SISTINE 3.0: Wearable System for Remote Functional Assessment of Phlebopathics.

Phlebopathic diseases are chronic conditions that impact the health status and affect functional capacity. We developed SISTINE 3.0, a wearable system for remote monitoring of patients, and the aim of the study is to evaluate whether it can detect differences between participants with phlebology and healthy ones. Twelve patients and five healthy subjects performed a 3-metres Timed-Up-Go wearing SISTINE 3.0 system. The results support the system's potential to discriminate participants, especially based on the linear walking and turning angular velocity.

Infected chronic ischemic wound topically treated with a multi-strain probiotic formulation: a novel tailored treatment strategy.

BACKGROUND: A wide debate is ongoing regarding the role of cutaneous dysbiosis in the pathogenesis and evolution of difficult-to-treat chronic wounds. Nowadays, probiotic treatment considered as an useful tool to counteract dysbiosis but the evidence in regard to their therapeutic use in the setting of difficult-to-treat cutaneous ulcers is still poor. AIM: CLINICAL REPORT: An 83-year-old woman suffering a critical limb ischemia and an infected difficult-to-treat ulcerated cutaneous lesion of the right leg, was complementary treated with local application of a mixture of probiotic bacteria. METHODS: Microbiological and metabolomic analysis were conducted on wound swabs obtained before and after bacteriotherapy. RESULTS: During the treatment course, a progressive healing of the lesion was observed with microbiological resolution of the polymicrobial infection of the wound. Metabolomic analysis showed a significant difference in the local concentration of propionate, 2-hydroxyisovalerate, 2-oxoisocaproate, 2,3-butanediol, putrescine, thymine, and trimethylamine before and after bacteriotherapy. CONCLUSION: The microbiological and metabolomic results seem to confirm the usefulness of complementary probiotic treatment in difficult-to-treat infected wounds. Further investigations are needed to confirm these preliminary findings.

Upper limb secondary lymphedema ultrasound mapping and characterization.

BACKGROUND: Ultrasound investigation potentials in lymphedema are still to be fully used in everyday practice. Aim of the present study was to report the sonographic characterization of the dermo-epidermal complex (DEC) and of the subcutaneous (SUBC) tissue, assessing the feasibility of a related mapping, in upper limb secondary lymphedema. METHODS: In this retrospective study 287 patients affected by monolateral upper limb post-mastectomy lymphedema (M5/F282; mean age 64±4.24) were enrolled and scanned by ultrasound, considering the healthy contralateral limb as control. In order to standardize the assessment, the limb was divided in sectors: 4 anterior, 4 posterior below the elbow, 4 anterior and 4 posterior above the elbow, plus the hand. DEC and SUBC regions B-mode appearance were reported, both in the healthy and in the pathological arms. DEC thickness was measured and compared among the same sectors of the healthy and pathological limbs. RESULTS: DEC and SUBC sonographic appearance was differentiated in fluid and sclerotic. DEC included a third category characterized by differentiation loss. The different sectors showed significantly different lymphatic involvement in the affected limb. In the comparison with the contralateral unaffected segments a significantly thicker DEC was reported in the forearm affected by lymphedema (P<0.005), while no significant difference was reported at the arm level. CONCLUSIONS: Traditional ultrasonography can provide a secondary upper limb lymphedema characterization with related mapping and useful data for a better lymphatic physiopathology understanding and for a properly addressed therapeutic protocol.

An Alternative Approach for Treating a Type Ia Endoleak after Conventional EVAR Using the Nellix Endovascular Aneurysm Sealing.

BACKGROUND: To report the use of a Nellix endovascular aneurysm sealing (EVAS) device, to successfully treat a type Ia endoleak (EL) after an endovascular aortic repair (EVAR). CASE REPORT: A 70-year-old man was diagnosed with a 90-mm aortic aneurysm, suspicious for being inflammatory. It was initially treated successfully, with a Medtronic Endurant (Medtronic, Minneapolis, MN, USA). Five years after the index endovascular repair, an asymptomatic type Ia EL was detected on duplex ultrasound and computed tomographic angiogram. Other endovascular solutions in the form of proximal cuff, chimney was considered difficult to execute due to challenges in planning, manipulation, and renal cannulation caused by the short proximal sealing zone above the existing stent graft and the constraints of the previous endograft. Thus, a relining of the previous endoprothesis was performed using the Nellix system (Endologix, Inc., Irvine, CA, USA). One-year follow-up imaging demonstrated successful resolution of the EL and persistent sealing of the Nellix device. CONCLUSIONS: Nellix EVAS system can be an alternative and safe option for relining a stent graft with a type Ia EL. Nellix platform can be added to the clinician's armamentarium for treating type Ia EL after conventional EVAR of infrarenal abdominal aortic aneurysm (AAA).

