High resolution mini-gammacamera and 99mTc [HMPAO] - leukocytes for diagnosis of infection and radioguided surgery in diabetic foot

Discovery of osteitis may be delayed because of late appearance of X-ray signs in patients with diabetic foot. Scintigraphy with labelled leukocytes is able to detect flogosis but often misses bone involvement, due to inadequate resolution of Anger camera, the commonest detector used in nuclear medicine. Radioguided surgery and biopsy with high resolution scintigraphy (HRS) started to be studied since 2000: although this method had never been tested for planning and guiding diabetic foot surgery, in our opinion it can help early diagnosis and surgical treatment of diabetic foot. Five patients with diabetic foot and suspected infection were studied with standard 99mTc [HMPAO]-leukocyte scan. In the same patients 2 mm spatial resolution HRS was performed 24 hours after administration of labelled WBC, using our inch2 field-of-view portable mini-gammacamera. Operations were done just after the 24h scan and were guided with the portable high resolution device in the four patients who showed positive scan. Scintigraphy with Anger camera and HRS were positive in four patients. HRS showed a bar-shaped radioactivity corresponding to small phalanges, close to the main inter-digital hot spot. The presence of osteitis on phalanges that had been shown by HRS was confirmed at surgery, that was successfully driven with the high resolution mini-camera. In conclusion HRS is able to diagnose early osteitis of diabetic foot and to guide diabetic foot surgery.

Control of the operated carotid with ultrasound. Anatomical and hemodynamical modifications, both local and intracranial

BACKGROUND

A study has been done on the operated carotid monitoring the modifications of the wall and of the flow in the site of the operation and at the intracranial level.

METHODS

146 operated carotids were studied using transcranial Doppler, duplex and color. The pre-surgical data were confronted with the postsurgical ones on the 4th day, one month later, 3 months later and every 6 months.

RESULTS

The cerebrovascular reactivity (CR) and the cerebral hemodynamic latency time (CHLT), improved in more than half of the patients with stenosis >80%. When the stenosis is of minor entity, the improvement appears in 10% of the cases. The VCR and CHLT modifications appear within 1 month following the operation. Kinkings are more frequent with the patch (6%) than with the direct suture (3%). The symptomatic restenosis is 2%, while the asymptomatic one is 11%. The restenosis is present in 8% of the cases with direct suture and in 3% of those with suture with patch.

CONCLUSIONS

The local and intracranial modifications after carotid revascularization depend on new anatomical and hemodynamical situation due to surgery. The response of the wall which can be of four types: myointimal reaction, is a "physiological" response to the trauma and its thickness does not exceed 3 mm; myointimal hyperplasia, with thickness exceeding 3 mm; early restenosis (12 to 18 months); late restenosis (after 2 years). Substantial differences in velocity between systole and diastole and the systolic stress favor hyperplasia more than low velocities with smaller differences.

A new classification of varicose veins to compare various surgical strategies

Considering the presupposition that chronic venous insufficiency (CVI) and varicose veins classifications are extremely difficult, and that none of those presently in use are sufficiently complete, the authors propose the classification of the haemodynamic venous disease (HVD) and of the varicose veins from the clinical, anatomotopographical, etiopathogenetical and haemodynamical point-of-view. This type of classification allows us to closely follow the disease's evolution, to distinguish the benign forms from the more aggressive ones, and to evaluate the results of the medical, surgical and schlerotherapical treatments, from the efficiently, functional, instrumental and aesthetically point-of-view.

Classification of the subclavian steal syndrome with transcranial Doppler

Ultrasound has provided a highlight of the different types of subclavian steal. The authors report epidemiological and clinical data concerning 40,000 ultrasound examinations performed on epiaortic arteries and particularly the last 12,000 in which Doppler c.w., duplex scanner and transcranial Doppler were used. Various types of steal are described; five types of subclavian steal have been classified and patients stratified as being symptomatic and asymptomatic. The neurological symptoms are divided as follows: generalized cerebral ischemia, vertebro-basilar ischemia and hemispheric ischemia. Based on this clinical and haemodynamic outline, surgical therapy is indicated and type of surgery suggested.

[Ultrasonic quantification, value of color and contribution of transcranial Doppler sonography in carotid artery surgery]

The authors briefly report their experience regarding the opportunities offered by the use of current ultrasound methods in carotid surgery. They describe: a system for the quantification of athcromasic plaque used to monitor non-operated patients over time; ultrasound methods used to analyse the carotid wall to establish whether it can be utilised as an index of vascular aggression in hypertension, diabetes and atherosclerosis; the use of transcranial Doppler; criteria for the definition of high risk plaque; the applications of eco-color Doppler. The paper also illustrates a new pathology identified by the authors, defined as primary intimal fibrous hyperplasia, and the evolution of the carotid wall after endarterectomy. The structural characteristics of primary hyperplasia can only be shown using ultrasound given that arteriography cannot distinguish it from atheromatic stenosis. After endarterectomy the carotid wall is subject to hematic and hemodynamic stimuli which determine the type of evolution of the wall itself. The authors therefore examine the myointimal reaction, myointimal hyperplasia, early restenosis and late restenosis as different facets of the same phenomenon.