The innovations for disease management need to be thoroughly evaluated so that their benefits and potential downsides can be compared with the already existing approaches. Endovascular laser (EVL) treatment for varicose veins offers today several advantages over surgical standard stripping. The Italian Endovenous-laser Working Group (IEWG) is a homogeneous group of surgeons and phlebologists who have been using EVL since 1999 and has undertaken to examine EVL in a multicenter study starting from a well defined rationale, with the benefit of a single protocol to use.
In a cooperative, multicenter, clinical study, 1076 limbs in 1050 patients, mean age of 54.5 years, 241 males and 809 females affected by chronic venous insufficiency (CVI) were considered eligible for surgery and stratified by CEAP classification in a four-year period (January 1999 December 2003). Inclusion criteria were insufficiency of the great and/or small saphenous vein at various levels, beyond those accessory saphenous trunks with incompetence in the saphenofemoral junction. In all cases truncular reflux apparead up on duplex scan examination, with or without associated varicosities. All the patients underwent a surgery on the basis of the clinical assessment. All the centres involved performed treatment in conformity with the Food and Drug Administration (FDA) validated procedure, using an endo-laser venous system kit with a 810-980 nm diode. Duplex scan was performed in all patients after 36 months with very few lost to follow-up cases.
In the immediate postoperative period the results have been impressive, with a very effective closure of incompetent great saphenous vein and the other treated varicose veins (the early occlusion rate has been 99%). Major complications have not been detected: in particular, no deep venous thrombosis (DVT) evaluated duplex ultrasound. The patients' acceptability and satisfaction regarding the procedure, have been measured by means of a questionnaire on the quality of life, and the result was 96.7%. After 36 months, the total occusion rate of saphenous trunks has been 97%.
The first important Italian experience with EVL based on preoperative, perioperative and postoperative duplex control and which is also based on the patients' satisfaction at mid/long-term has indicated some advantages over the standard treatment with the stripping method. In terms of reduced postoperative pain, shorter sick leave, a faster resumption of the normal activities, and, in particular, the total absence of DVT, we can conclude that EVL is a good solution for all patients with anatomic and hemodinamic patterns for saphenous vein surgery.
The aim of this paper was to evaluate the efficacy of the concomitant use of endovenous laser treatment (ELT) and ultrasound-guided foam sclerotherapy (USGFS) in the management of chronic venous disorder and to objectively analyze the influence of the combination therapy on the Health Related Quality of Life (HRQL) of the treated patients.
In this prospective series, 1 114 varicose veins in 924 consecutive subjects were treated either with a 980 nm (7-15W) or a 1320 nm (3-10W) endovenous laser. Inclusion criteria: informed consent, clinical, etiologic, anatomical, and pathophysiological (CEAP) clinical class >or=2, and an accessible vein. Exclusion criteria: coagulation disorder, pregnancy, lactation, current thrombosis, systemic disease, poor general health, or allergy to sodium tetradecyl sulfate (STS). ELT was performed on refluxing saphenous truncal and non-saphenous veins, including incompetent perforators. USGFS was utilized to treat selective refluxing, symptomatic varicose tributaries that were not amenable to ELT alone. The Venous Dysfunction Score (VDS) and Health Related Quality of Life (HRQL) were assessed. All of the patients were strictly monitored and had Duplex ultrasound scanning to evaluate for deep vein thrombosis (DVT) at 24-72 hours. Thorough Duplex scanning was done at 1 week, 1 month, 3 months, 6 months, 12 months, and 24 months.
At 1 month, there was continued reflux (> 0.5 seconds) in 26 SFJs (3.0%, N=824) and 4 SPJ s (2.5%, N=155) and at 3 months in 15 SFJs (1.8%), 5 SPJ s (3.7%). At 6 months, reflux was present in 10 SFJs (1.2%) and 4 SPJs (2.5%). At a mean of 12+/-10 months of post-treatment follow-up, 4 SFJ (1.9%, N=207) and 1 SPJ (1.9%, N=52) had reflux. Overall, there was elimination of reflux in 98% of junctions. The posterior accessory saphenous veins (PAV: N=117) had 100 % elimination of reflux at 1 month, a result that remained unchanged for more than a year (P<0.001). Similarly, anterior accessory saphenous veins (AAV: N=56), cranial, caudal, or thigh, extensions of the small saphenous vein (CESSV: N=31), and non-saphenous veins and incompetent perforators (NSV, IP: N=31) all had sustained and statistically significant response (P<0.001). Sequentially assessed VDS showed significant improvement (P<0.001). The Aberdeen Varicose Vein Questionnaire (AVVQ) revealed significant improvement in HRQL at 1-2 year (P<0.001). Failed ELT attempts occurred in six cases due to vein spasm (N=4, 0.36%) or fiber/laser machine malfunction (N=2, 0.18%). These veins were successfully treated with ultrasound-guided foam sclerotherapy. Thirty-two patients (2.9%) complained of a small area of numbness at one month. There was complete resolution in 6 (18.8%) of the patients by 6 months. There were four cases of a localized cellulitis at laser venous access sites. These resolved uneventfully with oral antibiotics. There were also two skin reactions, with localized urticaria, due to dressing tape. These required no additional treatment. There were two cases of superficial phlebitis that resolved with continued compression and NSAIDs. There was one asymptomatic popliteal DVT and one uncomplicated superficial skin burn that both resolved uneventfully with no treatment other than observation. No pulmonary embolism (PE), thrombophlebitis, or visual disturbance occurred.
Ultrasound-guided foam sclerotherapy given concomitantly with ELT is safe and highly efficacious in the management of GSV, SSV reflux and in their tributaries or in non-saphenous veins. CVD patients treated with combination therapy given in this manner demonstrated significant improvement in their HRQL.
The aim of our study was to evaluate a possible association between subclinical atherosclerosis in carotid arteries and the connexin 37 gene polymorphism (1019C>T; Pro319Ser) in a population of urban and rural women.
A 5% population sample of urban women aged 45-54 years (N.=896) and a 1% representative sample of rural women aged 33-72 years (N.=152) were examined using an identical protocol and genotyped for Cx37 gene polymorphism. The association between the Cx37 polymorphism and intima-media thickness in common carotid arteries measured by ultrasound (CIMT) was studied.
We have found a different pattern of the effect of the Cx37 gene on CIMT with regard to fasting glycemia with significant interaction between fasting glycemia and Cx37 gene on CIMT (test for equality of slopes P<0.0001). In addition, we also detected potential threshold effect of fasting glycemia at the concentration of 5.5 mmol/L (ANCOVA; P=0.026). Carriers of TT genotype showed protection against subclinical atherosclerosis if their fasting glycemia was above 5.5 mmol/L.
In women with higher fasting glycemia TT genotype of Cx37 polymorphism was protective against subclinical atherosclerosis. Therefore, the Cx37 gene may exert completely different effects in the artery wall, depending on glycemia.
The differential diagnosis of Raynaud's Phenomenon (RP) is still problematic because of the wide variety of underlying etiological possibilities. Therefore, the diagnostic screening of patients requires easily reproducible, rapid and reliable tests to find those cases of RP secondary to a connective tissue disorder. The present study of 106 consecutive RP patients was carried out by using a combination of clinical examination, biomicroscopy of fingernail folds and bulbar conjunctiva (with scoring of vascular damage), plus the assessment of antinuclear antibodies on HEP2 cells. On the basis of the reported findings, it can be concluded that patients with RP secondary to collagen disease or so suspected also show abnormalities of the conjunctival microcirculatory bed. Patients with both primary and suspected secondary RP are significantly younger at the time of first diagnosis than patients with collagen disease-associated RP.
