Paolo Sapienza

Vascular endothelial growth factor increases the migration and proliferation of smooth muscle cells through the mediation of growth factors released by endothelial cells

BACKGROUND Vascular endothelial growth factor (VEGF), a highly specific chemotactic and mitogenic factor for vascular endothelial cells (EC), appears to be involved in the development of atherosclerosis. The purpose of our study was to assess if VEGF might indirectly stimulate SMC migration and proliferation in a EC-SMC coculture system, through the mediation of growth factors released by EC. METHODS Bovine aortic SMC were cocultured with bovine aortic EC treated with hrVEGF, to assess SMC proliferation and migration. The release and mRNA expression of basic fibroblast growth factor (bFGF) and transforming growth factor beta(1) (TGFbeta(1)) were assessed by ELISA and PCR analysis. RESULTS hrVEGF (10 ng/ml), added to EC cocultured with SMC, induced a significant increase in tritiated thymidine uptake by SMC as compared to controls (P < 0.01) and a significant increase in SMC migration in respect to control (27%; P < 0.01). EC stimulated with hrVEGF increased the release and the expression of bFGF and decreased the release and the expression of TGFbeta(1) with a statistically significant difference in respect to controls (P < 0.001). CONCLUSIONS VEGF indirectly stimulates SMC proliferation and migration through the modulation of bFGF and TGFbeta(1) released by EC.

Influence of blunt needles on surgical glove perforation and safety for the surgeon

BACKGROUND Round-tipped blunt needle (BN) may decrease the risk of needlestick injuries and hand contamination. We prospectively determined the incidence of glove perforations in emergency abdominal procedures and the efficacy of BN in increasing the safety for surgeons. METHODS Two hundred patients were randomized to undergo closure of the abdominal fascia using sharp needle (SN) or BN. Gloves were tested at the end of the procedure. RESULTS Surgeons had 14 needlestick injuries and 76 perforations recorded in 69 pair of gloves. Sharp needles were responsible for all injuries and 58 (76%) perforations (P < 0.00004 and P < 0.00001, respectively). This difference was still higher when considering the perforations related to the abdominal fascia closure (BN 7% versus SN 50%; P < 0.0006). CONCLUSION The risk of glove perforation is sevenfold greater if SN are used. Blunt needles reduce sharp injuries and improve safety for surgeons.

Popliteal artery entrapment syndrome: The role of early diagnosis and treatment

BACKGROUND The purpose of this study was to evaluate whether certain factors could influence arterial impairment at presentation for treatment of popliteal artery entrapment syndrome (PAES) and whether its early diagnosis could optimize long-term results. METHODS Between 1979 and 1995, 30 patients were treated for PAES at our institution. Patients were characterized by age, risk factors, associated diseases, preoperative symptoms, affected side, dominant limb, duration of symptoms, musculotendinous structure causing the compression, arteriographic findings, arterial status at presentation, type of operation, postoperative complications, and long-term follow-up. RESULTS Twenty-nine (65%) limbs underwent musculotendinous section (MTS), 15 (33%) limbs underwent vascular reconstruction, and 1 (2%) was surgically explored. Patients submitted to MTS were younger (mean, 31 +/- 3 years) than patients who underwent vascular reconstruction (mean, 41 +/- 4 years; p < 0.05). MTS limbs had a greater number of minor symptoms compared with those that underwent vascular reconstruction (62% versus 20%; p < 0.02). Arteriogram showed that MTS limbs had a greater number of normal findings at rest when compared with limbs that underwent conventional reconstruction (85% versus 0%; p < 0.001). No specific factors influenced the arterial status at presentation. During follow-up, treadmill examination revealed that MTS limbs had a better response (96%) than limbs that had undergone vascular procedures (67%; p < 0.02). MTS limbs had a better long-term patency rate (mean, 87 +/- 7 months) compared with limbs that were submitted to vascular reconstruction (mean, 107 +/- 8 months) (95% versus 65%; p < 0.02). CONCLUSIONS Because PAES is a progressive disease that can create serious vascular obstructive disease and no specific factors seem to influence the degree of vascular impairment, the detection and treatment of PAES at an early stage permit better long-term results.

Persistent hypertension after removal of adrenal tumours

OBJECTIVE To assess the long-term results of operation for adrenal hypertension and to evaluate reasons and potential risk factors for the persistence or recurrence of hypertension. DESIGN Retrospective clinical study. SETTING Teaching hospital, Italy. SUBJECTS 48 patients with benign adrenal tumours who were preoperatively hypertensive and treated by adrenalectomy between 1980 and 1996. MAIN OUTCOME MEASURES Factors that influenced the persistence of hypertension after removal of the adrenal tumours. RESULTS During a mean (SD) follow-up of 77 (12) months, 4 (8.3%) patients developed cardiovascular or cerebrovascular complications. 24 patients had had a history of hypertension for less than 5 years and the remaining 24 for 5 years or more. Blood pressure returned to the normal range after operation in 22 patients (46%). 14 patients (29%) had persistent hypertension that required treatment with antihypertensive drugs, but 12 required less intensive treatment than before adrenalectomy. Multivariate analysis showed that age at presentation was the only significant factor predictive of persistent hypertension (p < 0.05); sex, haematochemical tests, raised preoperative blood pressure, duration of hypertension preoperatively, and size of tumour were not. CONCLUSION The success in reversing hypertension after adrenalectomy for benign tumour is strongly related to age at presentation.

