Spinal cord stimulation in the treatment of chronic critical limb ischemia.

This paper reviews the clinical experience and proposed working mechanisms of spinal cord stimulation (SCS) in the treatment of chronic critical limb ischemia (CCLI). SCS appears to provide a significant long-term relief of ischemic pain and to improve healing of small ulcers, most likely due to effects on the nutritional skin blood flow. Despite these observations, randomized trials were not able to show limb salvage. Assessment of the microcirculatory skin blood flow, by means of transcutaneous oxygen pressure measurements and videocapillaromicroscopy, is necessary to evaluate the remaining microcirculatory reserve capacity likely to be exploited by SCS and to help identify patients that will benefit most from this treatment and in whom stimulation could lead to limb salvage.

Systemic and local antibiotic prophylaxis in the prevention of prosthetic vascular graft infection: an experimental study.

AIM: to determine if local, in addition to systemic antibiotic prophylaxis (compared to that provided by systemic prophylaxis alone) provides additional benefit in terms of reducing graft infection. METHODS: gelatin-sealed Dacron grafts were interposed in the infrarenal aorta of 36 mongrels and inoculated with 1 ml of a S. aureus suspension. Group 1 (control group) received no prophylaxis and were inoculated with 1 ml containing 10(9)cfu/ml. Group 2 (n=6) received systemic prophylaxis (1 g cephamandole) and were inoculated with 10(5) cfu/ml (n=3) or 10(7) cfu/ml (n=3). Group 3 received systemic prophylaxis (1 g cephamandole) and were inoculated with 109 cfu/ml. Group 4 received systemic prophylaxis (2 g cephamandole) and were inoculated with 10(9)cfu/ml. In group 5 and 6 grafts were soaked in a rifampicin solution before use and inoculated with 10(9) cfu/ml. Group 5 received no systemic prophylaxis and group 6 received systemic prophylaxis (1 g cephamandole). Grafts were harvested at 2 weeks, and peritonitis, perigraft abscess, anastomotic disruption and graft occlusion recorded. Swabs were taken of the graft, the perigraft tissues and the peritoneal fluid. Graft segments were incubated in broth medium. RESULTS: inoculation with 10(9) cfu/ml ensured graft infection. Systemic or local prophylaxis alone failed to prevent graft infection. Only systemic and local antibiotic prophylaxis provided significant better results than no prophylaxis at all (p<0.01) and local prophylaxis alone (p<0.05). However, total "graft sterility" was not achieved as bacteriologic analysis of the graft segments showed low bacterial counts (<10 bacteria/graft) in 5 of 6 grafts. CONCLUSION: local and systemic prophylaxis provided more protection as demonstrated by the significant decrease in the incidence of "overt" graft infection. Total "graft sterility" cannot be expected in the case of an overwhelming bacterial challenge.

Improvement of microcirculatory blood flow under epidural spinal cord stimulation in patients with nonreconstructible peripheral arterial occlusive disease.

Epidural spinal cord stimulation (ESCS) has been suggested as a method to improve microcirculatory blood flow and to reduce the amputation rate in vascular patients. We studied the effects of ESCS on microcirculatory blood flow in 237 patients with nonreconstructible peripheral arterial occlusive disease. Clinical status was classified as Fontaine Stage 3 (ischemic rest pain) in 169 patients and as Fontaine Stage 4 (ulcers/gangrene) in 68 patients. After a mean follow-up period of 31.2 months, major pain relief (> 75%) was noticed in patients who retained their limbs. Sixty-four patients underwent major amputation despite ESCS. Clinical improvement was confirmed by the increase in transcutaneous oxygen (TcPO2).

The anatomic structure of the preperitoneal tissue (PPT) of the inguinal canal.

Anatomical examinations of the inguinal canal exist in many forms. The preperitoneal tissue, the structure directly adjacent to the transverse fascia, was examined in 62 cadavers. The left side of the inguinal abdominal wall was studied with special interest in the transverse fascia and the adjacent preperitoneal tissue. In 75% of the cases the transverse fascia and preperitoneal tissue built a continuous layer. A differentiation was difficult in cadavers with cachexia or an average nutritive state. The tissues could be differentiated without difficulty in individuals with adipositas. In these cases no connection between the two layers was detected. In the medial part of the inguinal abdominal wall the tissue thickness was larger than in the lateral part. However in 32% of the cases the tissue thickness was reverse. As a consequence, the isolated suture of the transverse fascia in inguinal hernia repair is anatomically virtually impossible, if both tissues build one continuous layer.

Transcutaneous oxygen pressure as predictive parameter for ulcer healing in endstage vascular patients treated with spinal cord stimulation.

OBJECTIVE AND DESIGN: This study was designed to test the hypothesis that initial TcPO2 helps predict clinical outcome in vascular patients treated with spinal cord stimulation. A randomized-controlled study with one year follow-up was made in 86 Fontaine stage IV patients with endstage peripheral arterial occlusive disease (PAOD) undergoing 21 day intravenous prostaglandin E1 (PGE1) therapy for nonhealing ulcers. MATERIALS AND METHODS: All patients had arteriosclerosis, 13 also diabetes mellitus. Entry criteria included: non-reconstructible PAOD as proven by intra-arterial angiography or patient condition, ankle systolic pressure < 50 mmHg, severe rest pain despite analgetic medication, and presence of nonhealing foot ulcers or dry gangrene. One week after the start of PGE1 therapy, patients were randomized into receiving SCS plus PGE1 (n = 45 patients), or just PGE1 (n = 41 patients). Follow-up examinations were done at 1, 3, 6 and 12 months. BASELINE: There were no significant differences between both groups in the following: age, sex distribution, ischemic skin lesions, risk factors and several key group mean physiological values including ankle systolic pressure, ankle/brachial ratio (ABI) and foot TcPO2. The SCS group had more prior vascular leg surgeries (1.77 vs 1.58 per patient). RESULTS AT 12 MONTHS: There was significantly better total healing of foot ulcers in the SCS-group (69 vs 17%; p < 0.0001). Significantly more SCS-patients achieved an outcome of Fontaine stage II (claudication pain, no rest pain or lesions) (40 vs 10%, p = 0.0014). The frequency of minor and major amputations was not different, respectively 13 vs 15% and 16 vs 20%. The mean ABI at 12 months of the treated limb of the SCS-patients was not significantly greater. Foot TcPO2 increased significantly for the SCS-group (+213 vs -2%; p < 0.0001). Patients in either group whose TcPO2 rose to 26.0 +/- 8.6 mmHg on average were able to heal ulcers or toe amputation wounds. PGE1-patients had temporary TcPO2 elevations of about 33% on average but this was gone by six months. SCS-patients had steady increases in TcPO2, and maintained them at 12 months. Among the SCS-patients, those with baseline TcPO2 < = 10 mmHg had significantly less success at 12 months, this was not observed for the OMT-patients. The regional perfusion index increased significantly, 187 vs 0%; p < 0.001. CONCLUSIONS: Spinal cord stimulation appears to provide a major benefit for lesion improvement in stage IV patients with non-reconstructible PAOD. Patients with an initial TcPO2 > 10 mmHg will respond better to the stimulation therapy. With pain relief and ulcer healing quality of life improved. Effects on limb salvage do not appear.