Elevated urinary 11-dehydrothromboxane levels place patients at an increased risk for experiencing cardiovascular events. Statins exert an inhibitory effect on platelets. The aim of our study was to determine the effect of 3-month statin therapy on 11-dehydrothromboxane elimination in two groups of patients, one not receiving antiplatelet therapy with acetylsalicylic acid and the other receiving 100 mg acetylsalicylic acid per day.
We examined the urinary levels of 11-dehydrothromboxane in a total of 58 patients before and after 3-month therapy with a statin at standard doses (simvastatin, fluvastatin, atorvastatin). We also examined the plasma levels of total cholesterol, triglycerides, LDL- and HDL-cholesterol, C-reactive protein, and blood glucose.
After 3-month statin therapy, both groups of patients (with and without antiplatelet therapy) showed a significant decrease in urinary 11-dehydrothromboxane levels. Significant decreases were also seen in LDL- and total cholesterol, and C-reactive protein. Changes in the other parameters were not significant.
Three-month statin therapy significant reduces the rate of 11-dehydrothromboxane elimination, even in patients on acetylsalicylic acid. In addition to its usual lipid-lowering effect, it significantly decreases the plasma levels of C-reactive protein. Combination therapy with a statin plus acetylsalicylic acid may be effective even in patients with incomplete thromboxane inhibition on antiplatelet therapy with acetylsalicylic acid.
The study was performed to evaluate the diagnostic value of Indium-111-leukocytes scintigraphy in arterial prosthetic infection. Scintigrams were performed in 19 patients in two groups. Group A consisted of 11 patients, where ten days after uncomplicated graft implantation, an Indium-111-scintigraphy was performed. Group B consisted of 8 patients, where we suspected an infected arterial graft. In group A we had one false-positive scan and in group B one false-negative scan. This gives an accuracy of 89%, a sensitivity of 87% and a specificity of 90%. These results indicate that Indium-111-leukocytes scintigraphy is a favourable test to detect a vascular graft infection.
The homozygous 677TT mutation of the MTHFR gene has been linked to deep vein thrombosis and to arterial atherosclerotic events of the coronary, carotid and peripheral arteries. Its putative association with renal arteriosclerosis and chronic renal failure (CRF) in the presence of hypertensive nephrosclerosis is yet to be investigated.
Two hundred and twenty-one Greek-Cypriot patients with CRF from one single renal unit in Cyprus were divided into 6 diagnostic categories: 49 due to chronic glomerulonephritis (22.2%), 43 due to diabetes mellitus (19.4%), 26 due to autosomal dominant polycystic kidney disease (11.8%), 30 due to essential hypertension leading to nephrosclerosis (13.6%), including 4 patients with primary malignant hypertension, 32 with other rarer causes of CRF (14.5%) and 41 of uncertain etiology (18.5%). These 221 CRF patients had their MTHFR C677T and A1298C genotypes analyzed by the polymerase chain reaction and agarose gel electrophoresis after restriction enzyme digestion. The frequency of the homozygous states 677TT and 1298CC and the double heterozygous 677CT/1298AC were compared to those of 210 unrelated normal local controls.
A statistically significant increase in the frequency of the 677TT genotype compared to controls was only found in the hypertensive nephrosclerosis CRF sub-group of patients. The prevalence rate of the 677TT genotype was 46.7% (controls 17.6%, P=0.0007). Combined together the homozygous 677TT and the double heterozygous 677CT/1298AC genotypes were found in 86.7% of the hypertensive nephrosclerotic CRF patients, compared to 46.6% in normal controls (P=0.0001).
The findings support the hypothesis that Caucasian patients with essential hypertension, homozygous for 677TT or doubly heterozygous for 677CT/1298AC genotypes, are predisposed to develop hypertensive nephrosclerosis and CRF.
The purpose of the present study is to document the short term clinical results after implantation of the new Stretch ePTFE (Gore-Tex) arterial prostheses in patients with aortic or aorto-iliac occlusive atherosclerotic disease or aneurysm.
A descriptive, prospective and non-randomized clinical series with clinical follow-up at three and 12 months.
The study was performed at an Academic Vascular Surgery Unit.
Within 20 months we consecutively implanted 379 prostheses (tubes or bifurcations): 132 Stretch ePTFE (Gore-Tex) and 247 Dacron (Unigraft, Braun-Melsungen) grafts.
There was no intraoperative deaths. Nine of 217 patients (= 4%) with occlusive atherosclerotic disease died < 30 days postoperatively; the mortality rate for asymptomatic aortic aneurysm was 8% (7/91), for symptomatic aneurysm 13% (4/30), and for ruptured aneurysm 22% (8/36). The primary patency of the aortic or aorto-iliac grafts was 99%, secondary patency at three months and one year 100 per cent. One patient with Stretch prosthesis developed a superficial groin infection, and one developed infection of an aortic tube graft. In the Dacron series six patients developed superficial groin infection, and two deep infections occurred. No graft-enteric fistulas or erosions were seen, and by clinical examination no anastomotic aneurysm developed. Five patients had in situ replacement of a pan-infected Dacron bifurcation graft with a Gore-Tex Stretch graft. With an observation time from 50 to 400 days these five patients are well without clinical signs of infection.
These short term results with implantation of aortic or aorto-iliac Stretch ePTFE prostheses are encouraging and will provide the basis for a continuing performance trial with long term follow-up and reporting.
Transcranial Doppler is often proposed for evaluation of the Circle of Willis prior to carotid endarterectomy. The purpose of this study was to evaluate preoperative TCD before carotid surgery.
This is a retrospective report of 137 carotid endarterectomies performed under regional anesthesia operated between January 1992 on June 1996. All patients have a tight stenosis between 70% on 99%, and 49% were symptomatic. Forty-three patients of the 132 had a controlateral hemodynamically significant carotid stenosis with none occlusion. The TCD examinations were all performed with ADMS Doppler Spectradop with 3-MHz and 2-MHz probes. Clinical evaluation during cross-clamping was compared to the preoperative TCD. In 14% of the patients, the TCD could not be performed because there are not temporal bone windows.
When the patients could be tested the positive predictive value of the TCD was 18% and the sensitivity was 33%. The negative predictive value was 94%. 8% of the patients were shunted. TCD had numerous difficulties. The most common is the lack of the temporal bone window (40% of the patients). The compression test is often difficult when the lesion is calcareous. Preoperative TCD is not according to our results, a reliable enough examination to modify operative strategy during carotid surgery. When coupled with arteriography it is a good way to study cerebral hemoynamics.
Regional anesthesia with local supplication remains the method of choice to select those patients who require a shunt during carotid surgery. It can be used routinely and it is less complex than the various methods.
Forty consecutive patients underwent extracranial arteriography between 1974-1976 because of cerebrovascular disease and were treated nonoperatively. This period was chosen to ensure a sufficiently long follow-up. The treatment selection was made individually by the patient's doctor. Deaths (n = 22) during 14 years of follow-up were caused by cerebrovascular disease in 41%, by coronary heart disease in 27% and other in 32%. The median age of decreased patients (group A) was 60.5 years at the time of arteriography and of patients alive after follow-up (group B) 55.5 years, respectively (p = 0.007). Findings were more severe arteriographically in group A than in group B. Twelve patients had occlusion or > 50% stenosis in the common carotid artery or the internal carotid artery in group A and three in group B (p = 0.014). During follow-up there were 17/22 cerebrovascular events in group A and 8/18 in group B (p = 0.033). Smoking was significantly more common in group A (p = 0.002). When the patients were divided on the basis of haemodynamically significant carotid artery stenosis, patients with significant stenosis (group C) proved to be older than patients with non-significant stenosis (group D), 62.0 versus 57.0 years, respectively (p = 0.001). The incidence of cerebrovascular events was equal in these groups. Our data suggest that patients with over 50% carotid stenosis have a poor long term prognosis, associated with age and smoking.
