Excimer laser ablation in the treatment of total chronic obstructions in critical limb ischaemia in diabetic patients. Sustained efficacy of plaque recanalisation in mid-term results.

This prospective study aims to evaluate the impact of the excimer laser technology as the first-line endovascular treatment of critical limb ischaemia (CLI) in diabetic patients. The protocol allowed the use of laser ablation of obstructive lesions when conventional endoluminal guidewire crossing of the plaque was unsuccessful. We extrapolate the data of consecutive patients treated, who completed at least 12 months of follow-up, extending the observation to a 26-month time frame. During this period, 67 diabetic patients with CLI were brought to the Cath Lab for 'operative angioplasty' and to be treated with endovascular techniques. Of the 67 cases, laser was used on 35 patients to treat 51 lesions. All patients had type C or D occlusive lesions, according to the TACS II classification, showing a single type D plaque or multiple tandem C/D occlusive plaques ranging from 4 to 23 cm in length. The immediate clinical success, defined as restored direct arterial flow to the foot, was 88.2%. The lesions were successfully crossed by laser in 45 out of 51 attempts. Stents were required in 25% of the patients with 21% lesions. Patency rates were assessed using the Kaplan-Meier survival curves. The patency rates of the successfully treated lesions (freedom from target lesion revascularisation) were 96.6% at 12 months and 82.7% at 24 months. Limb-salvage rate at 12 and 24 months were 100% and 94%, respectively. Our study showed that the excimer laser-assisted angioplasty, when feasible, is effective in granting event-free survival in CLI patients with diabetes, and that endoluminal-driven atherectomy allows long-term success in reducing the need of stents in the lower limb arteries.

External banding valvuloplasty of the superficial femoral vein in the treatment of recurrent varicose veins.

OBJECTIVES: The aim of this study is to evaluate the efficacy of reconstructive surgery of primary deep venous insufficiency in preventing recurrent varicose veins. DESIGN: Retrospective analysis of patients affected by recurrent varicose veins submitted to external banding valvuloplasty of the superficial femoral vein. SETTING: A division of vascular surgery in a hospital/scientific institute. MATERIALS: Nineteen limbs (19 patients) with recurrent varicose veins, severe chronic venous insufficiency and 3rd or 4th grade reflux in the superficial femoral vein and competence of the profunda femoris vein were selected for surgical reconstructive treatment after a complete diagnostic study by continuous wave Doppler duplex scanning and descending phlebography. INTERVENTIONS: External banding valvuloplasty of the superficial femoral vein was performed in all cases: A Dacron sleeve was used in nine patients and Venocuff in 10. RESULTS: In one case a deep venous thrombosis of the calf occurred in the first postoperative period; in three cases the correction of the deep reflux was incomplete and a recurrence of the varices was observed. After a mean follow-up of 50 months, abolition of reflux and relief of symptomatology were obtained in 15 cases (78%). CONCLUSIONS: Primary deep venous insufficiency, unknown at the time of the initial operation, may be the cause of recurrent varicose veins. External banding valvuloplasty of the superficial femoral vein may abolish the reflux and correct venous hypertension, preventing recurrences.

[Thromboendarterectomy of the superficial femoral artery with a femoro-popliteal endoprosthesis. Technical note on a preliminary experience]. / La Tromboendoarteriectomia (TEA) dell'arteria femorale superficiale (SFA) con posizionamento di endoprotesi femoro-poplitea. Note di tecnica su una esperienza preliminare.

BACKGROUND: The authors report an early experience with a new endovascular approach in the treatment of occlusive superficial femoral artery disease to evaluate the efficacy and the feasibility of the new technique. METHODS AND RESULTS: Four patients with disabling claudication or leg rest pain were treated for long segment occlusion of superficial femoral artery (SFA). A remote endarterectomy (EA) of SFAs has been performed using a single groin incision and a conventional Vollmar ring stripper to remove the entire atheroma core for a length of 20, 10, 9 and 8 cm. In 3 cases following complete extraction of intimal core and a guidewire placement across from the distal endpoint, the endarterectomized segment was lined endoluminally by implanting one or more Self-Expanding Coated Stent (Meadox Passager 6-10 mm); the stent was positioned under fluoroscopic guidance to prevent dissection without any further balloon-dilation. In 1 case a 5 mm diameter thin-walled PTFE endoluminal graft was positioned using a Strecker stent for distal fixation. One patient had an immediate post-operative occlusion of distal stent which required a femoro-popliteal autologous vein bypass. In the remaining 3 cases no postoperative complications were observed and the patients are asymptomatic with normal flow through the stent and the endoluminal PTFE graft at 6 months. CONCLUSIONS: In this report a combined surgical and endovascular procedure has been proposed. A prospective randomized study is carrying on at our Institute to verify if EA+ endovascular grafting of SFA represents an alternative to traditional femoro-popliteal vein bypass.

[The role of spinal cord electric stimulation in critical ischemia of the extremity]. / Il ruolo dell'elettrostimolazione midollare nell'ischemia critica d'arto.

