In vitro cell culture of amniotic fluid keratinocytes on amniotic membrane: the ideal tissue for repairing skin ulcers.

OBJECTIVE: The amniotic fluid contains a large population of stem keratinocytes demonstrating minimal immunological rejection. Recent evidence suggests that stem cells from the amniotic fluid can be employed in the field of tissue engineering. In this work we identified precursors of the epithelial cells and expanded them in vitro. MATERIALS AND METHODS: After collecting samples of amniotic fluid and separating the cells via centrifugation, we seeded a portion of these cells in selection media to analyze the proliferation of epithelial cells. The stem cells precursors of keratinocytes were identified through specific markers. The expression of these markers was evaluated by immunofluorescence and reverse transcription polymerase chain reaction (PCR). RESULTS: The stem cells demonstrated 90% confluence, after undergoing proliferation in the selection medium for 15 days. Most of these cells tested positive for the keratinocyte-specific markers, but negative for stem cell specific markers. Of note, the identity of the keratinocytes was well established even after several subcultures. CONCLUSIONS: These results suggested that it is feasible to isolate and expand differentiated cell populations in the amniotic fluid from precursor cells. Furthermore, amniotic membranes can be utilized as scaffolds to grow keratinocytes, which can be potentially exploited in areas of skin ulcer transplantation and tissue engineering interventions.

Diagnosis and Treatment of Venous Malformations. Consensus Document of the International Union of Phlebology (IUP): updated 2013.

Venous malformations (VMs) are the most common vascular developmental anomalies (birth defects) . These defects are caused by developmental arrest of the venous system during various stages of embryogenesis. VMs remain a difficult diagnostic and therapeutic challenge due to the wide range of clinical presentations, unpredictable clinical course, erratic response to the treatment with high recurrence/ persistence rates, high morbidity following non-specific conventional treatment, and confusing terminology. The Consensus Panel reviewed the recent scientific literature up to the year 2013 to update a previous IUP Consensus (2009) on the same subject. ISSVA Classification with special merits for the differentiation between the congenital vascular malformation (CVM) and vascular tumors was reinforced with an additional review on syndrome-based classification. A "modified" Hamburg classification was adopted to emphasize the importance of extratruncular vs. truncular sub-types of VMs. This incorporated the embryological ongm, morphological differences, unique characteristics, prognosis and recurrence rates of VMs based on this embryological classification. The definition and classification of VMs were strengthened with the addition of angiographic data that determines the hemodynamic characteristics, the anatomical pattern of draining veins and hence the risk of complication following sclerotherapy. The hemolymphatic malformations, a combined condition incorporating LMs and other CVMs, were illustrated as a separate topic to differentiate from isolated VMs and to rectify the existing confusion with name-based eponyms such as Klippei-Trenaunay syndrome. Contemporary concepts on VMs were updated with new data including genetic findings linked to the etiology of CVMs and chronic cerebrospinal venous insufficiency. Besides, newly established information on coagulopathy including the role of D-Dimer was thoroughly reviewed to provide guidelines on investigations and anticoagulation therapy in the management of VMs. Congenital vascular bone syndrome resulting in angio-osteo-hyper/hypotrophy and (lateral) marginal vein was separately reviewed. Background data on arterio-venous malformations was included to differentiate this anomaly from syndromebased VMs. For the treatment, a new section on laser therapy and also a practical guideline for follow up assessment were added to strengthen the management principle of the multidisciplinary approach. All other therapeutic modalities were thoroughly updated to accommodate a changing concept through the years.

Guideline. Diagnosis and treatment of venous malformations. consensus document of the international union of phlebology (iup): updated-2013.

