Angioplasty for diabetic patients with failing bypass graft or residual critical ischemia after bypass graft.

OBJECTIVE: To evaluate the efficacy of peripheral angioplasty (PTA) in the treatment of diabetic patients with previous peripheral bypass graft and recurrent critical limb ischemia (CLI). METHODS: Between January and December 2006, 293 diabetic patients presenting with critical limb ischemia (CLI) according to the TASC 2000 criteria were admitted to our footcare centre. Among these patients, 32 of them had previously undergone bypass grafting: femoropopliteal in 26 patients, femoroposterior tibial in 3 patients, femoroperoneal in the remaining 3. All these patients underwent angiography and, whenever possible, a concomitant PTA procedure. RESULTS: Six patients presented with stenosis at the distal anastomosis, 2 with stenosis at the proximal anastomosis and in 5 patients both the distal and proximal anastomosis were stenosed. In 12 patients the graft was completely occluded. In 7 patients the graft appeared patent but all the infrapopliteal arteries were occluded. The average time interval between bypass and subsequent hospital admission because of CLI was 6.3+/-4.2 months for patients with patent grafts and 20.5+/-12.0 months for those with failing grafts (p=0.004). A successful PTA was performed in 25 patients (78.1%). In all patients with patent grafts, PTA recanalized one infrapopliteal artery. Recanalization of the graft was obtained in all 13 patients with non-occluded graft. Recanalization of superficial femoral artery occlusion by means of PTA was obtained in 5 out of the 12 patients in whom the graft was completely occluded. Five patients underwent major amputation within 30 days and 3 further patients during the follow-up period. Patients were followed up until December 31 2007, with a mean follow-up of 1.89+/-0.27 years. Restenosis occurred in 7 (28.0%) of the 25 patients in whom a successful PTA was performed. In 5 of these 7 patients, PTA was repeated successfully. In 2 patients in whom a further PTA was not feasible a major amputation was performed. At the end of the follow-up period the cumulative primary patency rate was 72%, the assisted patency rate was 92%. CONCLUSIONS: PTA is an effective method for revascularizing secondary obstructions in patients with graft failure (and no possibility of a redo graft). PTA also is effective in at least one subgenicular artery in patients with diabetes with inadequate run-off after femoropopliteal bypass grafting.

[Treatment of uterine fibromyoma with bilateral uterine artery embolization: state of the art]. / Trattamento di fibromioma dell'utero mediante embolizzazione bilaterale dell'arteria uterina. Stato dell'arte.

Uterine fibroids are common tumors of the female pelvis. Uterine artery embolization (UAE) is a minimally invasive alternative procedure in appropriate candidates to conventional myomectomy and hysterectomy for symptomatic uterine leiomyoma, reducing or eliminating leiomyoma-related symptoms of bleeding, bulk, and/or pain. In order to completely block the arterial blood supply to the fibroid, UAE is typically performed in both uterine arteries. At 1 year follow-up, the uterus may shrink by up to 55%, however, a re-growth of the fibroid may occur. The rate of major complications and amenorrhea following this procedure is low, ranging in most series from 1% to 3.5% and 1% to 7%, respectively. Nevertheless, the rate of amenorrhea in women over 45 seems to be higher. Women who wish to become pregnant should be cautioned about potential complications during pregnancy. Despite the lack of controlled studies that compared UAE with conventional surgery, and despite limited extended outcome data, UAE has gained rapid acceptance, primarily because this procedure preserves the uterus, is less invasive, and has less short-term morbidity than most surgical options. This review focuses on recent publications evaluating UAE and concludes that it is a safe treatment option, providing substantial improvement in both health-related quality of life and symptom control for most patients, with a very low rate of major complications. Any centre that offers UAE should adhere to published clinical guidelines, maintain ongoing assessment of quality improvement measures, and observe strict criteria to obtain procedural privileges. The gynecologist is likely to be the primary initial consultant to patients who present with myomas symptoms. Therefore, they must be familiar with the indications, exclusions, outcome expectations, and complications of UAE. When hysterectomy is the only option, UAE should be seriously taken into consideration. At this particular moment in time, data are needed from randomized controlled trials comparing UAE with surgical procedures. Current efforts to provide prospective objective assessment of treatment outcomes and complications after UAE will help to optimize women options and clinical guidelines.