Chronic traumatic thoracic aneurysms are results of blunt trauma of the chest during motorcar accident. Treatment of choice is the endovascular procedure with stent-graft.
Between 2000-2012 in General and Thoracic Surgery Department 30 patients with post-traumatic aneurysms were operated. In all cases aneurysm was located below left subclavian artery and in 63% developed during road traffic accident.
All patients were operated on with 100% technical success and no device failure was noticed. None of patients died during the endovascular procedure and no serious complications like spinal cord ischemia was observed. In one (3%) case, where left subclavian artery was covered, stroke was diagnosed treated conservatively.
At long-term follow-up, one endoleak type IA was found, solved with balloon-plasty. Two patients died due to cardiac diseases.
In order to assess the role of percutaneous peripheral rotational ablation using Rotablator (PPRA), 95 symptomatic patients (58 M, 37 F, m. age: 77 +/- 1 y) (r: 50-90 y) having 146 peripheral vascular lesions (PVL) were treated by PPRA. 59% were below the knee and 41% above. The runoff status (n of distal leg art. involved) was as follows: 3:52 pts, 2:23 pts, 1:14 pts, 0:6 pts. The femoral lesions were significantly longer than those at other sites (5.27 +/- 0.43 vs 2.97 +/- 0.3 cm) (p < 0.001). The mean length was 3.73 +/- 0.26 cm (r: 1-20 cm). Complementary PTA was significantly (p < 0.001) more frequent in femoro-popliteal (32 PTA/48 Fem, 5 PTA/12 Pop) than in distal leg lesions (10/86.). RESULTS. After PPRA alone (99 PVL) the stenosis % decreased from 81 +/- 0.75 to 18 +/- 1.1. The residual stenosis was greater at femoral (26 +/- 2.3%) than at distal leg level (16 +/- 1.2%) (p < 0.01). Complementary PTA (47 PVL) lowered residual stenosis from 44% to 13%. 52 complications (spasm, perforation, dissection, distal emboli, no reflow, others) were cured in 47 PVL. Thus our primary technical success per PVL was 97% and per pt 95%. The mean follow-up period was 11 +/- 1 mths (r: 1-37 m). Among 78 pts having a follow-up period > or = 4 mths, 74 pts representing 115 treated PVL underwent an angiography control (2 deaths, 2 lost for follow-up). 87 lesions (76%) showed no restenosis and 28 lesions (34%) showed restenosis of 83 +/- 2.4% (r: 50-100%). The restenosis rate was higher in femoral (12/21: 36%) than in distal (15/58: 21%) or popliteal arteries (1/8: 12%). Restenosis was more frequent for PVL > or = 7 cm (67% vs 16%) (p < 0.001) at all sites. This result together with the complication rate would seem to indicate that lesions > or = 6.7 cm would be a limitation for PPRA. CONCLUSIONS. In our experience Percutaneous Peripheral Rotational Ablation has taken a pre-eminent position in the treatment of distal leg arteries. Our results lead us to broaden its indications to complex vascular lesions. The possibility of runoff treatment should allow an improvement in the long-term patency of PTA and bypass grafts.
We compared the use of two different laser wavelengths in the treatment of great saphenous vein (GSV) reflux: the 1500 nm versus the 980 nm diode laser. We studied the occlusion rates and noted possible side-effects.
In three centers 180 great saphenous veins were treated with endovenous laser ablation (EVLA). By random selection half of the patients were treated with a 980 nm laser and half with a 1500 nm laser. A Duplex scan was scheduled at one month and six months postoperatively. Ecchymosis was measured at one week using a calculated scale. In addition the need for analgesics, the induration around the treated vein and patient satisfaction rate were noted. At two weeks postoperatively a quality of life score (CIVIQ2) was obtained.
The complete occlusion rates at six months were not statistical significant different between both groups (95.5% for 980 nm and 93.1% for 1500 nm). Most of the non-occluded veins had a filiform internal lumen and did not show reflux. There was no significant difference in the postoperative appearance of ecchymosis (P=0.09). Patients treated with a 1500 laser had less induration around the treated vein (P=0.002), less need to take analgetics (1.8 days versus 2.9 days) and had a better postoperative quality of life (P=0.018). The patient satisfaction rate did not differ in the two groups.
Using a 1500 nm diode laser in the treatment of an incompetent GSV, compared to the use of a 980 nm laser, results in similar occlusion rates at six months, but somewhat less side-effects.
In order to evaluate regional muscle blood flow and oxygen utilization, we study with positron emission tomography (PET) the distribution of C15O2 and 15O2 in 17 subjects: 5 normals (24 +/- 3 years) and 12 patients (63 +/- 13.5 years). C15O2 and 15O2 are inhalated with a steady-state technique. Positron tomograms are recorded in supine position at the greatest diameter of the leg. Exercise consists in simultaneous ankle flexions. In all normals, C15O2 and 15O2 are distributed homogeneously and symmetrically in both legs. At rest, they concentrate in the region of vascular pedicle. After exercise, C15O2 and 15O2 are electively distributed in the anterolateral region of the leg. In patients, this pattern of distribution is similar but asymmetrical. Moreover, the regional uptake of C15O2 and 15O2 often dissociates. In conclusion, C15O2 and 15O2 allow to study repeatedly muscle blood flow and oxygen utilization in patients with peripheral ischemia, both at rest and after exercise. The broad spectrum of pathological changes observed in this study needs further metabolic investigations.
To evaluate the clinical features, angiographic findings and evolution of Takayasu's arteritis in a Belgian tertiary center, and to compare the findings with published series of Western patients.
Retrospective analysis of 15 patients with Takayasu's arteritis, satisfying the American College of Rheumathology criteria, in the period 1986 to 2002. Published series of Western patients were identified by means of a Medline search and citation-tracking.
Diagnosis was often delayed, with a median period of 9 months. Patients presented with a variety of symptoms and clinical signs and had on average 4.5 arterial segments involved at angiography. Twelve patients received corticosteroid treatment and 4 of them additional immunosuppressive drugs. Five patients underwent angioplasty and/or stenting and 8 patients had open surgical procedures. During follow-up, there were 2 cardiac deaths and 2 other patients died from intracranial hemorrhage. Comparison with published series of other Western patients did not reveal major differences of anatomical distributions of the lesions, but left the impression that more aggressive use of immunosuppressive drugs might have improved the outcome.
Takayasu's arteritis results in an important morbidity and mortality. More aggressive medical therapy may be advantageous, but this would require adequate investigation in a controlled trial for which a multicenter effort is needed because of the rarity of the disease.
The aim of this study is to evaluate early and long term results obtained with a retrospective review in 8-year experience with surgical/endovascular treatment of visceral artery aneurysm (VAA) in a single center.
