RESUMO
RATIONALE: The impact of diabetes mellitus on bone marrow (BM) structure is incompletely understood. OBJECTIVE: Investigate the effect of type-2 diabetes mellitus (T2DM) on BM microvascular and hematopoietic cell composition in patients without vascular complications. METHODS AND RESULTS: Bone samples were obtained from T2DM patients and nondiabetic controls (C) during hip replacement surgery and from T2DM patients undergoing amputation for critical limb ischemia. BM composition was assessed by histomorphometry, immunostaining, and flow cytometry. Expressional studies were performed on CD34(pos) immunosorted BM progenitor cells (PCs). Diabetes mellitus causes a reduction of hematopoietic tissue, fat deposition, and microvascular rarefaction, especially when associated with critical limb ischemia. Immunohistochemistry documented increased apoptosis and reduced abundance of CD34(pos)-PCs in diabetic groups. Likewise, flow cytometry showed scarcity of BM PCs in T2DM and T2DM+critical limb ischemia compared with C, but similar levels of mature hematopoietic cells. Activation of apoptosis in CD34(pos)-PCs was associated with upregulation and nuclear localization of the proapoptotic factor FOXO3a and induction of FOXO3a targets, p21 and p27(kip1). Moreover, microRNA-155, which regulates cell survival through inhibition of FOXO3a, was downregulated in diabetic CD34(pos)-PCs and inversely correlated with FOXO3a levels. The effect of diabetes mellitus on anatomic and molecular end points was confirmed when considering background covariates. Furthermore, exposure of healthy CD34(pos)-PCs to high glucose reproduced the transcriptional changes induced by diabetes mellitus, with this effect being reversed by forced expression of microRNA-155. CONCLUSIONS: We provide new anatomic and molecular evidence for the damaging effect of diabetes mellitus on human BM, comprising microvascular rarefaction and shortage of PCs attributable to activation of proapoptotic pathway.
Assuntos
Células da Medula Óssea/metabolismo , Diabetes Mellitus Tipo 2/metabolismo , Angiopatias Diabéticas/metabolismo , Fatores de Transcrição Forkhead/metabolismo , Células-Tronco Hematopoéticas/metabolismo , MicroRNAs/metabolismo , Microvasos/metabolismo , Transdução de Sinais , Nicho de Células-Tronco , Tecido Adiposo/metabolismo , Tecido Adiposo/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Antígenos CD34/metabolismo , Apoptose , Biomarcadores/metabolismo , Células da Medula Óssea/imunologia , Células da Medula Óssea/patologia , Exame de Medula Óssea , Estudos de Casos e Controles , Linhagem da Célula , Células Cultivadas , Inibidor de Quinase Dependente de Ciclina p21/metabolismo , Inibidor de Quinase Dependente de Ciclina p27/metabolismo , Diabetes Mellitus Tipo 2/genética , Diabetes Mellitus Tipo 2/patologia , Angiopatias Diabéticas/genética , Angiopatias Diabéticas/patologia , Células Endoteliais/metabolismo , Células Endoteliais/patologia , Feminino , Citometria de Fluxo , Proteína Forkhead Box O3 , Fatores de Transcrição Forkhead/genética , Regulação da Expressão Gênica , Células-Tronco Hematopoéticas/imunologia , Células-Tronco Hematopoéticas/patologia , Humanos , Imuno-Histoquímica , Isquemia/genética , Isquemia/metabolismo , Isquemia/patologia , Masculino , MicroRNAs/genética , Microvasos/imunologia , Microvasos/patologia , Pessoa de Meia-Idade , Doença Arterial Periférica/genética , Doença Arterial Periférica/metabolismo , Doença Arterial Periférica/patologia , TransfecçãoRESUMO
OBJECTIVE: The p75 neurotrophin receptor (p75(NTR)) contributes to diabetes mellitus-induced defective postischemic neovascularization. The interleukin-33 receptor ST2 is expressed as transmembrane (ST2L) and soluble (sST2) isoforms. Here, we studied the following: (1) the impact of p75(NTR) in the healing of ischemic and diabetic calf wounds; (2) the link between p75(NTR) and ST2; and (3) circulating sST2 levels in critical limb ischemia (CLI) patients. METHODS AND RESULTS: Diabetes mellitus was induced in p75(NTR) knockout (p75KO) mice and wild-type (WT) littermates by streptozotocin. Diabetic and nondiabetic p75KO and WT mice received left limb ischemia induction and a full-thickness wound on the ipsilateral calf. Diabetes mellitus impaired wound closure and angiogenesis and increased ST2 expression in WT, but not in p75KO wounds. In cultured endothelial cells, p75(NTR) promoted ST2 (both isoforms) expression through p38(MAPK)/activating transcription factor 2 pathway activation. Next, sST2 was measured in the serum of patients with CLI undergoing either revascularization or limb amputation and in the 2 nondiabetic groups (with CLI or nonischemic individuals). Serum sST2 increased in diabetic patients with CLI and was directly associated with higher mortality at 1 year from revascularization. CONCLUSIONS: p75(NTR) inhibits the healing of ischemic lower limb wounds in diabetes mellitus and promotes ST2 expression. Circulating sST2 predicts mortality in diabetic CLI patients.