The aim of this study is to evaluate, through a retrospective analysis of our experience, the effectiveness of spinal cord stimulation (SCS) in conservative treatment of critical limb ischaemia. During a 7-year period, at our Institution, SCS has been performed in 35 patients affected by severe lower limb ischaemia with angiographic multilevel distal lesions; femoro-distal bypass was not advisable or had failed due to poor outflow conditions. Basing upon clinical criteria (regression of rest pain, claudicatio and ischaemic lesions, limb salvage and need of amputation) the results of therapy were distinguished in "good,", "satisfactory" and "poor". Mean follow-up was 25 months (range 2-80). A good result has been achieved in 17 patients (48.5%) satisfactory in 11 (28.8%) and poor in 7 (20%), with a 80% limb salvage rate. No significative differences were observed in subgroups of patients with diabetes, hypertension or both. Appropriate management of critical limb ischaemia depends on a well-thought-out plan. Although femoro-distal vein bypass has been widely advocated as the treatment of choice, the good result of revascularization is related to adequate outflow conditions (adequate run-off). SCS has been reported to reduce ischaemic pain and improve ulcer healing and microcirculation in ischaemic limbs. Our experience and recent studies have provided strong evidence that SCS reduces tissue loss and improves limb salvage rate in inoperable patients. A prospective randomised study will be helpful in defining if SCS should represent an efficacious and alternative procedure to bypass in the treatment planning of critical leg ischaemia.

Surgical treatment of achalasia: a retrospective comparative study.

A retrospective study carried out on 74 patients among 101 consecutive cases of achalasia of the esophagus operated from 1967 to 1989 is reported. On 21 patients observed between 1967 and 1975, a standard transabdominal Heller cardiomyotomy was performed (group A). From 1976 to 1989, the treatment of choice was a Heller myotomy associated with a modified Dor's fundoplication. In 80 consecutive cases (group B) the extension of myotomy was regulated by intraoperative monitoring of lower esophageal sphincter pressure. A 5-year follow-up with questionnaires, physical examination, and barium swallows was carried out on 16 patients in group A and on 58 patients in group B. In 75.6% of the cases (56 patients) follow-up examinations included esophageal manometry and 24-hour esophageal pH monitoring. Recurrence of dysphagia was recognized in 3 cases in group A (18.7%) and in 2 cases in group B (3.4%) (P = 0.053); postoperative gastroesophageal reflux, measured as a percentage of total reflux time, showed a significantly lower mean value in group B than in group A (1.8% vs. 4.1%, P < 0.01). This study suggests that an anti-reflux procedure lowers postoperative gastroesophageal reflux after Heller myotomy. Due to the low incidence of postoperative reflux and the negligible recurrence of dysphagia, Heller myotomy associated with a modified Dor's fundoplication may represent the surgical treatment of choice for achalasia of the esophagus.

[Prosthetic reconstruction of the thoracic wall after resection for cancer]. / Ricostruzione protesica della parete toracica dopo resezione per neoplasia.

Primary tumors of lung and breast represent the most frequent cause of neoplastic involvement of the thoracic wall, being primary parietal neoplasms extremely rare; metastatic lesions of the thoracic wall are not an infrequent finding, but represent just an occasional indication for surgery. Prosthetic reconstruction after a resection that includes the bony structures of the thoracic cage is dependent upon the extension of the parietal excision. We report a personal experience with 11 cases of prosthetic reconstruction of the thoracic wall out of a total of 54 extended resections accomplished between 1979 and 1990. We did not find prosthetic reconstruction indicated for thoracic wall defects smaller than 5 cm in diameter, wherever located. As regards larger parietal defects, a reconstructive procedure appeared always necessary for anterior or lateral regions of the thorax, while we never used prosthetic implants for posterior defects, regardless of their size. In all cases we used a Silastic sheet, 1.016 mm thick, reinforced by Dacron mesh, whose margins were molded on the form of the thoracic defect and secured by 2/0 Prolene suture. Follow up ranged from 6 to 36 months. No case of rejection has been observed up to date and no interference with radiation treatment or chemotherapy has been reported.

[Stapling techniques in exeresis surgery of bronchogenic carcinoma]. / Tecniche di stapling nella chirurgia di exeresi del carcinoma broncogeno.

From January 1983 to October 1989, 221 bronchogenic carcinomas were surgically treated at our Department. Different stapling techniques were employed in 153 cases: 138 stapled sutures of main and lobar bronchi, 33 stapled parenchymal sutures and 21 stapled sutures of the pulmonary artery. Stapling-related complications were observed in 3 patients: 1 bronchopleural post-pneumonectomy fistula (0.72%); 2 persisting air leakages following stapled parenchymal suture (6%). The use of vascular staplers, though, has never been associated with complications. The advantages related to the use of stapling devices are represented by lower air leakage and bleeding rates, with a reduced operative trauma; on the other hand, disadvantages seem to be more theoretical than realistic. At our Department stapling devices nowadays represent the choice in thoracic surgery either for main and lobar bronchi or parenchymal sutures.