Between 2001 and 2008 in our vascular surgery unit visceral artery aneurysms were diagnosed with CT and/or angiography in 17 patients (9 male), mean age 66 years old (range: 18 to 78). All patients underwent surgical or endovascular treatment of splanchnic artery aneurysm. In 14 patients the localization was single, in 3 it was multiple. The arteries involved were: splenic artery 53%, superior mesenteric artery 17.7%, pancreaticoduodenal artery 17.7%, celiac axis 5.8% and hepatic artery 5.8%. The 29.4% of the patients presented with aneurysm rupture. Coil embolizzation was used in 11.6% of the cases while surgery was used in 88.4% of the cases.
Total survival rate was 94.2%, the survival rate in emergency cases was 80% while it was 100% in elective cases. Follow-up revealed excellent results after an average of 46 months (range: 8-102).
The worst prognosis for ruptured cases associated with the good result of the surgical/endovascular treatment in elective cases, suggests active interaction for such pathologies; in emergency cases the mortality incidence is too high. Today endovascular treatment presents lower morbidity and mortality rates and shorter hospitalization, but surgery is still a good therapeutic option for the treatment of the VAA, in subjects with low surgical risk, determining a definitive and long-lasting correction of the aneurysmal pathology and guaranteeing the correct perfusion of the organs, by grafts; moreover many aneurysms are not suitable for endovascular treatment.
The interleukin-6 (IL-6) -174 G/C polymorphism has been reported to determine IL-6 levels and contribute to the development of cardiovascular disorders. The aim of our study was to evaluate the effect of the IL-6 -174 G/C polymorphism on hemostatic or inflammatory markers in patients with peripheral arterial occlusive disease (PAOD), a common manifestation of obliterative atherosclerosis.
Plasma IL-6, fibrinogen, C-reactive protein (CRP), tissue plasminogen activator, plasminogen activator inhibitor-1 (PAI-1), fibrinopeptide A and intercellular adhesion molecule-1 levels were determined in PAOD patients (n=50) and healthy controls (n=30) genotyped for the IL-6 -174 G/C polymorphism.
In the control group, IL-6, CRP and fibrinogen levels were significantly associated with the IL-6 -174 G/C polymorphism with a gene-dosage effect being the highest in the CC subjects and the lowest in those with the GG genotype (P<0.0001, P=0.0002 and P=0.0001, respectively). Interestingly, the CC homozygotes had lower PAI-1 levels than carriers of the G allele (P=0.04). In PAOD patients, the IL-6 -174 G/C polymorphism had no effect on all the variables measured.
In contrast to apparently healthy subjects, the IL-6 -174 G/C polymorphism showed no association with plasma IL-6, CRP, fibrinogen and PAI-1 levels in PAOD patients.
The aim of this paper was to determine prevalence and incidence of intervention required for concomitant Asymptomatic Vascular Disease (AVD) on patients undergoing their first elective peripheral arterial intervention.
This is a prospective observational study Data was obtained on patients undergoing peripheral revascularisation, abdominal aortic aneurysmal (AAA) repair or carotid procedure from 2006 to 2009. Of 542 complex arterial procedures, 328 patients had their first vascular intervention. (PAD=127, AAA=97, CAD=83, concomitant AAA and PAD=21). Primary endpoint is detection of any concomitant asymptomatic AAA, CAS or PAD. Secondary endpoints are need for intervention of AVD detected on screening, and major adverse clinical events during follow-up.
Prevalence of AVD detected was 13% PAD, 51% CAS and 8%AAA. Symptomatic and Asymptomatic PolyVasBed patients had 11.4- and 8.16-fold increased likelihood for detection of asymptomatic CAS respectively (P<0.0001) relative to the remaining study population. Asymptomatic PolyVasBed patients had 8.2 fold increased likelihood of asymptomatic AAA, P<0.0001, compared to the remaining study population. Likelihood for intervention in Asymptomatic PolyVasBed is OR 5.740 (P=0.044) and Symptomatic PolyVasBed is OR 4.500 (P<0.001). Asymptomatic AAA detected in both symptomatic and asymptomatic vascular disease patients, is the strongest predicting factor of intervention in 18 months follow-up. In Asymptomatic PolyVasBed patients, CAS and AAA have the highest prevalence.
Screening for AVD is mandatory prior to any vascular intervention.
The records of 304 patients operated on for vascular injuries were reviewed; 76 (25%) of these presented an iatrogenic vascular injury: 13 involved the upper limbs, 49 the lower limbs and 14 the neck and trunk. The lesions were due to a vascular catheterism in 40 patients, to orthopaedic treatment in 27 patients, to general surgery procedure in 3 patients, to urologic surgery in 3 and to otorhinolaryngologic surgery in 3. In vascular catheterism the prevalent complications were thromboses and embolisms; 3 patients needed an amputation after the surgical repair. In orthopaedic surgery, vascular complications were linked prevalently to hip surgery, exchange arthroplasty and upper tibial osteotomy. In urologic, otorhinolaryngologic and general surgery, vascular lesions were prevalently related to haemorrhagic complications, followed by incorrect haemostatic manoeuvres. Retroperitoneal fibrosis or previous surgery increased the risk of vascular injuries. Delay in treatment was responsible for post-operative death or incomplete recovery.
Systemic lupus erythematosus (SLE) patients can frequently present cardiac symptoms, however its etiology is not well known.
specialized out-patient unit for SLE patients at an university hospital.
15 SLE patients (13 females, 2 males; age range 18-64 years).
metabolic studies of the heart were done using 18F-deoxy-glucose (18FDG, 296-333 MBq on a 2-head hybrid system) as well as heart perfusion studies (111MBq 201Tl). Additional studies: resting ECG, echocardiography, stress ECG, immunological activity parameters, antibody analyses (ANA, ENA, anti-cardiolipin antibodies), CPK, troponin-T, and lipid profiles.
degree of correlation between conventional diagnostics and the imaging techniques.
Abnormal ECG in 10 cases, pericardial involvement in 11 cases, elevated CPK in 1 case. ANTIBODY PROFILES: anti-cardiolipin in 10/15, ENA in 9/15, ANA in 14/15. None of these changes were associated with parameters of immune activation. In the majority of cases (10/15) the 18FDG scan showed a speckled, inhomogeneous pattern of distribution, which contrasted sharply with a normal 201Tl scan. A similar pattern was observed in the patients with ocular mitochondrial myopathy, the anti-phospholipid syndrome as well as in dermatomyositis.
Our preliminary results suggest that SLE patients with cardiac symptoms may have an abnormal glucose metabolism of the myocardium as shown by a pathological 18FDG scan, whereas perfusion appears to be normal (reversed mismatch). The lack of correlation with acute elevation of cardiac enzymes or with ECG changes suggest a chronic process.
The aim of the present study was to discuss the approach to a rare, but challenging, clinical situation: the coexistence of an abdominal aortic aneurysm (AAA) and a pancreatic tumor. The authors present their experience and a review of the literature of the last 40 years. From January 1988 to December 2006 the authors faced 3 cases of associated AAA and pancreatic neoplasia. Through a Medline search the authors found 15 cases of this comorbidity reported in the literature from 1967 to 2006, obtaining a total number of 18 cases. The treatment of the two diseases was in a single stage in 4 cases (22%) and in two stages in 5 cases (28%), while only one pathology was treated in 7 cases (39%) and no treatment at all was attempted in 2 cases (11%). Mortality was 0%, while morbidity was 22%, i.e. in 4 cases out of 18, although no aortic prosthesis infection was recorded. From literature analysis and their experience the authors concluded that the surgical strategy in cases of AAA and a pancreatic tumor is to be chosen depending on the pancreatic tumor prognosis, the AAA dimensions and the schedule of chemotherapy. According to the authors, AAA surgical repair is recommended in case of pancreatic cystic adenoma and neuroendocrine neoplasia, in view of their good prognosis, while endovascular repair (EVAR), when feasible, is better in patients with pancreatic adenocarcinoma.