Assuntos
Diabetes Mellitus Experimental/fisiopatologia , Diabetes Mellitus/mortalidade , Isquemia/fisiopatologia , Extremidade Inferior/irrigação sanguínea , Proteínas do Tecido Nervoso/fisiologia , Receptores de Superfície Celular/metabolismo , Receptores de Interleucina/metabolismo , Receptores de Fator de Crescimento Neural/fisiologia , Fator 2 Ativador da Transcrição/metabolismo , Idoso , Idoso de 80 Anos ou mais , Animais , Biomarcadores/metabolismo , Células Cultivadas , Complicações do Diabetes/complicações , Diabetes Mellitus/metabolismo , Diabetes Mellitus/fisiopatologia , Diabetes Mellitus Experimental/induzido quimicamente , Diabetes Mellitus Experimental/metabolismo , Modelos Animais de Doenças , Endotélio Vascular/efeitos dos fármacos , Endotélio Vascular/metabolismo , Endotélio Vascular/patologia , Feminino , Humanos , Proteína 1 Semelhante a Receptor de Interleucina-1 , Isquemia/etiologia , Masculino , Camundongos , Camundongos Knockout , Pessoa de Meia-Idade , Proteínas do Tecido Nervoso/farmacologia , Valor Preditivo dos Testes , Receptores de Fator de Crescimento Neural/deficiência , Receptores de Fator de Crescimento Neural/genética , Estreptozocina/efeitos adversos , Cicatrização/fisiologia , Proteínas Quinases p38 Ativadas por Mitógeno/metabolismoRESUMO
BACKGROUND: Diabetes mellitus impairs endothelial cell (EC) function and postischemic reparative neovascularization by molecular mechanisms that are not fully understood. microRNAs negatively regulate the expression of target genes mainly by interaction in their 3' untranslated region. METHODS AND RESULTS: We found that microRNA-503 (miR-503) expression in ECs is upregulated in culture conditions mimicking diabetes mellitus (high D-glucose) and ischemia-associated starvation (low growth factors). Under normal culture conditions, lentivirus-mediated miR-503-forced expression inhibited EC proliferation, migration, and network formation on Matrigel (comparisons versus lentivirus.GFP control). Conversely, blocking miR-503 activity by either adenovirus-mediated transfer of a miR-503 decoy (Ad.decoymiR-503) or by antimiR-503 (antisense oligonucleotide) improved the functional capacities of ECs cultured under high D-glucose/low growth factors. We identified CCNE1 and cdc25A as direct miR-503 targets which are downregulated by high glucose/low growth factors in ECs. Next, we obtained evidence that miR-503 expression is increased in ischemic limb muscles of streptozotocin-diabetic mice and in ECs enriched from these muscles. Moreover, Ad.decoymiR-503 delivery to the ischemic adductor of diabetic mice corrected diabetes mellitus-induced impairment of postischemic angiogenesis and blood flow recovery. We finally investigated miR-503 and target gene expression in muscular specimens from the amputated ischemic legs of diabetic patients. As controls, calf biopsies of nondiabetic and nonischemic patients undergoing saphenous vein stripping were used. In diabetic muscles, miR-503 expression was remarkably higher, and it inversely correlated with cdc25 protein expression. Plasma miR-503 levels were also elevated in the diabetic individuals. CONCLUSIONS: Our data suggest miR-503 as a possible therapeutic target in diabetic patients with critical limb ischemia.
Assuntos
Diabetes Mellitus Experimental , Isquemia , MicroRNAs/fisiologia , Neovascularização Fisiológica/fisiologia , Animais , Biópsia , Células Cultivadas , Diabetes Mellitus Experimental/genética , Diabetes Mellitus Experimental/patologia , Diabetes Mellitus Experimental/fisiopatologia , Células Endoteliais/citologia , Células Endoteliais/fisiologia , Extremidades/irrigação sanguínea , Expressão Gênica/fisiologia , Glucose/farmacologia , Humanos , Peptídeos e Proteínas de Sinalização Intercelular/farmacologia , Isquemia/genética , Isquemia/patologia , Isquemia/fisiopatologia , Masculino , Camundongos , Camundongos Endogâmicos , Músculo Esquelético/patologia , Músculo Esquelético/fisiologia , Veias Umbilicais/citologia , Fosfatases cdc25/genéticaRESUMO
OBJECTIVES: The aim of this study was to evaluate the 1-year safety and efficacy of a dual-layered stent (DLS) for carotid artery stenting (CAS) in a multicenter registry. BACKGROUND: DLS have been proved to be safe and efficient during short-term follow-up. Recent data have raised the concern that the benefit of CAS performed with using a DLS may be hampered by a higher restenosis rate at 1 year. METHODS: From January 2017 to June 2019, a physician-initiated, prospective, multispecialty registry enrolled 733 consecutive patients undergoing CAS using the CGuard embolic prevention system at 20 centers. The primary endpoint was the occurrence of death and stroke at 1 year. Secondary endpoints were 1-year rates of transient ischemic attack, acute myocardial infarction, internal carotid artery (ICA) restenosis, in-stent thrombosis, and external carotid artery occlusion. RESULTS: At 1 year, follow-up was available in 726 patients (99.04%). Beyond 30 days postprocedure, 1 minor stroke (0.13%), four transient ischemic attacks (0.55%), 2 fatal acute myocardial infarctions (0.27%), and 6 noncardiac deaths (1.10%) occurred. On duplex ultrasound examination, ICA restenosis was found in 6 patients (0.82%): 2 total occlusions and 4 in-stent restenoses. No predictors of target ICA restenosis and/or occlusion could be detected, and dual-antiplatelet therapy duration (90 days vs 30 days) was not found to be related to major adverse cardiovascular event or restenosis occurrence. CONCLUSIONS: This real-world registry suggests that DLS use in clinical practice is safe and associated with minimal occurrence of adverse neurologic events up to 12-month follow-up.
