Roberto Ferraresi

Long-term Follow-up of Tibiocalcaneal Arthrodesis in Diabetic Patients with Early Chronic Charcot Osteoarthropathy

Charcot osteoarthropathy with severe ankle instability and deformity is often managed with below-the-knee amputation if deformity and cutaneous compromise result in osteomyelitis. Recently, some surgeons have reported satisfactory outcomes with ankle arthrodesis in the coalescence or remodeling (subacute and chronic) stages of the disease before the onset of joint instability, severe deformity, and ulcer formation. This observational study describes the clinical outcomes of ankle arthrodesis in a cohort of 45 diabetic patients who underwent unilateral ankle arthrodesis for Charcot neuroarthropathic ankle deformity before the development of ulceration and bone infection. Two (4.44%) of the patients were lost to follow-up, whereas 2 (4.44%) others underwent below-the-knee amputation shortly after the ankle arthrodesis because of postoperative infection. After a mean follow-up duration of 5 ± 2.85 years, 39 (86.67%) patients returned to independent ambulation wearing custom-made shoes with molded insoles, whereas 2 (4.44%) others required pneumatic casts for ambulation.

Nonwindowed Nonremovable Fiberglass Off-Loading Cast Versus Removable Pneumatic Cast (AircastXP Diabetic Walker) in the Treatment of Neuropathic Noninfected Plantar Ulcers A randomized prospective trial

Neuropathic plantar ulcers are classical lesions secondary to diabetic polyneuropathy (1,2). The worldwide gold standard treatment is the nonremovable off-loading cast (3–5). However, the device is not widely used due to concerns related to risk factors of the off-loading cast (i.e., joint rigidity, additional ulcer formation beneath the cast, and infection of the ulcer enclosed in the cast). Our group recently demonstrated that it is possible to reduce the risk of side effects reported in literature by constructing the off-loading cast using fiberglass bandages of different rigidity. Considering the device’s scarce application because of the side effects, we conducted a controlled, randomized, prospective trial to evaluate the safety and efficacy of a removable pneumatic cast walker in comparison with a nonremovable fiberglass off-loading cast. Between January 2005 and October 2005, 60 consecutive diabetic patients with neuropathic plantar ulcers were seen and randomly assigned to two groups: group A, using an Aircast Pneumatic Walker (XP Diabetic Walker); and group B, using the fiberglass off-loading cast. All participants had peripheral neuropathy, as highlighted by insensitivity to 10 g monofilament and vibration perception threshold measured by biothesiometer at malleolus of at least 25 volts, and presented …

Non-Windowed Non-Removable Fiberglass Off-Loading Cast Versus Removable Pneumatic Cast (AircastXP Diabetic Walker)

Neuropathic plantar ulcers are classical lesions secondary to diabetic polyneuropathy (1,2). The worldwide gold standard treatment is the nonremovable off-loading cast (3–5). However, the device is not widely used due to concerns related to risk factors of the off-loading cast (i.e., joint rigidity, additional ulcer formation beneath the cast, and infection of the ulcer enclosed in the cast). Our group recently demonstrated that it is possible to reduce the risk of side effects reported in literature by constructing the off-loading cast using fiberglass bandages of different rigidity. Considering the device’s scarce application because of the side effects, we conducted a controlled, randomized, prospective trial to evaluate the safety and efficacy of a removable pneumatic cast walker in comparison with a nonremovable fiberglass off-loading cast. Between January 2005 and October 2005, 60 consecutive diabetic patients with neuropathic plantar ulcers were seen and randomly assigned to two groups: group A, using an Aircast Pneumatic Walker (XP Diabetic Walker); and group B, using the fiberglass off-loading cast. All participants had peripheral neuropathy, as highlighted by insensitivity to 10 g monofilament and vibration perception threshold measured by biothesiometer at malleolus of at least 25 volts, and presented …

Percutaneous transluminal angioplasty for treatment of critical hand ischemia

A 62-year-old man with insulin-dependent type II diabetes mellitus and chronic renal failure being treated with dialysis complained of chronic critical ischemia of the left hand with severe pain. A necrotic skin lesion with soft tissue infection and osteomyelitis of the distal part of the fourth finger was present (Figure 1A). A standard x-ray of the hand showed diffuse calcifications of the arteries (Figure 1B and 1C). An angiographic study was performed before therapeutic decisions were made. Homolateral antegrade brachial approach with an 11-cm 4F introducer sheath was …