This paper describes our overall experience with venous reconstructive surgery in the past 15 years. A thorough diagnostic evaluation of the patient with advanced chronic venous insufficiency is necessary to guide the surgeon in selecting a surgical approach that will address the specific problem in each patient. The diagnostic workup will separate those with insufficiency due to valve incompetence from those with deep vein obstruction as the basis for their problem. The operations vary from vein ligations to valve reconstruction or transplantation for valve incompetence and venous bypasses for obstructive problems. An aggressive surgical attitude in chronic venous disease makes it possible to restore selected patients to full activity with symptom-free extremities rather than teaching them to live within the confines of their disease state by nonsurgical management.
The SHARP survey data comprises personal information, family history, lifestyle and risk factor prevalence for 19,400 men and women sampled from the Scottish working population between 1991 and 1996. The purpose of the survey was the achievement of a clearer understanding of coronary risk factor prevalence in the working population of Scotland; the education of that population through counselling and advice; and a clearer appreciation of an individual's risk factor profile as a predictor for future events. In this paper a selection of attributes is explored for the information they yield about the characteristics of an apparently healthy population. Comparisons are drawn with earlier studies.
A mobile risk factor screening unit toured workplaces throughout Scotland and recorded information on age, sex, occupation, social class, personal and family history, smoking, alcohol and salt consumption, body mass index, blood pressure, glucose and total cholesterol.
The variation in measured levels for common risk factors in a sample of apparently healthy Scottish people shows substantial differences from the measured variation in an unstratified survey.
Across all conventional coronary risk factor measurements, working Scottish people are uniformly "more healthy" than the general population. A comparison of trend with age for male and female smokers and non-smokers in cholesterol level shows no difference between smokers and non-smokers; a similar comparison for body mass index and weight shows some consistent differences but without statistical significance.
The aim of this retrospective observational study was to review the use of an intermittent pneumatic compression device on nonhealing wounds in patients with critical limb ischemia at Mayo Clinic Rochester.
The setting was a community and referral multidisciplinary wound care clinic. The authors analysed 107 patients, median age 73, with critical limb ischemia and active ulcers started using a compression device between 1998 and 2000; 101 patients had lower extremity ulcers, and 25% had a history of amputation, and 64% had diabetes. Of all the wounds, 64% were multifactorial in etiology, and 60% had associated transcutaneous oxygen tension levels below 20 mmHg. Patients were typically asked to use the device at home on the affected limb(s) for 6 hours daily. The main outcome criterion was complete wound healing with limb preservation.
The median follow-up after initiation of treatment was 6 months. Complete wound healing with limb preservation was achieved by 40% of patients with TcPO(2) levels below 20 mmHg; by 48% with osteomyelitis or active wound infection; by 46% with diabetes treated with insulin; and by 28% with a previous amputation. Half of all amputations occurred in patients with prior amputations. Seven patients discontinued the device because of pain experienced with its use.
Patients with critical limb ischemia and nonhealing wounds at high risk of amputation can achieve complete wound healing and limb preservation by using an intermittent pneumatic compression device.
Inflammation is considered to be one of the main mechanisms for the development and progression of peripheral arterial disease (PAD). Many studies have demonstrated that maximal exercise enhances the acute inflammatory response in claudicant patients, but no one has assessed the duration of this acute inflammatory activation. The aim of this study was to assess of the inflammatory pattern in claudicants and of the inflammatory response after maximal exercise and during the recovery from calf pain.
Eleven patients with moderate claudication (MC) (age: 60.5+/-5.8 years; body mass index [BMI]: 27.5+/-4.6; absolute claudication distance [ACD]: 165.4+/-38), 10 patients with severe claudication (SC) (age: 60.3+/-5 years; BMI: 27+/-4.5; ACD: 91+/-11.3) and 8 healthy subjects (age: 59.4+/-6.8; BMI: 28.7+/-4.16) underwent to maximal treadmill test (speed 2.5 km/h, slope 15%). At rest, just after stop of the exercise (appearance of calf pain in patients, and 6 min of treadmill in controls) the circulating levels of interleukin (IL)-1beta and IL-6 have been measured. Statistical analysis: variance of mean values, Bonferroni t-test, split plot variance model, variance of d stop-before and stop-recovery have been utilized. P<0.05 has been considered the significant cut-off of the differences.
The maximal exercise excited significant (P<0.01) inflammatory activation in all patients: MC (rest IL-1beta: 1.55, 3.3 at stop; rest IL-6: 5.97, 8.38 at the stop); SC (rest IL-1beta: 2.97, 5.72 at stop; rest IL-6: 6.98, 9.99 at the stop). During recovery, MC showed a reduction of the inflammatory activation, whilst SC showed further increase (IL-1beta: 7.55; IL-6: 11.94).
The study confirms the higher inflammatory activation in claudicants and its enhancement after maximal exercise. During recovery, we found two kinds of response: type 1 (controls and MC), in which inflammation subsides, and type 2 (SC) characterized by further inflammatory increase. This trend is not univocal: 3 MC showed a type 2 response and 2 SC showed a type 1. In conclusion, inflammatory activation may depend not only on the degree of endothelial damage, but also on the individual inflammatory attitude, better assessed after maximal exercise than baseline values. This individual inflammatory responsiveness, considering the role of the rest measurement of markers of inflammation recently discussed, could be a useful marker for aggressive PAD.
This study had as its objective an estimate of the prevalence of venous thromboembolism (VTE) in the State of Minas Gerais and its projection to Brazil, based on an analysis of 2,331,353 hospitalisations in the period of January 1994 to November 1995.
Cardiovascular diseases, except for surgical cases, were responsible for 279,982 hospitalisations. The target population were the users of the Brazilian state health system. The evaluation, through clinical diagnosis, demonstrated the high incidence of VTE in patients over 50. The hospitalisation rate and mortality rate, were compared with those presented in studies in the United States and Europe.
The importance of awareness of thrombosis and use of prophylactic methods to reduce the risks of serious complications of VTE.
Outpatient surgery of varices of the lower limbs is currently considered a viable alternative to traditional surgery with hospitalization. This paper reports the experience of 4 university groups (Padua, Modena, Verona, Milan), where outpatient treatment has been used since 1987. From June 1987 to June 1992, 2,568 lower limb varices were treated in this way. Different techniques of anaesthesia were used (local infiltration, combined local and general, general, subarachnoid). In all cases, crossectomy was combined with short or long saphenous stripping. There were no intra- or perioperative deaths, and only limited morbidity. Postoperative hospitalization was required in only 2 cases: for hemorrhaging of the inguinal wound in one case, and headache 2 days after spinal anaesthesia in the other. In 2 separate samples of 100 patients, 88 and 89 indicated satisfaction with the surgical treatment. In conclusion, outpatient surgery of varices can be based on the same techniques as in-patients treatment. The risks of surgery and anaesthesia in specialised centres are very limited, with scope for a variety of anaesthetic techniques according to facilities available. Patients satisfaction is high.
The aim of this study was to investigate the prevalence and initial treatment of chronic venous disease (CVD) in the Spanish primary health care system during 2006 and to compare the results with those obtained in 2000.
