History of the team approach to management of the diabetic foot chronicles the emergence of the specialties of vascular surgery and wound healing. The partnership between the diabetologist, vascular surgeon, and podiatrist can be seen as a natural marriage that complements the skills and knowledge of each partner and results in more successful limb salvage and functional outcomes. Diabetic foot patients are among the most complex and vulnerable of all diabetes patients, with high morbidity and mortality. Specialized diabetic foot clinics of the 21st century should be equipped to coordinate revascularization procedures, to aggressively treat infections, and to manage medical comorbidities within a multidisciplinary forum. History has taught us that optimal management of diabetic foot complications is best provided in a hospital-based diabetic foot clinic. It is common experience that clinic must be available to manage emergencies and equipped to perform urgent investigations, wound debridement, and to initiate immediate parenteral antibiotic therapy. It must also be able to obtain rapid vascular, podiatric, and orthopaedic opinions and to arrange for emergency admissions to the hospital However, aside daily experience do we have evidences that multidisciplinary team (MDT) has an impact in the management of individuals with diabetic foot? In 2017, Buggy A. et al tried to explore the delivery of a diabetic foot MDT in detail and to identify if its existence leads to more positive diabetic foot outcomes. Thus, their systematic review explored the following question: What is the impact of the MDT in the management of individuals with DFUs? Their review counted 19 eligible studies in which the impact of the multidisciplinary team in the management of the diabetic foot compared with those who did not receive multidisciplinary care was assessed. They found some positive effects of the MDT on DFUs, namely; amputation rate, severity of amputation and resource use. MDT care also appears to improve mortality and quality of life of people with this condition. MDTs was heterogeneous; they were constituted for the most by diabetologist-endocrinologists, vasculargeneral surgeon and/or orthopaedics, podiatrists and nurses. Even if it is impossible to perform a correct statistical analysis because of the high heterogeneity of data and results, it is notable that MDTs where Vascular Surgeon was absent had the highest major amputation rates (9, 5-47%, mean 34%) compared to the groups where Vascular Surgeon was included (419%, mean 12, 5%). That data is without statistical weight but it is the mirror of what we live daily; in our daily practice we are used to see frequently diabetic patients with terrific diabetic foot gangrene sent by small peripheral centres where the Vascular Surgeon is not available. That is the reason why we strongly recommend an integrated, coordinate, multidisciplinary care. To date, in literature, different combinations of team members are described (in absence of comparisons among different team compositions) and some studies do not discuss how the team was formed. However we believe that a foot care team would consist ideally of a diabetologist, a vascular surgeon, an, a specialised nurse, a podiatrist, an educator and a plaster technician. In particular, it would be advisable that the multidisciplinary team leader for diabetic foot care would be a diabetologist because diabetic foot is a chronic complication of diabetes and poor vascular supply due to arterial disease involving small as well as large vessels is strongly influenced by the underlying pathology. Evidence on the need for an integrated approach to the management of diabetes: the surgical perspective

