Circular External Fixation as a New Offloading Standard of Treatment in Charcot Neuro-Osteoarthropathy Complicated by Midfoot Osteomyelitis: A Pilot, Prospective Case-Control Study

After surgical treatment of Charcot neuro-osteoarthropathy (CNO) complicated by plantar ulcer and midtarsal osteomyelitis, offloading is mandatory to protect the surgical site. Total contact casting is, to date, the standard-of-care to offload the foot during the postoperative period. We have compared the application of external circular fixator, to the standard of care, with regard to surgical wound healing and time to healing. During the time period from January 2020 to December 2021, 71 consecutive patients admitted to our unit with diabetes and CNO complicated by plantar ulceration and midtarsal osteomyelitis were enrolled in our study. All patients were classified as stage 2, according to the Frykberg & Sanders classification. Wifi wound stage was W2 I0 FI2 in 43 of 71 patients (60.6%) and W2 I2 FI2 in 28 of 71 patients (39.4%). In cases where critical limb ischemia occurred, we performed an endovascular procedure to obtain patency in at least one of the tibial arteries. Localization of osteomyelitis was carried out with magnetic resonance imaging studies, and the degree of deformity was assessed using plain X-ray or computed tomography. A localized ostectomy through the ulceration was carried out with a fasciocutaneous flap to cover the surgical site. In 36 patients, an external circular fixator was applied intraoperatively (exfix+ group); the remaining 35 patients received fiberglass cast in the postoperative period (exfix- group). Complete healing of the surgical site was achieved in 36 of 36 patients in the exfix+ arm and in 22 of 35 in the exfix- arm (P < .02). Time to healing was 68 ± 28 days in exfix+ and 102 ± 88 days in exfix- (P = .05). Circular external frames should be considered as an effective offloading device that enhances the healing rate and reduces time to healing after surgical treatment of midfoot osteomyelitis in subjects affected by CNO.

SARS-COV-2 Pandemic for Patients with Chronic Obstructive Peripheral Arterial Disease: Impact of Interruption to Access According to Gender in a Single Center Experience

BACKGROUND

This retrospective study aims to evaluate the impact of interrupted services for peripheral arterial disease (PAD) patients and especially women in a single north-eastern Italian center over a period of 3 months prior to the pandemic, during the first (2020) and the second (2021) wave of contagion in northern Italy.

METHODS

Patients with PAD at Rutherford stages 3 to 6 that required revascularization between March 2019 and March 2021 were classified into 3 groups, according to the period of treatment: the prepandemic period, the pandemic-20 period, and the pandemic-21 period.

RESULTS

Twenty-eight patients were treated in the prepandemic period, 21 in the pandemic-20 period, and 39 in the pandemic-21 period. It was observed that in the both pandemic periods patients presented with more severe stages of limb ischemia, Rutherford 5 and 6 stages. During pandemic-20, patients underwent mostly open surgery, followed by hybrid procedures. No differences were observed between the 3 groups in major amputations, length of hospital stay, type of discharge, limb salvage and mortality. During long-term follow-up, limb salvage appeared to be significantly better in the pandemic-21 group. The gender analysis revealed a significantly reduced female proportion of overall treated patients in 2020 and 2021 compared to the prepandemic period. In the pandemic-20 this difference appears even more evident since treatments on females represented 19% of the total while in the same period of the previous year the male/female percentage was comparable (54% vs. 46%). The women admitted presented higher stages of disease and tended to have a longer hospital stay than men. At 12-month follow-up, limb salvage was similar between the 2 genders but was slightly worse in women.

CONCLUSIONS

An efficient reorganization of the vascular surgery services during the pandemic period guaranteed the quality and standard of treatment offered in the preceding periods. Among patients suffering from PAD the impact of the pandemic was greater for the female gender. It is therefore important that in addition to a reorganization of hospital services to provide adequate care for patients with ACOP in the pandemic period, greater information and awareness of women.

COVID-19 induced aorto duodenal fistula following evar in the so called "negative" patient

OBJECTIVES

Since October 2019, SARS-CoV-2 pandemic represents a challenge for the international healthcare system and for the treatment and survival of patients. We normally focus on symptomatic patients, and symptoms can range from the respiratory to the gastrointestinal system. In addition, we consider patients without fever and respiratory symptoms, with both a negative RT nasopharyngeal swab and lung CT, as a "Covid-19 negative patient." In this article, we present a so called Covid-19 "negative" patient, with an unsuspected vascular clinical onset of the viral infection.

METHODS

An 80 y.o. man, who previously underwent endovascular aortic repair for an infrarenal abdominal aortic aneurysm, presented to our department with an atypical presentation of an aorto-enteric fistula during the pandemic. While in hospital, weekly nasopharyngeal swab tests were always negative for SARS-CoV-2. However, the absence of aortic endograft complications, the gross anatomy of duodenal ischemic injury, and the recent history of the patient who lived the last months in Bergamo, the Italian city with the highest number of COVID-19 deaths, lead the senior Author to suspect an occult SARS-CoV-2 infection. The patient underwent to resection of the fourth portion of the duodenum and the first jejunal loop, with subsequent duodenum-jejunal latero-lateral anastomosis and the direct suture of the aortic wall. The intestinal specimen was investigated as suspected SARS-CoV-2 bowel infection by the means of immune-histochemistry (IHC). An ileum sample obtained in the pre-COVID-19 era was used as a control tissue.