The survey involved 1 118 general practitioners co-ordinated by 37 specialists in angiology and vascular surgery, assessing 15 consecutive patients, each attending the clinics between 29 May and 2 June 2006.
Of the16 186 patients reported, 82% had CVD risk factors. When asked about CVD signs or symptoms 11 277 patients (69.7%) mentioned some kind of clinical manifestation/sign compatible with the disease. Diagnosis was established in accordance with the clinical section of the CEAP classification, 38% of the total being classified as C2-C6. Sixty-two percent of the symptomatic patients had received prior treatment (vs 24.8% in year 2000), and following the survey 88% of the patients diagnosed with CVD were treated (vs 62% in 2000).
The results for 2006 confirm the high prevalence of CVD in primary health care in Spain. In comparison with the results for 2000, an improvement in the patterns of medical advice use, treatment and prescriptions are observed. Despite these findings, specific training programs in primary health care regarding the diagnosis and treatment of CVD continue to be necessary.
The aim of this paper was to prospectively monitor the performance of an isolated pharmacomechanical thrombolysis (IPMT) device, the Trellis(R) Peripheral Infusion System, through a company-sponsored registry.
Demographic, thrombus characterization, and procedural data were collected on the treatment of 2203 extremity deep venous thrombosis (DVTs) in 2024 patients via case-report forms submitted by the treating physicians. Data were analyzed using simple accrual and percentages.
Patients averaged 53 (+/-18) years of age and were 49% female. Thrombi were located in the iliofemoral (25.1%); iliofemoral to popliteal (19.3%); inferior vena cava (IVC) only or IVC and infrainguinal lower extremity (18.7%); femoral to popliteal (12.2%); isolated femoral (6%), iliac (6%) or popliteal (0.6%); and upper extremity (12.1%). Thrombus chronicity was reported as acute in 34.5% (N=760), acute-on-chronic in 41.5% (N=914), subacute in 10.4% (N=230), subacute-on-chronic in 9.8% (N=216), and chronic in 3.8% (N=83). The thrombolytic agent chosen by the physician most often was tissue plasminogen activator (tPA; 95.8%) at an average total dose per patient of 14.9 +/-8.3 mg. Combined Grade III and II venous patency following treatment across all thrombus chronicities was 95.5% and was achieved in a single setting in 83.3% (N=1753) of patients. Average IPMT run time per procedure was 22.3 +/-9.4 minutes. Sixteen percent of patients' limbs required additional catheter-directed thrombolysis (CDT); 75% required angioplasty and/or stent. No major bleeding complications, symptomatic pulmonary embolism (PE), or other significant adverse events occurred during the procedures.
IPMT is an effective therapeutic option for the acute management of extremity DVT. Low lytic doses and short infusion times are associated with a lower risk of bleeding than with CDT. Rapid restoration of patency may be associated with sustained valve function and a decreased incidence of post-thrombotic syndrome.
The microsurgical lympho-venous shunts have become one of the generally accepted modalities in treatment of limb lymphedema. This review highlight the indications for this procedure after over 40 years. This study was based on the personal experience of one surgeon and on the review of the literature. Patients with postinflammatory, postsurgical, idiopathic and hyperplastic lymphedema of lower limbs were included in the study. Basing on the review of results of the last 40 years the contemporary indications are: 1) lymphedema with local segmental obstruction but still partly patent distal lymphatics seen on functional lymphoscintigraphy (standard walking or pneumatic compression) and without an active inflammatory process in the skin, subcutaneous tissue and lymph vessels (DLA-dermatolymphangioadenitis); 2) classified according the etiology of lymphedema, this operation can bring about satisfactory results in cases of hyperplastic, postsurgical and postinflammatory types of lymphedema, whereas primary idiopathic lymphedema of non-genetic type should be treated with conservative means, although in a small number of cases an improvement was observed after lympho-venous shunting as long as 10 years. Microsurgical lymph node or lymphatic vessel to vein shunts have their established position among the therapy modalities for lymphedema of lower limbs in a strictly defined group of patients using lymphoscintigraphic imaging.
Primary lymphedema can be managed safely as one of the chronic lymphedemas by a proper combination of DLT with compression therapy. Treatment in the maintenance phase should include compression garments, self management including the compression therapy, self massage and meticulous personal hygiene and skin care in addition to lymph-transport promoting excercises. The management of primary lymphedema can be further improved with proper addition of surgical therapy either reconstructive or ablative. These two surgical therapies can be effective only when fully integrated with MLD-based DLT postoperatively. Compliance with a long-term commitment of DLT postoperatively is the most critical factor determining the success of any new treatment strategy with either reconstructive or palliative surgery. The future of management of primary lymphedema caused by truncular lymphatic malformation has never been brighter with the new prospect of gene-oriented management.
Venous malformations (VMs) are the most common vascular developmental anomalies (birth defects) . These defects are caused by developmental arrest of the venous system during various stages of embryogenesis. VMs remain a difficult diagnostic and therapeutic challenge due to the wide range of clinical presentations, unpredictable clinical course, erratic response to the treatment with high recurrence/persistence rates, high morbidity following non-specific conventional treatment, and confusing terminology. The Consensus Panel reviewed the recent scientific literature up to the year 2013 to update a previous IUP Consensus (2009) on the same subject. ISSVA Classification with special merits for the differentiation between the congenital vascular malformation (CVM) and vascular tumors was reinforced with an additional review on syndrome-based classification. A "modified" Hamburg classification was adopted to emphasize the importance of extratruncular vs. truncular sub-types of VMs. This incorporated the embryological origin, morphological differences, unique characteristics, prognosis and recurrence rates of VMs based on this embryological classification. The definition and classification of VMs were strengthened with the addition of angiographic data that determines the hemodynamic characteristics, the anatomical pattern of draining veins and hence the risk of complication following sclerotherapy. The hemolymphatic malformations, a combined condition incorporating LMs and other CVMs, were illustrated as a separate topic to differentiate from isolated VMs and to rectify the existing confusion with name-based eponyms such as Klippel-Trenaunay syndrome. Contemporary concepts on VMs were updated with new data including genetic findings linked to the etiology of CVMs and chronic cerebrospinal venous insufficiency. Besides, newly established information on coagulopathy including the role of D-Dimer was thoroughly reviewed to provide guidelines on investigations and anticoagulation therapy in the management of VMs. Congenital vascular bone syndrome resulting in angio-osteo-hyper/hypotrophy and (lateral) marginal vein was separately reviewed. Background data on arterio-venous malformations was included to differentiate this anomaly from syndrome-based VMs. For the treatment, a new section on laser therapy and also a practical guideline for follow up assessment were added to strengthen the management principle of the multidisciplinary approach. All other therapeutic modalities were thoroughly updated to accommodate a changing concept through the years.
