Tips and tricks for a correct "endo approach".

The world is facing an epidemic of diabetes, consequently in the next years critical limb ischemia due to diabetic artery disease will become a major issue for vascular and endovascular operators. Revascularization is a key therapy in these patients because reestablishing an adequate blood supply to the wound is essential for healing avoiding a major amputation. In this paper, we summarize our experience in endovascular treatment of diabetic critical limb ischemia, focusing of the main technical challenges in treating below-the-knee vessels. We describe the following topics: 1) targets of the revascularization therapy: "complete" versus "partial" revascularization and the concept of wound related artery. Every procedure must be tailored on technically realistic strategies and on the general patient status; 2) the antegrade femoral access using both, the X-ray and the ultrasound guided techniques; 3) the chronic total occlusions crossing strategy proposing a step-by-step approach: endoluminal, subintimal, retrograde approaches. Particular attention has been given to the different retrograde approaches: pedal-plantar loop technique, trans-collateral approaches and the different types of retrograde puncture. For each step we provide a complete description of the technical details and of the suitable devices. Eventually we in brief describe: 3) acute result optimization and 4) prevention of restenosis.

Ischemic Charcot foot: different disease with different treatment?

AIM: Aim of the study was to describe the presence of peripheral arterial disease in combination with Charcot neuroarthropathy in diabetic patients, and to evaluate the role of revascularization supporting surgical and orthopedic treatment. METHODS: We retrospectively collected and analyzed data of all diabetic patients affected by Charcot neuroarthropathy in combination with critical limb ischemia, which arrived to our care for the presence of foot lesions and underwent endovascular revascularization, followed by surgical and orthopedic treatment between January 2010 and January 2012. The primary end point was to assess the limb salvage rate. The secondary end point was to evaluate the healing time of the lesions. RESULTS: Ten diabetic patients (10 men; mean age 69.1±8.5 years), affected by ischemic Charcot neuroarthropathy underwent endovascular revascularization, surgical debridement and orthopedic correction. The limb salvage rate was 90%, avoiding major amputation in 9 patients. In one patient (10%) the infection could not be controlled and below-the-knee amputation was carried out. The required time to heal the lesion was in mean 197.4±22.4 days, after revascularization, surgical and orthopedic treatment. CONCLUSION: Patients with Charcot foot deformity can be affected by critical limb ischemia and revascularization therapy is necessary, to support surgical and orthopedic treatment, avoiding amputation and leading to limb and foot salvage.

Is digital arteries recanalization useful to preserve the foot functionality and avoid toes amputation, after pedal recanalization? Clinical results.

AIM: The authors aimed to assess clinical results following percutaneous transluminal angioplasty (PTA) of pedal arteries and digital branches in order to avoid minor amputations or support surgical skin incisions, in patients with CLI and distal wounds on the toes. METHODS: Baseline, procedural and mid-term outcome data of all consecutive patients with CLI and ulcerative lesion on the toes, in which endovascular treatment of the foot arteries and digital branches was attempted, were prospectively collected between January 2010 and January 2011. The primary end-point was acute success (i.e. technical, angiographic and procedural success). Secondary end-points included limb, foot and toes salvage rates, minor amputations, reocclusion/restenosis and repeat treatment. RESULTS: 1057 consecutive patients with CLI were treated and in 24 cases (2.3%), after tibial and foot arteries PTA, related to the presence of arterial lesion (stenosis/occlusion) in the digital branches, the recanalization of the target vessel was performed. Acute technical success was achieved in 100% of cases, with adequate angiographic results without peri-procedural complications. Clinical improvement was obtained and maintained after an average of 9 months. Amputation was avoided in 9 patients (37.5%), in 8 patients (29.6%) amputation involved only a distal phalange, in 5 patients (20.8%) toe amputations was necessary, in 2 patients (8.4%) trans-metatarsal amputation was performed. No below the ankle (BTA) or major amputations were performed. CONCLUSION: Endovascular recanalization of digital branches in patients with CLI and distal wounds on the toes is feasible and safe; represent a support to avoid minor amputations or surgical skin lesion healing.

Paclitaxel-coated balloon angioplasty for lower extremity revascularization: a new way to fight in-stent restenosis.

In the last years the development of new techniques and technologies for the endovascular treatment of peripheral arterial occlusive disease has allowed to treat a vast array of lesions with high technical success and low complications. Despite these advances, restenosis, and in particular in-stent restenosis, is a problem that significantly affects middle and long-term results and remains to be solved. Drug-eluting balloons (DEB) have shown good results in the treatment of coronary in-stent restenosis in experimental and clinical trials, but only few experimental and clinical trials focus on the peripheral district. This review summarizes the available experimental and clinical data in support of DEB in the treatment of ISR in the peripheral district. Larger clinical trials focused on paclitaxel-coated balloon in the treatment of ISR in the peripheral arteries will be necessary to provide definitive evidence of clinical benefit.

CT Diagnosis of Cerebral Venous Thrombosis: Importance of the First Examination for Fast Treatment.

This study is a retrospective investigation of the role of non contrast-enhanced CT (NCCT) in the diagnosis of cerebral venous thrombosis (CVT) in clinical practice. We retrospectively identified 24 patients discharged with a diagnosis of CVT between January 2002 and December 2008 who had undergone NCCT as the first imaging modality. NCCT had been evaluated by a general radiologist and subsequently by a neuroradiologist in five cases. Final diagnosis was established by CT angiography (CTA), magnetic resonance (MR) and digital subtraction angiography (DSA). NCCT diagnosis was defined as "positive" when the neuroradiologist suggested the diagnosis of CVT on the report, as opposed to the "negative" diagnosis group. All NCCT examinations were reviewed by a neuroradiologist experienced in cerebrovascular pathology. We compared his evaluation and analysed the location and number of direct signs found on NCCT. The neuroradiologist strongly suggested an NCCT diagnosis of CVT in 63% (15/24) of patients: 80% (4/5) with deep venous thrombosis (DVT) and 57% (11/19) with sinus venous thrombosis (SVT). The general radiologist's NCCT evaluation was incorrect in four cases, subsequently diagnosed at NCCT by the neuroradiologist. After reviewing the NCCT examination the experienced neuroradiologist identified the CVT direct sign in two that belonged to the NCCT negative diagnosis group. Thus the direct sign was present in 71% (17/24) of the cases: all the patients with DVT and 63% (12/19) of the patients with SVT. NCCT still plays an important role for fast and accurate diagnosis of CVT in the emergency setting. NCCT displayed the CVT direct sign more frequently than previously thought and it was correctly interpreted in most cases. Neuroradiological consultation adds value to the general radiologist's evaluation.