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Biomedical subjects

D Palombo

Publications and source records attributed to D Palombo.

At least 19 recordsLinked to original sources
PubMed2005

Cardiac risk assessment of asymptomatic patients by stress echocardiography before infrarenal aortic aneurysm surgery.

AIM: Aggressive cardiac assessment before aortic abdominal aneurysm (AAA) surgery is indicated for patients with symptomatic coronary artery disease (CAD). Assessment of intermediate and moderate risk patients is still under debate. The purpose of the study was to prospectively evaluate the effectiveness of stress echocardiography (SE) in the detection of CAD in patients undergoing AAA surgery who have no symptoms and/or signs of CAD, but who have risk factors for it. METHODS: Patients with 1 or more risk factors for CAD underwent SE. All patients with positive SE underwent coronary arteriography, and, when indicated, treatment. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for SE by comparing results to coronary arteriography. Moreover, major perioperative cardiac events were recorded. RESULTS: Ninety-one patients with AAA and risk factors for CAD were studied. SE was positive in 9 cases, including 7 presenting critical CAD on the basis of coronary arteriography. One major cardiac event (1.1%), a nonfatal myocardial infarction, occurred in 1 patient with positive SE and non-critical, single-vessel CAD. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of SE proved to be 100%, 98%, 78%, 100%, and 92%, respectively. CONCLUSIONS: Positive SE should be considered a valid method for testing high-risk patients for CAD. The low rate of major cardiac events in this series suggests that cardiac assessment by SE and selective coronary arteriography prior to AAA surgery is effective in asymptomatic patients with one or more risk factors.

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PubMed2004

Early experience with the minimal extracorporeal circulation system (MECC) during thoracoabdominal aortic aneurysm repair.

AIM: The purpose of this report is to describe our early experience with a minimal extracorporeal circulation system (MECC), a compact closed heparin coated system consisting of a centrifugal pump and a membrane oxygenator, during thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: Between January and December 2002 the MECC system was employed in seven consecutive patients (four TAAA type II, two TAAA type I and one TAAA type III according to the Crawford classification). In all patients distal aortic, selective renal and visceral perfusion was performed with this compact closed heparin coated system consisting of a centrifugal pump and a membrane oxygenator. RESULTS: The MECC system was used in all cases with no technical malfunctions. Six out seven patients were discharged from the unit. One patient developed paraplegia after TAAA repair and died on the third post-operative day from multi-organ failure. In this case the total spinal ischaemic time was 120 min and the distal aortic perfusion pressure was <50 mmHg. No cardiac, cerebral, renal, hepatic or bleeding complications were recorded in the remaining six patients. CONCLUSION: Our early experience with MECC during TAAA repair showed that it is feasible for distal aortic spinal and visceral selective perfusion. Further large clinical trials are required to determine the efficacy of this technique.

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PubMed2003

Intra-operative assessment of technical defects after carotid endarterectomy: a comparison between angiography and colour duplex scan.

We compared the intra-operative diagnostic value of CDS vs IA-DSA in identifying major and minor technical defects after CEA. Between August 1997 and December 1998, 138 consecutive patients undergoing 141 carotid endarterectomies were intra-operatively investigated with colour duplex scan and intra-arterial digital subtraction angiography. Thirty-six (25.5%) technical defects were identified. Four (11.1%) major defects were detected by both methods and they were immediately corrected. Fifteen (41.6%) minor defects were detected by both methods, thirteen (36.1%) minor defects were detected by colour duplex but ignored by angiography. Angiography detected four (11.1%) kinkings missed with the colour duplex. The overall sensitivity of both methods for major defect was 100%. The sensitivity of colour duplex for minor defects was 87% vs 59% for angiography. On the basis of our study, colour duplex could be considered the choice method for quality control after carotid endarterectomy.

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PubMed2000

Eversion versus conventional carotid endarterectomy: late results of a prospective multicenter randomized trial.

