A reliable approach to diabetic neuroischemic foot wounds: below-the-knee angiosome-oriented angioplasty.

PURPOSE: To evaluate the clinical benefit in wound healing and limb preservation after primary below-the-knee angioplasty guided by an angiosome model of perfusion in diabetic patients with neuroischemic foot ulcers. METHODS: From September 2001 to April 2010, 232 limb-threatening neuroischemic wounds in 208 diabetic patients (147 men; mean age 74.3 years, range 42-97) were treated by below-the-knee endoluminal and/or subintimal angioplasty. There were 19 (8%) TASC II type B, 80 (34%) type C, and 133 (57%) type D infrapopliteal lesions. Patients treated prior to 2005 when the angiosome-targeted revascularization protocol was introduced (89 limbs, group 1) were compared to 134 limbs treated subsequently according to the angiosome model (group 2). The angiosome-oriented group 2 included 25% procedures focusing on the anterior tibial and dorsalis pedis arteries, 68% on the posterior tibial and plantar vessels, and 7% on the peroneal arteries. RESULTS: The global technical success was 80% (187/232): 82% in group 1 and 79% in group 2. The cumulative patient survival rates were 90%, 78%, and 65% in group 1 and 93%, 82%, and 71% in group 2 at 12, 24, and 36 months, respectively (p = 0.545). At the same time points, the freedom from amputation rates were 84%, 79%, and 79% in group 1 versus 90%, 89%, and 89% in group 2 (p = 0.035). Clinical success rates were 76%, 68%, 68% in the group 1 and 85%, 79%, and 79% in group 2 (p = 0.025). Primary and secondary patency rates did not differ between groups (p = 0.813 and p = 0.511). Patients in group 2 treated with angiosome-targeted revascularization had significantly better wound healing (p<0.018) and limb preservation (p<0.030). CONCLUSION: Below-the-knee first-line angioplasty guided by an angiosome model may prove beneficial in terms of better wound healing of diabetic foot ulcers and subsequent limb salvage. Further technical improvements and large comparative studies are necessary to support these observations.

Selective primary angioplasty following an angiosome model of reperfusion in the treatment of Wagner 1-4 diabetic foot lesions: practice in a multidisciplinary diabetic limb service.

PURPOSE: To evaluate the technical and clinical outcomes of primary subintimal (SA) and endoluminal angioplasty (EA) guided by an angiosome model of revascularization in diabetic patients with critical limb ischemia (CLI) and Wagner grade 1-4 foot ulcers. METHODS: A retrospective review was undertaken of 98 diabetic CLI patients (68 men; mean age 72.8 years, range 46-94) who presented to our institution from January 2005 to January 2008 for treatment of Wagner grade 1-4 foot ulcers involving 124 limbs. Following the angiosome model of perfusion in the foot and ankle, the target arterial lesions in the 124 limbs were treated with 80 (64%) associated SA and EA procedures, 21 (17%) multilevel EAs, and 23 (18%) single SA techniques. RESULTS: Initial technical success was achieved in 102 (82%) interventions: 82/103 SAs and 20/21 of the EAs. The 30-day survival rate was 98% (1 fatal myocardial infarction). The cumulative rates of primary and secondary patency, limb salvage, and clinical success were: 57%+/-4%, 71%+/-4%, 91%+/-3%, and 85%+/-3% at 12 months and 48%+/-5%, 61%+/-4%, 84%+/-6%, and 73%+/-6% at 32 months, respectively. Limb salvage appeared to be negatively affected at 3 years by the presence of Wagner grade 3-4 lesions (p<0.0002), the bedridden condition of patients (p<0.0001), end-stage renal disease (p<0.0001), left ventricular dysfunction (p<0.0001), and peripheral neuropathy (p = 0.023). Using the angiosome approach, complete healing of ulcers with or without minor amputation was seen in 79% (98/124 limbs), while 62 of 70 Wagner grade 1-2 and 36 of 54 Wagner 3-4 foot lesions healed in the first 1 to 3 months after revascularization. CONCLUSION: Targeted primary angioplasty following the angiosome model could be an effective therapeutic method in the ulcer healing process. However, beyond appropriate revascularization, aggressive control of concurrent risk factors in diabetic wound healing probably plays an equally relevant role.

Deep calf veins arterialization for inferior limb preservation in diabetic patients with extended ischaemic wounds, unfit for direct arterial reconstruction: preliminary results according to an angiosome model of perfusion.

