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Chronic venous disease (CVD) and its most frightening complication, chronic venous ulceration (CVU), represent an important socioeconomic burden in the western world. Metalloproteinases have been identified in the pathogenesis of several vascular diseases such as venous problems. The aim of this study was to evaluate a broad range of metalloproteinases, such as matrix metalloproteinases (MMPs), ADAMs (a disintegrin and metalloproteinases) and ADAMTSs (a disintegrin and metalloproteinases with thrombospondin motifs) and their inhibitors, tissue inhibitor of metalloproteinases (TIMPs) and a related protein, neutrophil gelatinase‐associated lipocalin (NGAL), in patients with CVD in order to correlate their serum levels with each stage of the disease. We performed a multicenter open‐label study that comprised the enrolment of 541 patients with CVD of clinical stages C1–C6, (178 males, 363 females; mean age 57·29, median age 53·72, age range 29–81); 29 subjects without CVD were included in this study (9 males and 20 females; mean age 54·44, median age 50, age range 28–84) as the control group. Enzyme‐linked immunosorbent assay (ELISA) was performed for measuring serum levels of proteases and related proteins. The study found that the serum elevation of MMP‐2, ADAMTS‐1 and ADAMTS‐7 appeared to be correlated with the initial stages of CVD, whereas the serum elevation of MMP‐1, MMP‐8, MMP‐9, NGAL, ADAM‐10, ADAM‐17 and ADAMTS‐4 was particularly involved in skin change complications. This study showed that each stage of CVD may be described by particular patterns of metalloproteinases, and this may have therapeutic implications in discovering new targets and new drugs for the treatment of CVD.

Chronic leg ulcers (CLUs) are a common occurrence in the western population and are associated with a negative impact on the quality of life of patients. They also cause a substantial burden on the health budget. The pathogenesis of leg ulceration is quite heterogeneous, and chronic venous ulceration (CVU) is the most common manifestation representing the main complication of chronic venous disease (CVD). Prevention strategies and early identification of the risk represent the best form of management. Fuzzy logic is a flexible mathematical system that has proved to be a powerful tool for decision-making systems and pattern classification systems in medicine. In this study, we have elaborated a computerised prediction system for chronic leg ulcers (PredyCLU) based on fuzzy logic, which was retrospectively applied on a multicentre population of 77 patients with CVD. This evaluation system produced reliable risk score patterns and served effectively as a stratification risk tool in patients with CVD who were at the risk of developing CVUs.

The aim of this study is to report our experience about the treatment of complex sternal and thoracic wounds following cardiothoracic surgery, using vacuum-assisted closure (VAC therapy. Twelve patients presenting with sternal (five cases) and thoracic (seven cases) wounds that were difficult to heal were treated through VAC therapy after the first surgical debridement. The duration of VAC application ranged from 12 to 36 days with an average hospital stay of 24·6 ± 11·4 days. During a mean follow-up of 12 months, we observed complete wound healing in seven cases (58·3%), in an average period of 25·5 ± 14·3 days; one patient died during follow-up, two patients were lost to follow-up and two patients required definitive surgical closure of the wound cavity. In conclusion, VAC therapy promotes faster wound healing, with shorter hospital stay and subsequent lesser in-hospital cost, reducing the mortality rate in the long run. It also promotes early rehabilitation and alleviates the need for a second procedure, thus improving patient satisfaction, with minimal discomfort or inconvenience.

Foot ulcers are frequent in diabetic patients and are responsible for 85% of amputations, especially in the presence of infection. The diagnosis of diabetic foot ulcer infection is essentially based on clinical evaluation, but laboratory parameters such as erythrocyte sedimentation rate (ESR), white blood count (WBC), C‐reactive protein (CRP) and, more recently, procalcitonin (PCT) could aid the diagnosis, especially when clinical signs are misleading. Fifteen diabetic patients with infected foot ulcers were admitted to our department and were compared with an additional group of patients with non‐infected diabetic foot ulcers (NIDFUs). Blood samples were collected from all patients in order to evaluate laboratory markers. In the current study, the diagnostic accuracy of PCT serum levels was evaluated in comparison with other inflammatory markers such as CRP, ESR and WBC as an indicator to make the distinction between infected diabetic foot ulcers (IDFUs) and NIDFUs. CRP, WBC, ESR and especially PCT measurements represent effective biomarkers in the diagnosis of foot infections in diabetic patients particularly when clinical signs are misleading.