OBJECTIVE: The durability of carotid endarterectomy (CEA) may be affected by carotid restenosis. The data from randomized trials show that the highest incidence of restenosis after CEA occurs from 12 to 18 months after surgery. The optimal CEA technique to reduce perioperative complications and restenosis rates is still undefined. This study examines the long-term clinical outcome and incidence of recurrent stenosis in patients who undergo eversion CEA. Previously published perioperative results of this study did not show statistically significant differences in study endpoints between the eversion and standard techniques. METHODS: From October 1994 to March 1997, 1353 patients with surgical indications for carotid stenosis were randomly assigned to undergo eversion (n = 678) or standard CEA (n = 675; primary closure, 419; patch, 256). Withdrawal from the assigned treatment occurred in 1.6% of the patients (in 13 assigned to eversion CEA, and in nine assigned to standard CEA). The clinical and duplex scan follow-up examination was 99% complete, and the mean follow-up interval was 33 months (range, 12 to 55 months). The primary outcomes were perioperative and late major stroke and death, carotid restenosis (stenosis >/= 50% of the lumen diameter detected at duplex scanning), and carotid occlusion. The primary evaluation of study outcomes was conducted on the basis of an intention-to-treat analysis. RESULTS: Restenosis was found at duplex scanning in 56 patients (19 in the eversion group, and 37 in the standard group). Within the standard group, the restenosis rates were 7.9% in the primary closure population and 1.5% in the patched population. Of the patients with restenosis, 36% underwent cerebral angiography that confirmed restenosis in all cases. The cumulative restenosis risk at 4 years was significantly lower in the group that underwent treatment with eversion CEA as compared with the standard group (3.6% vs 9.2%; P =.01), with an absolute risk reduction of 5. 6% and a relative risk reduction of 62%. Eighteen patients would have had to undergo treatment with eversion CEA to prevent one restenosis during the 4-year period. The incidence rate of ipsilateral stroke was 3.3% in the eversion population and 2.2% in the standard group. There were no significant differences in the cumulative risks of ipsilateral stroke (3.9% for eversion, and 2.2% for standard; P =.2) and death (13.1% for eversion, and 12.7% for standard; P =.7)) in the two groups. Of the 18 variables that were examined for their influence on restenosis, eversion CEA (hazard ratio, 0.3; 95% confidence interval, 0.2 to 0.6; P =.0004) and patch CEA (hazard ratio, 0.2; 95% confidence interval, 0.07 to 0.6; P =. 002) were negative independent predictors of restenosis with multivariate Cox proportional hazards regression analysis. CONCLUSION: The EVEREST (EVERsion carotid Endarterectomy versus Standard Trial) showed that eversion CEA is safe, effective, and durable. No statistically significant differences were found in late outcome between the eversion and standard techniques at the available follow-up examination.

Actuarial Analysis↗
PubMed1999

Matrix metalloproteinases. Their role in degenerative chronic diseases of abdominal aorta.