Venous malformations (VMs) are the most common vascular developmental anomalies (birth defects). These defects are caused by developmental arrest of the venous system during various stages of embryogenesis. VMs remain a difficult diagnostic and therapeutic challenge due to the wide range of clinical presentations, unpredictable clinical course, erratic response to the treatment with high recurrence/persistence rates, high morbidity following nonspecific conventional treatment, and confusing terminology. The Consensus Panel reviewed the recent scientific literature up to the year 2013 to update a previous IUP Consensus (2009) on the same subject. ISSVA Classification with special merits for the differentiation between the congenital vascular malformation (CVM) and vascular tumors was reinforced with an additional review on syndrome-based classification. A "modified" Hamburg classification was adopted to emphasize the importance of extratruncular vs. truncular subtypes of VMs. This incorporated the embryological origin, morphological differences, unique characteristics, prognosis and recurrence rates of VMs based on this embryological classification. The definition and classification of VMs were strengthened with the addition of angiographic data that determines the hemodynamic characteristics, the anatomical pattern of draining veins and hence the risk of complication following sclerotherapy. The hemolymphatic malformations, a combined condition incorporating LMs and other CVMs, were illustratedas a separate topic to differentiate from isolated VMs and to rectify the existing confusion with namebased eponyms such as Klippel-Trenaunay syndrome. Contemporary concepts on VMs were updated with new data including genetic findings linked to the etiology of CVMs and chronic cerebrospinal venous insufficiency. Besides, newly established information on coagulopathy including the role of D-Dimer was thoroughly reviewed to provide guidelines on investigations and anticoagulation therapy in the management of VMs. Congenital vascular bone syndrome resulting in angio-osteo-hyper/hypotrophy and (lateral) marginal vein was separately reviewed. Background data on arterio-venous malformations was included to differentiate this anomaly from syndrome-based VMs. For the treatment, a new section on laser therapy and also a practical guideline for follow up assessment were added to strengthen the management principle of the multidisciplinary approach. All other therapeutic modalities were thoroughly updated to accommodate a changing concept through the years.

Consensus Document of the International Union of Angiology (IUA)-2013. Current concept on the management of arterio-venous management.

Arterio-venous malformations (AVMs) are congenital vascular malformations (CVMs) that result from birth defects involving the vessels of both arterial and venous origins, resulting in direct communications between the different size vessels or a meshwork of primitive reticular networks of dysplastic minute vessels which have failed to mature to become 'capillary' vessels termed "nidus". These lesions are defined by shunting of high velocity, low resistance flow from the arterial vasculature into the venous system in a variety of fistulous conditions. A systematic classification system developed by various groups of experts (Hamburg classification, ISSVA classification, Schobinger classification, angiographic classification of AVMs,) has resulted in a better understanding of the biology and natural history of these lesions and improved management of CVMs and AVMs. The Hamburg classification, based on the embryological differentiation between extratruncular and truncular type of lesions, allows the determination of the potential of progression and recurrence of these lesions. The majority of all AVMs are extra-truncular lesions with persistent proliferative potential, whereas truncular AVM lesions are exceedingly rare. Regardless of the type, AV shunting may ultimately result in significant anatomical, pathophysiological and hemodynamic consequences. Therefore, despite their relative rarity (10-20% of all CVMs), AVMs remain the most challenging and potentially limb or life-threatening form of vascular anomalies. The initial diagnosis and assessment may be facilitated by non- to minimally invasive investigations such as duplex ultrasound, magnetic resonance imaging (MRI), MR angiography (MRA), computerized tomography (CT) and CT angiography (CTA). Arteriography remains the diagnostic gold standard, and is required for planning subsequent treatment. A multidisciplinary team approach should be utilized to integrate surgical and non-surgical interventions for optimum care. Currently available treatments are associated with significant risk of complications and morbidity. However, an early aggressive approach to elimiate the nidus (if present) may be undertaken if the benefits exceed the risks. Trans-arterial coil embolization or ligation of feeding arteries where the nidus is left intact, are incorrect approaches and may result in proliferation of the lesion. Furthermore, such procedures would prevent future endovascular access to the lesions via the arterial route. Surgically inaccessible, infiltrating, extra-truncular AVMs can be treated with endovascular therapy as an independent modality. Among various embolo-sclerotherapy agents, ethanol sclerotherapy produces the best long term outcomes with minimum recurrence. However, this procedure requires extensive training and sufficient experience to minimize complications and associated morbidity. For the surgically accessible lesions, surgical resection may be the treatment of choice with a chance of optimal control. Preoperative sclerotherapy or embolization may supplement the subsequent surgical excision by reducing the morbidity (e.g. operative bleeding) and defining the lesion borders. Such a combined approach may provide an excellent potential for a curative result. Conclusion. AVMs are high flow congenital vascular malformations that may occur in any part of the body. The clinical presentation depends on the extent and size of the lesion and can range from an asymptomatic birthmark to congestive heart failure. Detailed investigations including duplex ultrasound, MRI/MRA and CT/CTA are required to develop an appropriate treatment plan. Appropriate management is best achieved via a multi-disciplinary approach and interventions should be undertaken by appropriately trained physicians.

Management of the marginal vein: current issues.