Clinical results of epidural spinal cord electrical stimulation in patients affected with limb-threatening chronic arterial obstructive disease.

Between 1982 and 1990, 76 patients (33 women, 43 men, mean age 71.4±10 years) affected with limb-threatening peripheral vascular disease (claudication < 20 m: 3 patients; rest pain: 10 patients; necrosis1 smaller than 3 cm2: 28 patients ; necrosis2 larger than 3 cm2: 35 patients) not amenable to medical and/or surgical therapy, were treated by epidural spinal cord electrical stimulation (ESES). Effectiveness of ESES was evaluated by consideration of pain control, walking distance, and healing of ischemic lesions. At a mean follow-up of twenty-six months (range: one to seventy-six) 44 limbs (58%) were amputated (rest pain 2; necrosis1 13; necrosis 2 29) and 39% of necrotic lesions smaller than 3 cm2 healed. The overall limb salvage rate was 42%. Pain control was obtained in 80% of patients at the one-year and 75% at the two-year follow-up, with infrequent use of pain relievers. Despite the poor clinical results observed, the limb salvage rate testifies to the effectiveness of ESES in limb-threatening ischemia. Moreover, the authors noticed a good ESES effect on pain relief, maximal in the early and intermediate postimplant periods. In conclusion ESES must be considered the last resort in peripheral vascular disease in patients in whom medical and/or surgical therapies are ineffective or impossible. Necrotic lesions larger than 3 cm2 contraindicate, in their opinion, ESES implant.

Long-term results and outcomes of crossover axilloaxillary bypass grafting: A 24-year experience

OBJECTIVE The outcome of crossover axilloaxillary bypass grafting in patients with stenosis or occlusion of the innominate or subclavian arteries was investigated. METHODS The study was designed as a retrospective clinical study in a university hospital setting with 61 patients as the basis of the study. Fifty-eight patients (95.1%) had at least two risk factors or associated medical illnesses for atherosclerosis, and 35 patients (57.4%) had concomitant carotid artery stenosis that necessitated a staged procedure in 12 patients (19.7%). The patients underwent a total of 63 crossover axilloaxillary bypass grafting procedures. Demographics, risk factors and associated medical illnesses, preoperative symptoms and angiographic data, blood flow inversion in the vertebral artery, concomitant carotid artery disease, graft shape, caliber and material, and intraoperative and postoperative complications were studied to assess the specific influence in determining the outcome. RESULTS One postoperative death (1.6%), four early graft thromboses (6.2%), and six minor complications (9. 8%) occurred. The overall mortality and morbidity rates were 1.6% and 16.1%, respectively. During the follow-up period (mean, 97.3 +/- 7.9 months), we observed five graft thromboses (8.3%). Primary and secondary patency rates at 5 and 10 years were 86.5% and 82.8% and 88.1% and 84.3%, respectively. Overall, two patients (3.3%) had recurrence of upper limb symptoms and none had recurrence of symptoms in the carotid or vertebrobasilar territory. The 5-year and 10-year symptom-free interval rates were 97.7% and 93.5%, respectively. Nine patients (15%) died of unrelated causes. The 5-year and 10-year survival rates were 93.2% and 67.3%, respectively. Multivariate analysis showed that no specific variables exerted an influence in the short-term and long-term results and the outcome. CONCLUSION The optimal outcome of axilloaxillary bypass grafting supports its use as the most valuable surgical alternative to transthoracic anatomic reconstructions for innominate lesion, long stenosis of the subclavian artery, and short subclavian artery stenosis associated with ispilateral carotid artery lesions.

Management of abdominal aortic prosthetic graft infection requiring emergent treatment

The purpose of this study was to investigate mortality and morbidity rates and long-term outcome of patients who underwent emergency treatment of abdominal aortic prosthetic graft infection. Between January 1984 and December 1993, 18 men aged fifty-nine ±sixteen years were operated on as an emergency for an acute life-threatening complication of aortic prosthetic graft infection. The grafts had been implanted for abdominal aortic aneurysm in 9 patients and aortoiliac occlusive disease in 9, from one to one hundred seventy months previously. Five (28%) patients presented with a hemorrhagic shock due to a fistula between the vascular reconstruction and the small bowel (4 patients) or the right ureter (1 patient) and 13 (72%) had generalized sepsis. The grafts were always radically explanted. Extraanatomic revascularization procedures included 6 axillopopliteal and 12 axillofemoral bypass grafts. Operative mortality was 39% (7 patients), and 3 (9%) limbs were amputated within thirty days. Two (11%) patients died after seven and twelve months, respectively, of septic complications, and 1 (5%) patient died after six months from an unrelated cause. Eight (73%) patients are still alive at a mean follow-up of fifty ±thirty-four months, but in 3 the extraanatomic bypass was removed for infection and 5 major amputations were performed. Two-year survival and limb salvage rates were 44% and 50%, respectively. Aortic prosthetic graft infections that require emergent treatment continue to demon strate high early and late mortality and limb loss rates despite aggressive intervention and limb salvage procedures. Newer methods of managing these complications should continue to be investigated.

