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Research paper thumbnail of An uncommon cause of sciatic pain: tuberculous osteomyelitis of the ischial tuberosity

Acta Clinica Belgica, Jan 11, 2017

A 66-year-old Caucasian female presented with insidious sciatic pain leading to an uncommon diagn... more A 66-year-old Caucasian female presented with insidious sciatic pain leading to an uncommon diagnosis of tuberculous osteomyelitis with unknown portal entry. The patient did not report a history of a previous tuberculosis (TB) infection and her chest X-ray was negative for TB. Considering TB in the differential diagnosis of a 'bone abscess', it is of paramount importance to come to a correct diagnosis. Conventional radiographs still remain the first-line imaging modality for evaluation of skeletal symptomatology. However, biopsies or aspirates are often needed to yield the definitive diagnosis. The lack of awareness of the potential extrapulmonary involvement of TB leads to an important delay in diagnosis and treatment. Antituberculous drugs should be started at the time of biopsy and continued during 12-18 months, due to poor drug penetration into osseous and fibrous tissues.

Research paper thumbnail of Impact of Angiosome Targeted Femorodistal Bypass Surgery on Healing Rate and Outcome in Chronic Limb Threatening Ischaemia

European Journal of Vascular and Endovascular Surgery, Jul 1, 2020

WHAT THIS PAPER ADDS Based on the angiosome concept definition of direct (DR) and indirect revasc... more WHAT THIS PAPER ADDS Based on the angiosome concept definition of direct (DR) and indirect revascularisation (IR), this study concludes that there is no difference between DR or IR in wound healing rate, major amputation, or mortality. Therefore, revascularisation should not be denied to patients in whom only IR is possible. Cryopreserved allografts can be a valuable alternative when no good quality autologous vein is available. Objective: In the presence of long lesions, in patients with chronic limb threatening ischaemia, a femorodistal bypass is often the only option to avoid major amputation. This study investigated whether targeted bypass to the affected angiosome, according to the angiosome concept definition of direct (DR) and indirect revascularisation (IR), has an impact on wound healing, major amputation rate, and mortality. Methods: A retrospective analysis was performed at Ghent University Hospital of 201 non-healing ischaemic wounds (Rutherford categories 5 and 6) requiring femorodistal bypass surgery in 177 patients (61% male, median age 69 years) with a follow up of 36 months. For every patient, the site of the ulcer, the type of bypass, and material were identified. Based on ulcer location and distal anastomosis, the legs were divided into DR and IR. KaplaneMeier univariable analysis was used to estimate cumulative ulcer healing, leg salvage, survival, and patency. Results: DR was performed in 103 legs (51%) and IR in 98 legs (49%), with no difference in comorbidity. The mean wound healing time was seven months. DR did not lead to a higher healing rate. The fastest healing rate was obtained when opting for a DR with an autologous greater saphenous vein (GSV; 90% at 12 months). Cryopreserved allografts also yielded good results, especially for wound healing after IR (85% at 12 months). Major amputation was performed in 28.5% after IR vs. 17.3% after DR (p ¼ .071). There was no difference in mortality rate (36.8% [DR] vs. 41.3% [IR]) (p ¼ .088). Autologous GSV had a longer primary patency, primary assisted patency, and secondary patency (26, 34, and 38 months, respectively) than cryopreserved GSV (12.5, 18, and 24 months, respectively) (p ¼ .002, p ¼ .003, and p ¼ .018, respectively), with no difference between DR and IR. Conclusion: Direct or indirect revascularisation performed according to the angiosome concept definition yields similar results with regard to healing rates, limb salvage, and mortality.

Research paper thumbnail of The impact of an angiosome-targeted revascularization on healing rate, limb salvage and survival in critical limb threatening ischemia

