Venous Vascular Closure System Versus Figure-of-Eight Suture Following Atrial Fibrillation Ablation - The STYLE-AF Study

BACKGROUND

Simplified ablation technologies for pulmonary vein isolation (PVI) are increasingly performed worldwide. One of the most common complications following PVI are vascular access-related complications. Lately, venous closure systems (VCS) were introduced into clinical practice, aiming to reduce the time of bedrest, to increase the patients' comfort and to reduce vascular access-related complications.

AIMS

To compare the safety and efficacy of using a VCS to achieve haemostasis following single shot PVI to the actual standard of care (figure-of-eight suture and manual compression (MC)).

METHODS

This is a prospective, multicentre, randomized, controlled, open-label trial performed at 3 German centres. Patients were randomized 1:1 to undergo haemostasis either by means of VCS (VCS group) or of a figure-of-eight suture and MC (F8 group). The primary efficacy endpoint was the time to ambulation, while the primary safety endpoint was the incidence of major periprocedural adverse events until hospital discharge.

RESULTS

A total of 125 patients were randomized. The baseline characteristics were similar between the groups. The VCS group showed a shorter time to ambulation (109.0 (82.0, 160.0) vs. 269.0 (243.8, 340.5) min; p<0.001), shorter time to haemostasis (1 (1, 2) vs. 5 (2, 10) min; p<0.001) and shorter time to discharge eligibility (270 (270, 270) vs. 340 (300, 458) min; p<0.001). No major vascular access related complication was reported in either group. A trend towards a lower incidence of minor vascular access related complications on the day of procedure was observed in the VCS group (7 (11.1%) vs. 15 (24.2%); p=0.063) as compared to the control group.

CONCLUSION

Following AF ablation, the use of a VCS results in a significantly shorter time to ambulation, time to haemostasis and time to discharge eligibility. No major vascular access related complications were identified. The use of MC and a figure-of-eight suture showed a trend towards a higher incidence of minor vascular access related complications.

Fifty-fifty - a comparison of two 50 watts high power short duration protocols using temperature- versus power- controlled radiofrequency ablation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Radiofrequency-guided catheter ablation (RFCA) is an established treatment option for atrial fibrillation (AF). New approaches applying higher than usual energy levels for shorter periods (high power short duration, HPSD) to improve lesion quality have been reported. The novel DiamondTemp (DT) catheter allows for temperature-guided high power RFCA. Data on a direct comparison of the two emerging RFCA approaches are lacking.

Purpose

This observational single center study aimed to compare the efficacy, safety and characteristics of the novel DT catheter to an ablation index (AI) guided 50 W high power short duration (HPSD) ablation protocol using a conventional force-sensing equipped ablation catheter with surround-flow.

Methods

A total number of 101 patients undergoing RFA for AF were included. 33 patients treated with the DT catheter (50 W, 9 sec), were compared to 69 consecutive patients undergoing AI-guided AF ablation (AI anterior 550; AI posterior 400) with an open-irrigated catheter adherent to a 50 W HPSD protocol. Procedural data and recurrence rates were documented. Follow-up examinations were scheduled after 3, 6 and 12 months.

Results

Acute procedural success was achieved in all patients (n=101, 100%). DT-guided AF ablation was associated with a significantly longer mean procedure duration (98.8±30.1min vs. 78.2±25.6, p=0.002*). PVI using the DT ablation catheter required significantly more RF applications (75.4±30.8min vs. 61.3±14.1, p=0.019*). Total RF duration was significantly lower in the DT group (792.1±311.2sec vs. 1035.5±287.2sec, p&lt;0.001*) as well as fluoroscopy time (4.6±2.1min vs.5.5±2.5min, p&lt;0.006*) and dose (183.8±178.1yGym2 vs. 295.8±247.5yGym2, p&lt;0.013*). Procedure related mayor complications occurred in 1 patient from the DT group (acute stroke; 3%) and in no patients from the HPSD cohort. Early recurrence was reported from 4 patients treated with the DT catheter (12%) compared to 8 patients undergoing HPSD RFA (12 %) (p=1.000).

Conclusion

Temperature- and power- controlled AF ablation using 50 W was safe and effective. AI-guided HPSD ablation resulted in significantly shorter procedure times with significantly fewer RF applications for PVI, whereas total RF duration and fluoroscopy times were significantly higher in this cohort. Further studies are needed to confirm this initial observation.

The novel POLARx ablation system improves cryothermal single-shot guided pulmonary vein isolation: impact of individual pulmonary vein anatomy

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon (CB)-guided pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). Recently, a novel balloon-guided cryothermal single shot device (POLARx) was introduced.

Purpose

This observational study aimed to evaluate ablation efficacy and outcome using the novel POLARx CB system compared to the established one and to access the impact of individual PV characteristics on freedom from arrhythmia recurrence in paroxysmal (PAF) and persistent (PERS) AF.

Methods

666 patients undergoing CB-guided ablation for AF were included. 601 patients treated with the AFA ablation system (Arctic Front Advance Pro, AFA) were compared to 65 consecutive patients who underwent PVI using the POLARx. Individual anatomical characteristics of the left atrium and PVs were assessed using pre-procedural cardiac magnetic resonance imaging (MRI). For each PV, the cross-sectional orifice area (CSOA) was determined. Follow-up examinations were scheduled after 3 and 6 months.

Results

Acute PVI was achieved in all patients (100%). 6-months AF-free survival was significantly higher in the POLARx cohort (POLARx: n=45, 69%; AFA: n=359, 60%; Log-rank p=0.037*). This applies to PAF (n=42, 65%, p=0.033*), PERS (n=23, 35%, p&lt;0.001*) and normal PV anatomy (2 left- and two right-sided PVs; n=57, 88%, p&lt; 0.001*). MRI found a comparable percentage of patients with normal PV anatomy (POLARx: n=57, 88%; AFA: n=512, 85%, p=0.126). A higher amount of variant PV anatomy was revealed in patients with PERS AF (p=0.043*), but this factor was not predictive for AF-recurrence (PAF: p=0.610; PERS: p=0.096). PAF patients with AF-recurrence presented with significantly larger CSOA of the left sided PVs and the right superior PVs (LSPV: 224.8 ± 98.1 mm2 vs. 220.6 ± 64.8 mm2, p&lt;0.001*; LIPV: 145.9 ± 63.2 mm2 vs. 140.4 ± 52.8 mm2, p&lt;0.001*; RSPV 268.9 ± 79.3 mm2 vs. 262.3 ± 75.6 mm2, p&lt;0.001*). In patients with PERS AF no association between CSOA and ablation outcome was observed. Multivariate Cox regression analyses identified the AFA ablation system (p=0.022*, hazard ratio (HR) 1.776, confidence interval (CI) 0.240-9.281) and PERS AF (p&lt;0.001*, HR 6.608, CI 0.220-73.839) as independent predictors for AF-recurrence.

Conclusion

PVI using the POLARx system improves freedom from AF recurrence independent of individual anatomical considerations and PV occlusion rates. For PAF patients, a significant association between CSOA and the outcome after CB- guided PVI was demonstrated.