Health and social challenges require the adoption of new approaches to prevention, diagnostics and care, which pose important sustainability and equity issues to the different healthcare systems of Italian regions. It is therefore essential to set up sustainable models, as part of an overall health innovation process, where ongoing structural reforms are able to increase the effectiveness and resilience of health systems. The participation of citizens, patients, formal and informal caregivers in the planning, set-up and evaluation of these new solutions is pivotal to overcome those current approaches which are no longer fulfilling the provision of integrated social and health services. Digital transformation of health and care provides tools capable to support the modernization of social and health systems, and their adaptation to challenges such as the progressive population ageing, especially in a framework of shared resources and skills, that bring the citizen at the center of the healthcare politics, addressing health needs at individual and community level. The adoption of advanced technologies for diagnostics and therapy, and the digitization of services and care, represent an opportunity to be seized to set a virtuous circuit connecting needs, innovation and investments, through the adoption of transparent procedures. The collaborative approach to the provision of health services through network models allows the multidisciplinary management of the innovative tools that are progressively adopted, while supporting operators training, citizen empowerment and outcomes monitoring, also through rationalization and centralized management of financial resources. With these premises, on 1st October 2018 MeFAVS, the Mediterranean Federation for Advancing of Vascular Surgery was founded, willing to connect University Professors, heads of Vascular Departments and consultant surgeons for ongoing scientific, educational and clinical cooperation amongst the Mediterranean basin countries, such as Italy, France, Spain, Portugal, Greece, Morocco, Algeria, Tunisia, Egypt, Lebanon, Emirates, Albania, Croatia and Turkey, among others. Its activities, some currently and actively ongoing, have been a series of verbal information exchanges, meetings and surveys based on common topics of vascular pathology, epidemiology, new treatments and materials for Vascular Surgery. This project was born in collaboration with the “Federico II” University of Naples and the Campania Region which, according to the European Community directives and regulations, aimed to include MeFAVS in the Pro.M.I.S. (“Progetto Mattone Internazionale” Italian Ministry of Health Programme for Internationalization of Regional Health Systems) linked to the Horizon 2020 cycle to gain access to European Community funds managed by the Regional Governance. During a two-days meeting held in Pozzuoli (Naples) between the 19th and 20th of June 2019, collaborative networking approaches to innovative services for citizens' health and sustainability problems related to the Regional Health System were thoroughly discussed. On the first day of the 2nd International Congress of MeFAVS several topics like "High Technologies in Vascular Surgery" were faced, in line with the general theme of the Forum, and "The diabetic artery disease", an issue of great interest and relevance, selected as a common research topic among all the countries belonging to the Federation. The second day was dedicated to the abovementioned Forum: “Health Technologies: a challenge to be faced in network”. In this Issue, selected original papers from this conference are reported. All those papers are divided Editorial: Health Technologies: a challenge to tackle in NETWORK

In February 2017, the "Programma Mattone Internazionale Salute" (ProMis), that is the Italian Program for Internationalization of Regional Health Systems of the Ministry of Health (MoH), presented the first version of its Position Paper on Health Tourism, which embeds a first shared approach to the recommendations expressed by the European Committee of Regions (CoR) on "Age-Friendly" tourism. The CoR stresses the importance of local and regional authorities in the coordination of multi-sectoral policies such as healthcare, social assistance, transport, urban planning and rural development in relation to the promotion of mobility, security, accessibility of services, including health care and social services. "Age-friendly" tourism is an example of an innovative tourist offer that strives to meet the health needs of the entire "traveling" population, with an integrated and cross-sector approach that involves various organizations operating in sectors such as healthcare, accessibility and transport. The aim of the workshop was to explore the interest of the stakeholders to participate in a systemic action in the field of "health" tourism, and to identify priority implementation areas that offer opportunities to take advantage of validated, innovative experiences that strengthen the accessibility to health and social services in regional, national and international contexts. This effort provides the opportunity to take advantage of aligning the European Structural and Investment Funds (ESIF) to the development of tourism, coherently with the needs and resources of local and regional health authorities.

Introduction: Anastomotic pseudoaneurysm following renal transplantation is uncommon. Indications for repair, treatment options and outcomes remain controversial.Report: We present 6 renal transplant recipients with large anastomotic pseudoaneurysms. Five of the patients underwent open repair while one had a stent-grafting and delayed transplant nephrectomy for a ruptured pseudoaneurysm. A transplant nephrectomy was needed in all cases but one. Arterial reconstruction enabled limb salvage in all cases. One patient died of sepsis postoperatively. No patient presented late infection, failure of vascular reconstruction, nor pseudoaneurysm recurrence.Conclusions: Surgical excision of anastomotic pseudoaneurysms results in high rates of allograft loss. Less invasive techniques have a place in selected cases. (C) 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Aim The aim of this study was to evaluate the Impact of intra-operative cell salvage (ICS) on the early outcome after open repair (OR) of ruptured abdominal aortic aneurysm (rAAA)Methods This is a retrospective review of 73 consecutive patients who underwent emergency OR of infrarenal rAAA with ICS between 2005 and 2008 (Group 1), compared to 51 repairs from 2002-2004 with no ICS (Group II) In addition, a transfusion protocol of platelets and fresh frozen plasma (FFP) administration on admission and during surgery was adopted in patients in Group I to maintain coagulation competenceResults ICS reduced bank blood demand by 63 6% (from 11 to 4 units, P<0 001) compared to controls, and had a strong impact on rates of postoperative complications (P=0 05), or death (43 8% vs 52 9%, P<0 05) or in-hospital LOS (P<0 07) in these patients Patients surviving in Group I had significantly higher postoperative haemoglobin level (11 5 vs 9 6 g/dL, P<0 05) and platelet count (267 vs 95 x 10(9)L, P<0 001), a shorter APTT (31 s vs 47 s, P<0 05) and a lower INR (1 3 vs 2 1, P<0 01) than patients who died postoperatively ICS volume was significantly higher in patients with suprarenal aortic clamping and in those who had bifuricated grafting reconstruction (P<0 05), but amount of red blood cells (RBC) collected did not influence outcomeConclusion These results suggest that intraoperative cell salvage, minimizing perioperative homologous blood transfusion, Is an important determinant of outcome after rAAA repair Combined administration of balanced blood components may contribute to Improve the survival of the patients