Arterio-venous malformations (AVMs) are congenital vascular malformations (CVMs) that result from birth defects involving the vessels of both arterial and venous origins, resulting in direct communications between the different size vessels or a meshwork of primitive reticular networks of dysplastic minute vessels which have failed to mature to become 'capillary' vessels termed "nidus". These lesions are defined by shunting of high velocity, low resistance flow from the arterial vasculature into the venous system in a variety of fistulous conditions. A systematic classification system developed by various groups of experts (Hamburg classification, ISSVA classification, Schobinger classification, angiographic classification of AVMs,) has resulted in a better understanding of the biology and natural history of these lesions and improved management of CVMs and AVMs. The Hamburg classification, based on the embryological differentiation between extratruncular and truncular type of lesions, allows the determination of the potential of progression and recurrence of these lesions. The majority of all AVMs are extra-truncular lesions with persistent proliferative potential, whereas truncular AVM lesions are exceedingly rare. Regardless of the type, AV shunting may ultimately result in significant anatomical, pathophysiological and hemodynamic consequences. Therefore, despite their relative rarity (10-20% of all CVMs), AVMs remain the most challenging and potentially limb or life-threatening form of vascular anomalies. The initial diagnosis and assessment may be facilitated by non- to minimally invasive investigations such as duplex ultrasound, magnetic resonance imaging (MRI), MR angiography (MRA), computerized tomography (CT) and CT angiography (CTA). Arteriography remains the diagnostic gold standard, and is required for planning subsequent treatment. A multidisciplinary team approach should be utilized to integrate surgical and non-surgical interventions for optimum care. Currently available treatments are associated with significant risk of complications and morbidity. However, an early aggressive approach to elimiate the nidus (if present) may be undertaken if the benefits exceed the risks. Trans-arterial coil embolization or ligation of feeding arteries where the nidus is left intact, are incorrect approaches and may result in proliferation of the lesion. Furthermore, such procedures would prevent future endovascular access to the lesions via the arterial route. Surgically inaccessible, infiltrating, extra-truncular AVMs can be treated with endovascular therapy as an independent modality. Among various embolo-sclerotherapy agents, ethanol sclerotherapy produces the best long term outcomes with minimum recurrence. However, this procedure requires extensive training and sufficient experience to minimize complications and associated morbidity. For the surgically accessible lesions, surgical resection may be the treatment of choice with a chance of optimal control. Preoperative sclerotherapy or embolization may supplement the subsequent surgical excision by reducing the morbidity (e.g. operative bleeding) and defining the lesion borders. Such a combined approach may provide an excellent potential for a curative result. Conclusion. AVMs are high flow congenital vascular malformations that may occur in any part of the body. The clinical presentation depends on the extent and size of the lesion and can range from an asymptomatic birthmark to congestive heart failure. Detailed investigations including duplex ultrasound, MRI/MRA and CT/CTA are required to develop an appropriate treatment plan. Appropriate management is best achieved via a multi-disciplinary approach and interventions should be undertaken by appropriately trained physicians.
The purpose of this experiment was to evaluate the effects of the aminosteroid U74389G on skeletal muscle reperfusion injury in rabbits. In 24 white New Zealand rabbits (weighing 7.0-8.0 lb), the rectus femoris muscle on both sides was completely isolated on a single vascular pedicle (artery and vein) and a major accessory vein. All muscles were weighed using a suspension spring balance and then underwent 4 hours of normothermic ischemia followed by 24 hours of reperfusion. Muscle ischemia was induced by the application of atraumatic vascular clamps to the vascular pedicles. Complete muscle ischemia and reperfusion were documented by a laser flow meter. The animals were divided into three groups; Group I (n = 8) served as control, Group II (n = 8) received an i.v. bolus of U74389G (1.5 mg/kg) five minutes prior to ischemia, Group III (n = 8) was given the same dose of lazaroid five minutes prior to reperfusion. Muscle biopsies were obtained before ischemia and after reperfusion for quantification of myeloperoxidase (MPO) activity. At the completion of reperfusion, the muscles were excised, weighed and cut into slices along the longitudinal axis and then incubated for 30 minutes in 0.05% nitroblue tetrazolium. Areas of necrosis were determined by computerized planimetry. The following results indicate that reperfusion muscle necrosis in rabbits is significantly decreased by the administration of the lazaroid U74389G. Leukocyte sequestration was not affected by the lazaroid administration. These beneficial effects were observed whether the lazaroid was administered prior to ischemia or prior to reperfusion and were independent of leukocyte sequestration.
The Authors report a new iatrogenic complication of preventive or curative standard heparinotherapy. This so called "white clot syndrome" or "Heparin associated thrombocytopenia and thrombosis" is an anatomico-clinical entity characterized by severe, multiple, recurrent, arterial and/or venous thromboembolic accidents which are sometimes fatal. They appear, paradoxically, under heparin treatment and are concomitant with thrombocytopenia (generally less than 100 10(9)/l). Antiplatelet immunoallergic phenomena, via type IgG antibodies, induced by heparin, are the most commonly admitted in physiopathology; however they remain controversial. Treatment of "WCS" includes urgent suppression of standard heparin, administration of antivitamin K, or the new generation of low molecular weight heparin. This series presents 26 cases of HATT treated by LMWH (CY 216 CHOAY). Severe complications must be surgically cured. Prevention of WCS or HATT is mandatory by the systematic survey of platelet count during heparinotherapy.
Acute limb ischemia (ALI) is one of the most potentially devastating but treatable diseases, resulting from a sudden obstruction in the arterial flow. The aim of this study was to examine the outcome of thromboembolectomy, and to determine the risk factors associated with limb loss and mortality in ALI.
A retrospective chart review of 270 patients on whom thromboembolectomy was performed between September 2002 and December 2009 due to ALI. Of these, 146 (54.1%) were men and mean age was 64.3.
Etiology was embolic in 63.3% of cases. Late thromboembolectomy after 72 hours was performed in 57.8% of patients. On admission 38.9% of patients had grade IIb ischemia; grade III ischemia was present in 9.6% of patients. Failure of first thromboembolectomy developed in 21.1% of patients and bypass surgery was performed on 25.2% of patients. Amputation and mortality rates were 7.4% and 8.5% respectively. Binary logistic regression analysis revealed that risk factors of limb loss were thromboembolectomy failure, high ischemic stage, high level of plasma creatinine kinase and compartment syndrome on admission and predictors of mortality were congestive heart failure, ischemic heart disease, reperfusion injury and longer ischemic time.
In ALI, thromboembolectomy is highly protective against amputation, as well as mortality, even in delayed cases with more than one week in the clinical absence of tissue necrosis. At least, it provides partial limb salvage. In addition, patients must be given a chance for limb salvage in the case of stage 3 ischemia, too.
The aim of this randomized, double-blind and prospective clinical trial was to investigate whether an increase of the conventional daily dosage (3,000 IU aXa) of the low molecular weight heparin certoparin up to 5,000 IU aXa/day might lower the incidence of deep vein thrombosis (DVT) in patients undergoing elective hip surgery.
The main criterium of this trial was the incidence of DVT diagnosed by bilateral ascending venography, which was performed either if DVT was clinically suspected or in each remaining patient between the 12th and the 14th postoperative day. A total number of 172 patients were enrolled to receive the conventional dosage of 3,000 IU aXa (Mono-Embolex NM) and 169 patients to receive the high dosage form (5,000 IU aXa) once daily. The mean age (+/-SD) was 69.6+/-9.5 and 67+/-11.7 years.
No relevant differences were found concerning predisposing risk factors. The duration of surgery was 93+/-25.2 and 88+/-21.4 min (mean+/-SD). Surgical type and approach were not different between the groups. Deep vein thrombosis was detected in 17 patients (9.9%) in the conventional dose group and in 16 patients (9.5%) in the high dose group (intent-to-treat analysis; n.s.). The rate of bleeding complications was not significantly different except the cell saver volumes (770+/-136 vs 475+/-186 ml; p<0.001). No significant difference was found in the serious adverse event reporting along the lines of EC-GCP (10 vs 8 events; p=0.65).