The marginal vein, an abnormal superficial vein of the lateral lower limb, is a remnant of primitive embryonic vessels that have failed to regress. According to the extent, topography and sites of connection with the deep veins, five types have been distinguished by Weber. The marginal vein is valveless and may create venous stasis. Limb-length discrepancy and nevus may coexist. Diagnosis is made by duplex scan examination and phlebography; angio computerized tomography or magnetic resonance effectively demonstrates the vein but yield less haemodynamic data. The best treatment is complete surgical resection of the vein. Resection should be avoided in the rare cases when aplasia of the deep veins exists. A careful skeletonization can be performed if arterio-venous fistulas converge into the vein.

Vascular bone syndrome--angio-osteodystrophy: current concepts.

Congenital vascular bone syndrome (CVBS) is an abnormal enhancement or reduction of growth in long bones due to pathologic circulation during childhood. Several authors have described these clinical pictures with limb lengthening; well known are Klippel and Trenaunay and Parkes-Weber. Later, Servelle and Martorell also described cases of limb length difference, but with shortening of the pathologic limb. The mechanism of limb overgrowth is probably due to the effect of A-V shunts, while shortening occurs due to mechanical compression on bones by dysplastic vessels or flow reduction. Some molecules, like vascular endothelial growth factor and others, probably affect bone growth through a poorly understood mechanism. Diagnostically, one should try to demonstrate A-V shunts around or inside the bone or low flow vascular mass. Correction of length differences can occur spontaneously if the cause of CVBS is treated in childhood. In adults, limb length differences may be corrected by orthopaedic techniques.

Advanced management of arteriovenous shunting malformation with transarterial lung perfusion scintigraphy for follow-up assessment.

AIM: The clinical assessment of arteriovenous malformations (AVMs), including treatment response (surgical and/or embolosclerotherapy), has traditionally been done by arteriography, mainly by looking for residual lesions. However, arteriography is disadvantaged as it is an expensive invasive test with high morbidity and provides only limited anatomical information at the qualitative level. Here, transarterial lung perfusion scintigraphy (TLPS), which was developed as a less invasive test for the physiologic assessment of the arteriovenous shunting status of AVM lesions located in the lower extremities, was evaluated for its ability to replace traditional arteriography as a means of following-up treatment results. METHODS: The shunting volume of radioisotope-tagged macro-aggregated albumin injected into the arterial system of the affected limb was counted by TLPS before and after AVM treatment, as a quantitative measure of treatment response. The findings obtained were compared with a matching duplex scan, whole body blood pool scintigraphy (WBBPS) findings, and arteriographic findings. RESULTS: Twenty-one TLPS tests were performed as follow-up assessments on 15 patients with AVM in the extremity, who underwent multistaged embolo/sclerotherapy alone or combined with surgical therapy. These 21 TLPS findings, including 6 interim TLPS results (average 16 months follow-up), provided quantitative measurements of lesion reductions as percentile ratios versus the baseline pretreatment values. Matching posttreatment duplex scan (14 out of 17 sets) and WBBPS (12 out of 15 sets) findings confirmed the posttreatment TLPS assessment. RESULTS: In addition, all 12 available arteriographic studies confirmed the matching TLPS findings. CONCLUSIONS: TLPS can provide accurate information on shunting volume reduction, occurring in response to various treatments during or after the completion of therapy. TLPS, therefore, may be able to replace arteriography, and provide a reliable means of follow-up assessment for the determination of the future treatment strategy.

Contemporary diagnosis and management of venous and arterio-venous shunting malformation by whole body blood pool scintigraphy.

