Buerger's disease or obliterating thromboangiitis is an inflammatory pathologic condition affecting the distal vascular segments; it strikes young adults, especially males and heavy smokers. Medical and surgical treatment often fail to heal these patients, especially considering the frequent relapse of this disease linked with tobacco abuse--definitive healing often involves limb amputation. Electrical spinal cord stimulation is evaluated in this study with an analgesic aim and for improvement in skin microcirculation, with the goal of long-term healing of diseased limbs.
Chlamydia pneumoniae (CP) is a bacterium that in recent years has been investigated as an etiologic agent for atherosclerosis. It is a ubiquitous microorganism that has been isolated in various regions of the vascular system and its prevalence is about 10% in the patient population. This study involved a group of 43 patients (27 men, 16 women, mean age 68 years) who underwent carotid endarterectomy. About 9.3% of the patients yielded plaques that tested positive for the DNA genome of Chlamydia pneumoniae.
The aim of this study was to compare the clinical efficacy and the safety of spinal cord stimulation (SCS) plus medical treatment versus iloprost plus medical treatment in patients with severe unrevascularizable ischemia of the lower limbs due to atherosclerotic disease of the limbs and to identify predictive parameters for a positive outcome of SCS. Methods: A multicenter randomized controlled trial (RCT) with central randomization and core laboratory evaluation of angiography, subdivided into two treatment arms (SCS and iloprost) and two subgroups (rest pain and ulcer/gangrene). After the 15-day clinical efficacy evaluation, responder patients continued follow-up in their arm, while nonresponders could change arms or decline participation. The primary endpoint was 1-year limb salvage. Principal secondary endpoints were: survival rate; minor amputations and stump healing; ulcer healing; pain relief and analgesic intake; and predictive criteria for SCS treatment. Results: The trial was stopped at 35.6% of the expected sample due to low accrual rate. Fiftytwo patients (55 legs) entered the study. At the 15-day efficacy evaluation, responders (reduced pain, no increase of ulcer area) comprised 74% of the SCS arm and 26% of the iloprost arm, (P=0.003). Nine nonresponders in the iloprost arm underwent SCS implantation. Three severe adverse events (one fatal) were recorded in the iloprost arm and four in SCS treatments. Oneyear limb salvage rates in SCS, iloprost treatment, and iloprost plus SCS implantation (I-SCS) were 66.8%, 57.1%, and 100%, respectively (P=0.09), and survival rates were 73.2%, 93.9%, and 88.9%, respectively (P=0.45), confirming results of other studies that showed a trend toward better amputation-free salvage in the SCS group. The small number of recruited patients prevented statistical significance being reached. Pain reduction was obtained in 87% of SCS patients and 35% of those in the iloprost arm (P=0.001). Among the examined parameters, only the angiographic resistance index was an independent predictive value of good results after SCS implantation. Discussion and conclusion: The SPINAL study is the first RCT comparing SCS and iloprost. Although incomplete, it evaluated a sample greater than those studied in three out of five available RCTs on SCS. However, the small sample size reduced the statistical power of the study, with possible type II errors. SCS was associated with a quick and more effective answer to pain, with better tolerability and better early results, than iloprost, but without significant 1-year limb salvage-rate improvement. Iloprost improved the 1-year survival in spite of adverse events, and, following these results, perhaps should be administered before other treatments. The results of this trial suggest that prostanoids and SCS are not alternative treatments: as prostanoids present many contraindications and side effects, SCS can be considered the complementary and consecutive treatment for patients who are no longer treatable with open or endovascular revascularizations...
A 2-year-old girl with asymmetrical upper limbs and underdevelopment of the bones of the left forearm, wrist and hand with associated muscular and osteal hypoplasia is described. Doppler ultrasonography of the arterial trunks of the upper limb suggested a normal ulnar trunk in the left upper arm, an arterial vessel extending from the bend of the elbow to the distal third of the forearm, and the absence of any other arterial trunks in the radial region. Angiography confirmed that vascularization of the forearm was sustained by the ulnar artery, which supported the dorsal arch of the carpus and digital arteries arising from it. The interosseal artery was morphologically normal but there was aplasia of the radial artery. It is suggested that this malformation is the result of suppressed development of the vascular system of the left radial segment as other pathologies normally associated with the condition were absent.
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