Management of vascular traumas is frequently delayed. Vascular injuries after elective operation for bone lengthening or correction of a deformity are very'rare situations. We describe 3 cases. Case 1: male, aged 22, undergoing corticotomy for bone lengthening; immediately presented acute limb ischaemia due to a partial lesion of the popliteal artery, documented by U.S. After 7 h, direct reconstruction of the artery and fasciotomies were performed. Case 2: male, aged 27, undergoing directional osteotomy for genu varus correction. For 30 days, constant increase in leg volume and decrease in function. US showed an important haematoma at the popliteal level; arteriography documented a partial lesion of the infra-genicular popliteal artery and a voluminous false aneurysm. Direct correction of the artery and fasciotomies were performed. Case 3: male, aged 22, undergoing corticotomy for leg lengthening; immediately presented leg pain with decreased distal pulses. After 4h, there was an increase in leg volume, and arteriography showed a total lesion of the infra-genicular popliteal artery and an arteriovenous fistula. Popliteo-tibial bypass with the contralateral greater saphenous vein and fasciotomies were performed. After 1 month endovascular closure of the fistula was obtained. All patients had recovered after two months with only minor leg insufficiency. Patency of the bypass and absence of infections or delayed false aneurysms were achieved. Vascular injuries after elective orthopaedic procedures are very rare situations. Such lesions are caused by an osteotomy via corticotomy performed percutaneously. The variety of clinical presentations accounts for the difficulty in diagnosing such lesions and for the delays in implementing treatment. It is very important to obtain an early diagnosis complete with an arteriography.

The aim of this study was to evaluate the accuracy and sensitivity of colour Doppler ultrasonography for the diagnosis of postoperative recurrent varicose veins in patients submitted to surgical ligation of the saphenofemoral junction with a view to classifying the recurrences according to the causes. We studied 401 lower limbs in the orthostatic position with colour Doppler ultrasonography in 318 patients (64 M and 254 F) presenting postoperative varicose vein recurrence during the follow-up (12-60 months). We evaluated the type of reflux at the inguinal level under the Valsalva manoeuvre and divided them into 5 types. We observed an incomplete crossectomy (type 1) in 23.2% of the cases; an incontinent saphenofemoral junction, intact and in an anatomical site in 12.5% (type 2); a major tributary (double saphena) originating from the common femoral vein near to the crossectomy site in 10.2% (type 3); neovascularization in 9.7% (type 4) and the presence of a number of major tributaries from the veins of the perineal and pudendal region or from the abdominal parietal veins in 44.4% (type 5). In all cases it was possible to note and classify the type of recurrence. Colour Doppler ultrasonography is an accurate, reliable tool for the diagnosis and classification of postoperative varicose vein recurrences in patients submitted to surgical obliteration of the saphenofemoral junction. It is decisive in the preoperative evaluation and follow-up of patients. In our experience, more than one half of the cases of recurrence were not due to an error of surgical technique.

The aim of the study was to evaluate the possibility of reducing the blood loss during elective surgery for abdominal aortic aneurysms using particular intraoperative surgical expedients. From 1993 to 1999, 200 patients were recruited into the study. We performed 90 aorto-aortic, 84 aorto-bisiliac, 4 aorto-iliac-femoral, 12 aorto-bisiliac-hypogastric, and 10 aorto-bifemoral reconstructions. Several surgical techniques were used and are described in detail. The mortality rate was 3.5%. Haemoglobinaemia 24 hours after the operation had decreased by 2.5 +/- 0.9 g/dl. In 67% of cases the estimated blood loss was lower than 300 ml. There were no transfusions in 44% of cases, and autologous transfusions in 17%. The average estimated blood loss was 350 ml, with mean reinfusion of 0.98 blood units. Our study suggests the possibility (44%) of avoiding the use of blood transfusions thanks to intraoperative blood saving by means of particular surgical techniques.