MMP and TIMP Alterations in Asymptomatic and Symptomatic Severe Recurrent Carotid Artery Stenosis

OBJECTIVES This study aimed to determine whether the plasma levels of matrix metalloproteinases (MMPs)-2 and -9 and their specific inhibitors (tissue inhibitors of metalloproteinases (TIMPs-1 and -2)) were altered in patients with symptomatic and asymptomatic, severe, recurrent carotid artery stenosis. PATIENTS Fifty-two patients (out of a total of 621) who had undergone successful carotid artery endarterectomy (CEA) between 1999 and 2003 and developed recurrent carotid artery stenosis (>/=70%) were included in the study. Restenosis was symptomatic in 23 patients and asymptomatic in 29 patients. METHODS Recurrent carotid artery stenosis was classified based on presentation, and as early-intermediate (6 months to 3 years) or late (>3 years). A detailed clinical history was taken and two blood samples were drawn from each patient to determine plasma levels of MMPs and TIMPs along with other biological parameters. Recurrent stenosis was confirmed with computed tomographic angiography. RESULTS Patients with symptomatic restenosis had significantly (p<0.001) higher active MMP-2 and -9 plasma values and significantly (p<0.001) lower TIMP-1 and -2 plasma values when compared to patients with asymptomatic restenosis. Plasma concentrations of active MMPs were higher and TIMPs lower in patients affected with late recurrent stenosis as compared to early-intermediate restenosis (p<0.001). No differences were recorded in latent MMP plasma values. Multivariate analysis showed that active MMP-2 and -9 were independent predictors of late recurrent carotid artery stenosis (p<0.03 and p<0.001, respectively). CONCLUSIONS Higher plasma concentrations of active MMP-2 and -9 were associated with an increased risk of carotid restenosis with plaque recurrence.

Carotid endarterectomy in young adults: Is it a worthwhile procedure?

PURPOSE The aim of the study was to investigate surgical indication and long-term outcome of carotid endarterectomy (CE) in young adults. METHODS Between 1973 and 1990, 1693 patients underwent CE. Forty-nine patients (group T) 35 to 45 years of age who had carotid artery stenosis greater than 70%, formed the basis for the analysis. They were compared with two additional groups of patients older than 45 years of age selected from the entire series. Group 2 was randomly chosen to determine differences in risk factors, associated diseases, operative indications, preoperative findings, and outcome. Group 3 was matched with patients in group 1 for sex, risk factors, associated diseases, preoperative findings, and operative indications to assess the importance of age in determining the short- and long-term outcome of CE. RESULTS Postoperative mortality, cerebrovascular accidents, and cardiac complications in patients of group 1 (2%, 2%, and 2%, respectively) were similar to those of the other groups (p = NS). During the follow-up (76.7 +/- 3.6 months; range, 1 to 120 months) the incidence of strokes and transient ischemic attacks in group 1 was lower than in group 2 (p < 0.05) but similar to group 3 (p = NS). Ten-year disease-free intervals were 75.7%, 58.7%, and 77.6%, respectively, for groups 1, 2, and 3. Mortality rate unrelated to cerebrovascular disease was similar between group 1 and group 3 (p = NS) but was higher in group 1 than in group 2 (p < 0.02). Ten-year survival rates were 46.1%, 71.7%, and 55.5%, respectively, for groups 1, 2, and 3. CONCLUSIONS CE in patients younger than 45 years of age is a safe procedure with low operative risks and good disease-free intervals. However, life expectancy is poor because of the high incidence of deaths resulting from complications of atherosclerosis.

Distal runoff and the development of degenerative changes in autologous reversed saphenous vein femoropopliteal bypass.

MATERIAL A total of 10 patients randomly selected from those who had reversed saphenous vein femoropopliteal bypass at our Institution and who had a postoperative angiogram were included into the study. METHODS The occurrence of degenerative changes at the control angiography was correlated to the quality of the distal runoff as seen at the preoperative angiography and to the level of the index of distal resistances, calculated as the difference between the upper calf pressure and that at the ankle, divided by the arm pressure. RESULTS Three patients had degenerative changes which were more common in case of poor distal runoff and high index of distal resistances. CONCLUSIONS Degenerative changes in reversed saphenous vein grafts are more common in case of poor distal runoff and high distal resistance. These factors should be added to the many risk factors that have been analyzed previously.