P1438Predictors and clinical impact of bleeding events after left atrial appendage closure in patients with high risk or a history of bleeding

Background

Left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation and may be especially attractive in patients with high risk or a history of bleeding. However, data of clinical benefit and incidence of post-procedural bleeding in patients with both high risk of bleeding and ischemic cerebral stroke after LAAC are lacking.

Objectives

This study sought to identify predictors and the prognostic impact of post-LAAC bleeding in patients at high risk and/or history of bleeding in the direct oral anticoagulant therapy (DOAC) era.

Methods and results

We retrospectively enrolled a total of 195 patients (75 ± 8.7 years, 38% female, 47% with previous major bleeding, mean CHA2DS2-VASc score 4.3 ± 1.6 and mean HAS-BLED score 2.7 ± 1.1) undergoing endocardial (91%) or epicardial (9%) LAAC during a mean follow-up of 339 ± 319 days. Twenty-three (11.9%) patients developed procedure-unrelated bleeding events after a median of 147 (43, 362) days after LAAC, in 12/23 (52%) patients under single antiplatelet therapy (SAPT), 6/23 (26%) dual antiplatelet therapy (DAPT), 1/23 (4%)  DOAC, 1/23 (4%) VKA, 2/23 (9%) dual therapy (SAPT and DOAC/VKA) and 1/23 (4%) triple therapy (DAPT and DOAC/VKA). (Figure) Diabetes mellitus and previous major bleeding were identified as the independent predictors of post-LAAC bleeding (Odds ratio 2.65 [95% CI:1.04-6.73], p = 0.041, and 5.50 [95% confidence interval:1.72-17.5], p = 0.004). Post-LAAC bleeding was associated with all-cause death (9/23 [39%] vs 18/171 [11%], p = 0.001), but not ischemic stroke/TIA (1/23 [4%] vs 6/171 [4%], p = 0.593) nor device thrombus (2/23 [9%] vs 3/171 [2%], p = 0.108). Kaplan-Meier curve estimated that patients with post-LAAC bleeding had a worse mortality than those without post-LAAC bleeding (3-year mortality; 35.6% [95%CI; 11.6-61.0%] vs 68.7% [45.0-83.8], p = 0.029)

Conclusions

In AF patients with high bleeding risk or history of bleeding undergoing LAAC, bleeding events are common and may occur even after long-term duration after LAAC. Previous major bleeding history strongly predicts subsequent bleeding events following LAAC and is associated with unfavorable mortality. Further investigations are required to identify optimal post-procedural antithrombotic strategies for patients undergoing LAAC with previous major bleeding.

Abstract Figure. The association between time to bleeding

Adjuvant Systemic Therapies in Patients with Colorectal Cancer: An Audit on Clinical Practice in Italy

Aims and Background

Rarely are conclusions from clinical trials summarized in international consensus conferences and promptly transferred to patient care. The adjuvant therapy for colorectal cancer used in daily clinical practice in Italy is described and compared with the recommendations of the 1990 NIH Consensus Conference.

Patients and Methods

We audited prescriptions of adjuvant systemic therapies for Italian colorectal cancer patients in 82 centers during a fixed one-week period.

Results

Among 434 patients receiving adjuvant chemotherapy there were 139 (42.5%) colon cancer patients with N- and 169 (51.7%) with N+ regional nodal involvement. Treatment at academic centers, a young age, T4 and a low total number of lymph nodes removed at surgery were the factors potentially justifying the decision for adjuvant chemotherapy in stage II colon cancer patients. The most common chemotherapy used was a bolus of 5-fluorouracil/folinic acid for 6 months (75.8%). Adjuvant radiotherapy was not administered to 37 (38.5%) of 96 patients with stage II and III rectal cancer.

Conclusions

The study shows that a substantial proportion of patients on adjuvant treatment at a certain time point in a large enough sample of Italian centers are stage II (potential over-treatment) and that an under-treatment of stage II and III rectal cancer patients (lack of radiotherapy) occurs too often in daily clinical practice in this country.

Continuous monitoring of noise levels in the Gulf of Catania (Ionian Sea). Study of correlation with ship traffic

Acoustic noise levels were measured in the Gulf of Catania (Ionian Sea) from July 2012 to May 2013 by a low frequency (<1000Hz) hydrophone, installed on board the NEMO-SN1 multidisciplinary observatory. NEMO-SN1 is a cabled node of EMSO-ERIC, which was deployed at a water depth of 2100m, 25km off Catania. The study area is characterized by the proximity of mid-size harbors and shipping lanes. Measured noise levels were correlated with the passage of ships tracked with a dedicated AIS antenna. Noise power was measured in the frequency range between 10Hz and 1000Hz. Experimental data were compared with the results of a fast numerical model based on AIS data to evaluate the contribution of shipping noise in six consecutive 1/3 octave frequency bands, including the 1/3 octave frequency bands centered at 63Hz and 125Hz, indicated by the Marine Strategy Framework Directive (2008/56/EC).

[Troponin I and B-type Natriuretic Peptide (BNP) as biomarkers for the prediction of cardiotoxicity in patients with breast cancer treated with adjuvant anthracyclines and trastuzumab]

Adjuvant trastuzumab with chemotherapy is the treatment of choice for patients with human epidermal growth factor receptor positive (HER2+) breast cancer and improves the outcome of patients with early breast cancer. However, it is potentially cardiotoxic and there are no validated methods of early detection of cardiotoxicity from trastuzumab following anthracycline-based chemotherapy. Currently, changes in left ventricular ejection fraction (LVEF) are assessed but this approach has limited sensitivity and specificity. Early identification of patients at risk for cardiotoxic effects is a primary goal for both cardiologists and oncologists. Plasma markers such as b-type natriuretic peptide (BNP - an index of elevated filling pressure) and troponin I (TnI - an index of cardiomyocyte damage) may be used to identify the risk of developing cardiac dysfunction during treatment. In this review, we discuss if TnI and/or BNP could be used to help the prevention or treatment of cardiac dysfunction at the earliest possible time.

Pretreatment of Dacron Prostheses with Gelatin: Experimental Research and Clinical Evaluation

Experimental evaluation of a new type of dacron graft, pretreated with mod ified mammalian gelatin, has been performed on the beagle dog. After grafting of the infrarenal aorta, dogs were monitored from three days to three months. Pretreatment with gelatin effectively avoided the need for preclotting and did not affect the normal healing of the prosthesis as compared with similarly tex tured not pretreated grafts.

This graft, when applied in man as an abdominal aortic substitute, has yielded uniformly gratifying results (within a follow-up range of twenty to twenty-seven months).

Unusual endotracheal and breast metastasis from renal clear cell carcinoma: a case report

We report a case of a woman affected by a metastatic renal clear cell carcinoma who showed unusual metastasis into the trachea and in the right breast 17 years and 21 years after nephrectomy respectively. Two endotracheal metastasis were identified during rigid bronchoscophy and were treated with endotracheal electro-surgery. Solitary metastasis in the right breast was identified by a mammography that revealed a dense mass of 1.5 cm at lower outer quadrant and she underwent to a right breast quadrantectomy. Histological examination showed a clear cell renal carcinoma metastasis as for the trachea as for the breast mass.