The Management of the Infected Diabetic Foot

Diabetes is a chronic disease with a worldwide increasing trend. Foot complications, closely related to neuropathy and obstructive peripheral vascular disease, are responsible for more than 1 million of leg amputations every year. Foot infection can dramatically increase the risk of amputation. Although many ulcer classification systems have been proposed to stratify the severity of the infectious process, the definition of a specific therapeutic approach still remains an unsolved problem. A Diabetic Foot Triage and an Integrated Surgical Protocol are proposed to identify a diagnostic flowchart and a step-by-step surgical protocol that can be applied in the treatment of diabetic foot infection. Considering the rapid climbing of multidrug resistant strains it is very important to rationalize the use of antibiotics utilizing them only for the treatment of true infected ulcers. PAD is widely considered the most important factor conditioning the outcome of a diabetic foot ulcer. Currently no randomized control trials are reported in the international literature directly comparing open versus endovascular revascularisation in diabetic patients with CLI. Insufficient data are available to demonstrate whether open bypass surgery or endovascular interventions are more effective in these patients. A decisional flow chart in choosing the best revascularization strategy in diabetic patients with CLI is proposed. Goals and technical aspects of emergency and elective surgical procedures in diabetic foot are analysed to evaluate critical aspects and to suggest proper surgical choices.

A new device to seal large coronary aneurysms: a case report.

IntroductionCoronary artery aneurysm is an uncommon disease. It is defined as a coronary artery dilatation, exceeding the diameter of the normal adjacent segment or the diameter of the patients largest coronary vessel by 1.5 to 2 times. Coronary artery aneurysms are typically diagnosed by coronary angiography. The prognosis of coronary artery aneurysm is not well known and the management is challenging.Case presentationA 68-year-old Italian-Caucasian man presented to our hospital with angina. Coronary angiography revealed a large coronary aneurysm of the right coronary artery, which was successfully treated by the percutaneous implantation of an MGuard™stent.ConclusionThis case report provides evidence that coronary artery aneurysms, even if very large, can be safely treated by MGuard™stent implantation. We strongly emphasize the high flexibility and good deliverability of this device, which leads to the complete exclusion of the aneurysm mediated by the process of endothelization of its thin mesh sleeves.

Dialysis access pseudoaneurysm: endovascular treatment with a covered stent

Iatrogenic pseudoaneurysms of the brachial artery are rare complications of haemodialysis access procedures and can lead to substantial morbidity and mortality if not managed promptly; however, surgery is also associated with the potential risk of severe complications. We describe the clinical and radiological findings relating to a dialysed patient who developed a huge iatrogenic pseudoaneurysm of the brachial artery (due to an inadvertent artery puncture), which was successfully treated by means of the percutaneous implantation of a polytetrafluoroethylene (PTFE)-covered stent.

Endovascular Treatment of the Arteries of the Foot

This chapter gives a detailed description of the below-the-ankle vascular anatomy, vessel disease distribution, and treatment strategies for percutaneous revascularization. A description of anatomic variants that are important for revascularization treatment of ischemic patients is provided. Furthermore, vessel disease distribution in a large series of treated patients is reported. Current concepts in endovascular treatment of patients with critical limb ischemia, such as the «angiosome concept» and the concept of «wound-related artery» are also explained. The chapter also describes standard and extreme revascularization techniques in order to provide the reader with a complete overview of below-the-ankle peripheral artery disease.

Indications to Revascularization in the Ischaemic Diabetic Foot

Critical limb ischaemia is frequently associated to diabetic foot ulcers, and its recognition and timely treatment are crucial to achieve ulcer remission. Lower limb atherosclerosis in diabetic patients is characterized by having an earlier onset, a more aggressive pattern, a higher degree of arterial wall calcification and a multi-level lower limb arteries involvement, with frequent distal localizations. Foot ischaemia is usually diagnosed by integrating the clinical exam with non-invasive tests like ankle pressure measurement and Ankle Brachial Index, as well as, transcutaneous oximetry (TcPO2) or Colour-Doppler Ultrasound Scanning. Once the need for revascularization is established, the main artery to target is chosen in keeping with the foot angiosomal arrangement, so that a direct blood flow to the diseased area could be achieved. We usually favour an “angioplasty first” revascularization strategy, as this offers several advantages including better tolerability by the patient and repeatability in case of re-occlusion. We usually prefer surgical bypass as first choice in case of long femoro-popliteal or infrapopliteal occlusions; however, this should be preceded by evaluating the patients eligibility, considering his general status and expected procedure tolerability; foot conditions and planned foot surgery; presence of a suitable conduit and of an adequate distal vessel for anastomosis.