS for treatment of severe vasospastic disease (VD) and peripheral arterial disease (PAD) of the upper extremities remains uncertain. Therefore, the efficacy of SCS for pain reduction and increase of blood supply was studied in four patients with severe PAD and in six patients with VD of the upper limbs. Transcutaneous oxygen tension index (chest TcpO2/hand TcpO2), Doppler wrist pressure index (WPI), capillary microscopy (CM), and a patients pain score (PS) graded from 1 to 10 (1=no pain) were used as follow-up parameters. Pain reduction after SCS was excellent in all patients and remained significant throughout the follow-up period. TcpO2 index decreased significantly (2.01±0.79 prae-OP vs 1.57±0.62 at 18 months). Capillary microscopy improved regarding red blood cell velocity and capillary density. Doppler WPI remained unchanged throughout the course. The results demonstrate that treatment of severe PAD and VD by use of thoracic SCS reduces pain significantly in these patients and increases blood supply. SCS provides a successful method of treatment for refractory VD and PAD of the upper extremity.

Spinal cord stimulation in the treatment of Buerger’s disease

Buerger’s disease is a segmental, inflammatory occlusive disease primarily involving small and medium-sized arteries and veins of the extremity, affecting males who are in the third or fourth decade of life and heavy smokers.

Critical limb ischemia: definition, incidence and prevalence, pathophysiology and diagnostic management

The earliest classification, described by Fontaine in 1950’s (1) is based on signs and clinical symptoms, and is very useful in daily practice: stage I, asymptomatic or oligosymptomatic; stage II, intermittent claudication; stage III, ischemic pain at rest (forefoot); stage IV, ulceration or gangrene (inflammatory pain).

Spinal cord stimulation in non-reconstructable or daredevil reconstructable patients with critical limb ischemia

The Gate Theory of pain transmission in the dorsal horn of the spinal cord provided the foundation for the use of electrical stimulation for pain relief.

Spinal cord stimulation (SCS) in the treatment of non-reconstructable arterial occlusive disease of upper extremities

Ischemic vascular disease of the upper extremity is less common than peripheral arterial vascular disease of the lower limbs. Arterial occlusive vascular disease of the upper extremities as a result of severe generalized atherosclerotic disease represents a difficult therapeutic problem. In the presence of extensive distal atherosclerotic disease, arterial reconstruction is frequently impossible (15). Aggressive medical treatment has been the mainstay of treatment in these situations. Medical treatment, however, sometimes fails and tissue loss, dysfunctional limbs or major amputation may occur (16). The importance of the hand in daily living activities mandates aggressive therapeutic attempts.

Epidural spinal cord stimulation in the treatment of non-reconstructible peripheral arterial occlusive disease

Vascular reconstruction remains the treatment of choice for patients with severe PAOD. However, once thrombosis of the bypass has occurred, secondary procedures to restore the patency are complex and associated with 3–5 year patency rates of less than 50%. The ideal treatment in nonreconstructible peripheral arterial occlusive disease should allow the patient to retain his limb with no or minimal pain and to maintain a satisfactory level of function.