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Foot ulcers associated with Diabetes mellitus require immediate attention due to risk of amputation if left untreated. Herein we focus on the mitigating risk factors and physiopathology of the diabetic foot, recounting our own surgical approach and revascularization procedures.
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Nowadays patients affected by deep vein thrombosis (DVT) and pulmonary embolism (PE) are studied widely but the challenge for physicians is when and how they are to be treated. Most patients present serious comorbidities that can potentially make treatment difficult. An increasing cohort of patients cannot be treated with systemic fibrinolysis but fortunately today, physicians can utilize a number of different instruments to resolve acute DVT and PE.
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Marfan syndrome is the most prevalent connective tissue disorder, with an autosomal dominant inheritance with variable penetrance. This paper aims to summarize epidemiology and treatment for type B dissection in Marfan patients.
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Aneurisma Aórtico/epidemiologia , Dissecção Aórtica/epidemiologia , Síndrome de Marfan/epidemiologia , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/cirurgia , Animais , Aneurisma Aórtico/diagnóstico , Aneurisma Aórtico/cirurgia , Implante de Prótese Vascular , Diagnóstico por Imagem/métodos , Procedimentos Endovasculares , Predisposição Genética para Doença , Humanos , Síndrome de Marfan/diagnóstico , Síndrome de Marfan/genética , Fenótipo , Valor Preditivo dos Testes , Prevalência , Fatores de Risco , Resultado do TratamentoRESUMO
Isolated spontaneous dissection of the superior mesenteric artery is extremely rare. In December 2012, a 45-year-old man, without significant comorbidities, presented at the emergency room of another hospital with abdominal pain. The patient was treated with medical therapy and discharged on resolution of the pain. Three months later he returned to the emergency room with a new onset of pain. CT-angiography (CTA) showed an isolated SMA dissection associated with aneurysmal dilatation. The patient was referred to our attention. We attempted endovascular exclusion of the dissecting aneurysm in May 2013. We deployed a self-expandable nitinol stent (BostonSC Adapt 4-9×32 mm) in order to simultaneously repair the dissection, preserve the branches and exclude the aneurysm. Postoperative course was uneventful and the patient was discharged on postoperative day 2. At 10-month follow-up CTA showed excellent positioning of the stent, patency of the visceral branches and shrinkage of the aneurysm.
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Aneurisma/cirurgia , Dissecção Aórtica/cirurgia , Procedimentos Endovasculares , Artéria Mesentérica Superior/cirurgia , Dor Abdominal/etiologia , Aneurisma/diagnóstico por imagem , Dissecção Aórtica/diagnóstico por imagem , Humanos , Masculino , Artéria Mesentérica Superior/diagnóstico por imagem , Artéria Mesentérica Superior/lesões , Pessoa de Meia-Idade , Radiografia , StentsRESUMO
Endovascular repair of abdominal aortic aneurysm has become a milestone in the treatment of patients with abdominal aortic aneurysm.Technological improvement allows treatment in more and more complex cases. This review summarizes all grafts available in the market. At the best of our knowledge a complete review of most important trial on this topic are provided and at least technical tips and tricks for standard cases are recapitulated.
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According to the World Health Organization, every year, 5 million peoples die for stroke and another 5 million are permanently disabled. Although there are many causes of acute stroke, a common treatable cause of acute stroke is atheromatous narrowing at the carotid bifurcation. Carotid endarterectomy is still the standard of car, even if carotid artery stenting (CAS) has become an effective, less invasive alterantive. Unfortunately, CAS procedure is not yet perfect; regardless the use of an embolic protection device (EPD), percutaneous treatment has been correlated with a risk of cerebral ischemic events related to distal embolization. The objective of the IRON-Guard Registry is to evaluate the clinical outcome of treatment by means of stenting with the C-Guard (InspireMD, Boston, MA, USA) in subjects requiring CAS due to significant extracranial carotid artery stenosis with a physician-initiated, Italian, prospective, multicenter, single-arm study. A total of 200 enrolled subjects divided over different centers are planned to be enrolled. CAS will performed by implanting of C-Guard stent. Procedure will be performed according to the physician's standard of care. Standard procedures will be followed based on the Instructions for Use, for the C-Guard device of Inspire. The primary endpoint of this study is the 30-day rate of major adverse events (MAE), defined as the cumulative incidence of any periprocedural (≤30 days postprocedure) death, stroke or myocardial infarction. Secondary endpoints are rate of late ipsilateral stroke (31 through 365 days), system technical success, device malfunctions, major adverse events (MAEs), serious device-related and procedure-related adverse events, target lesion revascularization, and in-stent restenosis rates.
