Benefit of revascularisation to critical limb ischaemia patients evaluated by a patient-oriented scoring system.

OBJECTIVES: The concept of patency and limb salvage are physician-oriented endpoints in critical limb ischaemia (CLI). These endpoints have failed to enhance function after revascularisation. The aim of this study was to create a scoring system to predict 1-year functional status and to assess the benefit to patients possible by revascularisation. MATERIALS AND METHODS: During the period 2007-2009, 480 consecutive patients (mean age ± SD, 83.2 ± 8.7 years) underwent repair for CLI. Preoperative, operative and functional status characteristics and post-operative outcomes were recorded. The following patient-oriented outcomes were investigated pre- and postoperatively: basic and instrumental activities of daily living (BADL and IADL) and ambulatory and living status. Statistical analysis was performed to assess predictors of functional benefit from revascularisation. The variables significant on multivariable analysis were used to generate a scoring system to pre and postoperatively grade individual patient risk of losing baseline functional status at 1 year (CLI functional score). RESULTS: Ninety-three of 480 patients (19.3%) were in Rutherford class IV, 208 (43.3%) in class V and 179 (37.4%) in class VI. Surgical, endovascular and hybrid operations were performed in 108 (22.5%), 319 (66.5%) and 53 (11%) patients, respectively; mean follow-up was 408 ± 363 days. Improved or unchanged functional status was observed in 276 patients (57.5%). Preoperative mean ± SD BADL and IADL (4.26 ± 1.98 and 3.92 ± 2.69, respectively) were modified from mean values at 1-year follow-up (4.19 ± 2.06 and 4.12 ± 3, respectively) (p = 0.401 and p < 0.05, respectively). In the same time interval, mortality was 50%, limb salvage 50.4%, CLI-related new hospitalisations 50.8%, relief of symptoms 18.5% and tissue healing 14.5%. A CLI functional score of >80% indicates that patients are likely to lose functional abilities and require assistance for ambulation or ADL, as well as risking outcomes such as major amputation, new CLI-related hospitalisation or re-operation (p < 0.001). Preoperative poor living status, dependence in daily activities, advanced local disease (lesion >2 cm, infection and poor tibial runoff), American Society of Anesthesiologists (ASA) score > II, previous cerebrovascular event and heart disease were the strongest pre-operative negative predictors of losing baseline functional status. Major amputation was the only negative post-operative predictor. CONCLUSIONS: Considering patient-oriented outcomes, our study showed that revascularisation could be worthwhile in nearly 60% of CLI patients. A non-revascularisation strategy such as primary amputation or palliation could be indicated in patients with a poor pre-operative living status, dependence for daily activities, advanced local disease, extensive comorbid conditions and a score >80%. To make our findings generalisable, the score needs to be validated in independent cohorts at different centres before it can be recommended for application.

Acute aortic dissection: natural history and classification.

Acute aortic dissection is an uncommon but potentially catastrophic pathology with high mortality and morbidity. Significant advances in the understanding, diagnosis and management of aortic dissection have been made since the first case was reported 3 centuries ago. This article aims to review our current understanding of the natural history and classification of acute aortic dissection.

Management of abdominal endograft infection.

Incidence, clinical presentation and management of aortic grafts infection after open surgical repair are well described in the literature. Infective complications involving endografts after endovascular aneurysm repair (EVAR) have been scarcely investigated, since more attention has been given to the technical aspects of the procedure, including endoleaks, device migration, neck dilatation, endotension and aneurysm rupture. Nevertheless, that is a rare but severe complication occurring after EVAR; potentially difficult to diagnose and treat. Since 1991 only 102 cases of abdominal endograft infections have been reported in the literature. Treatment of infected abdominal endografts is controversial. Although reports have shown that high-risk patients with infected stent grafts treated conservatively with antimicrobial therapy and percutaneous drainage can still survive, most authors agree that an infected endograft should be removed if patient's conditions allow intervention. Standard treatment for infected abdominal endografts includes complete graft excision and local debridement followed by extra-anatomical bypass revascularization or in situ reconstruction with an aortic-bisiliac or bifemoral graft (Dacron or PTFE) or with a homograft. Lower overall mortality was observed for surgical management by explantation of infected endograft followed by in situ replacement as compared to other surgical solutions, but no definitive conclusions can be drawn about the optimal treatment strategy for aortic reconstruction.

A rare vascular tumour with distinctive clinical findings.