AIM: Various non- to less-invasive tests have been recently introduced in the management of congenital vascular malformations (CVM) and have become essential for the initial diagnostic work-up, largely replacing the traditional role of invasive tests. Whole body blood pool scintigraphy (WBBPS) was initially adopted as a supplementary test to reinforce other well-established essential diagnostic tests, and has been used extensively together in our Clinic, for years. We have evaluated WBBPS retrospectively for the diagnosis of venous malformation (VM) and arterio-venous malformation (AVM), and also for a further possible role for the interim assessment of treatment results during multistaged embolo/sclerotherapy. METHODS: Of 123 VMs and 48 AVMs selected for various treatments, 80 patients (66 VMs and 14 AVMs) were reviewed. The reliability of WBBPS as an initial diagnostic tool for VMs and AVM was assessed first by comparing its findings with matching MRI and/or duplex scan findings. These 80 patients underwent embolo/sclerotherapy with absolute ethanol mostly for VM, and N-butyl cyanoacrylate for AVM. A total of 251 sessions were performed either as a primary treatment independently or in conjunction with surgical treatment preoperatively. Thirty-six patients were available in terms of the subsequent review of the treatment results, to compare their 72 post-therapy WBBPS findings with matching duplex scan and MRI findings. The WBBPS assessment of treatment response was based on the percentage reduction of abnormal blood pooling over the region of interest (ROI) from baseline (initial) value. Treatment response was also qualitatively and semi-quantitatively assessed according to the degree of abnormal blood pool reduction. RESULTS: Of the 80 CVM (66 VM and 14 AVM) patients, 61 of 66 WBBPS findings of VM on initial diagnosis were confirmed as true-positive. Twelve of 14 AVMs were also confirmed as WBBPS true-positive findings. The sensitivity of WBBPS for the initial diagnosis was 93.8% (61/65) for VM and 92.3% (12/13) for AVM. The positive predictive value was 98.4% (61/62) for VM and 92.3% (12/13) for AVM. Of 72 post-therapy WBBPS performed for follow-up assessment of the results of treatment on 36 patients, 52 WBBPS showed positive findings qualitatively and/or quantitatively, the remaining 20 were negative. Fifty-one of the 52 WBBPS-positive findings were true-positive and 18 of the 20 were true-negative. Hence, WBBPS for follow-up assessment showed a sensitivity of 96% (51/53); a specificity of 95% (18/19); a positive predictive value of 98% (51/52); and a negative predictive value of 90% (18/20). CONCLUSIONS: Contemporary management of CVMs can be improved by using WBBPS, which is a less expensive, simple, and safe non-invasive test, especially for venous and arterio-venous malformations. WBBPS is a cost-effective and practical test with dependable accuracy for the assessment of treatment results, especially for interim measurements during multistage embolo/sclerotherapy.

Differential diagnosis in congenital vascular-bone syndromes.

Congenital vascular-bone syndrome is an alteration in limb growth caused by congenital vascular malformations in childhood. A precise study of the anatomic and hemodynamic nature of the underlying defect is necessary, not only for diagnosis, but also for therapy. The use of old eponyms for diagnosis, such as "Klippel-Trenaunay," "Parkes-Weber," and "Servelle-Martorell" should be abandoned because they are meaningless and misleading. An anatomic/pathological categorization, according to the simple "Hamburg classification," is more practical for clinical purposes. Seven different types of vascular defects, all associated with a-v fistulas, are related with limb overgrowth. Four different types of vascular malformations may produce limb shortening. Complete diagnostic study should allow classifying the malformation into one of the groups listed and illustrated above. Precise diagnosis is useful because interventional therapy can correct limb length discrepancy if performed before epiphyseal closure.

Changing trends in the outcome of urgent aneurysms surgery. A retrospective study on 170 patients treated in the years 1966-1990.

During the last 25 years 170 patients with ruptured aortic aneurysms were treated in our centre for vascular surgery with an overall mortality of 54%. We have subdivided these patients into three groups according to temporal factors: the 1st group includes 16 patients treated in the years 1966-1978; the 2nd group includes 93 patients treated from 1979 to 1987; the 3rd group includes patients from 1988 to 1990. In these years no selection of patients was made and everybody still alive was operated on. Starting from the second period, haemodynamical monitoring of the patients was performed with the adoption of the Swan-Ganz catheter in almost all cases. Mortality in the first period was 69%, in the second period 60% and in the third period 40%. There was no difference in the haemodynamical state in the three groups. The difference lies in the number of surgical interventions per year: 1.33 intervention per year in the first period; 11.625 interventions per year in the second period and 20 in the third. We conclude that an improvement in the survival rate of patients undergoing urgent aortic aneurysm repair is due to precise haemodynamical intraoperative monitoring and a well trained surgical team.

Surgical treatment of congenital arteriovenous defects.

Congenital vascular arteriovenous malformations can be treated by surgery in the majority of cases. Contraindications for surgical correction are only slight cases and very few of the severe cases in which amputation is the only possibility of treatment. After illustrating guidelines for surgical strategy, tactics and techniques of operative treatment are discussed. Results obtained in 52 cases are demonstrated.

Thoracic sympathectomy. Review of indications, results and surgical techniques.

87 patients operated upon for 125 thoracic sympathectomies with different surgical techniques (supraclavicular, axillar and posterior approach) were studied. Authors noticed clear differences in results according to the sex of the patient and basic disease. Some observations about advantages and disadvantages of the different surgical techniques are also reported. According to the results, Authors suggest a particular therapeutical behaviour.