A multicenter prospective observational study appraising the effectiveness of the Supera stent after subintimal recanalization of femoro-popliteal artery occlusion: The SUPERSUB II study

BACKGROUND

Complex femoropopliteal artery disease represents a challenge. The Supera stent holds the promise of improving the results of endovascular therapy for complex femoropopliteal disease.

AIMS

We aimed at appraising the early and long-term effectiveness of the Supera stent after successful subintimal angioplasty (SuperSUB strategy) for complex femoropopliteal lesions.

METHODS

We conducted a multicenter, prospective, single-arm observational study including consecutive patients at participating centers in whom Supera was implanted after successful subintimal angioplasty for complex femoropopliteal lesions.

RESULTS

A total of 92 patients were included Femoropopliteal arteries were the most common target, and lesion length was 261 ± 102 mm. Most procedures were technically demanding, with antegrade femoral access in 35 (38%) and retrograde distal access in 55 (60%). Supera stent length was 281 ± 111 mm, with 4, 5, and 6 mm devices being most commonly used: 32 (35%), 35 (38%), and 23 (25%), respectively. Technical success was achieved in 100% of subjects, as was clinical success (per subject), whereas procedural success (per subject) was obtained in 98%. At 24 months, freedom from clinically driven target lesion revascularization was 93%, whereas primary patency was 87%. When compared with a similar historical cohort, Supera stent use appeared to be associated with a reduction in resources.

CONCLUSION

Use of Supera stent after successful subintimal recanalization of complex lower limb arterial lesions yields favorable procedural results, which are maintained over follow-up, and are associated also with a favorable resource use profile.

Sex differences in outcome after thrombectomy for acute ischemic stroke. A propensity score-matched study

BACKGROUND AND PURPOSE

We sought to investigate whether there are gender differences in clinical outcome after stroke due to large vessel occlusion (LVO) after mechanical thrombectomy (EVT) in a large population of real-world patients.

METHODS

From the Italian Registry of Endovascular Thrombectomy, we extracted clinical and outcome data of patients treated for stroke due to large vessel occlusion. We compared clinical and safety outcomes in men and women who underwent EVT alone or in combination with intravenous thrombolysis (IVT) in the total population and in a Propensity Score matched set.

RESULTS

Among 3422 patients included in the study, 1801 (52.6%) were women. Despite older age at onset (mean 72.4 vs 68.7; p < 0.001), and higher rate of atrial fibrillation (41.7% vs 28.6%; p < 0.001), women had higher probability of 3-month functional independence (adjusted odds ratio-adjOR 1.19; 95% CI 1.02-1.38), of complete recanalization (adjOR 1.25; 95% CI 1.09-1.44) and lower probability of death (adjOR 0.75; 95% CI 0.62-0.90). After propensity-score matching, a well-balanced cohort comprising 1150 men and 1150 women was analyzed, confirming the same results regarding functional outcome (3-month functional independence: OR 1.25; 95% CI 1.04-1.51), and complete recanalization (OR 1.29; 95% CI 1.09-1.53).

CONCLUSIONS

Subject to the limitations of a non-randomized comparison, women with stroke due to LVO treated with mechanical thrombectomy had a better chance to achieve complete recanalization, and 3-month functional independence than men. The results could be driven by women who underwent combined treatment.

IER-SICH Nomogram to Predict Symptomatic Intracerebral Hemorrhage After Thrombectomy for Stroke

Background and Purpose—

As a reliable scoring system to detect the risk of symptomatic intracerebral hemorrhage after thrombectomy for ischemic stroke is not yet available, we developed a nomogram for predicting symptomatic intracerebral hemorrhage in patients with large vessel occlusion in the anterior circulation who received bridging of thrombectomy with intravenous thrombolysis (training set), and to validate the model by using a cohort of patients treated with direct thrombectomy (test set).

Methods—

We conducted a cohort study on prospectively collected data from 3714 patients enrolled in the IER (Italian Registry of Endovascular Stroke Treatment in Acute Stroke). Symptomatic intracerebral hemorrhage was defined as any type of intracerebral hemorrhage with increase of ≥4 National Institutes of Health Stroke Scale score points from baseline ≤24 hours or death. Based on multivariate logistic models, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver operating characteristic curve.

Results—

National Institutes of Health Stroke Scale score, onset-to-end procedure time, age, unsuccessful recanalization, and Careggi collateral score composed the IER-SICH nomogram. After removing Careggi collateral score from the first model, a second model including Alberta Stroke Program Early CT Score was developed. The area under the receiver operating characteristic curve of the IER-SICH nomogram was 0.778 in the training set (n=492) and 0.709 in the test set (n=399). The area under the receiver operating characteristic curve of the second model was 0.733 in the training set (n=988) and 0.685 in the test set (n=779).