[Uterine fibroids embolization: results about 454 cases]. / Embolisation des fibromes utérins: résultats sur 454 cas.

OBJECTIVE: To determine the effectiveness of uterine arterial embolization (UAE) as primary treatment in the management of symptomatic leiomyomas. PATIENTS AND METHOD: UAE was performed on 454 patients (age range: 21-68) with menorrhagia, bulk-related symptoms or both, due to leiomyomas. The effectiveness of this therapy in the control of symptoms and reduction of uterine and leiomyoma volume was measured by clinical and imaging controls at 3, 6 and 9 months after the procedure. RESULTS: Four hundred and thirty-three patients were evaluated, and 42 failures were observed (9.6%). Six months after the procedure, 391 patients were symptom-free. Follow-up ultrasonic examination showed an average reduction of 55% in dominant myoma volume at 6 months, 70% at 1 year. Twenty-seven women became pregnant (30 pregnancies). Complications related to procedure, and requiring surgery, occurred in three cases. Principal complications are amenorrhoea and fibroid sloughs. Severe complications are rarely found. DISCUSSION AND CONCLUSION: UAE is an efficient therapy in the management of symptomatic myomas and proves to be a valid alternative to surgical procedure. The future of this mini-invasive and conservative technique appears to be a very promising one.

When is a technically successful peripheral angioplasty effective in preventing above-the-ankle amputation in diabetic patients with critical limb ischaemia?

AIM: To determine parameters predictive of avoidance of major (above-the-ankle) amputation after a technically successful peripheral angioplasty (PTA) in patients with diabetes with critical limb ischaemia. METHODS: From January 1999 to December 2003, 420 consecutive patients with diabetes admitted to hospital because of critical limb ischaemia underwent peripheral angiography and concomitant technically successful PTA. Transcutaneous oxygen tension (TcPO(2)) was measured before and after PTA. Major amputation at 30 days was recorded. RESULTS: After PTA, the iliac-femoral-popliteal axis was patent in all patients. In 67 patients, all three crural arteries were patent, in 143 patients 2 crural arteries were patent, and in 186 patients one crural artery was patent (104 peroneal, 62 anterior tibial, 20 posterior tibial). In 24 patients, all three crural arteries were occluded. Twenty-two major amputations were performed. Of these, 15 were performed in the 24 patients with occlusion of all the infrapopliteal arteries. Seven of the 186 patients in whom only the peroneal artery was patent required amputation. In patients not requiring amputation, TcPO(2) increased from 15.5 +/- 11.9 to 45.0 +/- 12.0 mmHg (P = 0.000), while in those requiring amputation, TcPO(2) increased from 9.6 +/- 7.7 to 18.6 +/- 8.1 mmHg (P < 0.082). Multivariate analysis indicated an independent role of occlusion of infrapopliteal arteries after PTA (OR 8.20 for every crural obstructed artery, P = 0.022, CI 1.35-49.6) and TcPO(2) after PTA (OR 0.80 for increase of 1 mmHg, P < 0.001, CI 0.74-0.88). CONCLUSIONS: In patients with diabetes, PTA is effective in avoiding major amputation, provided recanalization occurs in at least one tibial artery down to the foot. In a few patients, re-canalization of the peroneal artery alone is not sufficient to avoid major amputation.

Early and five-year amputation and survival rate of diabetic patients with critical limb ischemia: data of a cohort study of 564 patients.