Turing pattern formation in the Brusselator system with nonlinear diffusion

In this work we investigate the effect of density-dependent nonlinear diffusion on pattern formation in the Brusselator system. Through linear stability analysis of the basic solution we determine the Turing and the oscillatory instability boundaries. A comparison with the classical linear diffusion shows how nonlinear diffusion favors the occurrence of Turing pattern formation. We study the process of pattern formation both in one-dimensional and two-dimensional spatial domains. Through a weakly nonlinear multiple scales analysis we derive the equations for the amplitude of the stationary patterns. The analysis of the amplitude equations shows the occurrence of a number of different phenomena, including stable supercritical and subcritical Turing patterns with multiple branches of stable solutions leading to hysteresis. Moreover, we consider traveling patterning waves: When the domain size is large, the pattern forms sequentially and traveling wave fronts are the precursors to patterning. We derive the Ginzburg-Landau equation and describe the traveling front enveloping a pattern which invades the domain. We show the emergence of radially symmetric target patterns, and, through a matching procedure, we construct the outer amplitude equation and the inner core solution.

Risk factors for otitis media with effusion: case-control study in Sicilian schoolchildren

OBJECTIVE

To identify the prevalence and demographic, maternal and child risk factors for otitis media with effusion (OME) in Sicilian schoolchildren and analyse the results with reference to the review of the literature.

METHODS

Associations of possible risk factors with prevalence of otitis media with effusion (OME) were studied in a cohort of 2097 children, aged 5-14 years. In order to determine OME, otoscopy and tympanometry were performed at 3-monthly intervals beginning at term date. Sixteen epidemiologically relevant features were inventoried by means of standardized questionnaires and skin tests were performed. Univariate analysis was performed to examine the association between determinants and occurrence of OME; multivariate logistic regression analysis was made to investigate the joint effect of atopy and other determinants on OME.

RESULTS

Prevalence of OME resulted 6.8% (143/2097) and it was most strongly associated with atopy (P<0.0001; or=12.67; 95% CI=8.78-18.27). Other factors significantly associated with the prevalence of OME were snoring (P<0.0001), previous history of acute otitis media (P<0.001) and of recurrent URTIs (P<0.0001), mother's no schooling (P=0.01) and no breastfeed (P=0.05). No significance was found for school type, economic status of the family, family size, family history of presence of allergy and of ear disease, mother's work status, smoking parents and birth history. Moreover on multivariate logistic regression analysis it resulted that age, positive URTI's history and smoking exposure were found to be significant (P<0.0001).

CONCLUSIONS

OME during infancy is a common and multifactorial disease; as most of the risk factors associated with its etiology and pathogenesis, are modifiable, their modification should represent the reasonable primary care intervention leading to a decrease in OME prevalence.

Upper extremities deep venous thrombosis: comparison of light reflection rheography and colour duplex ultrasonography for diagnosis and follow-up

BACKGROUND

Non-invasive diagnosis of axillary-subclavian vein thrombosis or documentation of the post-thrombotic syndrome performing methods currently in use is not definitive. The purpose of this prospective study was to compare two methods for the diagnosis and follow-up of patients with primary and secondary axillary-subclavian vein thrombosis: light reflection rheography (LLR) which is a reflection of venous pressure changes in the extremity as record from the subdermal capillary plexus, and colour duplex ultrasonography (CDUS).

METHODS

In 36 patients with primary and secondary axillary-subclavian vein thrombosis were used a 4006 GE (Milwaukee, USA) colour duplex ultrasonography and an AV-1000 Hemodynamics instrument for the light reflection rheography for diagnosis and follow-up. The LLR methodology that applied was simple, involving testing of the venous outflow in the upper extremities in response to exercise, and with normally respiratory variations of an open venous system that was also assessed by the non-invasive modalities. In the LLR application of venous congesting pressure, and measurement of the rate of venous outflow when the congesting pressure is released was also performed.

RESULTS

Both methods were able to diagnose the axillary-subclavian thrombosis in the initial acute state. There were no cases of false-positive results in either method. The CDUS presented a lower sensitivity in comparison to LLR in the follow-up period of the patients. A positive study was confirmed by phlebography in each instance.

CONCLUSIONS

The tracing obtained by LLR is easy to interpret and provides objective evidence of proximal venous occlusion. The test is easy to apply and the instrumentation is relatively inexpensive. Both LLR and CDUS, could prove to be an exciting development among non invasive diagnostic techniques for axillary-subclavian vein thrombosis, with major sensitivity of LLR in the follow-up.

Recurrent gastric carcinoma causing pseudoachalasia: case report

We report the case of a patient with a gastric remnant relapse of an antral carcinoma resected 5 years before and presenting with the clinical feature of a secondary achalasia (pseudoachalasia). In spite of the patient's 4-month history of dysphagia and weight loss that suggested a malignant lesion, barium swallow, repeated endoscopic biopsies and computed tomography (CT) scan of the upper abdomen did not reveal any abnormalities to indicate a recurrence. However, in the following months, because of worsening symptoms, a further CT scan was performed and revealed thickening of the cardia and gastric wall. The patient underwent an exploratory laparotomy that showed an unresectable lesion involving the gastric fundus, the diaphragm and penetrating into the mediastinum, and therefore a palliative jejunostomy was performed.

Diagnosis and treatment of Barrett's oesophagus. A general survey

Barrett's oesophagus is an acquired condition with columnar metaplasia of the distal oesophagus. This condition represents the most serious consequence of chronic gastro-oesophageal reflux as it is associated with an increased incidence of oesophageal adenocarcinoma. Since the exact pathophysiology is not known, prevention is not possible. The diagnosis of Barrett's oesophagus requires the presence of intestinal metaplasia in at least one biopsy specimen from the lower oesophagus. Barrett's oesophagus is considered a premalignant condition and some cases progress from dysplasia to invasive adenocarcinoma. Medical or surgical antireflux treatment controls symptoms and oesophagitis, but Barrett's oesophagus remains. Patients are usually followed up by endoscopy for detection of dysplasia or early cancer. Several reports in the literature have assessed the effects of H2-blocker and proton pump inhibitors treatment on Barrett's epithelium, but none has clearly documented a significant and consistent regression of the metaplastic epithelium. Even with high doses of proton pump inhibitors given for a prolonged period of time, it does not appear that a significant regression of Barrett's epithelium can be achieved. Various studies have assessed the effects of antireflux surgery on the regression of columnar epithelium and dysplasia and its potential protective effect on the subsequent development of carcinoma. Overall, it appears from these reports that antireflux surgery, despite adequate symptomatic results, does not significantly and consistently lead to a reduction in length or disappearance of the Barrett's mucosa, and does not prevent the development of dysplasia and its progression to carcinoma. Recently, numerous reports have documented the regression of Barrett's mucosa by using various experimental techniques: these thermal therapies focus on the removal of the columnar epithelium with restoration of the squamous epithelium. Technological advances including laser and especially photodynamic therapy have allowed for endoscopic mucosal ablation. Long-term results are more encouraging when this mucosal ablation is associated with antireflux medical or surgical therapy. Currently, none of these approaches can obviate the need for continued endoscopic surveillance; however the photodynamic therapy seems to be a promising alternative in the future.