BACKGROUND: The main chronic degenerative diseases of the abdominal aorta, namely aneurysmatic and steno-obstructive pathologies, have a common denominator: atherosclerosis. Both pathologies are characterised by the destruction of the structural integrity of the extracellular protein matrix (ME). A number of studies have shown the presence and involvement of a group of enzymes with proteolytic activity towards one or more ME components, the matrix metalloproteinases (MMPs), in the pathogenesis of aneurysms of the abdominal aorta. Other authors have underlined the role of MMPs in the proliferation and migration process of smooth muscle cells into the intima in the pathogenesis of atheromasic plaque. The aim of this study was to evaluate the possible role of these enzymes in the pathogenesis of chronic degenerative diseases of the aorta. METHODS: Fragments of aortic wall were removed from patients undergoing elective aortic surgery for aneurysms (14 patients) or aortic steno-obstruction (4 patients). The samples obtained were treated appropriately and then subject to immunohistochemical analysis. The preparations were incubated with specific anti-MMP antibodies and were also incubated with substrate and chromogen, forming a pigmented precipitate on the site of the antigen, before being observed using an optic microscopic at an enlargement of 250x. Nuclear positivity linked to the presence of the antigen testified the validity of staining. Lastly, the MMP INDEX, or in other words the number of positive cells out of 100, was stained in the adventitia and in the tunica media in each preparation. RESULTS: MMPs were divided into three main groups: interstitial collagenase (MMP1) which degrade type I and III native collagen; gelatinases (MMP9, MMP2) which act on elastin and type IV collagen; stromelysins (MMP3) with specific proteolytic action towards proteoglycans, fibronectin and laminine. In our experience, those preparations obtained from aorta affected by steno-obstructive pathologies (4 patients) revealed the presence of MMPs with a preferential localisation on the intimal side of the tunica media. In particular, the increased activity of gelatinases MMP9 in atherosclerotic aorta might be responsible for destroying the internal elastic lamina and fostering the proliferation and migration of smooth muscle cells and the formation of atheromasic plaque. On the other hand, preparations obtained from aneurysmatic aorta (14 patients) showed an opposite situation with a preferential localisation within the adventitia and on the adventitial side of the media. Above all, the loss of elastin represents an essential stage in the formation of aortic aneurysms. CONCLUSIONS: This study concords with numerous authors who have demonstrated the involvement of proteinase MMPs in the development of aortic aneurysms and their possible role in the pathogenesis of atheromasic plaque. The different origin of these enzymes (inflammatory cells and macrophages or endothelial cells) may be the result of different pathogenetic mechanisms. Although they present different pathogenetic features, aortic aneurysms and steno-obstructions have a common denominator in atherosclerosis. The mechanisms responsible for their evolution towards one or other form are not known. The different expression of MMPs in the context of the aortic wall represents a field for future research.

Aorta, Abdominal↗
PubMed1998

A randomized study on eversion versus standard carotid endarterectomy: study design and preliminary results: the Everest Trial.

PURPOSE: The EVEREST Trial was designed to determine whether the surgical technique influences the durability and complications of carotid endarterectomy (CEA). The current report focuses on the study design and preliminary results. METHODS: EVEREST is a randomized multicenter trial. A total of 1353 patients with carotid stenosis requiring surgical treatment were randomly assigned to received standard (n = 675) or eversion (n = 678) CEA. Primary end points included carotid occlusion, major stroke, death, and restenosis rate. RESULTS: The rate of perioperative major stroke and death (1.3 for each study group) and the incidence of early carotid occlusion (0.6% for eversion vs 0.4% for standard) were similar. No significant differences were found between eversion and standard CEA with respect to incidence of perioperative transient ischemic accident, minor stroke, cranial nerve injuries, neck hematoma, myocardial infarction, or surgical defects as detected with intraoperative quality controls. Clamping time was significantly shorter for eversion CEA compared with patch standard procedures (31.7 +/- 15.9 vs 34.5 +/- 14.4 minutes, p = 0.02). A shunt was inserted in 11% of patients undergoing eversion CEAs and in 16% of patients undergoing standard procedures. Overall 30-day events occurred in 13.3% of the eversion group and in 11.4% of the standard group (p = 0.3). At a mean follow-up of 14.9 months (range, 1 to 38 months), 16 (2.4%) restenoses occurred in the eversion group and 28 (4.1%) occurred in the standard group (odds ratio, 0.56; 95% confidence interval, 0.3 to 1.1; p = 0.08). CONCLUSION: The preliminary results of the EVEREST Trial suggest that eversion CEA is a safe and rapid procedure with low major complication rates. No significant differences in restenosis rates were observed between eversion and standard CEA at the available follow-up. Longer-term results are necessary to assess whether the eversion technique influences the durability of CEA.

Adult↗
PubMed1995

[Limb salvage in critical ischemia. Our experience].