OBJECTIVE: To evaluate the early and late major amputation and survival rates and related risk factors in diabetic patients with critical limb ischemia (CLI). DESIGN: Retrospective study. METHODS: Revascularization feasibility, major amputation, survival rate and related risk factors were recorded in 564 diabetic patients consecutively hospitalized for CLI from 1999 to 2003 and followed until June 2005. RESULTS: Peripheral angioplasty (PTA) was carried out in 420 (74.5%), bypass graft (BPG) in 117 (20.7%) patients. In 27 (4.8%) patients both PTA and BPG were not possible. Twenty-three above-the-ankle amputations (4.1%) were performed at 30 days: 6 in PTA patients, 3 in BPG patients, 14 in non revascularized patients. In the follow-up of 558 patients (98.9%), 62 repeated PTAs and 9 new BPGs, 32 new major amputations (16 in PTA patients, 14 in BPG patients and 2 in non-revascularized patients) were performed. Major amputation was associated with absence of revascularization (OR 35.9, p < 0.001, CI 12.9-99.7), occlusion of each of the three crural arteries (OR 8.20, p = 0.022, CI 1.35-49.6), wound infection (OR 2.1, p = 0.004 CI 1.3-3.6), dialysis (OR 4.7, p = 0.001 CI 1.9-11.7) increase in TcPO2 after revascularization (OR 0.80, p < 0.001 CI 0.74-0.87). One hundred seventy three patients died during follow-up and this was associated with age (HR 1.05, p < 0.001 CI 1.03-1.07), history of cardiac disease (HR 2.16, p < 0.001 CI 1.53-3.06), dialysis (HR 3.52, p < 0.001 CI 2.08-5.97), absence of revascularization (HR 1.68, p < 0.001, CI 1.29-2.19) and impaired ejection fraction (HR 1.08, p < 0.001, CI 1.05-1.09). CONCLUSIONS: In diabetic patients with CLI the revascularization is feasible in most cases and allows a low rate of early major amputation. This rate is higher in the follow-up period. Major amputation is very high in patients where revascularization is not feasible while the high mortality rate is due to the serious comorbidities observed in these patients.

Peripheral angioplasty as the first-choice revascularization procedure in diabetic patients with critical limb ischemia: prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003.

OBJECTIVE: To evaluate the effectiveness of peripheral angioplasty (PTA) as the first-choice revascularisation procedure in diabetic patients with critical limb ischemia (CLI). DESIGN: Prospective study. METHODS: PTA was employed as first choice revascularisation in a consecutive series of diabetic patients hospitalized for CLI between January 1999 and December 2003. RESULTS: PTA was successful performed in 993 patients. Seventeen (1.7%) major amputations were carried out. One death and 33 non-fatal complications were observed. Mean follow-up was 26+/-15 months. Clinical restenosis was observed in 87 patients. The 5 years primary patency was 88%, 95% CI 86-91%. During follow-up 119 (12.0%) patients died at a rate of 6.7% per year. CONCLUSIONS: PTA as the first choice revascularisation procedure is feasible, safe and effective for limb salvage in a high percentage of diabetic patients. Clinical restenosis was an infrequent event and PTA could successfully be repeated in most cases.

[Vascular risk in angiography examinations (author's transl)]. / Le risque en radiologie vasculaire.

About an experience of 7,757 investigations and after study of the published series in the literature, it appears the frequency of the accidents following vascular roentgenology has not really changed since ten years. -- 0,5% complications; 0,07% death in aortographies; -- 0,4% complications; 0,09% death in femoral artery catheterization; -- 3% complications; no death in axillary artery catheterization. The authors use the term "complications" when a surgical operation is necessary or after effects are present in the evolution. The study of the recent literature proves no significant amelioration in comparison with the last ten years. The accidents are analysed in aortography, in arterial catheterization using femoral or axillary arteries: the latter is the most dangerous. The considerable increment of the number of investigations suppressed the progresses provided by the material improvements. An explanation: in hospitals, it is necessary to train the students for roentgenology.