Induced-hyperglycemia attenuates erythromycin-induced acceleration of hypertonic liquid-phase gastric emptying in type-I diabetic patients

BACKGROUND

Erythromycin has been found to be a gastrointestinal prokinetic agent of hypertonic liquids, while acute hyperglycemia has been associated with delayed gastric emptying in diabetic patients.

AIM

To investigate whether hyperglycemia, per se, reduces gastric motility during erythromycin-induced acceleration on gastric emptying of hypertonic liquids in diabetic patients.

METHODS

In 12 type-I diabetic patients following a hypertonic radiolabeled liquid meal, gastric emptying was measured scintigraphically during normoglycemia (5-8.9 mmol/l glucose) or hyperglycemia induced by intravenous (16-19 mmol/l) glucose infusion. The tests were performed on 4 separate days in random order after administering either placebo or 200 mg i.v. erythromycin.

RESULTS

In the hyperglycemic state compared to normoglycemia, the gastric emptying of the hypertonic liquid was reduced after placebo or erythromycin administration. The lag-phase duration (17.8+/-5.5 and 7.8+/-4.5 vs. 10.8+/-3.4 and 3.7+/-2.5 min, respectively, p<0.001), the overall gastric emptying time of the half meal (52.8+/-13 and 24.9+/-5.5 vs. 42.5+/-10.5 min and 16.6+/-6 min, respectively, p<0.001) and the retained percentage of liquid meal in the stomach at 60 and 100 min postprandially (p<0.001) were significantly increased.

CONCLUSIONS

The erythromycin-induced acceleration on gastric emptying of hypertonic liquids in diabetic patients is related to the plasma glucose level. The induced hyperglycemia reduces the erythromycin-induced acceleration of liquid-phase gastric emptying, decreasing the overall gastric emptying rate. In spite of the inhibitory effect of induced hyperglycemia on the gastric emptying of hypertonic liquids, erythromycin is still able to accelerate the emptying rate and could prove to be a useful prokinetic agent under hyperglycemic conditions.

Spinal cord stimulation in diabetic lower limb critical ischaemia: transcutaneous oxygen measurement as predictor for treatment success

OBJECTIVES

to evaluate whether transcutaneous oxygen tension (TcpO(2)) measurements could be used as a specific prognostic parameter in selecting diabetic patients for permanent device implantation.

METHODS

sixty consecutive diabetic patients (28 with autonomic neuropathy), classified as Fontaine stage III or IV, underwent spinal cord stimulation (SCS) for ischaemic pain, after failed conservative or surgical treatment. Pedal TcpO(2)on the dorsum of the foot and ankle-pressure Doppler measurements were performed before, and 2 and 4 weeks after implantation.

RESULTS

limb salvage and good pain relief were achieved in 35 patients, while in 12 partial pain relief and limb salvage for at least 6 months were obtained. In 13 patients the method failed and the ischaemic limbs were amputated. Only 3 of the 28 patients with neuropathy had any long-term benefit. Limb salvage was achieved in those patients with a significant increase in TcpO(2)within 2 weeks of stimulation. The stage of the neuropathy was inversely related to the success of SCS therapy. The ankle-brachial pressure index (ABPI) did not change after stimulation.

CONCLUSIONS

diabetic patients with significant increase of TcpO(2)and pain relief during a 2-week test period may be successfully treated by long-term SCS unless they have advanced autonomic neuropathy.

Erythromycin enhances solid-phase gastric emptying in induced-hyperglycemia in patients with truncal vagotomy and pyloroplasty

Erythromycin has been found to be a gastrointestinal prokinetic agent while acute hyperglycemia has been associated with delayed gastric emptying in healthy controls and diabetics. The aim of this study was to investigate whether hyperglycemia, per se, alters gastric motility, during erythromycin-induced acceleration of gastric emptying of solids in patients with truncal vagotomy and pyloroplasty (TVP) and the role of vagus nerves. Eight TVP patients and six controls underwent scintigraphic measurement of gastric emptying of a solid meal, during placebo in normoglycemia (5-8.9 mmol/liter glucose) or 200 mg intravenous erythromycin lactobionate in normo- or hyperglycemia (16-19 mmol/liter glucose) induced by intravenous glucose infusion, on separate days in random order. In the TVP patients during normoglycemia, the erythromycin compared to placebo accelerated the meal gastric half-emptying time (T1/2), (37.12 +/- 6.87 vs 91.88 +/- 11.53, P < 0.001) and decreased the lag-phase duration (P < 0.001) and the percentage of meal retained in the stomach at 120 min (P < 0.001). Erythromycin in hyperglycemia compared to normoglycemia increased T1/2 (61.25 +/- 10.67 vs 37.12 +/- 6.87, P < 0.001), prolonged lag-phase duration (P < 0.001), and the percentage of isotope retained in the stomach at 120 min (P < 0.001). The T1/2, the lag phase duration, and the meal retained in the stomach at 120 min, after giving placebo was significantly increased, compared to erythromycin administration in hyperglycemia (P < 0.001). Significant differences among patients and controls were found during gastric emptying after giving placebo and after erythromycin in hyperglycemia (P = 0.04 and P = 0.007, respectively), while nonsignificant differences were found after giving erythromycin in normoglycemia. We conclude that the effect of erythromycin-induced acceleration on gastric emptying is related to the plasma glucose level. Hyperglycemia reduces the erythromycin-induced acceleration of gastric emptying of solids in both controls and TVP patients. A significant increase in the delay of gastric emptying was achieved in TVP patients compared to controls after giving erythromycin in hyperglycemia and after placebo. Despite the inhibitory effect of induced hyperglycemia on gastric emptying, erythromycin is still able to accelerate the emptying rate and could prove to be a useful prokinetic agent under hyperglycemic conditions. Hyperglycemia may indicate a cholinergic-antagonist pathway that delays the erythromycin-induced acceleration of gastric emptying of solids and is more evident in vagotomized patients than controls, who retain the functional integrity of the vagus nerves.

Prospective study of transcutaneous oxygen tension (TcPO2) measurement in the testing period of spinal cord stimulation in diabetic patients with critical lower limb ischaemia

BACKGROUND

Spinal cord stimulation improves microcirculatory blood flow, relieves diabetic neuropathic and ischaemic pain and reduces the amputation rate in patients with severe peripheral arterial occlusive disease.

AIM

To evaluate whether transcutaneous oxygen tension (TcPO2) measurements can be used as a specific prognostic parameter in the assessment of suitability for permanent device implantation in a prospective controlled study on diabetic patients with peripheral arterial occlusive disease.

METHODS

Sixty patients (39 men, 21 women; mean age: 60 years; range: 46-75) were submitted to implantation of a spinal cord electrical generator for severe peripheral vascular disease, after failed conservative or surgical treatment. The clinical status was classified as Fontaine's stage III and IV and the main pathology was diabetic vascular disease. Pedal TcPO2 was assessed on the dorsum of the foot and ankle and toe pressure Doppler measurements were performed before, two weeks and four weeks after implantation.

