Endovascular first as "preliminary approach" for critical limb ischemia and diabetic foot.

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.

The role of hybrid procedures in the treatment of critical limb ischemia.

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.

Acute limb ischemia in nonagenarians.

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.

Adrenocortical responses to submaximal exercise in postmenopausal black and white women.

The purpose of this study was to determine whether racial differences exist in the dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), and cortisol concentrations of black and white postmenopausal women at rest and in response to submaximal exercise. Twenty-three postmenopausal women (13 white and 10 black) were studied on 2 occasions. On one occasion subjects rested quietly for 4 hours (control day), whereas on the other occasion after 50 minutes of rest, subjects exercised at 70% of Vo(2) peak for 30 minutes on a cycle ergometer (exercise day). Blood was sampled at rest, during exercise, and during recovery and assayed for DHEA, DHEAS, and cortisol concentrations. Resting DHEA and cortisol concentrations and integrated area under the curve (AUC) were similar between the black and white women; however, the black women had lower resting DHEAS concentrations compared with the white women (DHEAS, black: 1.32 +/- 0.29 v white: 2.18 +/- 0.25 micromol. L(-1), P <.05). Regardless of race, DHEA and cortisol AUC increased significantly above resting values (P <.01), but the exercise AUC for DHEA and cortisol were not different between the black and white women (DHEA: 607 +/- 133 and 824 +/- 108 min x nmol. L(-1); cortisol: 9,604 +/- 1,247 and 8,076 +/- 1,093 min x nmol. L(-1), respectively). No exercise-induced change in integrated DHEAS AUC was found in either group. In conclusion, racial differences exist in the resting DHEAS levels of postmenopausal women, but with no racial differences in resting DHEA and cortisol concentrations. Race had no impact on these adrenal hormone responses to submaximal exercise.