AIM OF THE STUDY: The study proposes to evaluate the limb salvage in diabetic ischemic limbs with foot wounds, where all types of common arterial reconstructions have previously failed or were impracticable, by using the "SAVES" technique (selective arterio-venous endoluminal switch) for deep calf veins arterialization upon an angiosomes model of distribution. MATERIALS AND METHODS: Since January 2001 until September 2009, a series of 26 limbs with threatening ischemic wounds in 25 diabetic patients at high risk for major amputation and no feasible conventional revascularizations, were treated by the hybrid (surgical and endovascular) SAVES technique and were retrospectively reviewed. The method consists in selective arterialization of the deep calf veins with synchronous endoluminal exclusion of the collaterals, guided by an angiosomes- model of vascularization. There were 12 limbs treated by preferential anterior tibial veins arterialization, 11 with revascularizations in the posterior tibial and three others targeting the peroneal-related territorial wound distribution. RESULTS: The initial technical success was achieved in 21 of 26 limbs (80%) with 0% 30-day perioperative mortality rate. The cumulative primary and secondary patency were: 66%, 60% and 48%, at 12, 24 and 36 months, respectively. Limb salvage revealed 73% at one year and steady 73% afterwards, while the clinical success was: 68%, 60% and 60% at identical time intervals. CONCLUSION: Selective deep calf venous arterialization oriented by an angiosome model for reperfusion may represent a complementary alternative for limb salvage in extreme situations, inoperable by direct arterial methods. Larger groups of study are needed to ascertain these preliminary observations.

Laparoscopic gastric banding as revisional procedure to failed vertical gastroplasty.

BACKGROUND: Vertical gastroplasty (VG) was worldwide and until recently a very popular restrictive bariatric procedure. Unfortunately, many patients required revisional surgery for failure of this technique. The present study aimed to evaluate retrospectively the feasibility, safety, and efficiency of conversion of failed VGs to laparoscopic adjustable gastric banding (LAGB). METHODS: Forty patients underwent LAGB as revisional surgery between August 2001 and June 2008. Preceding VGs were performed either by open procedure {silastic ring vertical gastroplasty (SRVG, n = 21) and vertical-banded gastroplasty (VBG, n = 10)} or by laparoscopy {laparoscopic silastic ring vertical gastroplasty (L-SRVG, n = 9)}. The delay between initial and revisional surgery was significantly shorter for SRVG (5.5 +/- 1.7 years; p < 0.001) as compared to VBG and L-SRVG (9.2 +/- 2.3 and 9.4 +/- 1.8 years, respectively). The reasons for failure of the VG were: disruption of the staple line (n = 23), excessive enlargement of the gastric pouch (n = 15) and inefficient stoma (n = 2). Patients were qualified for revisional surgery in case of uncontrolled weight regain with or without frequent vomiting. RESULTS: There were three conversions from laparoscopy to laparotomy (7.5%). There was no mortality. Minor morbidity was 12.5%. There were two major complications (5%); one incarcerated port-site hernia requiring small bowel resection, and one band erosion necessitating band removal. The mean BMI dropped from 38.9 kg/m(2) before revision to 30.7 kg/m(2) after conversion to LAGB (follow-up 6-88 months). CONCLUSIONS: Conversion of failed VGs to gastric banding is safe and efficient. The morbidity rate is acceptable. Gastric banding to correct failing VG is a reasonable option when performed in selected patients.

Filter-protected carotid stenting via a minimal cervical access with transitory aspirated reversed flow during initial passage of the target lesion.

PURPOSE: To evaluate the preliminary results of filter-protected carotid artery stenting (CAS) via a minimal cervical access, with temporary common carotid artery (CCA) occlusion and aspiration in selected high-risk candidates for carotid endarterectomy. METHODS: Since February 2002, 26 patients (17 men; mean age 73.7 years, range 54-98) at high surgical risk according to the SAPPHIRE eligibility criteria underwent 29 transcervical CAS procedures under filter protection. Under general anesthesia, a 6-F short introducer sheath was directly mounted in the CCA through a small (2-4 cm) laterocervical cutdown. The CCA was briefly clamped, and blood was aspirated while the filter device was positioned above the target lesion. With the filter in place and the clamp released, nitinol stents were deployed under filter protection. Hemostasis was achieved by direct suture. RESULTS: Twenty-eight (96%) interventions were technically successful; 1 complex lesion could not be crossed and was converted to surgery. Mean clamping time was 1.7 (range 1.0-3.5) minutes. Combined 30-day stroke/mortality was 0%. Ultrasound surveillance demonstrated a < 60% asymptomatic in-stent restenosis in 1 (4%) patient with radiation-induced arteritis after 28 months. During a mean follow-up of 11.6 months (range 3-38), 1 (4%) minor ipsilateral stroke was noted at 6 months in a patient whose antiplatelet therapy was transitorily interrupted. CONCLUSION: Our preliminary observations from this small early experience suggest that this variant CAS technique is feasible and probably diminishes the neuroembolic risk during initial navigation of the ICA target stenosis.