RESULTS

Pain relief of over 75% and limb salvage were achieved in 35 diabetic patients, while in 12 a partial success with pain relief over 50% and limb salvage for at least 6 months was obtained. In 13 patients the method failed and the affected limbs were amputated. Clinical improvement and spinal cord stimulation success were associated with increases of TcPO2, within the first two weeks after implantation (temporary period). Limb salvage was achieved with significant increase of TcPO2 within the first two weeks of the testing period (from 21.4 to 31.5 mmHg in rest pain patients, p=0.030, from 15.1 to 22.0 mmHg, p=0.030 in patients with trophic lesions under 3 cm2 in size and in those with trophic lesions over 3 cm2, from 12.1 to 17.9 mmHg, p=0.025) unrelated to the stage of the disease and the initial TcPO2 value. TcPO2 changes were related to the presence of adequate paraesthesias and warmth in the painful area during the trial period. The systolic ankle/brachial blood pressure index and toe pressure did not change under stimulation.

CONCLUSIONS

A two-week testing period should be performed in all diabetic patients treated with spinal cord stimulation for peripheral arterial occlusive disease to identify the candidates for permanent implantation. Only diabetic patients with significant increases of TcPO2 and clinical improvement, during the test period, should be considered for permanent implantation and not merely all patients with pain relief. TcPO2 changes could be used as a predictive index of the therapy success and should be considered in terms of cost effectiveness before the final decision to permanent implantation.

Does autonomic neuropathy influence spinal cord stimulation therapy success in diabetic patients with critical lower limb ischemia?

BACKGROUND

Spinal cord stimulation (SCS) improves microcirculatory blood flow and relieves diabetic neuropathic and ischemic pain, reducing the amputation rate in patients with peripheral arterial occlusive disease (PAOD). The purpose of this study was to evaluate whether the presence of autonomic neuropathy in diabetic patients with PAOD influences the success of SCS therapy.

METHODS

Sixty consecutive diabetic patients (15 with early and 13 with definite and/or combined autonomic neuropathy) with an ankle/brachial systolic pressure index (ABI) less than 0.20 +/- 0.08, underwent spinal cord stimulation after failed conservative or surgical treatment. The neuropathic status of the patients was evaluated before implantation and pedal TcpO2 measurements on the dorsum of the foot were performed.

RESULTS

Limb salvage and pain relief >75%, evaluated with the visual analogue scale, were achieved in 35 patients, whereas in 12 a partial success with pain relief >50% and limb salvage for at least 6 months were obtained. In 13 patients the method failed and the ischemic limbs were amputated. Among the 28 diabetic patients with autonomic neuropathy the treatment failed or resulted in only partial success in 25, whereas in all 32 patients without neuropathy limb salvage and pain relief >75% were achieved (p < 0.0001). Partial success in 10 patients with early neuropathy and in two with definite was achieved (p = 0.008), whereas in 11 patients with definite neuropathy and in two with early the method failed (p < 0.001). The stage of the neuropathy was inversely related to the success of SCS therapy, independent of the stage of the disease. The method's success was related to the presence of adequate paraesthesias and warm feeling in the painful area with size reduction of the trophic lesions.

CONCLUSIONS

Diabetic patients with peripheral arterial occlusive disease presenting with intractable pain may be successfully treated with spinal cord stimulation unless they have associated severe autonomic neuropathy.

Two Different Therapeutic Modalities in the Treatment of the Upper Extremity Deep Vein Thrombosis: Preliminary Investigation With 20 Case Reports

Primary or secondary axillary or/and subclavian vein thrombosis (ASVT) can produce long-term disability, mostly in young patients, while the final vein recanalization after various therapeutic modalities often fails. Our aim was to compare the results of two different therapeutic modalities: the thrombolytic vs anticoagulant therapy, in primary and secondary ASVT in a retrospective data analysis in terms of efficacy, negative side effects, long-term positive results. Eleven patients (Group A), with primary and secondary to central venous cannulation or cardiac pacing ASVT, were treated with anticoagulant therapy, while another 9 patients (Group B), were treated with thrombolytic therapy, that included urokinase or streptokinase for 24-48 hours. The phlebographic, duplex ultrasonographic findings and clinical improvement were compared between the two patient groups. In Group A patients, after a mean period of 81.7 months follow-up (range 58-106), one patient with open vein were noticed, while in Group B patients after a mean follow up period of 52.1 months (range 35-68) five patients presented with recanalized veins (P = 0.040). Complete clinical recovery and vein patency was achieved in one Group A patient, contrary to 5 Group B patients (P = 0.040). When the patients with complete clinical recovery were combined with those who presented some clinical improvement, four Group A patients and eight Group B had satisfactory outcome (P = 0.028). Thrombolytic therapy should be the treatment of choice in primary and secondary ASVT, in productive patients whose lifestyle depends on continued strenuous use of the involved limb with a reasonable medium-term life expectancy. The thrombolytic agents prevent the vein valves damage and malfunction, avoiding re-thrombosis related to venous reflux and stasis, preserving the valve functional integrity.

Spinal cord stimulation in critical limb ischemia of the lower extremities: our experience

BACKGROUND

Spinal cord stimulation (SCS) improves microcirculatory blood flow, relieves ischemic pain and reduces amputation rate in patients with severe peripheral arterial occlusive disease.

AIM

To evaluate the specific prognostic parameters in the prediction of successful SCS and to perform a retrospective data analysis obtained during our patient follow-up.

METHODS

150 patients (97 men, 53 women; mean age: 68 years; range: 46-81) were submitted to implantation of a spinal cord electrical generator for rest pain, and trophic lesions with dry gangrene in severe lower limb ischemia, after failed conservative or surgical treatment. The clinical status was classified as Fontaine's stage III and IV and the main pathology was essentially due to atherosclerosis and diabetic vascular disease. In clinical controls, pedal transcutaneous oxygen tension (TcPO2), ankle and toe pressure Doppler measurements were utilised to select and follow-up the patients.

RESULTS

After a mean follow-up of 71 months (range 24-138), pain relief >75% and limb salvage was achieved in 85 patients. In 28 patients was obtained a partial success with pain relief >50% and limb salvage for at least 6 months, while in 37 patients the method failed or for technical problems the device was removed, and the patients were amputated. TcPO2 was assessed on the dorsum of the foot. Clinical improvement and SCS success was associated with the increasing of TcPO2, before and after implantation (temporary period). Limb salvage was achieved in the patients that presented significant TcPO2 changes within the first 2 weeks of the testing period, indifferent from the stage of the disease, and from the initial TcPO2 value. After long-term patient follow-up TcPO2 changes, from 22.6 to 43.1 mm Hg in these with rest pain (p<0.01), from 16.2 to 36.1 mmHg (p<0.02) in those with trophic lesions <3 cm2, and from 12.4 to 28.1 in the patients with trophic lesions >3 cm2. A TcPO2 increase of more than 50% in the first 2 months after implantation was predictive of success, and was related with the presence of adequate paresthesias in the painful area during the trial period. The systolic ankle/brachial blood pressure index did not change under stimulation.