OBJECTIVE:Inflammation is a pivotal process in atherosclerosis development and progression, but the underlying molecular mechanisms remain largely obscure. We have conducted an extensive expression study of atherosclerotic plaques to identify the inflammatory pathways involved in atherosclerosis.METHODS:We studied 11 human carotid plaques, their respective adjacent regions and 7 control arteries from different subjects. Expression of 92 genes was studied by TaqMan low-density array human inflammation panel. Human aortic endothelial and smooth muscle cells were used for in vitro experiments.RESULTS:The mRNA levels of 44/92 genes (48%) differed significantly between the tissues examined (13 up-regulated and 31 down-regulated). Dysregulated genes encode molecules belonging to different functional classes although most of them encode enzymes involved in the eicosanoid synthesis pathway. The expression of PTGIS and PTGIR genes was decreased in human aortic endothelial and smooth muscle cells stimulated with oxLDL and TNF-α.CONCLUSIONS:This study not only reveals several dysregulated genes in human lesions but also focuses the role played by the genes involved in the eicosanoid synthesis pathway during atherosclerotic development. The decrease of PTGIS and PTGIR expression after oxLDL treatment mirrors the decreased mRNA levels in atherosclerotic lesions versus control arteries, which suggests that oxidation is important for PTGIS and PTGIR regulation in human vessel cells during atherosclerosis development.

Objective. The aim of this prospective study was to compare outcomes after CEA and CAS in patients with contralateral carotid artery occlusion.Materials and Methods. Between 2004 and 2009, 527 consecutive patients underwent CEA (n = 281) or CAS (n = 246) for severe stenosis of internal carotid arteryOf them; 85 (16.1%) were identified with Cl contralateral carotid artery occlusion. CEA was performed in 31(36.4%) patients with contralateral ICA occlusion. and 15 (48.4%) were symptomatic. Intraoperative shunts were placed in 12% versus 41.9% 5) patients with patent (n = 250) or occluded contralateral ICA (n = 31). 54 (63.5%) patients with contralateral ICA occlusion underwent CAS with distal protection. and 38 (70.4 %) were symptomatic.Results. The ICA occlusion time during CEA was 27.9 +/- 2 min, and 5 +/- 1 s duringballoon inflations in CAS (P < 0.001). The perioperative rate of adverse neurologic events was not significantly higher in patients with contralateral ICA occlusion after both CEA (3.22% vs 1.20%) and CAS (1.85% vs 1.04%). Also the incidence of the 30-d total stroke/imortality rate was not significantly different (CEA: 6.45% vs 1.60%; CAS: 3.70% vs 1.56%).Conclusions. CAS is a safe and efficacious alternative for the treatment of carotid artery stenosis in patients with contralateral occlusion. The avoidance of general anesthesia and other CEA-related factors. and a siginficantly shorter period of ICA occlusion during balloon inflation can be the reasons for a 1.7-fold decreased risk after CAS.

A 72-year-old man with sudden abdominal pain and congestive cardiac failure presented a high-How aortocaval fistula with a large abdominal aortic aneurysm as detected by Duplex ultrasonography and computed tomography angiography. As the patient's multiple comorbidities precluded open repair, an emergency left aortouniiliac stent-graft deployment and femoro-femoral crossover bypass grafting were performed. Notwithstanding, incomplete exclusion of the fistula due to a small inflow from the contralateral iliac axis, the patient's cardiac overload decreased with a rapid resolution of cardiac failure, allowing for a staged ligation of the right iliac artery with a complete occlusion of the aortocaval fistula. At present there have been only 12 known cases, including our own, of patients treated with aortic stent-grafts; however, in consideration of the high mortality rate of open repair, endovascular repair is increasingly being recognized as a valuable treatment option.