Acta Chirurgica Belgica, Jun 21, 2021

Abstract Objective According to the angiosome concept ulcer healing and limb salvage should be su... more Abstract Objective According to the angiosome concept ulcer healing and limb salvage should be superior if direct arterial flow to the source vessel of an affected angiosome is established compared to indirect flow where the angiosome is perfused by means of collaterals. The objective of this study was to evaluate the impact of direct versus indirect revascularization (DR/IR) in endovascular versus bypass surgery on ulcer healing, limb salvage and mortality. Materials and methods A retrospective analysis of both endovascular and bypass distal (below the knee) lower limb revascularizations for chronic limb-threatening ischemia (CLTI) between 1993 and 2014 was performed. Results The study population consisted of 126 endovascular and 198 bypass procedures. DR and IR were achieved in 57.4% and 42.6% limbs respectively. DR was not superior to IR regarding all three major endpoints when endovascular and bypass procedures were analyzed separately. Endovascular and bypass procedures resulted in comparable healing rates. All patients who did not achieve wound healing (HR 7.49; 95% CI 4.25–13.20, p = .0001) or needed to be treated with a bypass (HR 1.79; 95% CI 1.05–3.05, p = .034) were at an increased risk for major amputation. Increased mortality rate was noted after endovascular procedures (HR 1.45; 95% CI 1.04–2.00, p = .026). Conclusion This retrospective study with comparable results for DR and IR did not support the angiosome concept. Achieving wound healing remains critical in patients with CLTI to reduce major amputation rates. Overall the implications of the angiosome concept seem to be limited due to its feasibility in patients with CLTI.

Research paper thumbnail of Extracranial metastases of an intraosseous meningioma: a rare occurrence in a not so rare tumor

Research paper thumbnail of A false diagnosis of focal nodular hyperplasia at gadoxetic acid-enhanced hepatobiliary phase MRI

Research paper thumbnail of Impact of Angiosome Targeted Femorodistal Bypass Surgery on Healing Rate and Outcome in Critical Limb Ischemia

European Journal of Vascular and Endovascular Surgery, 2015

factors, using vascular endothelial growth factor A165 (VEGF) as a model component. Methods: Poly... more factors, using vascular endothelial growth factor A165 (VEGF) as a model component. Methods: Polymeric PEA microspheres were prepared and loaded with VEGF. The release of VEGF from these microspheres, in both cell culture medium and human serum at 37 C was followed over time. VEGF concentrations were analyzed by ELISA; biological activity of the released VEGF was assessed using proliferation assays on human umbilical vein endothelial cells (HUVECs). VEGF-loaded microspheres were investigated for their pro-angiogenic potential in vivo, either in matrigel plugs or by intramuscular injection after induction of hindlimb ischemia in mice. Neovascularization was monitored by immunohistochemistry and Laser Doppler Perfusion Imaging. Results: Our experiments showed that VEGF remains stable and biologically active during both fabrication and long-term storage of the microspheres. After re-suspension in either cell culture medium or human serum, VEGF is released from the microspheres. An initial burst release over 48 hours is followed by a gradual, sustained release over 2 weeks. The released VEGF was able to induce proliferation of HUVECs with virtually no loss of biological activity. In vivo, microspheres containing approximately 15 ng VEGF were able to induced angiogenesis similar to 250 ng of unprotected VEGF in a matrigel plug assay in mice. After induction of hindlimb ischemia, both VEGF and VEGF-loaded microspheres show a comparable increase in blood flow recovery. Immunohistochemical analyses however show a stronger increase in the number of collateral arteries in the adductor muscles of mice treated with VEGF loaded microspheres compared to free VEGF. Conclusion: VEGF can be loaded into polymeric PEA microspheres and stored without loss of biological activity. Under physiological conditions, a burst of VEGF is released over 48 hours, followed by sustained release of VEGF over 2 weeks. VEGF-loaded microspheres showed an over tenfold increase in angiogenic potential compared to free VEGF in vivo in matrigel plugs. Furthermore the increase in number of collateral arteries in the adductor muscles of mice subjected to hindlimb ischemia suggests a beneficial effect of sustained release of VEGF.

Research paper thumbnail of The impact of an angiosome-targeted revascularization on healing rate, limb salvage and survival in critical limb threatening ischemia

