Romeo Martini

An unexpectedly high rate of pulmonary embolism in patients with superficial thrombophlebitis of the thigh

PURPOSE The rate of objectively proven pulmonary embolism in patients with thrombophlebitis of the greater saphenous vein was studied. METHODS Consecutive ambulant patients with thrombophlebitis of the greater saphenous vein, involving the above-knee segment, underwent a complete venous echo color Doppler examination of the lower limbs, perfusion lung scanning, and chest radiography. A high probability of pulmonary embolism was defined as the presence of two or more large segmental defects, one large and two or more moderate perfusion defects, or four or more moderate perfusion defects, with no corresponding abnormality found by means of chest radiography. RESULTS Of the 21 patients included in the study, findings compatible with a high probability of pulmonary embolism were detected in seven patients (33.3%; 95% CI, 14.6 to 57. 0), although clinical symptoms of pulmonary embolism were present only in one patient. No association was found between the presence of thrombosis at the saphenofemoral junction and the risk for pulmonary embolism. CONCLUSION The rate of pulmonary embolism in patients with thrombophlebitis of the greater saphenous vein is unexpectedly high. This risk is similarly high in patients with thrombosis at the saphenofemoral junction and in patients without thrombosis at the saphenofemoral junction. Our results are consistent with those of other recent investigations and suggest that superficial thrombophlebitis of the thigh is not as benign a disease entity as previously described.

The ILAILL study: iloprost as adjuvant to surgery for acute ischemia of lower limbs: a randomized, placebo-controlled, double-blind study by the italian society for vascular and endovascular surgery.

Summary Background Data:High rate of complications has been reported following revascularization for acute limb ischemia (ALI). No adjuvant pharmacologic treatment, apart from anticoagulation and standard perioperative care, has been shown clinically effective. Objective:Aim of this study was to evaluate the effects of the prostacyclin analog iloprost as adjuvant to surgery for ALI. Methods:A total of 300 patients were randomly assigned to receive perioperative iloprost (intra-arterial, intraoperative bolus of 3000 ng, plus intravenous infusion of 0.5–2.0 ng/kg/min for 6 hours/day for 4–7 days following surgery), or placebo. The primary endpoint was the combined incidence of death and amputation at 3-month follow-up. Secondary endpoints were the incidence of each single major complication, total event rate, symptomatology, and tolerability. Results:The combined incidence of death and amputation was 19.9% in the placebo and 14.1% in the iloprost group (relative risk, 1.56; 95% confidence interval, 0.89–2.75, P = 0.12, Cox regression analysis). A statistically significant lower mortality (4.7%) was reported in patients receiving iloprost, compared with controls (10.6%; relative risk, 2.61; 95% confidence interval, 1.07–6.37, P = 0.03). The overall incidence of fatal plus major cardiovascular events was 33.1% and 22.8% in placebo and iloprost groups, respectively (relative risk, 1.61; 95% confidence interval, 1.04–2.49, P = 0.03). No serious adverse reactions occurred after iloprost administration, nor differences in the incidence of bleeding or hypotension between treatment groups. Conclusions:Although at lower levels than previously reported, our results confirm the severity of ALI. Iloprost as adjuvant to surgery significantly reduced mortality and overall major event rate. Further data are needed to support this finding, and to face a still open medical issue.

A Large Spontaneous Splenorenal Shunt in a Patient with Liver Cirrhosis and Uncomplicated Portal Hypertension

The aim of this paper is to describe and discuss, on the basis of a thorough review of the literature, the case of a 70-year-old woman with probable cirrhosis secondary to chronic hepatitis B and C, uncomplicated portal hypertension (without ascites, encephalopathy or bleeding varices), splenomegaly and hypersplenism, and an unusual, spontaneous, large splenorenal shunt and recanalization of the umbilical vein. The tortuous and varicose splenorenal shunt was diagnosed by abdominal ultrasound and CT investigations. A duplex Doppler ultrasonography evaluation was performed to study shunt flow direction and velocity. No gastroesophageal varices were identified on endoscopic examination. The clinical relevance of spontaneous splenorenal shunt, often associated with fundic gastric varices, is discussed.

Anatomical remodelling of the anterior abdominal wall arteries in obesity.