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Angioplastia/instrumentação , Estenose das Carótidas/terapia , Sistema de Registros , Projetos de Pesquisa , Stents , Angioplastia/efeitos adversos , Angioplastia/mortalidade , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico , Estenose das Carótidas/mortalidade , Humanos , Itália , Estudos Prospectivos , Desenho de Prótese , Falha de Prótese , Recidiva , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Fatores de Tempo , Tomografia de Coerência Óptica , Resultado do TratamentoRESUMO
Although traditional surgical repair by aneurysm exclusion and bypass is still considered the gold standard in the treatment of popliteal artery aneurysms (PAAs), the endovascular repair (ER) has been gaining great interest in the last decades. ER offers several advantages over open bypass, including lower morbidity and mortality, and faster functional recovery, but some concerns about migration, occlusion, or fracture remain when a stent graft is deployed across a joint that undergo constant flexion. This review summarizes the current evidence on ER for PAAs. Level I evidence is still very limited, while the majority of published data come from retrospective studies. Moreover the heterogeneity of PAA morphology seems to play a major role in the outcomes after popliteal endografts placement, so that many anatomical criteria should be taken into account to determine which patient is best treated endovascularly. In conclusion, while it is unlike that endovascular treatment may displace open surgical bypass in the near future, it indeed does provide a feasible option for selected patients with high surgical risk and good anatomical features.
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Aneurisma/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Artéria Poplítea/cirurgia , Aneurisma/diagnóstico , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Humanos , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Desenho de Prótese , Medição de Risco , Fatores de Risco , Stents , Resultado do TratamentoRESUMO
AIM: A new stent was designed, conceived for being placed externally around blood vessels to perform vessel banding in a much simple and fast way. In fact it requires the dissection of a single segment of the aortic wall, as its mechanical features allow it to slide on the tunica adventitia. After previous tests (ex vivo and in vivo test), the new stent has been evaluated in vivo long-term study. METHODS: In female pig of average weight of 60 kg, after placement of endoprosthesis in infrarenal abdominal aorta, immediately below renal arteries, aortic banding was performed with new stent at the level of each end of endoprosthesis, identified under fluoroscopic guidance. Pigs were followed up for six months, and acetylsalicylic acid was administrated: 100 mg once a day. After six months, histological evaluation of explanted abdominal aorta was performed. RESULTS: New stent made the aortic banding simple and fast. Postoperative course was uneventful. Histological results were similar to previous 10-week survival tests and not damages of aortic wall were observed. CONCLUSION: Positive outcome of three last long-term survival tests, as of all those ex vitro and in vivo tests previously performed, makes conceivable further scientific investigation and trials.
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Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Stents , Animais , Aorta Abdominal/patologia , Aspirina/administração & dosagem , Esquema de Medicação , Feminino , Teste de Materiais , Modelos Animais , Inibidores da Agregação Plaquetária/administração & dosagem , Desenho de Prótese , Suínos , Fatores de TempoAssuntos
Procedimentos Endovasculares/efeitos adversos , Doença Iatrogênica , Artéria Ilíaca/lesões , Isquemia/etiologia , Doença Arterial Periférica/terapia , Lesões do Sistema Vascular/etiologia , Doença Aguda , Angiografia Digital , Constrição Patológica , Humanos , Artéria Ilíaca/diagnóstico por imagem , Isquemia/diagnóstico , Isquemia/terapia , Masculino , Pessoa de Meia-Idade , Doença Arterial Periférica/diagnóstico , Ruptura , Resultado do Tratamento , Ultrassonografia Doppler , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/terapiaRESUMO
In recent years the number of carotid revascularization has increased steadily. This increased has inevitably resulted in an increase (relative) in complications, both after carotid endarterectomy (CEA) and carotid stenting (CAS), despite the technical evolutions of new available materials and the expertise of the operators. So, complications which may potentially require operative intervention, although not very frequent, are possible. However, after diagnosis, immediate management should be undertaken in order to avoid sequelae which are often irreversible and potentially fatal. To minimize this risk, it's important that these procedures are performed by skilled operators in high-volume Centers of activity. The aim of this review is to assess local complications which can lead to re-interventions after CEA and CAS.