Purpose: To describe a unique case of misdiagnosed leiomyosarcoma of the common femoral artery presenting with signs and symptoms of high-grade stenosis, which was treated with stent placement.Case Report: A 31-year-old woman with a history of diabetes and hyperlipidemia had recurrent claudication and showed significant in-stent restenosis of the common femoral artery in a postoperative angiogram at 5 months. The patient's clinical stage remained unchanged after repeat percutaneous intervention, and leiomyosarcoma was diagnosed from surgical specimens. The patient underwent resection and repair of the involved artery. She has survived 30 months with no further evidence of local recurrence or systemic metastatic disease.Conclusions: Endovascular repair may cause a long delay in the diagnosis of an arterial leiomyosarcoma mimicking peripheral occlusive disease.

The nitinol TrapEasee inferior vena cava filter is a new device for pulmonary embolism prophylaxis. No cases of filter migration or filterrelated complications with this type of device have so far been described. We report a case of intracardiac migration of this filter in a patient with a patent foramen ovale, resulting in severe cardiogenic shock, cerebral and right arm paradoxical embolism. Surgical treatment, results, causes of these complications are discussed. q 2002 Published by Elsevier Science B.V.

The nitinol TrapEase(TM) inferior vena cava filter is a new device for pulmonary embolism prophylaxis. No cases of filter migration or filter-related complications with this type of device have so far been described. We report a case of intracardiac migration of this filter in a patient with a patent foramen ovale, resulting in severe cardiogenic shock, cerebral and right arm paradoxical embolism. Surgical treatment, results, causes of these complications are discussed. (C) 2002 Published by Elsevier Science B.V.

Background: No effective pharmacologic intervention is available for critical leg ischemia, a severe clinical condition associated with high morbidity and mortality.Objective: To assess the safety and efficacy of prostaglandin E-1 in improving the prognosis and quality of life in patients with critical leg ischemia.Design: Multicenter, centrally randomized, controlled, open-label trial.Setting: 56 vascular surgery and angiology departments of the Italian National Health Service.Patients: 1560 patients with chronic critical leg ischemia.Interventions: In addition to routine treatments practiced in each center, patients were randomly assigned to receive either a daily intravenous infusion of 60 mu g of prostaglandin E-1 in the form of alprostadil-alpha-cyclodextrine (n = 771) or no prostaglandin E-1 (n = 789) during their hospital stay. The treatment period lasted for up to 28 days.Measurements: A combined end point consisting of death and peripheral and cardiocerebrovascular illness (major amputation or persistence of critical leg ischemia, acute myocardial infarction, or stroke) evaluated at hospital discharge and during 6 months of follow-up.Results: The incidence of the combined outcome measure was lower in the alprostadil group than in controls at hospital discharge (493 [63.9%] patients compared with 581 [73.6%] patients; relative risk, 0.87 [95% CI, 0.81 to 0.93]; P < 0.001) but differed only modestly at 6 months (348 of 661 [52.6%] patients compared with 387 of 673 [57.5%] patients; relative risk, 0.92 [CI, 0.83 to 1.01]; P = 0.074). Most of the observed benefit was due to recovery from critical leg ischemia.Conclusions: Short-term treatment with alprostadil-alpha-cyclodextrine provides patients with critical leg ischemia clinical benefit that is apparent in the short term but decreases over time.

Objective: The prognostic factors and treatment options for thoracic aortic intramural hematoma are controversial. The purpose of this study was to determine the most suitable treatment of this condition in very elderly patients. Methods: In a review of the world literature, eight octogenarians with thoracic aortic intramural hematoma were found; to these the three cases reported here must be added. The descending thoracic aorta was involved in eight cases and the ascending/arch in three. Results: In spite of patients' poor general conditions, the medical treatment group showed survival rates of 85.7% (descending) and 66.6% (ascending/arch), respectively. Conclusion: Extensive atherosclerotic changes of the aortic wall in the elderly, combined with control of hypertension, may probably prevent thoracic aortic intramural hematoma from progressing to dissection, with a favourable outcome. An earlier and more accurate preoperative diagnosis by modern diagnostic techniques, including spiral computed tomography (CT), as were performed in our own patients, will allow optimal treatment and increased patient survival. (C) 1999 Elsevier Science B.V. All rights reserved.