Made available in DSpace on 2022-04-28T19:47:00Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-10-01 Introduction: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection. Methods: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed. Results: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01) Conclusion: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material. University Hospitals Cleveland Medical Center Case Western Reserve University School of Medicine the Ronald Reagan UCLA Medical Center University of California Los Angeles SSM Healthcare Semmelweis University Keck School of Medicine University of Southern California University of North Carolina School of Medicine University of Arizona the Indiana University Health Physicians Vascular Surgery Michigan Medicine University of Michigan University Heart Center Hamburg University Medical Center Hamburg-Eppendorf Penn State Heart and Vascular Institute Milton S. Hershey Medical Center Johns Hopkins Hospital The Heart Hospital Baylor Plano the Cardiovascular Surgery Clinic University of Messina National & Kapodistrian University of Athens University of Patras Keio University University of Pennsylvania Vancouver General Hospital & University of British Columbia Mayo Clinic Christiana Health System University of Chicago Harborview Medical Center University of Washington Washington University Stanford University CHU de Poitiers Baylor College of Medicine MedStar Georgetown University Hospital SSM Health St. Louis University Faculdade de Medicina de Botucatu-Unesp Beth Israel Deaconness Medical Center Brigham and Women's Hospital St. Joseph's Hospital Massachusetts General Hospital Robert Wood Johnson Medical School Rutgers University Vita-Salute University School of Medicine San Raffaele Scientific Institute Kaiser Permanente University Heart Center Freiburg-Bad Krozingen Freiburg University of Virginia Medical Center University of Siena Kyung Hee University Gustave Dron Hospital Centro Hospitalar de Lisboa Norte Wexner Medical Center Ohio State University Uppsala University University Hospital of Trieste University Hospital of Verona University Hospital of Padova University of Alabama University of California Davis University of Florida Michael E. DeBakey Department of Surgery Baylor College of Medicine University Hospital University of Missouri Faculdade de Medicina de Botucatu-Unesp

The optimal revascularization modality in secondary aortoenteric fistula (SAEF) remains unclear in the literature. The purpose of this investigation was to determine the revascularization approach associated with the lowest morbidity and mortality using real-world data in patients with SAEF.A retrospective, multi-institutional study of SAEF from 2002 to 2014 was performed using a standardized database. Baseline demographics, comorbidities, and operative and postoperative variables were recorded. The primary outcome was long-term mortality. Descriptive statistics, Kaplan-Meier survival analysis, and univariate and multivariate analyses were performed.During the study period, 182 patients at 34 institutions from 11 countries presented with SAEF (median age, 72 years; 79% male). The initial aortic procedures that resulted in SAEF were 138 surgical grafts (76%) and 42 endografts (23%), with 2 unknown; 102 of the SAEFs (56%) underwent complete excision of infected aortic graft material, followed by in situ (in-line) bypass (ISB), including antibiotic-soaked prosthetic graft (53), autogenous femoral vein (neoaortoiliac surgery; 17), cryopreserved allograft (28), and untreated prosthetic grafts (4). There were 80 patients (44%) who underwent extra-anatomic bypass (EAB) with infected graft excision. Overall median Kaplan-Meier estimated survival was 319 days (interquartile range, 20-2410 days). Stratified by EAB vs ISB, there was no significant difference in Kaplan-Meier estimated survival (P = .82). In comparing EAB vs ISB, EAB patients were older (74 vs 70 years; P = .01), had less operative hemorrhage (1200 mL vs 2000 mL; P = .04), were more likely to initiate dialysis within 30 days postoperatively (15% vs 5%; P = .02), and were less likely to experience aorta-related hemorrhage within 30 days postoperatively (3% aortic stump dehiscence vs 11% anastomotic rupture; P = .03). There were otherwise no significant differences in presentation, comorbidities, and intraoperative or postoperative variables. Multivariable Cox regression showed that the duration of antibiotic use (hazard ratio, 0.92; 95% confidence interval, 0.86-0.98; P = .01) and rifampin use at time of discharge (hazard ratio, 0.20; 95% confidence interval, 0.05-0.86; P = .03) independently decreased mortality.These data suggest that ISB does not offer a survival advantage compared with EAB and does not decrease the risk of postoperative aorta-related hemorrhage. After repair, 50% of SAEF patients survive 10 months. Each week of antibiotic use decreases mortality by 8%. Further study with risk modeling is imperative for this population.

The mainstay of treatment of chronic venous ulceration (CVU), as also suggested by current treatment guidelines for chronic venous disease (CVD), is represented by surgery and compression therapy for which there is strong evidence of their role in clinically relevant improvement in wound healing and also in the reduction of CVU recurrence, but no information is available as to whether or not these treatments provide effective protection from the onset of CVU. In our study, we have followed, for a median time of 13 years, a total of 3947 patients with CVD at classes C2-C3 of CEAP classification, treated with our treatment protocol (surgery and compression therapy) in order to track the natural history of these patients with regards to CVU development. We identified four groups of patients: 2354 patients (59·64%) (Group A) fully adherent to protocols; 848 patients (21·48%) (Group B) fully adherent to surgery and non-compliant to compression therapy; 432 patients (10·95%) (Group C) fully adherent to compression therapy and non-compliant to surgery; and 313 patients (7·93%) (Group D) non-compliant to either treatments. Regardless of compliance to treatments, the ulcer development rates were very similar between groups (range: 3·23-4.79%), with no statistical significance (P = 0·1522). Currents treatments used in the early stages of CVD appear to have no effects to progression to CVU. Additional longitudinal studies are required to confirm these findings.