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Angioplastia com Balão/efeitos adversos , Doenças das Artérias Carótidas/terapia , Endarterectomia das Carótidas/efeitos adversos , Complicações Pós-Operatórias/terapia , Angioplastia com Balão/instrumentação , Doenças das Artérias Carótidas/diagnóstico , Doenças das Artérias Carótidas/cirurgia , Humanos , Complicações Pós-Operatórias/diagnóstico , Retratamento , Fatores de Risco , Stents , Resultado do TratamentoRESUMO
Implantation of a vascular prosthesis increases surgical site infection risk by producing a microenvironment conducive to bacterial attachment and biofilm formation, which sustains bacterial colonization and protects encased organisms from host defenses and antimicrobial therapy. Many maneuvers are used in an attempt to reduce infection in arterial reconstructions, but there are no clear guidelines on the most appropriate or effective. As well, there is no good evidence to guide management. A general principle is that indication for removal of the entire infected graft is mandatory when a suture line is involved in the infectious process, an infected anastomotic aneurism and a suture-line hemorrhage is evident, or when a graft-enteric fistula is diagnosed. Conservative, non-resectional management of graft infection is still a respectable solution for selected patients, as those with significant comorbidities, or those where the implanted aortic graft is in a location that precludes excision without causing a high likelihood of morbidity and/or mortality. Anyway, definitive management depends on the patient's condition and a tailored approach should be always offered. Surgical techniques favor in terms of mortality, patency and reinfection rate the in situ reconstruction. Currently, the choice of the technique used relies on center and operator's experience. This article summarizes the incidence of graft infection, analyze the predisponding factors to graft infection, and review current strategies for prevention and treatment of prosthesis and endograft infection.
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Antibacterianos/uso terapêutico , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Prótese Vascular/efeitos adversos , Remoção de Dispositivo , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Infecções Relacionadas à Prótese/prevenção & controle , Infecções Relacionadas à Prótese/terapia , Stents/efeitos adversos , Humanos , Seleção de Pacientes , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/microbiologia , Reoperação , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
When Juan Parodi implanted an endograft in a human body for the first time on September 7, 1990 in Buenos Aires, Argentina, the delivery system of the handmade device was primitive, extremely rigid, and had a bulky profile of 27 French (F). Since then, stent-graft technology has evolved rapidly, limitations of earlier-generation devices have been overtaken, and endovascular aneurysm repair (EVAR) eligibility has increased enormously. Nevertheless (still) challenging aortoiliac anatomy such as short and complex proximal aortic neck seal zones and narrow access vessels are responsible for EVAR ineligibility in up to 50% of cases. The Ovation Prime abdominal stent-graft system (TriVascular, Inc., Santa Rosa, CA, USA) is a trimodular device designed with the aortic body delivered via a flexible, hydrophilic-coated, ultra-low profile catheter (14-F outer diameter - OD). The aortic body is provided with a suprarenal nitinol stent with anchors that provide active fixation, while a network of rings and channels that are inflated with a low-viscosity radiopaque polymer during stent-graft deployment, provides effective sealing. The previous EVAR technology aimed to both anchor and seal using stents combined with fabric, with neither optimized for their roles and each forced to compete for the same space within their delivery catheters, which inevitably led to larger profile of the delivery system. The technical revolution of the Ovation endograft includes the idea to truly uncouple the stages of stent-graft fixation and seal during the procedure. In the Ovation endograft platform, stent and fabric are not competing the same space within the delivery system and an ultra-low profile delivery can be achieved without compromise. With such a low-profile delivery catheter, approximately 90% of men and 70% of women with abdominal aortic aneurysm have access vessel diameters considered fit for endovascular repair. The aim of this review paper was to analyze the main properties of Ovation endograft, to emphasize the advantage of the ultra-low profile device, and to sum up current literature.