Hypertension, Acute Stent Thrombosis, and Paraplegia 6 Months after Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury in a 22-Year-Old Patient.

Thoracic endovascular aortic repair (TEVAR) is a less invasive option for managing traumatic injuries of the descending aorta in polytraumatized patients. Concerns arise when treating young patients with TEVAR. A 22-year-old male was admitted to the emergency department following a high-impact road traffic collision. Whole-body computed tomography (CT) scan documented multiple injuries, including rupture of descending thoracic aorta just below the isthmus. There was no evidence of paraplegia or stroke. We decided to treat him in an endovascular fashion with a Zenith Cook (Cook Incorporated, Bloomington, IN) endograft. Final angiography confirmed the proper positioning of the device, no infoldings, and the optimal filling of the thoracic aorta downstream of the endoprosthesis. In the postoperative period, the patient showed high blood pressure which was treated with 4 different antihypertensive drugs. He was discharged on cardioaspirine. CT scan control was scheduled after 30 days and 6 months, but he referred to our emergency department after less than 6 months with paraplegia, abdominal pain, and acute renal failure. He had independently discontinued antiplatelet therapy 3 months before. Emergency CT control documented the presence of intimal flap and thrombus at the distal edge of the device. The magnetic resonance imaging revealed ischemic damage of the spinal cord. We decided to reline the endograft using another Zenith Cook device with very good results. Renal failure and bowel pain gradually improved, but paraplegia is still present. TEVAR is the most suitable treatment for blunt thoracic aortic injury in the modern era. Concerns arise from what can happen to a young aorta receiving a stiff endovascular graft that should be carried all lifelong. These devices have been associated with acute hypertension and cardiac remodeling. Less stiffer stent grafts should be studied for young patients. High attention must be posed in the follow-up for the immediate resolution of eventual problems.

Therapeutical Options in the Management of Carotid Dissection.

BACKGROUND: The best management of carotid artery dissection (CAD) is still controversial ranging from antiplatelet medication to open surgery or endovascular treatment. In this retrospective study, we assessed the safety and efficacy of endovascular stent angioplasty for the treatment of CAD. METHODS: From February 2006 to February 2016, 44 patients (28 women and 16 men, age range 25-65 years, mean 42) with CAD were included in this study. The internal carotid artery dissection was spontaneous in 32 patients and posttraumatic in the remaining 12 (in 1 case, it was bilateral). Twenty-eight patients were treated by intravenous heparin infusion followed by standard oral anticoagulation. Carotid artery stenting was carried out in 14 cases with recurrent ischemic events despite optimal anticoagulation management. Two patients with an open trauma of the neck were submitted to a common carotid to internal carotid bypass (CC-CI bypass). The follow-up ranged from 6 to 60 months and was performed clinically first and with Doppler ultrasound and computed tomography or magnetic resonance at 6, 12, and 24 months. RESULTS: Follow-up ranged from 6 to 60 months. Mortality was nil. All patients submitted to the endovascular or surgical management had an immediate relief of their neurologic symptoms with no procedure-related complications. No thrombosis or restenosis of the CC-CI bypass or of carotid artery stents occurred during intraoperative and postoperative period and follow-up. CONCLUSION: An alternative therapeutic option is mandatory in a subset of patients regarded as being at high risk for stroke because anticoagulant therapy was either contraindicated or failed clinically with recurrent transient ischemic attacks/transient symptoms associated with brain infarction. In these selected cases, endovascular stent placement seems to be a safe and effective option to restore vessel lumen integrity and prevent stroke.

Severe Thrombotic Complications in Congenital Afibrinogenemia: A Pathophysiological and Management Dilemma.