RESULTS

The histological analysis of the bowel revealed sustained wall ischemia and liponecrosis of the duodenal wall, with intramural blood vessels thrombosis. Blood vessel endotheliitis and neo-angiogenesis were also observed. Finally, the IHC was strongly positive for SARS-CoV-2 RNA and for HLA-G presence, with a particular concentration both in blood vessels and in the intestinal villi. The control tissue sample was not positive for both SARS-CoV-2 and HLA-G.

CONCLUSIONS

Coronavirus pandemic continues to be an international challenge and more studies and trials must be done to learn its pathogenesis and its complications. As for thromboembolic events caused by SARS-COV-2, vascular surgeons are involved in treatment and prevention of the complications of this syndrome and must be ready with general surgeons to investigate atypical and particular cases such as the one discussed in this article.

Superficial femoral artery access for infrainguinal antegrade endovascular interventions in the hostile groin: A prospective randomized study

INTRODUCTION

In a hostile groin, it may be difficult to perform antegrade endovascular procedures at the lower extremities using the ipsilateral common femoral artery as vascular access; therefore, the use of the ipsilateral superficial femoral artery (SFA) could be a useful alternative. In this study, we evaluated the feasibility and safety of ultrasound-guided SFA puncture versus traditional SFA cutdown to achieve arterial access.

METHODS

This prospective observational randomized study examined patients with symptomatic peripheral arterial disease who required endovascular interventions at the lower extremities. A hostile groin was defined as high femoral bifurcation, obesity, and surgical scarring due to previous surgical interventions. A 6-Fr sheath (12 cm long; ULTIMUM™ EV INTRODUCER; Abbott, Plymouth, MN, USA) was used in all procedures. In the percutaneous group, the puncture was performed under ultrasound guidance and hemostasis was performed using a percutaneous closure device (PCD) (Angioseal Vip 6-Fr; Terumo Medical Corporation, Somerset, NJ, USA). The primary endpoints were technical success and perioperative complications. The secondary endpoints were the time required for the management of vascular access and the type of anesthesia administered.

RESULTS

Between 2020 and 2021, 107 patients who underwent antegrade revascularization were enrolled. SFA was achieved in 50 cases by the femoral cutdown technique (c-group) and in 57 cases by percutaneous ultrasound-guided puncture (p-group). In the c-group, the time from incision to sheath introduction and the time of suturing the artery and wound closure was 35 ± 8 min. In the p-group, the time from skin puncture and sheath placement plus that from the sheath removal and hole closure with the PCD was 6 ± 3 min. For the c-group versus p-group, the following variables were as follows: high bifurcation, 10 vs. 6 cases (=p 0.2); severe obesity, 33 vs. 40 cases (p 0.46); and previous surgical groin interventions, 7 vs. 9 cases (p 0.53), respectively. The technical success rates were 100% vs. 96.49% for the c-group vs. p-group, respectively (p 0.63). Two percutaneous puncture failures were managed using the cutdown technique. In the p-group, two post-procedural hematomas were recorded, with only one requiring surgical treatment and two with SFA occlusion to intravascular cap hemostatic dislocation, which were subjected to surgical revision. A total of three percutaneous procedures in the p-group required surgical revision versus none in the c-group (p =0.1). Within 3 months, complications consisted of 6 cases of surgical wound complications in the c-group versus none in the p-group (p 0.009). All procedures in the p-group versus 72% of patients in the c-group were managed with local anesthesia (p<0.0001).

CONCLUSIONS

The femoral cutdown technique seems to be safe and successful approach for achieving vascular access in cases of hostile groin. Ultrasound-guided puncture and PCD make SFA puncture a successful and safe alternative with an acceptable complications rate. Moreover, it reduces the time required to manage vascular access and can be performed mainly under local anesthesia.

Segmental saphenous ablation for chronic venous disease treatment

BACKGROUND

Endovenous thermal ablation for chronic venous disease treatment is recommended over traditional surgery. The present investigation compares endovenous laser ablation (EVLA) with radiofrequency (RF) for segmental endovenous sapheno-femoral junction ablation.

METHODS

This is a retrospective study in which 79 patients underwent a 6 cm great saphenous vein ablation by RF or by EVLA.Primary outcome was occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score, peri-procedural pain, aesthetic satisfaction.

RESULTS

At 12 ± 1 months recanalization of shrunk tract was recorded in 5/85 (5.8%) cases (2 RF, 3 EVLA) [OR: 1.6; 95%CI: 0.2-10.4; P = 0.6689]. Two cases (1/44 RF group and 1/38 EVLA group) also showed reflux recurrence [OR: 1.0; 95%CI: 0.06-17.8; P = 1.0000]. No significant differences between groups were found in AVVQ, VCSS, peri-procedural pain, or aesthetic satisfaction.

CONCLUSION

Saphenous sparing is feasible and effective by means of both EVLA and RF, representing a possible alternative to surgery.

Open repair with resection and reimplantation for popliteal artery aneurysm

Popliteal artery aneurysms are the most frequent type of peripheral arterial aneurysm and can be repaired by either open or endovascular techniques. An 81-year-old man presented with leg swelling and during duplex ultrasound examination was diagnosed a popliteal aneurysm. The transverse diameter was 3.6 × 4.5cm, length 2.8cm, one run-off vessel patent. The popliteal aneurysm was asymptomatic for clinical signs of limb ischaemia. We opted for an open surgical repair through a posterior approach. During dissection of the popliteal artery above and below the aneurysm, the two non-diseased popliteal extremities appeared to be very close, leading to the decision to perform an end-to-end anastomosis between the two arterial extremities. The patient was discharged after three days with no adverse events. Follow-up consisted of duplex ultrasound examination at one, three and six months, and then annually. At the six-month follow-up there was no restenosis at the anastomosis.