Obesity is associated with structural alterations in subcutaneous small resistance arteries. The aim of the present work is to study modifications of perforators vessels of abdominal wall and subcutaneous tissue characteristics in obese patients after massive weight loss. An anatomo-radiologic study was carried out on 15 patients (5M, 10F, mean age 54.9 y), who underwent abdominoplasty after massive weight loss. Their pre-operative Computed Tomographic (CT) results of the anterior abdominal wall were compared with CT of 15 normal weighted controls. Anatomo-microscopic and morphometric examinations were conducted on full-thickness specimens of panniculectomy samples. 10 right panniculectomy were sampled from donor cadavers. All the measurements were taken on transverse sections. In patients, at CT the mean luminal diameter (LD) and standard deviation of perforator branches of the deep inferior epigastric artery (DIEA) was 3.7 ± 0.4 mm (control 2.2 ± 0.1 mm; p < 0.05). At microscopic examination, the wall thickness of perforator arteries was 212.7 μ ± 83.9 versus 143.9 ± 32.8 (p < 0.05) deep to the superficial fascia and 120.4 μ ± 74.8 versus 72.3 ± 23.5 (p < 0.05) superficial to it. A thickening of the muscular layer was observable and the tunica media represented 71.4% ± 5.6 of the whole area of the wall (controls 37.1% ± 3.5, p < 0.0001). Our data demonstrate that the major LD of the perforators in patients matches with hypertrophy of the tunica media and we think that the major thickness of perforator walls can facilitate the microsurgical technique in free microsurgical flap reconstruction.

Preliminary study of laser doppler perfusion signal by wavelet transform in patients with critical limb ischemia before and after revascularization

The haemodynamics of skin microcirculation can be quantitatively evaluated by Laser Doppler Fluxmetry (LDF). LDF signal in human skin shows periodic oscillations. Spectral analysis by wavelet transform displays six characteristic frequency intervals (FI) from 0.005 to 2 Hz, related to distinct vascular structures activities: heart (0.6-2 Hz), sympathetic respiratory (0.145-0.6 Hz), myogenic (0.052-0.145 Hz), local sympathetic nerve (0.021-0.052 Hz) and endothelial cells NO dependent (0.0095-0.021 Hz) and NO independent (0.005-0.0095 Hz). The most advanced stage of peripheral arterial obstructive disease is the critical limb ischemia (CLI), which causes the reduction of blood perfusion threatening limb viability. Besides macrocirculatory alterations, many studies have shown microvascular misdistribution of skin blood flow as the main factor that leads patients to CLI. Revascularization can save limb and patients life, too. In the present study, LDF signals have been recorded on the skin of the foot dorsum in 15 patients suffering from CLI. LDF signals have been analyzed before and after limb revascularization by means of the wavelet analysis. Significant changes in frequency distribution before and after limb revascularization have been detected: the median normalized values of spectral power increases for 49.8% (p = 0.0341) in the frequency range 0.050328-0.053707 Hz, whereas spectral power decreases for 77.1% (p = 0.0179) in the frequency range 0.018988-0.029284 Hz. We can conclude that changes in the frequency intervals occur after revascularization, shifting from a prevailing endothelial activity toward a prevailing sympathetic activity.

L-Propionyl-Carnitine Protects Tissues from Ischaemic Injury in an 'In Vivo' Human Ischaemia-Reperfusion Model

AbstractObjective: To assess the acute effects of L-propionyl-carnitine (LPC) on vaso-motion, tissue perfusion and tissue acidosis during an ischaemia-reperfusion test in patients with intermittent claudication. Design: Open pharmacodynamic study. Study participants: Sixteen male patients with intermittent claudication (mean absolute claudication distance 193.19 ± 51.51m). Interventions: Intravenous infusion of LPC 600mg. Main outcome measures and results: Laser-Doppler perfusion units and power spectrum, transcutaneous oxygen pressure (TcPO2) and transcutaneous carbon dioxide pressure (TcPCO2) were measured at baseline, during ischaemia (which was induced by means of an inflated pneumatic cuff wrapped around the calf) and during reperfusion, before and after LPC infusion. Perfusion units and TcPO2 did not change significantly after LPC infusion compared with pretreatment values. Conversely, mean laser-Doppler power spectrum, which was 0.20 units at rest and 1.13 during reperfusion before treatment, increased significantly to 0.89 and 2.24, respectively, after LPC infusion (p = 0.01 and p = 0.00074, respectively, vs pretreatment values). LPC had no significant effects on resting TcPCO2, but induced a significant decrease in TcPCO2 measured at hypoxia point (96.9mm Hg before treatmentvs 90.2mm Hg after treatment; p = 0.001) and during reperfusion (115.9vs 103.5mm Hg, respectively; p = 0.0006). Conclusions: These results show that LPC protects tissues from ischaemic injury by improving arteriolar function and reducing acidosis, without affecting arterial inflow. This may explain the beneficial effects of LPC in patients with intermittent claudication and suggests a potential use of this drug in other stages of peripheral arterial disease and in patients undergoing surgery.

Changes of the cutaneous flowmotion pattern after limb revascularization in patients with critical ischemia

The skin flowmotion of 13 patients suffering from critical limb ischemia (CLI) was studied with wavelet analysis (WA) of the laser Doppler signals (LDS). The WA selects six different frequency components (FCs), each relating to a specific cardiovascular system structures activities; FC I 1-2 Hz heart, FC II 0.2 Hz respiratory, FC III 0.1 Hz myogenic, FC IV 0.04 Hz, sympathetic, FC V 0.01 Hz, and FC VI 0.007 Hz endothelial. The aim of the study was to observe which FC changed after the limb revascularization. The LDS was measured at the dorsum of the foot, one week before and no later than 30 days after revascularisation. The absolute and relative amplitude and energy of the flowmotion WA FCs, the ankle brachial pressure index (ABI) and the transcutaneous pressure of oxygen (TcpO2) were assessed before and after revascularization. The results showed that after successful revascularization ABI and TcpO2 increased from 0.34 ± 0.10 to 0.54 ± 0.09 (p 0.0003) and from 20.3 ± 13.4 to 43.8 ± 18.7 mmHg (p 0.0002) whereas only the absolute amplitude and energy of the cardiac FC I increased from 0.57 ± 0.44 to 1.07 ± 0.69 (P 0.002) AU and 1.14 ± 1.78 AU2 to 3.54 ± 3.78 AU2 (p 0.004). In conclusion after limb revascularization the cardiac component of the flowmotion increased maybe because the cardiac stroke volume had more influence over the skin arterioles.

Wavelet analysis of the Laser Doppler signal to assess skin perfusion

The hemodynamics of skin microcirculation can be clinically assessed by means of Laser Doppler Fluxmetry. Laser Doppler signals show periodic oscillations because of fluctuations of microvascular perfusion (flowmotion), which are sustained by contractions and relaxations of arteriolar walls rhythmically changing vessels diameter (vasomotion). The wavelet analysis applied to Laser Doppler signals displays six characteristic frequency intervals, from 0.005 to 2 Hz. Each interval is assigned to a specific structure of the cardiovascular system: heart, respiration, vascular myocites, sympathetic terminations, and endothelial cells (dependent and independent on nitric oxide). Therefore, mechanisms of skin perfusion can be investigated through wavelet analysis. In the present work, examples of methods and results of wavelet analysis applied to Laser Doppler signals are reported. Laser Doppler signals were acquired in two groups of patients to check possible changes in vascular activities, before and after occlusive reactive hyperaemia, and before and after revascularization.

Wavelet analysis of skin perfusion to assess the effects of FREMS therapy before and after occlusive reactive hyperemia

Laser Doppler Fluxmetry is used to evaluate the hemodynamics of skin microcirculation. Laser Doppler signals contain oscillations due to fluctuations of microvascular perfusion. By performing spectral analysis, six frequency intervals from 0.005 to 2 Hz have been identified and assigned to distinct cardiovascular structures: heart, respiration, vascular myocites, sympathetic terminations and endothelial cells (dependent and independent on nitric oxide). Transcutaneous electrical pulses are currently applied to treat several diseases, i.e. neuropathies and chronic painful leg ulcers. Recently, FREMS (Frequency Rhythmic Electrical Modulation System) has been applied to vasculopathic patients, too. In this study Laser Doppler signals of skin microcirculation were measured in five patients with intermittent claudication, before and after the FREMS therapy. Changes in vascular activities were assessed by wavelet transform analysis. Preliminary results demonstrate that FREMS induces alterations in vascular activities.

Videocapillaroscopy study of post traumatic lower limb loss of tissue treated with and without acellular dermal substitute

A 46 years old male with a post traumatic loss of tissue localized on the anterior surface of the right thigh and knee due to a road accident, was treated with different surgical reconstructive techniques. Combined use of autologous skin graft and acellular dermal substitute Integra® allowed the satisfactory recovery of the patient who was discharged after 82 days from the trauma. To analyse the characteristics and the quality of the healing tissues we performed a videocapillaroscopy study to assess the microcirculatory pattern of the autologous skin grafted on the dermal substitute in comparison with the autologous skin grafted on granulation tissue. The videocapillaroscopy was performed in the zone skin grafted directly on granulation tissue, Zone 1 (Z1); on the region of the lesion in the knee, treated with dermal substitute and autologous skin graft, Zone 2 (Z2), and on the undamaged controlateral knee skin. Zone 3 (Z3). The results showed that the capillary density was similar between Z2 and Z3, while in Z1, the zone skin grafted on the granulation tissue without Integra® the capillary density was significatively reduced. These preliminary observations within the clinical data may be an useful contribute to better understand the tissue healing process.