Clinical and Pathological Correlations in Chronic Venous Disease.

BACKGROUND: Chronic Venous Disease (CVD) has a high prevalence in the western world. Varicose veins (VVs) are the main signs of this disease that is characterized by important pathological vessel wall changes. The aim of this study is to correlate the main histopathological abnormalities with related clinical issues of CVD. METHODS: A cohort of patients with VVs scheduled for open surgical treatment namely stab avulsion of VVs was recruited. Subsequently, venous tissue from stab avulsion was collected in order to evaluate the following biomarkers: Vascular-Endothelial Growth Factor (VEGF), Protein Gene Product 9.5 (PGP 9.5), Fibronectin (FN), and Matrix Metalloproteinase-9 (MMP-9). The Clinical-Etiology-Anatomy-Pathophysiology (CEAP) criteria were used to classify CVD. RESULTS: Fourteen tissue fragments were processed for histological and immunohistochemical studies. Of these, 43% were from CEAP C2 patients, 36% from CEAP C3 patients, and 21% from CEAP C4 patients. CEAP Class C2 had few to moderate structures positive to VEGF; occasional structures positive to Fibronectin, numerous structures positive to MMP9, few to moderate structures positive to PGP 9.5. CEAP Class C3 had moderate structures positive to VEGF; few to moderate structures positive to Fibronectin; many structures positive to MMP9; few to moderate structures positive to PGP 9.5. CEAP Class C4 had numerous structures positive to VEGF; numerous structures positive to Fibronectin; abundant structures positive to MMP-9; few structures positive to PGP 9.5. CONCLUSIONS: In this study, positive VEGF, FN, and MMP-9 structures were found with increasing trends in relation to the disease staging. VEGF and FN are associated with a progressive increase from C2 to C4. The MMP-9 marker has an important positivity even at early stage of the disease, being higher in CEAP C4 patients. PGP 9.5 decreases in CEAP C4 patients and this is concordant to decreased vein wall innervation.

Endovascular recanalization of chronic total occlusions of the native superficial femoral artery after failed femoropopliteal bypass in patients with critical limb ischemia.

BACKGROUND: Femoropopliteal bypass occlusions are a significant issue in patients with critical limb ischemia and chronic total occlusion of the native superficial femoral artery, which challenges vascular surgeons and interventional radiologists. Performing a secondary femoropopliteal bypass is still considered the standard of care, although it is associated with a higher complication rate and lower patency rate in comparison with primary bypass. Over the past few years, angioplasty has been commonly used, with the development in endovascular technologies, to treat chronic total occlusions of the native superficial femoral artery, with a good technical success rate and clinical prognosis. The purpose of the study is to assess the outcome of endovascular recanalization of chronic total occlusions of the native superficial femoral artery, in patients unfit for surgery with critical limb ischemia after failed femoropopliteal bypass. RESULTS: A total of 54 patients were treated. 77.8 % of the conduits were PTFE grafts; the remainder were single-segment great saphenous veins. The most common clinical presentation was rest pain. Technical success was achieved in 51 (94.4 %) of 54 limbs. Angiographically, 77.8 % of the lesions were TASC II category D, while 22.2 % were TASC II category C. The average length of the native SFA lesions was 26.8 cm. Clinical success, with improved Rutherford classification staging, followed each case of technical success. The median follow-up value was 5.75 years (IQR, 1.5-7). By Kaplan-Meier survival analysis, primary patency rates were 61 % (± 0.07 SE) at 1 year and 46 % (± 0.07 SE) at 5 years. Secondary patency rates were 93 % (± 0.04 SE) at 1 year and 61 % (± 0.07 SE) at 5 years. Limb salvage rates were 94 % (± 0.03 SE) at 1 year and 88 % (± 0.05 SE) at 5 years. CONCLUSIONS: The endovascular recanalization of chronic total occlusions (CTO) of the native superficial femoral artery (SFA) after a failed femoropopliteal bypass is a safe and effective therapeutic option in patients unfit for surgery with critical limb ischemia.

Fatal early peripheral post-reperfusion syndrome and the role of cutaneous signs.

The purpose of this report is to present the case of a 75-year-old male affected by right common femoral artery and abdominal aortic aneurysms. His clinical history was also characterised by post-ischaemic cardiomyopathy, arterial hypertension, chronic respiratory disease and peripheral arterial disease. We performed two surgical procedures: right femoral aneurysmectomy and femoro-femoral bypass and subsequently a femoro-femoral crossover bypass plus right femoro-popliteal bypass below the knee. The second operation became necessary in order to treat acute occlusion of the right iliac-femoral arterial axis. The patient developed a progressive and aggressive lower limb post-perfusion syndrome associated to frank peripheral oedema, myocardial stunning, reperfusion arrhythmias, renal failure and respiratory distress. Cutaneous alterations (oedema of the leg, mottled skin and cyanosis of the foot) were more specific compared with Doppler ultrasound that showed the presence of adequate blood flow in the early phase. On the basis of this experience and of pertinent literature, this study represents a challenge for the understanding of the exact mechanism of origin and progression of post-reperfusion syndrome.