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[en] This study was designed to report our experience with 'cutting' balloon angioplasty (CBA) for the treatment of short femoral bifurcation arterial stenosis. Between March 2005 and September 2007, 18 consecutive patients who were high-risk for surgery with critical limb ischemia or severe lifestyle-limiting claudication underwent 'cutting' balloon angioplasty (4-6 mm diameter/15-20-mm length) for the treatment of 27 focal (<3 cm) severe fibro-calcified stenosis of the common femoral artery (n = 14) and/or the proximal part of the superficial femoral artery (n = 6) or profunda femoris (n = 7). Baseline patient demographic data, pre- and post-procedural patient clinical data, and procedural results were recorded. Follow-up consisted of clinical check-up and color duplex ultrasonography (CDU) examination 1, 3, 6, 12, and 18 months after the procedure. All endovascular treatments were successfully performed with clinical success obtained for all patients. No complications occurred during all treatments and no patient required surgical conversion or placement of a stent because of recoil, dissection, or arterial tears. No acute vessel closure was registered. During a mean follow-up of 9.4 (range, 6-18) months, endovascular treatment (CBA) was performed for restenosis/occlusion of seven lesions (25.9%) in four patients, whereas surgical treatment (endarterectomy with patch) for restenosis/occlusion of three lesions (11.1%) was performed in two patients with a consequent reintervention rate of 37%. Primary and secondary patency rates were 84.6 and 88.4% at 6 months and 57.9 and 79.6% at 12 months, respectively. No major limb amputation was performed, with a 12-month limb salvage rate of 88.9%. CBA seems to be a valuable tool for the endovascular treatment of focal femoral bifurcation stenotic lesions for patients who are poor candidates for surgery.
[en] Enterolith formation is a rare cause of afferent limb obstruction following Billroth II gastrectomy and Roux-en-Y hepaticojejunostomy surgery. A case of ascending cholangitis caused by an enterolith incarcerated in the afferent loop of a 15-year-old Roux-en-Y hepaticojejunostomy was emergently decompressed under direct ultrasound guidance prior to surgery. This is the thirteenth reported case of an enterolith causing afferent loop obstruction. A discussion of our management approach and a review of the relevant literature are presented.
[en] A hyperfractionated radiotherapy schedule has been evaluated in the treatment of 29 adults with limb or limb girdle soft tissue sarcomas. The objective was to increase the total administered dose and possibly improve local control, without increasing late normal tissue damage. Twice daily 1.25 Gy fractions (with a minimum interval of 6 h) have been given over 5-6 weeks to 12 patients pre-operatively, 10 post operatively and 7 palliatively. Nineteen of the remaining 21 patients received 75 Gy in 6 weeks with a field size reduction after 5 weeks. 16/29 tumors were situated in the thigh and only 2 in the upper limb. Twenty were of high grade. The mean tumor size of those treated radically was 13.1cm (range 5-40cm). Sixteen patients (76 percent) given 75 Gy developed moderate or severe skin erythema maximal at 5 weeks. Despite the large field sizes used (mean phase I of 34.5cm, and phase II of 22.8cm) only 2 patients failed to complete planned treatment because of the severity of these reactions. Two other patients developed partial wound breakdown after the end of treatment - both healing spontaneously. Fourteen patients developed an area of moist desquamation - 11 mild, 2 moderate and 1 severe. There have been 4 late wound breakdowns requiring surgical intervention; all have since healed well. Median follow-up is short at 556 days. 10/19 evaluable patients developed moderate/severe induration, 5/19 mild and 4/19 none. There has been 1 local failure associated with regional node involvement and lung metastases. Although it was feasible to deliver the planned very high doses to these patients by the use of hyperfractionation, early results suggest that late damage caused by this regime is greater than that from standard once daily 2 Gy fractionation to a total dose of 60 Gy in 6 weeks. A lower dose per fraction is now being evaluated. (author). 42 refs.; 3 figs.; 8 tabs
[en] Popliteal venous aneurysm is a rare cause of recurrent pulmonary embolism, although the true incidence of aneurysm is probably underestimated. One-third of patients suffer further embolic events despite therapeutic anticoagulation. We report the case of a 59-year-old male who presented with recurrent PEs over a period of 12 years despite anticoagulation therapy. A thrombophilia screen and abdominal ultrasound were normal at that time. He reattended with recurrent pulmonary emboli, left calf swelling, and a mass in his left popliteal fossa causing limitation of knee movement. Venous duplex and MRI of his popliteal fossa demonstrated a thrombosed true popliteal venous aneurysm with popliteal and superficial femoral vein occlusion. In view of the mass effect we proceeded to surgical excision of his aneurysm after prophylactic placement of an IVC filter. The patient regained normal knee function with intensive inpatient physiotherapy. He has been recommenced on lifelong anticoagulant. The presentation, investigation, and management of the condition are briefly discussed. We suggest that a bilateral lower limb duplex is performed to exclude venous aneurysm in all patients presenting with pulmonary embolism in which an underlying source cannot otherwise be identified and no thrombophilic tendency is detected.
[en] Excellent results with small stents in coronary arteries have led endovascular therapists to their use in infrapopliteal vessels. However, to date no level I evidence exists to recommend primary stenting over infrapopliteal angioplasty alone. The aim of this randomized single-center trial was to compare their 1-year outcome. A total of 38 limbs in 35 patients with critical limb ischemia were randomized to angioplasty (22 pts) or primary stenting (16 pts). Target lesions were infrapopliteal occluded (36) or stenotic (20) lesions ranging from <2 to >15 cm in length. The mean age was 72 years. At 12 months, there was no statistical difference in survival (angioplasty, 69.3%; primary stenting, 74.7%), in limb salvage (angioplasty, 90%; primary stenting, 91.7%), or in primary and secondary patency (angioplasty, 66 and 79.5%; primary stenting, 56 and 64%) between the groups Renal insufficiency was the only significant negative predicting factor for limb salvage in both groups. In conclusion, the 1-year results for both groups were broadly similar. Stenting has its place in infrapopliteal angioplasty if the procedure is jeopardized by a dissection or recoil, but our results do not support primary stenting in all cases.
[en] The shoulder joint is the most common joint to dislocate. The most common direction of dislocation is the anterior dislocation of the shoulder. These dislocations are often associated with a variety of associated injuries. In this article are presented two case reports of patients with anterior and posterior luxation. (author)
[en] Patients with severe critical limb ischemia (CLI) due to long tibial artery occlusions are often poor candidates for surgical revascularization and frequently end up with a lower limb amputation. Subintimal angioplasty (SA) offers a minimally invasive alternative for limb salvage in this severely compromised patient population. The objective of this study was to evaluate the results of SA in patients with CLI caused by long tibial occlusions who have no surgical options for revascularization and are facing amputation. We retrospectively reviewed all consecutive patients with CLI due to long tibial occlusions who were scheduled for amputation because they had no surgical options for revascularization and who were treated by SA. A total of 26 procedures in 25 patients (14 males; mean age, 70 ± 15 [SD] years) were evaluated. Technical success rate was 88% (23/26). There were four complications, which were treated conservatively. Finally, in 10 of 26 limbs, no amputation was needed. A major amputation was needed in 10 limbs (7 below-knee amputations and 3 above-knee amputations). Half of the major amputations took place within 3 months after the procedure. Cumulative freedom of major amputation after 12 months was 59% (SE = 11%). In six limbs, amputation was limited to a minor amputation. Seven patients (28%) died during follow-up. In conclusion, SA of the tibial arteries seem to be a valuable treatment option to prevent major amputation in patients with CLI who are facing amputation due to lack of surgical options.