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Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Stents , Dispositivos de Acesso Vascular , Aneurisma da Aorta Abdominal/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Desenho de Equipamento , Humanos , Desenho de Prótese , Resultado do TratamentoRESUMO
AIM: The aim of this paper was to evaluate the influence of a challenging neck on mid-term results using the Endurant I stent-graft system in high risk patients. METHODS: A retrospective study was conducted on a prospectively compiled database of 72 elective patients with challenging neck treated with the Endurant I system (Endurant Stent Graft, Medtronic AVE, Santa Rosa, CA, USA). These patients were compared to a control group (65 patients) without significant neck problems. The endpoints were mid-term 2-years technical, clinical success and the event free survival of all treated patients. RESULTS: Mean age was 76.12 years; 76.6% of patients were males. Risk factors and preoperative variables did not differ significantly between the two groups. Only 4 (5.5%) patients of the study group vs. 2 (3.1%) in the control group developed type I endoleak during the follow-up. Three (4.1%) study group patients developed type III endoleak vs. 2 (3.1%) in the control group. All these patients required an adjunct procedure of relining with a new endograft. No type II endoleaks requiring adjunctive endovascular procedures were detected in our series. The 2-year event free survival rate did not differ statistically between the two groups (P=0.425). CONCLUSION: Treatment with the Endurant stent-graft is technically feasible and safe, yielding satisfactory results even in challenging anatomies. Mid-term results are promising and challenge current opinion concerning the negative influence of challenging neck anatomy on EVAR especially after a longer follow-up.
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Aneurisma Aórtico/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Stents , Idoso , Idoso de 80 Anos ou mais , Aneurisma Aórtico/diagnóstico , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Intervalo Livre de Doença , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Desenho de Prótese , Reoperação , Estudos Retrospectivos , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ultrassonografia Doppler em CoresAssuntos
Estenose das Carótidas/diagnóstico , Estenose das Carótidas/terapia , Diagnóstico por Imagem/normas , Endarterectomia das Carótidas/normas , Procedimentos Endovasculares/normas , Estenose das Carótidas/complicações , Diagnóstico por Imagem/métodos , Endarterectomia das Carótidas/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Humanos , Ataque Isquêmico Transitório/etiologia , Valor Preditivo dos Testes , Recidiva , Fatores de Risco , Stents/normas , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
Introduction. Critical limb lschemia (CLI) and particularly diabetic foot (DF) are still considered "Cinderella" in our departments. Anyway, the presence of arterial obstructive disease increases the risk of amputation by itself; when it is associated with foot infection, the risk of amputation is greatly increased. Methods. From January 2007 to December 2011, 375 patients with DF infection and CLI have been admitted to our Unit; from 2007 to 2009, 192 patients (Group A) underwent surgical debridement of the lesion followed by a delayed revascularization; from 2010 to 2011, 183 patients (Group B) were treated following a new 4-step protocol: (1) early diagnosis with a 24 h on call DF team; (2) urgent treatment of severe foot infection with an aggressive surgical debridement; (3) early revascularization within 24 hours; (4) definitive treatment: wound healing, reconstructive surgery, and orthesis. We reported rates of mortality, major amputation, and foot healing at 6 months of followup. Results. The majority of patients in both groups were male; no statistical differences in medical history and clinical condition were reported at the baseline. The main difference between the two groups was the mean time from debridement to revascularization (3 days in Group A and 24 hours in Group B). After 6 months of follow-up, mortality was 11% in Group A versus 4.4% in Group B. Major amputation rate was 39.6% and 24.6% in Groups A and B, respectively. Wound healing was achieved in 17.8% in Group A and 20.8% in Group B. Conclusions. This protocol requires a lot of professional skills that should to reach the goal to avoid major amputations in patients with DF. Only an interdisciplinary integrated DF team and an early intervention may significantly impact the outcome of our patients: "Time is Tissue"!
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The treatment of the critical limb ischemia (CLI) and diabetic foot (DB) is still object of discussion and the gold standard for revascularization has not yet been identified. In these two decades the introduction of endovascular procedures had a large impact on the surgical revascularization and were added to the practice of vascular surgeons in patients who cannot be candidates for a bypass. This may be due to significant comorbidities, a reduced life expectancy, infection or gangrene in the possible sites of distal anastomoses, the unavailability of suitable veins, or the absence of an adequate "landing zone" for the distal part of the bypass. Various studies have evaluated the role of PTA in DF and CLI that resulted favourable in terms of feasibility, technical efficacy, the reduced number of complications, and limb salvage rates. Anyway, long-term patency is better after bypass surgery than after angioplasty, which is burdened by a high restenosis rate. In our experience we tried to practice endovascular approach as a first choice. If the procedure cannot be concluded safely, we continue the intervention surgically or use a hybrid approach. The endovascular-first strategy seems to be the future regardless of comorbidity of the patient and the degree of pathology. The vascular surgeon remains the only specialist that can decide the correct intervention without pressure or been forced and, last but not least, the only one who can independently perform hybrid interventions.