Conclusions—

The IER-SICH nomogram is the first model developed and validated for predicting symptomatic intracerebral hemorrhage after thrombectomy. It may provide indications on early identification of patients for more or less postprocedural intensive management.

Surgical and Endovascular Management of Patients with Chronic Mesenteric Ischemia: A Single Center Experience

Chronic mesenteric ischemia is a rare intestinal disorder, with a potential evolution toward intestinal infraction. The choice of the appropriate treatment is currently the most crucial issue in the management of patients with chronic mesenteric ischemia. We describe our experience with 16 cases, and we discuss the current diagnostic and therapeutic approaches. A retrospective review of the clinical records was performed, and demographic, clinical, therapeutic, and prognostic data were collected. Six patients were females (37%), and the mean age was 62 years. Postprandial pain was present in all the cases, whereas sitophobia and weight loss were detected in 87 per cent of them. Eight patients were treated with open surgery; no perioperative deaths or relevant complications occurred. One patient had a restenosis of the celiac trunk and superior mesenteric artery 10 months after surgery. No deaths or relevant complications occurred in the remaining patients, who underwent an endovascular procedure. One patient presented a restenosis distal to the vascular stent, whereas two patients died due to comorbidities. The low rates of postoperative morbidity, mortality, and restenosis obtained suggest that surgical or endovascular correction of chronic mesenteric ischemia is satisfactory when performed by experienced surgeons, with an adequate selection of the patients.

Surgical and Endovascular Management of Patients with Chronic Mesenteric Ischemia: A Single Center Experience

Chronic mesenteric ischemia is a rare intestinal disorder, with a potential evolution toward intestinal infraction. The choice of the appropriate treatment is currently the most crucial issue in the management of patients with chronic mesenteric ischemia. We describe our experience with 16 cases, and we discuss the current diagnostic and therapeutic approaches. A retrospective review of the clinical records was performed, and demographic, clinical, therapeutic, and prognostic data were collected. Six patients were females (37%), and the mean age was 62 years. Postprandial pain was present in all the cases, whereas sitophobia and weight loss were detected in 87 per cent of them. Eight patients were treated with open surgery; no perioperative deaths or relevant complications occurred. One patient had a restenosis of the celiac trunk and superior mesenteric artery 10 months after surgery. No deaths or relevant complications occurred in the remaining patients, who underwent an endovascular procedure. One patient presented a restenosis distal to the vascular stent, whereas two patients died due to comorbidities. The low rates of postoperative morbidity, mortality, and restenosis obtained suggest that surgical or endovascular correction of chronic mesenteric ischemia is satisfactory when performed by experienced surgeons, with an adequate selection of the patients.

Non-invasive ventilation outside the Intensive Care Unit for acute respiratory failure: the perspective of the general ward nurses

BACKGROUND

The introduction of non-invasive ventilation outside the Intensive Care Unit (ICU) is an increasing phenomenon, motivated by the shortage of intensive care beds and growing confidence with the technique. However, although general ward nurses are responsible for carrying out the daily management of the treatment and the extra monitoring it requires, their perspective on non-invasive ventilation (NIV) has never before been studied, and as a result their training is often neglected.

METHODS

A questionnaire was administered to the nurses of four non-intensive wards. The questionnaire addressed several issues, including the extent of the nurses' involvement in the decision to start the treatment, their relationship with the ward physicians and the Medical Emergency Team (MET), the monitoring, incidence, and management of errors and complications, the adhesion to the prescribed ventilatory program, and the desired training.

RESULTS

Out of 115 nurses, 90 completed the questionnaire (78.3%). Of this group, 67% did not feel involved in the decision-making process, and half felt they were inadequately informed. Approximately one third reported that they did not have adequate consultations with the doctors in the ward or with the MET. Only 13% of the nurses stated that the training was adequate (0% in medical wards).

CONCLUSIONS

Nurses indicated a strong demand for training on NIV, in order to improve their involvement with the therapeutic program and for better communication with the MET and ward doctors. We conclude that active research towards understanding their point of view should be included as part of the quality control of NIV treatments outside the ICU.