CONCLUSIONS

In patients with failed conservative and surgical treatment for severe critical lower limb ischemia, the SCS increases the skin blood flow, is associated with a significant pain relief and could be proven an excellent alternative therapy that improves the quality of life. TcPO2 changes, within a test period of 2 weeks, is a predictive index of therapy success and should be considered before the final decision in terms of cost effect, for the permanent implantation.

A simple technique for trocar site closure after laparoscopic surgery

Hernias have been reported to occur at trocar sites and small anterior wall defect has been casually identified during laparoscopic surgery. The aim of this article is to describe a simple, fast, and cheap technique for the safe closure of trocar sites in laparoscopic surgery. Closure is accomplished with a #0# absorbable suture, which is applied in a pursestring manner using 15 gauge spinal cord needle. This procedure is also suitable for the laparoscopic repair of uncomplicated small hernias or fascial defects of the anterior abdominal wall; a mesh prosthesis in case the defect is > cm(2). This technique allows a secure closure of umbilical or fascial defects of the anterior abdominal wall. It is a useful method for large trocar sites closure and is recommended for small uncomplicated hernias or fascial defects of the anterior abdominal wall. In case of > cm(2) defects the technique could be an optimal laparoscopic alternative for patch tension free repair.

Epidural spinal cord electrical stimulation in diabetic critical lower limb ischemia

Spinal cord stimulation (SCS) has been suggested to improve microcirculatory blood flow to relieve ischemic pain and to reduce amputation rate in patients with peripheral arterial occlusive disease (PAOD). The aim of this study was to evaluate the specific prognostic parameters in the prediction of successful SCS, in diabetic patients, performing a retrospective data analysis. To perform this evaluation, 64 diabetic patients (39 men, 25 women; mean age, 69 years) classified as Fontaine's stage III and IV, with PAOD, were treated with SCS for rest pain and trophic lesions with dry gangrene, after failed conservative or surgical treatment. In clinical controls, pedal transcutaneous oxygen tension (TcPO(2)), ankle/brachial blood pressure index (ABI), and toe pressure Doppler measurements were utilized to select and follow-up the patients. After 58 months of follow-up (range, 20-128 months), pain relief greater than 75% and limb salvage were achieved in 38 diabetic patients. A partial success was obtained in nine patients with pain relief greater than 50% and limb salvage for at least 6 months. The method failed in 17 patients or the device was removed due to technical problems, and the limb was amputated in these patients. TcPO(2) was assessed on the dorsum of the foot. Clinical improvement and SCS success were associated with increase of TcPO(2), before and after implantation. Limb salvage was achieved in the patients who had significant TcPO(2) increase within the 2 weeks of the testing period, independently of the stage of the disease. A TcPO(2) increase of more than 50% in the first 2 months after implantation was predictive of success, and was related to the presence of adequate paresthesias in the painful area during the trial period. TcPO(2) significantly increased after long-term follow-up in all patients with limb salvage (from 22.1 to 43.1 mm Hg in the rest pain patients, from 15.8 to 36.4 mm Hg in those with trophic lesions of less than 3 cm(2), and from 12.1 to 28.1 in those with trophic lesions of greater than 3 cm(2), (p < 0.01). ABI did not changed under stimulation. In diabetic patients with PAOD, the SCS increases the skin blood flow, is associated with significant pain relief, and could be proven an excellent alternative therapy, improving the life quality. Significant TcPO(2) increase within the 2-week test period, is a predictive index of therapy success and should be considered before the final decision in terms of cost effectiveness, before the permanent implantation.

[Carotid body tumors. Apropos a case and a review of the literature]

Chemodectomas are rare tumors arising from paraganglionic cells located at the level of carotid bifurcation. They are usually benign and non functioning, presenting as a slow growing cervical mass. A preoperative diagnosis is mandatory, based on doppler color flow imaging and angiography. Surgery is the only therapy providing total eradication of this tumor. Subadventitial resection is the most established technique, although resection of a large mass may require carotid replacement by interposition graft. Cranial nerve palsy and stroke are the perioperative complications most frequently encountered. The Authors report here a case of carotid body tumor and a review of the literature in order to define clinical characteristics of the tumor and proper diagnostic and therapeutic approaches to this rare neoplasm.

Hyperglycaemia attenuates erythromycin-induced acceleration of solid-phase gastric emptying in idiopathic and diabetic gastroparesis

BACKGROUND

Erythromycin has recently been found to be a gastrointestinal prokinetic agent in humans. Acute hyperglycaemia has been associated with delayed gastric emptying in both healthy controls and diabetic patients. Our aim was to investigate in gastroparetic patients (diabetics and idiopathics) whether hyperglycaemia, per se, reduces gastric motility during erythromycin-induced acceleration of gastric emptying of solids.

METHODS

In 12 gastroparetic patients, 6 diabetics and 6 idiopathics, gastric emptying of solids was measured scintigraphically after giving placebo in normoglycaemia (5-8.9 mmol/l glucose) or 200 mg erythromycin lactobionate intravenously in normo- or hyperglycaemia (16-19 mmol/l glucose) induced by intravenous glucose infusion in random order on separate days.

RESULTS

Erythromycin in normoglycaemia accelerated solids gastric emptying compared with placebo in all patients by abolishing the lag-phase duration and by decreasing the retained percentage of a meal in the stomach at 120 and 150 min (14.5% +/- 5.3% versus 88.4% +/- 10.6% and 3.5% +/- 2.1% versus 70.1% +/- 15.4%, respectively) (P < 0.001). The retained isotopic percentage in the stomach after erythromycin in induced hyperglycaemia compared with erythromycin in normoglycaemia, at 120 and 150 min, was increased (51.9% +/- 9.8% versus 14.5% +/- 5.3%, and 24.5% +/- 5.9% versus 3.5% +/- 2.1%, respectively) (P < 0.001) but was decreased in comparison with placebo (P < 0.001). A significantly increased percentage of isotope was retained in the stomach of the diabetic patients at 120 and 150 min, compared with the idiopathics, only after giving erythromycin in the hyperglycaemic condition (57.6% +/- 8.7% versus 46.1% +/- 7.6% (P = 0.036) and 27.8% +/- 5.7% versus 21.1 +/- 4.4% (P = 0.040), respectively).

CONCLUSIONS

Hyperglycaemia attenuates erythromycin-induced acceleration of solid-phase gastric emptying in idiopathic and diabetic gastroparesis and increases the retained isotopic meal in the stomach. Hyperglycaemia reduces gastric motility more in the diabetic patients with gastroparesis than in idiopathic patients.

Transcutaneous oxygen tension (TcPO2) in the testing period of spinal cord stimulation (SCS) in critical limb ischemia of the lower extremities

BACKGROUND

Spinal cord stimulation (SCS) improves microcirculatory blood flow, relieves ischemic pain and reduces amputation rate in patients with severe peripheral arterial occlusive disease.

AIM

To evaluate the transcutaneous oxygen tension (TcPO2) measurements as a specific prognostic parameter in the prediction for permanent device implantation in a prospective controlled study in patients with lower limb ischemia.