The aim of this paper is to present our six-year experience in the treatment of critical limb ischaemia, even if in the period (1987-1993) considered the definition of critical ischaemia had been partly reviewed in the publication of the "European Consensus Document on Critical Limb Ischaemia" (March 1989). Two hundred thirty-nine patients have been treated in our Unit for critical limb ischaemia: reconstructive surgery was used in 34% of cases, lumbar sympathectomy or spinal cord stimulation in 17% of cases and pharmacotherapy in 14% of cases. Taking into account arterial and graft patency as well as the percentage of limb salvage, our results were similar to those presented in the literature.

Adult↗
PubMed1994

Cerebral reserve and indications for shunting in carotid surgery.

The aim of this study was to establish whether a preoperative evaluation of cerebral haemodynamic reserve, carried out by means of transcranial Doppler and single photoemission computed tomography with a provocative test (acetazolamide) is able to select those patients who require carotid shunting to avoid cerebral ischaemia during clamping. All patients were monitored during operation by means of somatosensitive evoked potentials. Those patients who required shunting because of abnormal evoked potentials were also those who had a poor cerebral reserve with a perfusion and velocity increase below 15%. Only one neurological deficit developed in patients who were not shunted.

Acetazolamide↗
PubMed1993

[Arterial recanalization with the Kensey catheter. Preliminary results].

Fifteen patients with chronic obstruction of leg arteries (mean length: 6 cm) were treated with the Kensey catheter and then with PTA. In 11 cases the procedure was successful (74%) and in 2 it was interrupted--in one case for dissection and in the other for vessel perforation. Two maneuvers, after dissection, were ended with PTA and stent placement (overall success rate: 87%). Emergency surgery was never needed. In the cases solved with the Kensey catheter, the cumulative patency rate was 51% at 6, 12 and 24 months. The Kensey catheter did not improve the results of conventional PTA, which means its role is complementary to that of PTA and an alternative to more expensive laser systems, if PTA fails.

Adult↗
PubMed1992

[Hemodynamic reserve in carotid surgery and the use of "superselective" shunt].

The aim of this study is to establish whether a preoperative evaluation of the Cerebral Hemodynamic Reserve, carried out by means of transcranial Doppler and SPECT with provocative test (acetazolamide) can single out those patients who, because they are supplied with a poor cerebral reserve, are truly in need of intraoperative shunting after carotid clamping. All patients were intraoperatively monitored by means of Somato Sensitive Evoked Potentials (SSEPs). Those patients who were shunted due to abnormalities in SSEPs were also those who showed a perfusion and velocity increase below 15%, and therefore supplied, in our opinion, with a scanty cerebral reserve. No, but one, neurological deficit appeared on awakening in patients who were not shunted.

Acetazolamide↗
PubMed1992

[Arterial embolism, venous thrombosis, pulmonary embolism: a suggestive triad].

The aim of this study is to present a relatively rare case of paradoxical arterial embolism, found in a patient who was sent to us for serious pulmonary embolism. Taking into account that the foramen ovale, despite being functionally competent, remains anatomically patent in 30% of the adult population, we cannot neglect the possibility of a paradoxical embolism, in the presence of a sudden embolic limb ischemia unless heart pathology or aortic lesions can be held responsible. Furthermore it must not be forgotten that deep venous thrombosis in the lower limbs or in the pelvic plexus may go unobserved on a purely clinical evaluation.

Axillary Artery↗
PubMed1992

[Deep phlebothrombosis disclosing aortoiliac aneurysms].

The purpose of the present study is to underline the importance of the systematic search for iliocaval venous compression on the part of an aortoiliac aneurysm in the face of a clinical picture of suspected deep venous thrombosis. Early diagnosis of this syndrome, although rare in everyday experience, is of decisive importance, as is every other clinical sign of aneurysmal pathology prior to rupture. Correct, systematic diagnostic exclusion procedure, which is capable of leading to certain diagnosis in all cases is therefore necessary.

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