Sex, mutation and fitness: asymmetric costs and routes to recovery through compensatory evolution

A wild-type population of Drosophila melanogaster was used to assess the impact of a known deleterious mutation, nub(1), when it had (1) evolved for up to 180 generations with the mutation or (2) recently had the same mutant allele introgressed into it. Relative to this benchmark, we observed much stronger initial fitness depression in males (-74%) than in females (-38%) and also relatively greater fitness recovery by evolved males (+55%) than females (+17%). Experimental assays revealed amelioration in both juvenile and adult fitness and suggested that the greater relative recovery of male fitness was from gains through sexual selection. These evolutionary changes in male fertility depended on pairing with their coevolved mates for both mate choice and post-copulatory components of sexual selection. Without replication at the population level, these results are used to motivate a general hypothesis rather than definitively test it: Differences in reproductive optima may generally skew mutational effects towards the more strongly sexually-selected sex due to genic capture and condition dependence.

Self-expandable metal stents in the management of cervical oesophageal and/or hypopharyngeal strictures

AIM

To assess the usefulness of self-expandable metal stents in the recanalization of cervical and/or hypopharyngeal strictures.

MATERIALS AND METHODS

We report our experience in 10 patients with inoperable cervical and/or hypopharyngeal strictures treated by implantation of 11 uncovered self-expandable metal stents inserted perorally under fluoroscopic guidance. The stent was placed in the hypopharynx and cervical oesophagus in 3 patients and cervical oesophagus alone in 7. There were 8 men and 2 women, mean age 70.2 years, range 45-85 years. All patients but two had malignant stricture caused by squamous cell carcinoma, in one case there was a benign postoperative stenosis secondary to laryngectomy, and in the last patient a local recurrence from thyroid cancer.

RESULTS

Eleven stents were placed in 10 patients: technical success was achieved in 9 cases while clinical improvement was obtained in 8 cases. Seven of ten patients had a rapid improvement of dysphagia. One patient had a distal misplacement of the prosthesis, while in the other two cases stent position was very proximal and interfered with swallowing. A mean 9-month follow-up was obtained (range 3-24 months). Four patients with malignant stricture developed proliferation of neoplastic tissue after 2-5 months. The only patient treated for a benign stricture developed inside proliferation of granulation tissue after 4 months.

CONCLUSION

Despite several technical difficulties and a high rate of late complications, recanalization of cervical oesophageal strictures by self-expandable metal stents allowed good palliation of symptoms. Stents proved to be effective and well tolerated palliative treatment also for hypopharyngeal stenoses.

Portohepatic gradient and portal hemodynamics in patients with cirrhosis due to hepatitis C virus infection

We evaluated the agreement between wedged hepatic vein pressure (WHVP), portal vein pressure (PVP), and its relationship with portal hemodynamics in 21 patients with HCV-related cirrhosis with esophageal varices. Direct measurements of the portohepatic gradient (HVPG) were obtained by ultrasound-guided fine needle puncture of the right hepatic and the portal veins. In five cases PVP was 6.4-10.4 mm Hg higher than WHVP. In 12 cases measurements were similar (WHVP - PVP < or = 3 mm Hg). In the remaining four cases WHVP was 3.6-9.6 mm Hg higher than PVP. WHVP and PVP agreement was not related to HVPG mean value, Child-Pugh score, or grading of esophageal varices. By contrast, the difference between WHVP and PVP was inversely related to the portal flow velocity (P = 0.053) and directly related to the portal vascular resistance (P = 0.02). Whereas the portal branches were visualized in patients with WHVP lower or similar to PVP, a predominant left portosystemic collateral flow was observed in patients with WHVP > PVP. Our data point out that, in patients with cirrhosis due to hepatitis C virus infection, discrepant HVPG values reflect true hemodynamic differences.

[Developments in the last 10 years in diagnostic imaging discovery of renal carcinoma]

We have reviewed the files of 69 patients who had presented with cancer of the renal parenchyma between 1985 and 1994. In 20% of cases in 1985-1989 and in 40% of cases in 1990-1994 these tumours were discovered incidentally, in example before the occurrence of any suggestive symptoms. In 20% (1985-1989) of cases and 40% (1990-1994) of cases, the credit for this early detection was due to ultrasound study prescribed by the attending physician waiting a general health assessment or the follow-up of some other disease. The early diagnosis treating cancers at less advanced staged, which will probably improve the prognosis.