Acta Chirurgica Belgica, 2021

OBJECTIVE According to the angiosome concept ulcer healing and limb salvage should be superior if... more OBJECTIVE According to the angiosome concept ulcer healing and limb salvage should be superior if direct arterial flow to the source vessel of an affected angiosome is established compared to indirect flow where the angiosome is perfused by means of collaterals. The objective of this study was to evaluate the impact of direct versus indirect revascularization (DR/IR) in endovascular versus bypass surgery on ulcer healing, limb salvage and mortality. Materials and methods: A retrospective analysis of both endovascular and bypass distal (below the knee) lower limb revascularizations for chronic limb-threatening ischemia (CLTI) between 1993 and 2014 was performed. Results: The study population consisted of 126 endovascular and 198 bypass procedures. DR and IR was achieved in 57.4% and 42.6% limbs respectively. DR was not superior to IR regarding all three major endpoints when endovascular and bypass procedures were analysed separately. Endovascular and bypass procedures resulted in comparable healing rates. All patients who did not achieve wound healing (HR 7.49; 95% CI 4.25-13.20, p=.0001) or needed to be treated with a bypass (HR 1.79; 95% CI 1.05-3.05, p=.034) were at an increased risk for major amputation. Increased mortality rate was noted after endovascular procedures (HR 1.45; 95% CI 1.04-2.00, p=.026). Conclusion: This retrospective study with comparable results for DR and IR did not support the angiosome concept. Achieving wound healing remains critical in patients with CLTI to reduce major amputation rates. Overall the implications of the angiosome concept seem to be limited due to its feasibility in patients with CLTI.

Research paper thumbnail of Impact of Angiosome Targeted Femorodistal Bypass Surgery on Healing Rate and Outcome in Chronic Limb Threatening Ischaemia

European Journal of Vascular and Endovascular Surgery

Research paper thumbnail of Intrathecal gadolinium-enhanced MR-cisternography for the detection of a petrous bone defect in a patient with spontaneous intraventricular pneumocephalus

Research paper thumbnail of An uncommon cause of sciatic pain: tuberculous osteomyelitis of the ischial tuberosity

Acta Clinica Belgica, 2017

A 66-year-old Caucasian female presented with insidious sciatic pain leading to an uncommon diagn... more A 66-year-old Caucasian female presented with insidious sciatic pain leading to an uncommon diagnosis of tuberculous osteomyelitis with unknown portal entry. The patient did not report a history of a previous tuberculosis (TB) infection and her chest X-ray was negative for TB. Considering TB in the differential diagnosis of a 'bone abscess', it is of paramount importance to come to a correct diagnosis. Conventional radiographs still remain the first-line imaging modality for evaluation of skeletal symptomatology. However, biopsies or aspirates are often needed to yield the definitive diagnosis. The lack of awareness of the potential extrapulmonary involvement of TB leads to an important delay in diagnosis and treatment. Antituberculous drugs should be started at the time of biopsy and continued during 12-18 months, due to poor drug penetration into osseous and fibrous tissues.

Research paper thumbnail of An uncommon cause of sciatic pain: tuberculous osteomyelitis of the ischial tuberosity

Acta Clinica Belgica, Jan 11, 2017

A 66-year-old Caucasian female presented with insidious sciatic pain leading to an uncommon diagn... more A 66-year-old Caucasian female presented with insidious sciatic pain leading to an uncommon diagnosis of tuberculous osteomyelitis with unknown portal entry. The patient did not report a history of a previous tuberculosis (TB) infection and her chest X-ray was negative for TB. Considering TB in the differential diagnosis of a 'bone abscess', it is of paramount importance to come to a correct diagnosis. Conventional radiographs still remain the first-line imaging modality for evaluation of skeletal symptomatology. However, biopsies or aspirates are often needed to yield the definitive diagnosis. The lack of awareness of the potential extrapulmonary involvement of TB leads to an important delay in diagnosis and treatment. Antituberculous drugs should be started at the time of biopsy and continued during 12-18 months, due to poor drug penetration into osseous and fibrous tissues.

Research paper thumbnail of Impact of Angiosome Targeted Femorodistal Bypass Surgery on Healing Rate and Outcome in Chronic Limb Threatening Ischaemia