Assuntos
Estenose das Carótidas , Artéria Carótida Interna , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/terapia , Humanos , Estudos Prospectivos , Stents , Resultado do TratamentoRESUMO
OBJECTIVES: During the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) pandemic, Northern Italy had to completely reorganize its hospital activity. In Lombardy, the hub-and-spoke system was introduced to guarantee emergency and urgent cardiovascular surgery, whereas most hospitals were dedicated to patients with coronavirus disease 2019 (COVID-19). The aim of this study was to analyse the results of the hub-and-spoke organization system. METHODS: Centro Cardiologico Monzino (Monzino) became one of the four hubs for cardiovascular surgery, with a total of eight spokes. SARS-CoV-2 screening became mandatory for all patients. New flow charts were designed to allow separated pathways based on infection status. A reorganization of spaces guaranteed COVID-19-free and COVID-19-dedicated areas. Patients were also classified into groups according to their pathological and clinical status: emergency, urgent and non-deferrable (ND). RESULTS: A total of 70 patients were referred to the Monzino hub-and-spoke network. We performed 41 operations, 28 (68.3%) of which were emergency/urgent and 13 of which were ND. The screening allowed the identification of COVID-19 (three patients, 7.3%) and non-COVID-19 patients (38 patients, 92.7%). The newly designed and shared protocols guaranteed that the cardiac patients would be divided into emergency, urgent and ND groups. The involvement of the telematic management heart team allowed constant updates and clinical discussions. CONCLUSIONS: The hub-and-spoke organization system efficiently safeguards access to heart and vascular surgical services for patients who require ND, urgent and emergency treatment. Further reorganization will be needed at the end of this pandemic when elective cases will again be scheduled, with a daily increase in the number of operations.
Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Cirurgia Torácica/organização & administração , COVID-19 , Teste para COVID-19 , Técnicas de Laboratório Clínico/métodos , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/prevenção & controle , Emergências , Reforma dos Serviços de Saúde/organização & administração , Prioridades em Saúde , Humanos , Controle de Infecções/organização & administração , Colaboração Intersetorial , Itália/epidemiologia , Pandemias/prevenção & controle , Pneumonia Viral/diagnóstico , Pneumonia Viral/prevenção & controle , SARS-CoV-2 , Centro Cirúrgico Hospitalar/organização & administração , Procedimentos Cirúrgicos Torácicos/normasRESUMO
OBJECTIVES: This study sought to evaluate 30-day safety and efficacy of dual-layer mesh-covered carotid stent systems for carotid artery stenting (CAS) in the clinical practice. BACKGROUND: When compared with carotid endarterectomy, CAS has been associated with a higher rate of post procedural neurologic events; these could be related to plaque's debris prolapsing through stent's mesh. Consequently, the need for increased plaque coverage has resulted in the development of dual-layer mesh-covered carotid stent systems. METHODS: From January 2017 to June 2019, a physician-initiated, prospective, multispecialty registry enrolled 733 consecutive patients undergoing CAS using the CGuard embolic prevention system in 20 centers. The primary endpoint was stroke up to 30 days; secondary endpoints were technical and procedural success; external carotid artery occlusion; and in-hospital and 30-day transient ischemic attack (TIA), acute myocardial infarction (AMI), and death rates. RESULTS: Symptoms were present in 131 (17.87%) patients. An embolic protection device was used in 731 (99.72%) patients. Procedural success was 100%, technical success was obtained in all but 1 (99.86%) patient, who died in hospital due to a hemorrhagic stroke. Six TIAs, 2 minor strokes, and 1 AMI occurred during in-hospital stay, and external carotid artery occlusion was evident in 8 (1.09%) patients. Between hospital discharge and 30-day follow-up, 2 TIAs, 1 minor stroke, and 3 AMIs occurred. Therefore, the cumulative stroke rate was 0.54%. CONCLUSIONS: This real-world registry suggests that use of CGuard embolic prevention system in clinical practice is safe and associated with a minimal occurrence of adverse neurological events up to 30-day follow-up.
Assuntos
Estenose das Carótidas , Acidente Vascular Cerebral , Humanos , Estudos Prospectivos , