Vincenzo Sciacca

Surgical treatment of popliteal artery entrapment syndrome: A ten-year experience

Popliteal artery entrapment syndrome is increasingly described in the world literature as a cause of lower limb arterial impairment. It is caused by the anomalous interrelationship between the popliteal artery and its surrounding muscular and/or tendineous structures. The first case surgically treated was reported in 1959 and since then more than 300 cases have been reported including our personal experience (31 cases in 23 patients). We have treated surgically 19 males and four females with symptoms which were moderate (cramping after intensive physical training, paraesthesia, etc.) in 14 limbs, intermittent claudication in 16 and necrosis (first toe) in one. Preoperative arteriography showed arterial occlusion in eight limbs, stenosis in eight and aneurysms in two. In 11 limbs stenosis or occlusion was only shown after active plantar hyperextension and in two arteriography was not done because surgical indications were established on the basis of a venogram positive for popliteal vein entrapment syndrome. Ten different anatomical variants were seen and the medial head of gastrocnemius muscle was involved in 74.2%. Surgical treatment consisted of division of the aberrant musculotendinous tissue in 18 cases (in two of these balloon angioplasty was also used). In 12 cases a vascular reconstruction was also required, while one case was explored without a specific procedure being warranted. Optimal results were obtained when the syndrome was treated at an early stage by simple division of musculotendinous tissue (94.4% long-term patency rate, mean follow-up 46.0 months, min 2, max 120 months). When arterial grafting was required the long-term patency rate was only 58.3% (mean follow-up 43.5 months, min 1, max 100 months).(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Predictive value of transcutaneous oxygen tension measurement in the indication for spinal cord stimulation in patients with peripheral vascular disease: preliminary results

Thirteen patients (12 males, 1 fe male, mean age 60.5 years) affected by peripheral vascular disease (21 lower limbs: 9 with intermittent clau dication and 12 with rest pain and/or necrosis smaller than 3 cm2) have been studied by means of transcuta neous oxygen tension (TcpO2) mea surements. They had been submitted to spinal cord stimulation (SCS) de vice implant from one day to twenty- two months previously. In 8 patients (15 limbs) implanted from one day to twenty-two months, the TcpO2 index was calculated to evaluate the neuro- stimulator effect on peripheral blood circulation. In 5 patients (6 limbs) studied before definitive implanta tion, preoperative and postoperative TcpO2 measurements were able to predict the SCS efficacy during the temporary trial period: when TcpO2 did not increase immediately (4 limbs), no result was achieved (am putation) ; a TcpO2 increase corre sponded to relief of symptoms (2 limbs). On the basis of this preliminary report, TcpO2 measurement could be useful for predicting SCS efficacy in vascular patients; the possibility of dividing the patients into responders and nonresponders to SCS by TcpO2 measurement represents an impor tant achievement in determining the indication for SCS implant.

Cystic adventitial degeneration of the popliteal artery: lectin-histochemical study.

A case of cystic adventitial degeneration (CAD) of the popliteal artery is presented. Histologically the cyst appeared localised in the adventitia, outside the elastic lamina. A lectin-histochemical study evaluated the following peroxidase conjugated lectins: Peanut agglutinin, Concanavalin A, Ulex Europaeus (UEA I) and Wheat Germ Agglutinin. The lack of UEA I reactivity excluded an arterial origin of the cyst. Moreover, the lectin binding pattern of CAD appeared to be similar to the reactivity pattern of normal synovia.

Epidural Spinal Cord Electrical Stimulation in Diabetic Critical Lower Limb Ischemia

Spinal cord stimulation (SCS) has been suggested to improve microcirculatory blood flow to relieve ischemic pain and to reduce amputation rate in patients with peripheral arterial occlusive disease (PAOD). The aim of this study was to evaluate the specific prognostic parameters in the prediction of successful SCS, in diabetic patients, performing a retrospective data analysis. To perform this evaluation, 64 diabetic patients (39 men, 25 women; mean age, 69 years) classified as Fontaines stage III and IV, with PAOD, were treated with SCS for rest pain and trophic lesions with dry gangrene, after failed conservative or surgical treatment. In clinical controls, pedal transcutaneous oxygen tension (TcPO(2)), ankle/brachial blood pressure index (ABI), and toe pressure Doppler measurements were utilized to select and follow-up the patients. After 58 months of follow-up (range, 20-128 months), pain relief greater than 75% and limb salvage were achieved in 38 diabetic patients. A partial success was obtained in nine patients with pain relief greater than 50% and limb salvage for at least 6 months. The method failed in 17 patients or the device was removed due to technical problems, and the limb was amputated in these patients. TcPO(2) was assessed on the dorsum of the foot. Clinical improvement and SCS success were associated with increase of TcPO(2), before and after implantation. Limb salvage was achieved in the patients who had significant TcPO(2) increase within the 2 weeks of the testing period, independently of the stage of the disease. A TcPO(2) increase of more than 50% in the first 2 months after implantation was predictive of success, and was related to the presence of adequate paresthesias in the painful area during the trial period. TcPO(2) significantly increased after long-term follow-up in all patients with limb salvage (from 22.1 to 43.1 mm Hg in the rest pain patients, from 15.8 to 36.4 mm Hg in those with trophic lesions of less than 3 cm(2), and from 12.1 to 28.1 in those with trophic lesions of greater than 3 cm(2), (p < 0.01). ABI did not changed under stimulation. In diabetic patients with PAOD, the SCS increases the skin blood flow, is associated with significant pain relief, and could be proven an excellent alternative therapy, improving the life quality. Significant TcPO(2) increase within the 2-week test period, is a predictive index of therapy success and should be considered before the final decision in terms of cost effectiveness, before the permanent implantation.

Does autonomic neuropathy influence spinal cord stimulation therapy success in diabetic patients with critical lower limb ischemia

BACKGROUND Spinal cord stimulation (SCS) improves microcirculatory blood flow and relieves diabetic neuropathic and ischemic pain, reducing the amputation rate in patients with peripheral arterial occlusive disease (PAOD). The purpose of this study was to evaluate whether the presence of autonomic neuropathy in diabetic patients with PAOD influences the success of SCS therapy. METHODS Sixty consecutive diabetic patients (15 with early and 13 with definite and/or combined autonomic neuropathy) with an ankle/brachial systolic pressure index (ABI) less than 0.20 +/- 0.08, underwent spinal cord stimulation after failed conservative or surgical treatment. The neuropathic status of the patients was evaluated before implantation and pedal TcpO2 measurements on the dorsum of the foot were performed. RESULTS Limb salvage and pain relief >75%, evaluated with the visual analogue scale, were achieved in 35 patients, whereas in 12 a partial success with pain relief >50% and limb salvage for at least 6 months were obtained. In 13 patients the method failed and the ischemic limbs were amputated. Among the 28 diabetic patients with autonomic neuropathy the treatment failed or resulted in only partial success in 25, whereas in all 32 patients without neuropathy limb salvage and pain relief >75% were achieved (p < 0.0001). Partial success in 10 patients with early neuropathy and in two with definite was achieved (p = 0.008), whereas in 11 patients with definite neuropathy and in two with early the method failed (p < 0.001). The stage of the neuropathy was inversely related to the success of SCS therapy, independent of the stage of the disease. The methods success was related to the presence of adequate paraesthesias and warm feeling in the painful area with size reduction of the trophic lesions. CONCLUSIONS Diabetic patients with peripheral arterial occlusive disease presenting with intractable pain may be successfully treated with spinal cord stimulation unless they have associated severe autonomic neuropathy.

A simple technique for trocar site closure after laparoscopic surgery

Abstract. Hernias have been reported to occur at trocar sites and small anterior wall defect has been casually identified during laparoscopic surgery. The aim of this article is to describe a simple, fast, and cheap technique for the safe closure of trocar sites in laparoscopic surgery. Closure is accomplished with a #0# absorbable suture, which is applied in a pursestring manner using 15 gauge spinal cord needle. This procedure is also suitable for the laparoscopic repair of uncomplicated small hernias or fascial defects of the anterior abdominal wall; a mesh prosthesis in case the defect is > cm2. This technique allows a secure closure of umbilical or fascial defects of the anterior abdominal wall. It is a useful method for large trocar sites closure and is recommended for small uncomplicated hernias or fascial defects of the anterior abdominal wall. In case of > cm2 defects the technique could be an optimal laparoscopic alternative for patch tension free repair.

Laser Doppler Flowmetry and Transcutaneous Oxygen Tension in Patients with Severe Arterial Insufficiency Treated by Epidural Spinal Cord Electrical Stimulation

Six patients (3 men, 3 women, mean age 74.2 years) affected by severe arterial insufficiency with rest pain and/or necrosis (smaller than 3 cm2) have been studied simultaneously by means of transcutaneous oxygen tension (Tcp02) and laser Doppler flowmetry (LDF) measurements. They had been submitted to epidural spinal cord electrical stimulation (ESES) device implant from one week to thirteen months previously. Tcp02 vasodilation index and LDF flow and LDF volume increased in 5 patients in whom the ESES was effective in pain relief and ulcer healing. In 1 diabetic patient the clinical result was poor and neither Tcp02 nor LDF showed any improvement. The LDF flow and LDF volume increase, coupled with the simultaneous Tcp02 vasodilation index increase, testify to the amelioration of the cutaneous microcir culation, related to a diminished vasomotor tone (sympathetic activity), induced by ESES . In diabetic patients with neuropathy (autonomic sympathectomy) a high vasodilation index contraindicates ESES implant.

Induced-Hyperglycemia Attenuates Erythromycin-Induced Acceleration of Hypertonic Liquid-Phase Gastric Emptying in Type-I Diabetic Patients

Background: Erythromycin has been found to be a gastrointestinal prokinetic agent of hypertonic liquids, while acute hyperglycemia has been associated with delayed gastric emptying in diabetic patients. Aim: To investigate whether hyperglycemia, per se, reduces gastric motility during erythromycin-induced acceleration on gastric emptying of hypertonic liquids in diabetic patients. Methods: In 12 type-I diabetic patients following a hypertonic radiolabeled liquid meal, gastric emptying was measured scintigraphically during normoglycemia (5–8.9 mmol/l glucose) or hyperglycemia induced by intravenous (16–19 mmol/l) glucose infusion. The tests were performed on 4 separate days in random order after administering either placebo or 200 mg i.v. erythromycin. Results: In the hyperglycemic state compared to normoglycemia, the gastric emptying of the hypertonic liquid was reduced after placebo or erythromycin administration. The lag-phase duration (17.8±5.5 and 7.8±4.5 vs. 10.8±3.4 and 3.7±2.5 min, respectively, p<0.001), the overall gastric emptying time of the half meal (52.8±13 and 24.9±5.5 vs. 42.5±10.5 min and 16.6±6 min, respectively, p<0.001) and the retained percentage of liquid meal in the stomach at 60 and 100 min postprandially (p<0.001) were significantly increased. Conclusions: The erythromycin-induced acceleration on gastric emptying of hypertonic liquids in diabetic patients is related to the plasma glucose level. The induced hyperglycemia reduces the erythromycin-induced acceleration of liquid-phase gastric emptying, decreasing the overall gastric emptying rate. In spite of the inhibitory effect of induced hyperglycemia on the gastric emptying of hypertonic liquids, erythromycin is still able to accelerate the emptying rate and could prove to be a useful prokinetic agent under hyperglycemic conditions.

Two different therapeutic modalities in the treatment of the upper extremity deep vein thrombosis: Preliminary investigation with 20 case reports

Primary or secondary axillary or/and subclavian vein thrombosis (ASVT) can produce long-term disability, mostly in young patients, while the final vein recanalization after various therapeutic modalities often fails. Our aim was to compare the results of two different therapeutic modalities: the thrombolytic vs anticoagulant therapy, in primary and secondary ASVT in a retrospective data analysis in terms of efficacy, negative side effects, long-term positive results. Eleven patients (Group A), with primary and secondary to central venous cannulation or cardiac pacing ASVT, were treated with anticoagulant therapy, while another 9 patients (Group B), were treated with thrombolytic therapy, that included urokinase or streptokinase for 24–48 hours. The phlebographic, duplex ultrasonographic findings and clinical improvement were compared between the two patient groups. In Group A patients, after a mean period of 81.7 months follow-up (range 58–106), one patient with open vein were noticed, while in Group B patients after a mean follow up period of 52.1 months (range 35–68) five patients presented with recanalized veins (P=0.040). Complete clinical recovery and vein patency was achieved in one Group A patient, contrary to 5 Group B patients (P=0.040). When the patients with complete clinical recovery were combined with those who presented some clinical improvement, four Group A patients and eight Group B had satisfactory outcome (P=0.028). Thrombolytic therapy should be the treatment of choice in primary and secondary ASVT, in productive patients whose lifestyle depends on continued strenuous use of the involved limb with a reasonable medium-term life expectancy. The thrombolytic agents prevent the vein valves damage and malfunction, avoiding re-thrombosis related to venous reflux and stasis, preserving the valve functional integrity.