European Journal of Vascular and Endovascular Surgery, Jul 1, 2020

WHAT THIS PAPER ADDS Based on the angiosome concept definition of direct (DR) and indirect revasc... more WHAT THIS PAPER ADDS Based on the angiosome concept definition of direct (DR) and indirect revascularisation (IR), this study concludes that there is no difference between DR or IR in wound healing rate, major amputation, or mortality. Therefore, revascularisation should not be denied to patients in whom only IR is possible. Cryopreserved allografts can be a valuable alternative when no good quality autologous vein is available. Objective: In the presence of long lesions, in patients with chronic limb threatening ischaemia, a femorodistal bypass is often the only option to avoid major amputation. This study investigated whether targeted bypass to the affected angiosome, according to the angiosome concept definition of direct (DR) and indirect revascularisation (IR), has an impact on wound healing, major amputation rate, and mortality. Methods: A retrospective analysis was performed at Ghent University Hospital of 201 non-healing ischaemic wounds (Rutherford categories 5 and 6) requiring femorodistal bypass surgery in 177 patients (61% male, median age 69 years) with a follow up of 36 months. For every patient, the site of the ulcer, the type of bypass, and material were identified. Based on ulcer location and distal anastomosis, the legs were divided into DR and IR. KaplaneMeier univariable analysis was used to estimate cumulative ulcer healing, leg salvage, survival, and patency. Results: DR was performed in 103 legs (51%) and IR in 98 legs (49%), with no difference in comorbidity. The mean wound healing time was seven months. DR did not lead to a higher healing rate. The fastest healing rate was obtained when opting for a DR with an autologous greater saphenous vein (GSV; 90% at 12 months). Cryopreserved allografts also yielded good results, especially for wound healing after IR (85% at 12 months). Major amputation was performed in 28.5% after IR vs. 17.3% after DR (p ¼ .071). There was no difference in mortality rate (36.8% [DR] vs. 41.3% [IR]) (p ¼ .088). Autologous GSV had a longer primary patency, primary assisted patency, and secondary patency (26, 34, and 38 months, respectively) than cryopreserved GSV (12.5, 18, and 24 months, respectively) (p ¼ .002, p ¼ .003, and p ¼ .018, respectively), with no difference between DR and IR. Conclusion: Direct or indirect revascularisation performed according to the angiosome concept definition yields similar results with regard to healing rates, limb salvage, and mortality.

Research paper thumbnail of The impact of an angiosome-targeted revascularization on healing rate, limb salvage and survival in critical limb threatening ischemia

Acta Chirurgica Belgica, Jun 21, 2021

Abstract Objective According to the angiosome concept ulcer healing and limb salvage should be su... more Abstract Objective According to the angiosome concept ulcer healing and limb salvage should be superior if direct arterial flow to the source vessel of an affected angiosome is established compared to indirect flow where the angiosome is perfused by means of collaterals. The objective of this study was to evaluate the impact of direct versus indirect revascularization (DR/IR) in endovascular versus bypass surgery on ulcer healing, limb salvage and mortality. Materials and methods A retrospective analysis of both endovascular and bypass distal (below the knee) lower limb revascularizations for chronic limb-threatening ischemia (CLTI) between 1993 and 2014 was performed. Results The study population consisted of 126 endovascular and 198 bypass procedures. DR and IR were achieved in 57.4% and 42.6% limbs respectively. DR was not superior to IR regarding all three major endpoints when endovascular and bypass procedures were analyzed separately. Endovascular and bypass procedures resulted in comparable healing rates. All patients who did not achieve wound healing (HR 7.49; 95% CI 4.25–13.20, p = .0001) or needed to be treated with a bypass (HR 1.79; 95% CI 1.05–3.05, p = .034) were at an increased risk for major amputation. Increased mortality rate was noted after endovascular procedures (HR 1.45; 95% CI 1.04–2.00, p = .026). Conclusion This retrospective study with comparable results for DR and IR did not support the angiosome concept. Achieving wound healing remains critical in patients with CLTI to reduce major amputation rates. Overall the implications of the angiosome concept seem to be limited due to its feasibility in patients with CLTI.

Research paper thumbnail of Extracranial metastases of an intraosseous meningioma: a rare occurrence in a not so rare tumor

Research paper thumbnail of A false diagnosis of focal nodular hyperplasia at gadoxetic acid-enhanced hepatobiliary phase MRI

Research paper thumbnail of Impact of Angiosome Targeted Femorodistal Bypass Surgery on Healing Rate and Outcome in Critical Limb Ischemia