Two unusual cases of iliac vein spontaneous rupture into the retroperitoneum are presented together with 18 cases reported by the literature. In one patient of ours, entrapment of clots in an IVC filter and proximal iliac vein involvement into the scar tissue surrounding the left Limb of an aortoiliac bifurcation graft might have caused flow disturbances and subsequent predisposition to rupture of the thrombosed external iliac vein. Inflammatory parietal changes, including infiltration of macrophages, T and B lymphocytes producing elastin degradation by means of cytokines, may have led ultimately to vein disruption. Despite clinical features and CT scan findings, the physician's awareness of this disease remains the most important factor for the early treatment.

This study was designed to compare the efficacy and safety of seaprose S and serratio-peptidase in the treatment of venous inflammatory disease. Forty patients entered the study (11 males, 29 females), mean age 54.3 years (range 30-77), mean weight 74.8 kg (range 51-96), with superficial thrombophlebitis. The trial was conducted following a controlled, between patients, randomized experimental design. Seaprose S was administered as 30 mg tablets at a daily dosage of 90 mg (one tab t.i.d.), and serratio-peptidase as 5 mg tablets, at a dose of 30 mg per day (two tabs t.i.d.), both orally, for 14 days. Twenty patients received seaprose S and 20 serratio-peptidase. The findings indicate that seaprose S was more effective and better tolerated than serratio-peptidase. Although the group of patients assigned to seaprose S had considerably more severe initial symptoms, by the end of treatment spontaneous pain was reduced 68.7% from the baseline mean score (from 3.2 to 1.0), as compared with a 63.3% reduction in the serratio-peptidase group (from 3.0 to 1.1). Pain on pressure was reduced 61.1% with seaprose S (from 3.6 to 1.4), compared to 57.6% with the reference treatment (from 3.3 to 1.4). Edema was reduced respectively 75% (from 1.6 to 0.4) and 56.2% (from 1.6 to 0.7); erythema diminished 72.4% (from 2.9 to 0.8) and 58.3% (from 2.4 to 1.0); nighttime cramps were 61.1% less (from 1.8 to 0.7) compared with 52.9% (from 1.7 to 0.8); hemorrhagic suffusion was 53.3% less (from 1.5 to 0.7) compared with 41.7% (from 1.2 to 0.7); cutaneous dystrophy was reduced by 11.1% (from 1.8 to 1.6) and 7.7% (from 1.3 to 1.2). At the end of the treatment with seaprose S efficacy was assessed as good or excellent in 85% of the cases, compared with 65% for serratio-peptidase. Seaprose S caused no adverse reactions. During serratio-peptidase treatment one patient reported diarrhea, requiring temporary dosage reduction and specific treatment. It can thus be confirmed that seaprose S was effective and well tolerated in patients with inflammatory venous diseases.

Objective: to evaluate the safety and efficacy of a stable prostaglandin E(1) added to the usual therapeutic practice (either invasive or not) in patients with chronic critical leg ischemia.Design: multicenter, controlled, randomised, open label trial.Setting: a representative sample (56 centers) of vascular and general surgery, angiology and general medicine departments of the Italian National Health Service.Patients: all patients suffering from leg ischemia considered as chronic and critical depending on the presence of persistently recurring rest pain for more than two weeks and/or foot ulceration or gangrene.Intervention: a daily i.v. infusion of 60 mu g of alprostadil alpha-cyclodextrine for the overall hospital stay, up to a maximum of 28 days (as an adjunct to the standard procedures adopted In each center) to patients randomly assigned to the experimental treatment.Measures: the primary evaluation of efficacy is based on the expected reduction of major amputations or persistence of critical leg ischemia at six months, The sum of these ''peripheral'' events, of death and of non-fatal myocardial infarction and stroke is used as a more comprehensive evaluation of the risk/benefit profile of the experimental treatment.Results: a reduction from 40% to 32% of the incidence of the primary end-points is the trial hypothesis, The recruitment of 1500 patients is required to verify this.Conclusions: this large-scale trial aims at providing a reliable estimate of the possibility of modifying hard end-points such as death and amputation in patients with critical leg ischemia.

A unique case of true inferior pancreaticoduodenal artery aneurysm (IPDA) associated with occlusion of common hepatic artery is reported. Radiological and MRI findings are described. Because of high risk of visceral ischemia that contraindicated a percutaneous transluminal embolization, a successful tangential resection of aneurysm was performed.