Homozygous beta-thalassaemia resulting in the beta-thalassaemia carrier state phenotype

This paper describes the phenotypic manifestations of a very mild beta-thalassaemia mutation detected in several members of two families of Italian descent. The molecular defect, defined by denaturing gradient gel electrophoresis analysis and direct sequencing, consists of a C-->G substitution at position 844 of IVSII of the beta-globin gene within the consensus sequence of the IVSII acceptor splice site. Heterozygotes for this mutation show a haematological phenotype ranging in severity from silent beta-thalassaemia to that of a mild beta-thalassaemia carrier state, whereas homozygotes have the typical manifestations commonly resulting from heterozygosity for a beta-thalassaemia mutation. Compound heterozygotes for the IVSII nt844 (C-->G) mutation and a severe beta-thalassaemia mutation have the phenotype of thalassaemia intermedia. This paper indicates that the presence of borderline red blood cell indices or HbA2 values should make one suspect the presence of a very mild or silent beta-thalassaemia.

[Role of arteriography and percutaneous transluminal angioplasty in the diagnosis and treatment of arterial vasculogenic impotence]

High quality arteriographic studies of the iliopudendal vascular tree are mandatory for the correct examination of arteriogenic impotence patients before revascularization procedures. Twenty-three patients with chronic erectile dysfunctions due to stenosis or occlusive arteries diseases of the iliac arteries were treated with percutaneous transluminal angioplasty (PTA) in our Department. A positive clinical result was obtained in 15 of 23 cases (65.2%). The maneuver was successful in 8 of 14 patients with vascular lesions of the common and/or external iliac artery (57%). The erectile dysfunction was resolved in 4 of 6 patients with stenosis of the external iliac artery associated with a stenosis of the hypogastric artery (66.6%). The erectile dysfunction was also resolved in 3 patients with a single vascular lesion in the hypogastric artery. No major post-angioplasty complications were observed. PTA is a repeatable and not very invasive method with a low complication rate and could represent a valuable alternative to surgical revascularization in the patients with associated impotence and claudication of leg and hip. Moreover, it makes the treatment of choice in the patients with erectile dysfunctions due to isolated lesions of the hypogastric arteries.

[Role of phlebography in the study of recurrent leg varices]

In the last four years, 668 phlebographies of the lower limbs were performed in patients affected with varices. Recurrences were detected in 239 patients. Different phlebographic approaches were used, including ascending phlebography of the popliteal and femoral veins and varicography. Specific indications to different techniques are discussed and possible causes of recurrence are analyzed. In patients with recurrent varices, atypical venous drains were often observed, whose involvement could not be detected by either clinical examination or noninvasive instrumental evaluation. Therefore, phlebography represents a reliable and sensitive technique to recognize recurrent varices.

[Incompetence of the m. gemellus veins in varicose veins: its incidence and phlebographic study]

The authors report on 466 venographies of the lower limbs performed over the past 2 years on 412 patients affected with varicose veins. Pathologic reflux of the gastrocnemius veins was observed in 15.7% of cases: 9.7% in the group of non-operated patients and 25.3% in the group with recurrent varicose disease. Ascending venography (and eventual popliteal venography) is the ideal diagnostic approach to show gastrocnemius veins incompetence, eventual anatomic variations, and isolated/associated incompetence of the short and/or long saphenous vein territory. Moreover, venography allows the hemodynamic evaluation, and shows reversed flow in the gastrocnemius veins in case of incompetence.

[Selective arteriography in the study of arterial vasculogenic impotence]

According to the fundamental circulatory nature of penile erection, insufficiency of the arterial blood supply to the corpora cavernosa caused by an organic arterial disease is found in a large fraction of case, overall among the patients aged more than 40. It is possible to evaluate arterial origin of erectile dysfunction by using of noninvasive methods, but to obtain the necessary panoramicity and the characterization of the lesions it needs the use of angiography. Performance of standard arteriography leads to insufficient visualization of pudendal and penile vessels and risks false positive results. Because of penile hemodynamic variability in its different states is necessary the use of pharmacologic devices to perform a diagnostic arteriography. For the selective study of the pudenda and peniena vascularization we perform a selective arteriography bilaterally, with the catheter tip placed in the proximal part of the internal iliac artery. We use a contrast medium particularly diluted and mixed with xylocaine. We perform angiographic sequences after intracavernous injection of 8-10 mgr of papaverine to obtain the maximum blood flow and to prevent spasm of the terminal arterioles. Arteriography gives a complete study of the pudenda arterial tree and its terminal ramifications, and it is able to supply all the necessary informations regarding the planning of revascularization procedures. Treatment of arterial lesions is possible with surgical and radiologic methods. As in other arteries, percutaneous transluminal angioplasty (P.T.A.) can be applied in the therapy of impotence caused by arterial insufficiency. P.T.A. is the election treatment in the stenosis of the common iliac and internal iliac arteries.(ABSTRACT TRUNCATED AT 250 WORDS)