Subungual glomus tumours are rare benign hamartomas arising from the arterial end of the glomus body (an arteriovenous shunt related to thermoregulation). A combination of clinical examination, Color-Doppler ultrasonography and magnetic resonance imaging (MRI) is used to support the diagnosis confirmed by histology. A 45 year old male patient with a three-year-old swelling of the proximal thumbnail presented himself at the Surgery Department. A slightly bluish nail plate and tenderness under the thumbnail were evident at clinical examination. He suffered the classic trilogy of sensitivity to pain, pressure and temperature of the thumb lesion. Ultrasound and MRI revealed the presence of a small oval-shaped mass with hypervascularisation. All these elements reinforced the assumed diagnosis of a glomic tumour. The patient underwent excisional surgery under local anaesthesia. Histological examination confirmed a typical glomus tumour. Postoperative follow-up was uneventful and all symptoms disappeared immediately after surgery. Whenever a patient presents suffering from a reddish-purple, tender lesion, usually located at the extremities and especially in the nail bed, with paroxysmal pain and cold-sensitivity, a glomus tumour should be investigated. Surgical excision is the treatment of choice and is commonly resolutive.

[Local excision of rectal cancer in early phase as an alternative to major surgery]. / L'escissione locale del cancro del retto in fase "early" quale alternativa agli interventi chirurgici maggiori.

The authors analyse the role of local excision as curative procedure of low rectal early cancer. In their opinion it's very important to select the patients in accordance with some characteristics of the tumor (site, grading, mobility, depth, size, stage, involvement of locoregional nodes, ploidia). Intrarectal ultrasonography is thought be the most important diagnostic tool, both in preoperative diagnosis and in postoperative follow-up; it has a high sensibility to define the parietal invasion of rectal cancer and to recognize metastatic nodes. They review various surgical techniques used to make local excision by several authors (transsacral approach by Kraske, transsphinteric approach by Mason and transanal approach by Bailey), as well as the alternative methods (surgical diathermy by Strauss, endocavitary irradiation by Papillon and cryosurgery by Heberer). The authors point out the technique of Bailey and coll. is getting the major approvals owing to its simplicity, low mortality and morbidity rates, poor incidence of recurrences and good survival. The most recent therapeutic protocols provide only local excision for the lesions limited into mucosa and submucosa (stage T1), also postoperative radio- and chemotherapy for tumors involving muscolaris propria (stage T2). On the other hand, advanced rectal cancer (stage T3) may be managed best by major operations. Recurrences rates (5-22%) and five-years survival rates (78-90%) are obviously conditioned by tumor features. Finally, the authors reaffirm, with their personal experience as well, the importance of local excision as curative operation for low rectal early cancer, provided that a careful case selection is made in accordance with macro- and microscopical features of the tumor.

[Transvaginal echocystourethrography]. / L'ecocistouretrografia transvaginale.

The anatomo-physiologic appearances of female urination obtained with a new ultrasonographic technique is illustrated. The technique is performed using an intravisceral linear probe positioned in the vagina and a special chair which allows the urination in physiological position; at the same time the urination is videorecorded. The results, compared with X-Ray cystourethrography, enabled us to show the normal aspects (both dynamic and morphologic) and several pathologic aspects. Basing upon the direction of the urethra, it is possible to establish the change of the position of the floor and the neck bladder, which are often responsible of stress incontinence. The Authors stress the relative simplicity and noninvasiveness of the echographic technique. X-Ray radiation aren't used: this test is particularly advisable to study the urination disease of women in fertile-age.

The schwannoma: an uncommon type of cystic lesion of the pancreas.

Schwannomas of the pancreas are rare and their number is lower than is usually reported in the literature since some were probably neurofibromas. We report a further case characterized by cystic feature, clinically mimicking a pancreatic pseudocyst. Cystic lesions of the pancreas also comprise the schwannomas, both benign or malignant, as has been previously reported and is stressed by the present case. Cyst formation characterizes many diseases of the pancreas, both neoplastic and not. Difficulties in the differential diagnosis of cysts are fortunately reduced by the preponderance of pseudocysts (i.e. non-neoplastic cysts) and, among neoplastic ones, of cystadenomas and cystadenocarcinomas. As a consequence, uncommon cystic neoplasms are neglected and very often misdiagnosed. We reported a case of solitary schwannoma mimicking a pancreatic pseudocyst, interesting both because of its rarity and because of its cystic feature which was previously reported in the literature but not emphasized.

[Comparative analysis of the technics of preoperative localization of the parathyroid glands]. / Analisi comparativa delle tecniche di localizzazione pre-operatoria delle paratiroidi.

Parathyroid surgery needs an appropriate diagnosis and a preoperative localization. We conducted a prospective study to compare the efficacy of 4 different imaging modalities in 17 patients: thallium-technetium subtraction scintigraphy, ultrasonography, computed tomography and arteriography. The sensitivity was: scintigraphy 58%, echotomography 86%, Tc 92% and arteriography only 33%. Neck exploration confirmed the imaging results. We found 15 cases of adenomas (2 cases of double adenoma) and 1 case of hyperplasia; in 1 patient, no lesions were found. We conclude that the association of such techniques appears to be the optimal strategy in about 100% of the patients.