METHODS

45 patients (35 men, 10 women; mean age 65 years, range: 46-70 years) were submitted to implantation of a spinal cord electrical generator for rest pain, trophic lesions dry gangrene in severe lower limb ischemia, after failed conservative or surgical treatment. The clinical status was classified as Fontaine's stages III and IV and the main pathology was essentially due to atherosclerosis and diabetic vascular disease. Pedal transcutaneous oxygen tension (TcPO2), ankle and toe pressure Doppler measurements were performed before, 2 weeks and 4 weeks after implantation.

RESULTS

After 18 months follow-up, pain relief was > 75% and limb salvage was achieved in 26 patients. In 9 patients, a partial success with pain relief > 50% and limb salvage was obtained for at least 6 months. In 10 patients, the method failed, and the patients' limbs were amputated. TcPO2 was assessed on the dorsum of the foot. Clinical improvement and SCS success was associated with an increase of TcPO2, within the first 2 weeks after implantation (temporary period). Limb salvage was achieved in those patients who presented significant TcPO2 increase within the first 2 weeks of the testing period (from 21.6 mmHg to 29.5 mmHg in the patients with rest pain, P = 0.035, from 15.2 mmHg to 21.1 mmHg, P = 0.035 in those with trophic lesions < 3 cm2, and in those with trophic lesions > 3 cm2, from 12.4 mmHg to 17.3 mmHg) independently of the stage of the disease and of the initial TcPO2 value. TcPO2 changes were related to the presence of adequate paresthesias and warmth in the painful area during the trial period. The systolic ankle/brachial blood pressure index did not change under stimulation.

CONCLUSIONS

In patients with failed conservative and surgical treatment for severe critical lower limb ischemia, the SCS increases the skin blood flow, is associated with a significant pain relief and could prove an excellent alternative therapy that improves the quality of life. We also demonstrate that TcPO2 increase within a test period of 2 weeks, is a predictive index of SCS therapy success and should be considered in terms of cost effect before the final decision for permanent implantation.

Iliorenal bypass for the treatment of type-3 Takayasu's disease. A case report with 10-year follow-up

The case of a 16-year old female with severe renovascular hypertension resulting from type-3 Takayasu's arteritis is reported. The entire thoracic and abdominal aorta was affected by an active inflammatory process and all its branches were stenotic or occluded. After the early failure of a percutaneous balloon angioplasty of the left renal artery, an iliac to renal artery bypass graft using a reversed autologous saphenous vein was performed through a retroperitoneal tunnel The patient is asymptomatic and the graft is patent at 10-year follow-up.

Separate sac of peritoneum: a case of an unusual cause of intestinal obstruction

Internal hernia is a rare condition. These hernias are classified in different categories, depending on the location of its orifice. It should be considered in cases of acute intestinal obstruction, particularly in the absence of an external hernia or in the absence of history of previous abdominal surgery. The authors report a unique case of obstruction of the small bowel, that was almost entirely wrapped in a separate peritoneal sac.

Spinal cord stimulation in vibration white finger

The authors report a case of vibration white finger syndrome in a 51-year old male, pneumatic drill worker. The patient complained of severe pain in the I, II, III and IV right fingers related to acral ischemic lesions. Dried skin with desquamation, tingling, paraesthesia and loss of sensation were present in both hands. Several arterial obstructions on forearm, hand and fingers were evident bilaterally at the angiography. Medical treatment, including administration of calcium-channel blockers, pentoxifylline and intravenous prostaglandin therapy, was unsuccessful. Under local anaesthesia an epidural spinal cord cervical electrode was implanted to control pain and ameliorate local microcirculatory conditions. The clinical result was excellent with the disappearance of symptoms and healing of acral lesions in a few weeks. Epidural spinal cord electrical stimulation represents an excellent technique for treatment in secondary Raynaud phenomenon related to vibration white finger syndrome.

Natural history of entrapment of the popliteal artery

Popliteal artery entrapment (PAE) is described with increasing frequency. Reviewing the world literature and corresponding with some investigators, we were able to collect 375 instances in 291 patients, including our personal experience (33 instances in 24 patients). The present study was done to establish the natural history and evolution of PAE. Two groups of patients were created to verify if an early diagnosis and treatment of PAE is justified. Group 1 included 129 patients treated by a simple musculotendinous section. In group 2, 226 patients were treated by a vascular procedure (bypass, thromboendarterectomy, other). Age, symptoms and arteriographic findings were the parameters considered in the two groups. Results demonstrated that patients in group 1 are younger than those in group 2 (p < 0.001). Preoperative symptoms demonstrated a larger number of mild symptoms (paresthesias, a cold foot and cramping after intensive physical training) in group 1, when compared with group 2 (p < 0.001). Arteriography demonstrated a larger number of patients with normal findings at rest, with popliteal stenosis or occlusion during maneuver, in group 1 than in group 2 (p < 0.001). PAE results in progressive arterial impairment. Early noninvasive screening is mandatory to detect PAE at an early stage. Surgical treatment is thereby limited to a musculotendinous section, which has the best results.

Cystic adventitial degeneration of the popliteal artery: lectin-histochemical study

A case of cystic adventitial degeneration (CAD) of the popliteal artery is presented. Histologically the cyst appeared localised in the adventitia, outside the elastic lamina. A lectin-histochemical study evaluated the following peroxidase conjugated lectins: Peanut agglutinin, Concanavalin A, Ulex Europaeus (UEA I) and Wheat Germ Agglutinin. The lack of UEA I reactivity excluded an arterial origin of the cyst. Moreover, the lectin binding pattern of CAD appeared to be similar to the reactivity pattern of normal synovia.

Clinical results of epidural spinal cord electrical stimulation in patients affected with limb-threatening chronic arterial obstructive disease

Between 1982 and 1990, 76 patients (33 women, 43 men, mean age 71.4 +/- 10 years) affected with limb-threatening peripheral vascular disease (claudication < 20 m: 3 patients; rest pain: 10 patients; necrosis1 smaller than 3 cm2: 28 patients; necrosis2 larger than 3 cm2: 35 patients) not amenable to medical and/or surgical therapy, were treated by epidural spinal cord electrical stimulation (ESES). Effectiveness of ESES was evaluated by consideration of pain control, walking distance, and healing of ischemic lesions. At a mean follow-up of twenty-six months (range: one to seventy-six) 44 limbs (58%) were amputated (rest pain 2; necrosis1 13; necrosis2 29) and 39% of necrotic lesions smaller than 3 cm2 healed. The overall limb salvage rate was 42%. Pain control was obtained in 80% of patients at the one-year and 75% at the two-year follow-up, with infrequent use of pain relievers. Despite the poor clinical results observed, the limb salvage rate testifies to the effectiveness of ESES in limb-threatening ischemia. Moreover, the authors noticed a good ESES effect on pain relief, maximal in the early and intermediate postimplant periods. In conclusion ESES must be considered the last resort in peripheral vascular disease in patients in whom medical and/or surgical therapies are ineffective or impossible. Necrotic lesions larger than 3 cm2 contraindicate, in their opinion, ESES implant.