This clinical trial confirmed that the conventional dosage (3,000 IU aXa/day) of certoparin ensures maximal antithrombotic activity.
Aim of this study was to evaluate the clinical efficacy of three-dimensional contrast-enhanced magnetic resonance angiography (3D CE-MRA); at 3.0T scanner in the classification of peripheral arterial occlusive disease (PAOD).
Thirty-five patients diagnosed of PAOD underwent 3D CE-MRA, 30 cases underwent digital subtracted angiography (DSA) successfully, and 12 cases underwent surgery.
The vascular tree from the distal aorta to the lower limbs was well demonstrated. The extent and grade of disease seen in 3D CE-MRA closely matched those seen in DSA and/or surgery. Compared to the results of DSA and/or surgery, the common coincidence of 3D CE-MRA in diagnosing PAOD was 96.89% (780/805), the coincidence in diagnosing mild, moderate, severe stenosis and occlusion was 90.48% (76/84), 87.14% (61/70), 95.77% (68/71), and 98.29% (115/117) respectively, the rate of overestimate in mild, moderate, and severe stenosis was 5.95% (5/84), 10% (7/70), and 2.82% (2/71) respectively, the rate of underestimate in mild, moderate, severe stenosis and occlusion was 3.57% (3/84), 2.86% (2/70), 1.41% (1/71) and 1.74% (2/115) respectively.
3D CE-MRA at 3.0T scanner is of great value in the accurate assessment of the classification of PAOD; it is a reliable and promising new technique.
In this work we present a novel methodology (called CALSFOAM) for the automated segmentation of ultrasound carotid images and intima-media thickness (IMT) measurement. CALSFOAM was developed in order to overcome limitations of a previously developed snake-based technique.
CALSFOAM consists of two stages: Stage-I is an automatic recognition of the carotid artery system in an image frame and Stage-II is a combination of segmentation and IMT measurement sub-system. Stage-I is performed by using local statistics and by automatically tracing the profile of the distal adventitia. Stage-II takes the traced adventitia boundary and builds an ROI for distal wall segmentation that uses a first order absolute moment (FOAM) technique. CALSFOAM was benchmarked against our previous snake based technique and validated on a 300-image multi-institutional dataset.
CALSFOAM's lumen-intima (LI) segmentation error was 0.049±0.039 mm, the media-adventitia (MA) error was 0.088±0.054 mm; the IMT measurement bias was 0.125±0.103 mm. To reduce CALSFOAM error, we adopted a GREEDY approach for fusing the boundaries from the two techniques and obtained LI and MA errors equal to 0.02±0.014 mm, 0.023±0.013 mm, and an IMT bias of 0.074±0.068 mm.
Even though CALSFOAM's performance was lower than snake-based segmentation techniques, it helped in avoiding possible inaccuracies of snakes and its parameter sensitivities. The very accurate performance obtained by the GREEDY approach demonstrated that the two techniques could be considered as complementary.
Three-hundred and ten cases of vascular malformations have been analyzed on the basis of pathomorphological examination by light and electron microscopy and by immunohistology. The findings demonstrate that all the vascular malformations have a common pathogenesis. Differences are only gradual and always follow the categories: agenesis-aplasia-hypoplasia-dysplasia-hyperplasia. Additional degenerative alterations are secondary. Hemangiomas in connection with angiodysplasias are congenital malformations and not tumors. On the level of differentiated vessels they mostly contain arteriovenous macro- or microshunts (a-v hemangiomas); if only capillaries are involved (cavernous hemangiomas), a-v microshunts are usually absent. Classification of angiodysplasias should be simplified and based on a pathomorphological concept. The descriptive diagnosis should include size and type of vessels involved, kind of alteration, presence of hemangiomas with or without a-v shunts and systemic involvement.
According to the performed trials, an introduction of the new oral anticoagulant drugs (NOAC) in the chronic anticoagulation in patients with non--valvular atrial fibrillation (NVAF) is an interesting treatment option. In addition to the encouraging results of the randomized controlled trials the efficacy of this treatment modality in the real--world clinical settings should also be confirmed. In the article, the 2--year single center experience with NOACs in the secondary prevention of cerebral stroke in patients with NVAF and previous ischemic stroke was presented. The objective of the study was to evaluate the efficacy, safety and tolerability of the NOACs in the secondary stroke prevention in patients with NVAF.
Material and methods:
311 patients (M/F 98/213) with NVAF [mean age 62.22 years (41--85)] on new oral anticoagulant drugs in secondary prevention of cardiogenic stroke, were enrolled into a prospective study. All of them started the therapy during the acute period of cerebral ischemia from 3rd to 9th day after the stroke onset. The estimated risk of stroke was based on the CHA2DS2VASc and the risk of hemorrhage on the basis of HAS--BLED scale. Patients underwent a long--term follow--up within the period from 12 to 24 months after initiation of NOAC therapy (mean follow up 18.6 months). 230 patients were treated by the means of rivaroxaban, in 78 patients dabigatran was administered and 1 patient received apixaban. The rate of stroke recurrence, bleeding as well as the drug intolerance were evaluated.
Ischemic stroke during NOAC treatment was diagnosed in 6 patients (1.92%); TIA was observed in 3 cases (0.96%). Hemorrhagic complications during follow--up were recorded in 29 patients (9.32%), of which 3 patients had major bleedings (0,96%): intracranial bleeding (1), bleeding from the genital tract (1) and from the urinary tract (1). There were no deaths caused by bleeding associated with the use of medications, 1 patient died after ischemic stroke when taking NOACs. In 59 patients (18.97%) NOAC therapy was discontinued in the course of follow--up, mostly because of bleeding (29 patients) or renal function worsening (10 patients). There were no significant differences in the efficacy and safety between the groups on selective factor II inhibitor (dabigatran) or factor Xa inhibitor (rivaroxaban).
Clinical application of new oral anticoagulant drugs in a real--world clinical setting results in the treatment profile of high efficacy and acceptable safety for patients with non--valvular atrial fibrillation and stroke.
In order to define the morphological variants involved in carotid elongation in terms of their clinical implications, we have analysed the prevalence of morphological alterations in patients routinely subjected to carotid colour duplex ultrasonography evaluation.
From January 1, 1993 to June 30, 1996, 3300 subjects were examined for central nervous system symptoms (41% of cases) or for screening related to ischaemic heart disease, lower limb arterial disease, hypertension or major dyslipidaemia (59% of cases). The chi(2)-test was used for statistical analysis.
Morphological alterations increased with age. While kinking was more prevalent in females (female:male ratio 58% vs 42%), sharp kinking was significantly more frequent in males (39% vs 15%, p<0.001). Atheromatous plaques predominated in males (79% vs 46%, p<0.001), as well as cases with haemodynamically significant involvement (16% vs 7%, p<0.001). In patients with kinking there was a prevalence of haemodynamically significant lesions (chi(2)=52.7, p<0.001). A possible link between conformational abnormalities and hypertension appeared highly significant owing to a very different prevalence of high blood pressure in the group of subjects with kinking (chi(2)=239, p<0.001). We did not find a significant association between major neurological symptoms and the presence of kinking (chi(2)=0.215, p=0.643), but we found an association with transient ischaemic attacks (chi(2)=6.9, p<0.01).
Conformational abnormalities like kinking, seem much more prevalent in subjects suffering from arterial hypertension. Even though high blood pressure is an important risk factor for transient ischaemic attacks, it is possible that the prevalence of atheromatous lesions and the flow turbulence linked to kinking may also play a role in their pathophysiology.