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Pé Diabético/cirurgia , Procedimentos Endovasculares/métodos , Isquemia/cirurgia , Extremidade Inferior/irrigação sanguínea , Humanos , Resultado do TratamentoRESUMO
Patients affected by critical limb ischemia (CLI) represent a complex and high risk clinical problem, and a multidisciplinary approach is often demanded. The amputation rate in patients affected by CLI is still high. Introduction of endovascular procedure shook up the CLI concept of treatment. The increasing experience of Vascular Surgeons in endovascular technique forced these specialist to match classic surgical skills and endovascular tools in order to achieve the best treatment for each patients. The combination of the two techniques identifies the hybrid procedure. Aim of this paper is to define indication, necessity and results of the hybrid procedure in patients suffering from CLI.
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Amputação Cirúrgica/métodos , Procedimentos Endovasculares/métodos , Isquemia/cirurgia , Salvamento de Membro/métodos , Extremidade Inferior/irrigação sanguínea , Animais , Humanos , Extremidade Inferior/cirurgia , Resultado do TratamentoRESUMO
AIM: Acute limb ischemia (ALI) is not infrequently associated with limb loss (10-30%) or death of the affected patient (15-30%). These results can be even worse in elderly population. The aim of this study is to quantify safety and efficacy of early revascularization in over 90 years old patients with acute limb ischemia. METHODS: This is a prospective registry lasting from January 2012 to January 2013. We include all consecutive over 90 years patients treated for ALI (N.=15). A careful preoperative Duplex scan (DS) were performed in each patient. All patients underwent surgery by Fogarty's embolectomy, and endovascular completion procedure if needed (N.=3). RESULTS: We performed 18 revascularizations (15 lower limbs, 3 upper limbs) in 15 patients (2 staged bilateral femoral, 1 simultaneous bilateral femoral). The mean follow-up was 124 days (4-365). Technical success was obtained in 16 cases (88.9%). At disharge mortality was 5.9% (1 case), and amputation rate was 6.2% (1 pt). The Kaplan-Meier curves at 1 year revealed an estimated freedom from death, amputation and re-occlusion of 76.5%, 88.2%, and 71.3%, respectively. CONCLUSION: The over 90 years old patient represent a challenging case for vascular surgeon. Vascular procedures involve high mortality rate but emergent revascularization by Fogarty Embolectomy in ALI is safe and effective even in older patient.
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Embolectomia/métodos , Procedimentos Endovasculares , Isquemia/terapia , Extremidade Inferior/irrigação sanguínea , Extremidade Superior/irrigação sanguínea , Doença Aguda , Fatores Etários , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Intervalo Livre de Doença , Embolectomia/efeitos adversos , Embolectomia/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Isquemia/diagnóstico , Isquemia/mortalidade , Isquemia/fisiopatologia , Isquemia/cirurgia , Estimativa de Kaplan-Meier , Salvamento de Membro , Masculino , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
"For the best vascular care to every patient, every day" is the goal of our practice, but is it a possible goal? Where are we now? The general idea is that we are pursuing the right way. The evolution of our discipline in the last two decades has been extraordinary and we reaffirm that we are the leaders in diagnose and treatment of the arterial pathology. Unfortunately, we can find some cases in which reality has to be faced as hardly as it can be, remembering us that we still have to go further with our job. The delay in the diagnose and treatment could lead to a permanent deficit and a money loss for the national health system due to prolonged hospitalization, multiple re-hospitalizations, loss of working capacity. This must be avoided. We strongly suggest that a vascular surgeon should be present in all the Emergency Room and should be routinely involved in the management of patients. The routine use of dedicated interdisciplinary protocols should be strongly advocated. Vascular surgery, as medical specialty, should be recognized as single specialty in all countries and as "peculiar" by the National Authority as well as Neurosurgery and Cardiac Surgery.