[Mayer-Rokitansky syndrome. Case report]

Uterine anomalies associated with congenital renal agenesis and skeletal abnormalities represent an uncommon pathology that often presents important diagnostic problems. A case of Mayer-Rokitansky syndrome is reported. The embryologic, clinical, pathologic and therapeutic implications of this disease are briefly discussed.

Evaluation of venous flow by light reflection rheography (LRR) in athletes performing track race

The venous flow physiology in the athletes represents an interesting research field of sports angiology. The frequent observation of phlebectasias and/or varicose veins in athletes incited us to investigate the venous pathophysiological mechanisms predisposing them to such diseases. The maximal venous outflow (Rmax in millivolts) and the 1/2 venous refilling time (1/2 VRT in seconds) were evaluated in track racers, at rest and after exercise, by means of the light reflexion rheography (LRR). Thirty-two athletes (16 males, 16 females; mean age 23.4 years, range 15-37) were studied, dividing them in three groups: (A) 100 m (13), (B) 2,000 m (13), (C) 6 x 100 m with 2 minute recovery time (6). Among them six athletes performed the test wearing elastic compression stockings (25-32 mmHg). The results demonstrated a significant post-exercise modification of LRR curves and parameters in all groups, testifying superficial venous flow augmentation and deep venous flow overloading.

Diagnosis of popliteal artery entrapment syndrome: the role of duplex scanning

The authors present a new diagnostic procedure to quickly and noninvasively diagnose the popliteal artery entrapment syndrome. A large personal experience on the surgical treatment of such a disease (29 cases in 22 patients) allowed us to focus on the optimal diagnostic procedure useful to detect this problem at an early stage. The technique is based on continuous-wave Doppler and duplex scanning studies done both in the resting state and during active contraction of the calf muscles. If compression of the popliteal artery occurs with contraction of the calf muscles, it will be detected by a decrease in flow. This finding will also direct the radiologist to obtain films when the maneuver is repeated. This makes it unlikely that the diagnosis will be missed. Since July 1988 a total of 1212 patients were evaluated with continuous-wave Doppler for suspected chronic ischemia. From this group 41 patients were selected to be studied again with the combined continuous-wave Doppler and duplex scanning method for possible popliteal artery entrapment syndrome. Two cases were discovered and verified by dynamic angiography guided by continuous-wave Doppler and treated surgically.

Surgical treatment of popliteal artery entrapment syndrome: a ten-year experience

Popliteal artery entrapment syndrome is increasingly described in the world literature as a cause of lower limb arterial impairment. It is caused by the anomalous interrelationship between the popliteal artery and its surrounding muscular and/or tendineous structures. The first case surgically treated was reported in 1959 and since then more than 300 cases have been reported including our personal experience (31 cases in 23 patients). We have treated surgically 19 males and four females with symptoms which were moderate (cramping after intensive physical training, paraesthesia, etc.) in 14 limbs, intermittent claudication in 16 and necrosis (first toe) in one. Preoperative arteriography showed arterial occlusion in eight limbs, stenosis in eight and aneurysms in two. In 11 limbs stenosis or occlusion was only shown after active plantar hyperextension and in two arteriography was not done because surgical indications were established on the basis of a venogram positive for popliteal vein entrapment syndrome. Ten different anatomical variants were seen and the medial head of gastrocnemius muscle was involved in 74.2%. Surgical treatment consisted of division of the aberrant musculotendinous tissue in 18 cases (in two of these balloon angioplasty was also used). In 12 cases a vascular reconstruction was also required, while one case was explored without a specific procedure being warranted. Optimal results were obtained when the syndrome was treated at an early stage by simple division of musculotendinous tissue (94.4% long-term patency rate, mean follow-up 46.0 months, min 2, max 120 months). When arterial grafting was required the long-term patency rate was only 58.3% (mean follow-up 43.5 months, min 1, max 100 months).(ABSTRACT TRUNCATED AT 250 WORDS)

Magnetic resonance imaging of abdominal aortic grafts

The widespread use of abdominal aortic grafting procedures and increasing awareness of related complications suggests the need for a reliable and non-invasive diagnostic technique which will allow early detection of both occlusive and non-occlusive complications. Ultrasound is generally used with satisfactory results, but has several limitations, whereas MRI has shown great promise in the study of cardiovascular disease, being non-invasive, multiplanar and multiparametric. The present research aims to evaluate MRI in the follow-up of abdominal aortic grafts, attempting to define its significance as a screening procedure in non-selected patients. MRI is reliable in ascertaining the normality of the graft as well as the complications, these being partial or total thrombosis, pseudoaneurysms and perigraft collections. The data obtained are highly satisfactory and are almost always superior to those achieved with ultrasound and CT.

The effect of body weight compression on axillo-femoral by-pass patency

The influence of external compression on extra-anatomic bypass patency is still debated. The specific purpose of this study is the evaluation of ankle Pressure Index (P.I.) and Pulse Volume Recorder (P.V.R.) wave amplitude changes after 5 and 10 minutes of external bypass compression by body weight, lying on the side of the reconstruction. Eight patients with axillo-femoral bypass (mean follow-up 15.5 months) have been evaluated. The external body weight compression caused important changes of graft haemodynamics: (1) decrease in ankle Pressure Index at 5 min (p less than 0.005) or 10 min (p less than 0.0005); (2) decrease in P.V.R. wave amplitude at 5 min (p less than 0.005) and 10 min (p less than 0.025).

[Hemorheologic, metabolic and blood coagulation changes in diabetics in treatment with sulfanyl ureas]

A study was carried out to see if chronic treatment with a sulphanylurea with hypoglycaemic action, with also haemoactive action in terms of anti-platelet aggregation, profibrinolytic and antifibrinogenetic action also acted haemorheologically. For this purpose a group of patients treated with Gliclazide was compared with a group under treatment with Glibenclamide. A significant variation was noted in terms of an increase in erythrocyte filtrability and a diminution in erythrocyte aggregation with diminution in blood viscosity at low shear-rates. The absence of parallel modifications in quantitative corpuscular viscous factors, the early onset of the process, the real diminution in the sense of a reduction below the range of normality suggests that the effect is pharmacological and not mediated by metabolic compensation.

[Hemorheology and acute in vivo changes in non-viscous serum factors]

During research into a real model permitting study of the rheological effect of serum constituents without viscous power, the viscous features of blood and plasma and erythrocyte deformability and aggregability were evaluated before and after dialysis in relation to variables acutely modified by therapy. Interdependence with certain serum factors often considered responsible for rheological changes in various pathologies after maximum alteration and, in the short term in the same subject, under normal conditions were controlled.

[Presentation of a method of interpreting erythrocyte deformability]

The physical principles of a method based on a haematic double filtration, according to Reid classic technique is explained. The aim is to determine a method for researching the characteristics of erythrocytic deformability, without changing the original medium, exoerythrocytic essential component of the membrane physiochemical quality and intraerythrocytic for the fast, active exchanges, after an evaluation of different techniques and instrumentation. A practical example for calculating the factor of correction, with reference to personal material, is made. This method has the advantage that it does not need the manipulation of the sample and does not delay the determination.