The role of a specialized approach for patients with diabetes, critical ischaemia and foot ulcers not previously considered for proactive management.

AIMS: To analyse the outcome of the proactive management of patients with diabetes, critical limb ischaemia and foot ulcers using percutaneous transluminal angioplasty as the only vascular procedure and adjuvant conservative surgery when indicated. METHODS: A retrospective study of patients with diabetes included in our database who sought a second opinion in our unit and met the following criteria: foot ulcer and critical limb ischaemia in patients for whom any proactive vascular treatment had not previously been considered by other teams. RESULTS: Twenty patients underwent endovascular procedures. Success was achieved in 19 cases (95%). No post-operative mortality (within 30 days after the procedure) was found. Additional surgery was required in eight cases (40%): one calcaneal ostectomy and seven minor amputations. The need for surgery was associated with infection (P < 0.01). Limb salvage was sustained during a mean period of follow-up of 642 days (SD 488) in 19 cases (95%). Healing was achieved in 14 cases (70%), four are still healing (20%), one underwent major amputation (5%) and the last one died before being healed (5%). Three patients died during follow-up (15%). CONCLUSIONS: Management of patients with diabetes, foot ulcers and critical limb ischaemia by means of a proactive approach including endovascular procedures in specialized settings provides a high rate of limb salvage. This may result in lowering the number of lower limb amputations in our community.

Endovascular treatment for pseudoaneurysms after surgical correction of aortic coarctation.

Late complications after surgical repair of aortic coarctation are not uncommon. Among these complications pseudoaneurysms are the most frequent complications, occurring between 3 and 38%. Reoperation in these patients is associated with high morbidity and mortality. In the last decade, endovascular techniques emerged as an alternative to conventional surgery with excellent results. We report the case of two patients who presented with pseudoaneurysms after surgical correction for aortic coarctation, which were treated by endovascular means.

Carotid artery stenting without angioplasty and cerebral protection: a single-center experience with up to 7 years' follow-up.

BACKGROUND AND PURPOSE: The use of cerebral protection during CAS in the treatment of carotid artery disease is matter of controversy. The purpose of this study was to evaluate the outcome of CASWBAP in a large cohort of patients, with ≤7 years' follow-up. MATERIALS AND METHODS: Two hundred thirty-six patients with 255 symptomatic carotid stenoses and/or with high-risk-morphology plaques of >50% and asymptomatic plaques of >70% were prospectively identified. Patients underwent neurologic and carotid US examination before the procedure and during follow-up at 1, 3, 6, and 12 months and annually thereafter. Plain films of the neck were obtained immediately after the procedure and then at 1 and 3 months. RESULTS: Technical success was achieved in 253/255 (99%) patients. Primary stent placement was successful in 248/253 (98%) patients. Neurologic periprocedural complications within 30 days included 1 (0.4%) nondisabling stroke, 1 (0.4%) disabling stroke, 11 (4.3%) TIAs, and 1 (0.4%) death. The mean duration of follow-up was 23 ± 1.4 months (range, 3-84 months). During the follow-up period, there were 9 additional deaths (7 unrelated to the carotid disease and 2 stroke-related) and 2 strokes (in other vascular territories). The degree of stenosis decreased from a mean of 82% before the procedure to a mean of 30% immediately after. During follow-up, 38 (14.8%) angioplasties were performed due to restenosis in 19 (7.4%) patients, lack of stent expansion in 14 (5.4%), or both in 5 (1.9%). CONCLUSIONS: CASWBAP is effective and safe with a low incidence of periprocedural complications, providing satisfactory long-term clinical results.

Primary stenting immediatly after surgery in occluded anastomoses of aortoaortic tube graft: a case report.

The conventional elective open procedures for abdominal aortic aneurysm repair are reliable and yield durable results. The aortoaortic tube graft has the lowest morbidity incidence when compared with different techniques. Albeit infrequent, thrombosis can be present in the first 30 days. Its treatment consists in thrombectomy and anastomosis evaluation, but with an increase in morbidity, especially in patients with urgent reintervention. This is a case report of a patient with aortoaortic tube graft, who present critical left limb ischemia immediately after surgical procedure. Angiography showed complete occlusion of left common iliac artery, affecting the distal graft anastomosis. The occlusion was resolved with endovascular treatment, and a noncovered, self-expanding, nitinol stent was deployed (primary stenting) covering the distal bypass anastomosis, with no complications and complete lower limb perfusion recovery. One month later, the patient was still asymptomatic, with distal pulse palpable and ankle-brachial index 1.

Salvage of a subacute failure in femoral dialysis loop graft using stent covering the arterial and venous anastomosis.

Endovascular treatment can be considered the first line therapy in the majority of dysfunctioning arteriovenous fistula. However, when early thrombosis of the arteriovenous access occurs, surgical treatment is recommended. In these cases, technical problems are the most frequent cause of the malfunction. We report a case of a subacute thrombosis of an arteriovenous fistula, femoral artery to femoral vein looped ePTFE with venous anastomosis occlusion and subocclusion lesion at the arterial anastomosis. Both anastomoses were treated using self-expandable stents, and no other intervention was necessary until the one-year follow-up for maintain patency.

Carotid stenting without use of balloon angioplasty and distal protection devices: preliminary experience in 100 cases.

BACKGROUND AND PURPOSE: A major concern during carotid artery stent placement is the potential for cerebral embolism. Diminishing the number of device manipulations across the lesion might reduce procedural stroke risk. For this purpose, we report our initial experience with carotid stent placement without the use of either balloon angioplasty or distal protection devices. MATERIALS AND METHODS: Eighty-seven consecutive patients with 100 carotid stenoses compose this series. Ninety four of the 100 hundred stented carotid arteries were either symptomatic (58 [58%]) or had a greater than 70% stenosis (36 [36%]). Six percent of them were asymptomatic and had stenosis between 50% and 70%. Patients underwent neurologic evaluation before the procedure and during follow-up at 1, 3, 6, and 12 months and annually thereafter. Carotid sonography and plain films of the neck were performed immediately after the procedure and then at the same time intervals. RESULTS: Primary stent placement was successful in 98 of 100 case subjects. In 2 case subjects, predilation was necessary before stent deployment. Neurologic periprocedural complications included 1 nondisabling and 1 disabling stroke and 5 transient ischemic attacks. The mean duration of follow-up was 23 months (range: 10-36 months). During the follow-up period, there were 5 deaths, all unrelated to the carotid disease, and no major stroke. The degree of stenosis decreased from a mean of 78.85% before the procedure to a mean of 21.23% immediately after. CONCLUSIONS: In this series, carotid stent placement without the use of either balloon angioplasty or distal protection devices was safe and effective with a low incidence of periprocedural complications.