European Journal of Vascular and Endovascular Surgery, 2015

factors, using vascular endothelial growth factor A165 (VEGF) as a model component. Methods: Poly... more factors, using vascular endothelial growth factor A165 (VEGF) as a model component. Methods: Polymeric PEA microspheres were prepared and loaded with VEGF. The release of VEGF from these microspheres, in both cell culture medium and human serum at 37 C was followed over time. VEGF concentrations were analyzed by ELISA; biological activity of the released VEGF was assessed using proliferation assays on human umbilical vein endothelial cells (HUVECs). VEGF-loaded microspheres were investigated for their pro-angiogenic potential in vivo, either in matrigel plugs or by intramuscular injection after induction of hindlimb ischemia in mice. Neovascularization was monitored by immunohistochemistry and Laser Doppler Perfusion Imaging. Results: Our experiments showed that VEGF remains stable and biologically active during both fabrication and long-term storage of the microspheres. After re-suspension in either cell culture medium or human serum, VEGF is released from the microspheres. An initial burst release over 48 hours is followed by a gradual, sustained release over 2 weeks. The released VEGF was able to induce proliferation of HUVECs with virtually no loss of biological activity. In vivo, microspheres containing approximately 15 ng VEGF were able to induced angiogenesis similar to 250 ng of unprotected VEGF in a matrigel plug assay in mice. After induction of hindlimb ischemia, both VEGF and VEGF-loaded microspheres show a comparable increase in blood flow recovery. Immunohistochemical analyses however show a stronger increase in the number of collateral arteries in the adductor muscles of mice treated with VEGF loaded microspheres compared to free VEGF. Conclusion: VEGF can be loaded into polymeric PEA microspheres and stored without loss of biological activity. Under physiological conditions, a burst of VEGF is released over 48 hours, followed by sustained release of VEGF over 2 weeks. VEGF-loaded microspheres showed an over tenfold increase in angiogenic potential compared to free VEGF in vivo in matrigel plugs. Furthermore the increase in number of collateral arteries in the adductor muscles of mice subjected to hindlimb ischemia suggests a beneficial effect of sustained release of VEGF.

Research paper thumbnail of The impact of an angiosome-targeted revascularization on healing rate, limb salvage and survival in critical limb threatening ischemia

Acta Chirurgica Belgica, 2021

OBJECTIVE According to the angiosome concept ulcer healing and limb salvage should be superior if... more OBJECTIVE According to the angiosome concept ulcer healing and limb salvage should be superior if direct arterial flow to the source vessel of an affected angiosome is established compared to indirect flow where the angiosome is perfused by means of collaterals. The objective of this study was to evaluate the impact of direct versus indirect revascularization (DR/IR) in endovascular versus bypass surgery on ulcer healing, limb salvage and mortality. Materials and methods: A retrospective analysis of both endovascular and bypass distal (below the knee) lower limb revascularizations for chronic limb-threatening ischemia (CLTI) between 1993 and 2014 was performed. Results: The study population consisted of 126 endovascular and 198 bypass procedures. DR and IR was achieved in 57.4% and 42.6% limbs respectively. DR was not superior to IR regarding all three major endpoints when endovascular and bypass procedures were analysed separately. Endovascular and bypass procedures resulted in comparable healing rates. All patients who did not achieve wound healing (HR 7.49; 95% CI 4.25-13.20, p=.0001) or needed to be treated with a bypass (HR 1.79; 95% CI 1.05-3.05, p=.034) were at an increased risk for major amputation. Increased mortality rate was noted after endovascular procedures (HR 1.45; 95% CI 1.04-2.00, p=.026). Conclusion: This retrospective study with comparable results for DR and IR did not support the angiosome concept. Achieving wound healing remains critical in patients with CLTI to reduce major amputation rates. Overall the implications of the angiosome concept seem to be limited due to its feasibility in patients with CLTI.

Research paper thumbnail of Impact of Angiosome Targeted Femorodistal Bypass Surgery on Healing Rate and Outcome in Chronic Limb Threatening Ischaemia

European Journal of Vascular and Endovascular Surgery

Research paper thumbnail of Intrathecal gadolinium-enhanced MR-cisternography for the detection of a petrous bone defect in a patient with spontaneous intraventricular pneumocephalus

Research paper thumbnail of An uncommon cause of sciatic pain: tuberculous osteomyelitis of the ischial tuberosity

Acta Clinica Belgica, 2017

A 66-year-old Caucasian female presented with insidious sciatic pain leading to an uncommon diagn... more A 66-year-old Caucasian female presented with insidious sciatic pain leading to an uncommon diagnosis of tuberculous osteomyelitis with unknown portal entry. The patient did not report a history of a previous tuberculosis (TB) infection and her chest X-ray was negative for TB. Considering TB in the differential diagnosis of a 'bone abscess', it is of paramount importance to come to a correct diagnosis. Conventional radiographs still remain the first-line imaging modality for evaluation of skeletal symptomatology. However, biopsies or aspirates are often needed to yield the definitive diagnosis. The lack of awareness of the potential extrapulmonary involvement of TB leads to an important delay in diagnosis and treatment. Antituberculous drugs should be started at the time of biopsy and continued during 12-18 months, due to poor drug penetration into osseous and fibrous tissues.