Congenital afibrinogenemia (CA) is a disease characterized by a complex pathophysiology, involving both the procoagulant and fibrinolytic systems, as well as platelet activity. Although hemorrhagic diathesis represents the most frequent clinical presentation of this disorder, severe thrombotic events can occur. It is not yet clear if these events are strictly related to the disease itself or to the fibrinogen replacement therapy. Different hypotheses on the pathophysiological mechanisms have been proposed. It is well known that fibrinogen/fibrin has a role in the downregulation of thrombin generation in plasma. In the absence of circulating fibrinogen, this "antithrombin" activity is missing and plasma thrombin levels rise; this excess of thrombin could promote clotting of the infused fibrinogen, initiating the thrombotic process. Furthermore, the observation of impaired plasmin generation in the plasma of CA patients has raised the hypothesis of a fibrinolytic system deficiency. We report the case of a CA male patient who at the age of 36 years experienced an arterial thrombosis in his left lower limb. Despite an aggressive medical treatment with low-molecular-weight heparin, fibrinolytic and antiplatelet agents, the arterial thrombosis progressed to the obstruction of the whole left arterial district and the patient underwent the amputation of the left lower limb. This case demonstrates the complexity of pathophysiology and clinical management of a "so-called" bleeding disorder as CA.

Successful Management of a Chronic Refractory Leg Ulcer in an Adolescent with Sickle Cell Anemia.

Sickle cell disease (SCD) is an inherited hemoglobinopathy characterized by a wide range of clinical manifestations. Chronic leg ulcers are a disabling complication with repercussions on the quality of life. We report the case of a 14-year-old girl with a diagnosis of SCD who developed a chronic leg ulcer that was successfully treated with a multi-disciplinary approach, including local and systemic therapies. The role of different treatments, in particular low molecular weight heparin, in the refractory chronic leg ulcer healing process will be discussed.

Large aortic pseudoaneurysm and subsequent spondylodiscitis as a complication of endovascular treatment of iliac arteries.

Both aortic pseudoaneurysm following endovascular aortoiliac reconstruction and spondylodiscitis subsequent to endograft infections are rare complications. We present a case of aortic false aneurysm following iliac arteries treatment complicated by spondylodiscitis after its endovascular repair. In this patient, a huge aortic pseudoaneurysm was diagnosed and treated in an emergency setting a few days after the procedure. A left aortomonoiliac endograft was placed and a femoro-femoral crossover bypass was performed. Afterward, the patient developed a stent graft infection and a lumbar spondylodiscitis. The patient was managed with a conservative treatment and, after 4 years, he continues to live. Analyzing this case, we would like to point out the following aspects: any procedure, although well established and technically simple, can cause life-threatening complications; hematomas resulting from endovascular exclusion of large pseudoaneurysms could be drained, to prevent bacterial infections.

Persistent type II endoleak: two cases of successful sacotomy.

Endovascular treatment of persistent type II endoleak may not resolve the complication. We report two cases of sacotomy performed to treat this problem: the first case was in an emergency setting for aneurismal sac rupture, and the second occurred in an elective surgery setting after several unsuccessful endovascular procedures. In both cases, sacotomy allowed us identify the bleeding sources without aortic cross-clamping and endograft explantation. By minimizing hemodynamic modifications and reducing operative time, this procedure can be carried out even in patients considered unfit for surgery. Sacotomy could be considered as an alternative in selected cases of persistent type II endoleak with aneurysm sac enlargement.

Mid- and long-term results of endovascular treatment in thoracic aorta blunt trauma.

STUDY AIM: Evaluation of results in blunt injury of the thoracic aorta (BAI) endovascular treatment. MATERIALS AND METHODS: Sixteen patients were treated for BAI. Thirteen patients had associated polytrauma, 4 of these had a serious hypotensive status and 4 had an hemothorax. In the remaining 3, two had a post-traumatic false aneurysm of the isthmus and 1 had a segmental dissection. In those 13 patients a periaortic hematoma was associated to hemothorax in 4. All patients were submitted to an endovascular treatment, in two cases the subclavian artery ostium was intentionally covered. RESULTS: One patient died for disseminated intravascular coagulation. No paraplegia was recorded. No ischemic complications were observed. A type I endoleak was treated by an adjunctive cuff. During the followup (1-9 years) 3 patients were lost. A good patency and no endoleaks were observed in all cases. One infolding and 1 migration of the endografts were corrected by an adjunctive cuff. CONCLUSION: The medium and long term results of the endovascular treatment of BAI are encouraging with a low incidence rate of mortality and complications. More suitable endo-suite and endografts could be a crucial point for the further improvement of these results.

Abdominal aortic aneurysm following acute pancreatitis.

Vascular lesions may complicate the course of acute pancreatitis. The activated pancreatic enzymes, particularly elastase, might cause lysis of the elastic component of the arterial wall thus leading to aneurysmal changes. This report is on a case of aneurysm of the infrarenal aorta following complicated acute pancreatitis and treated by endovascular technique.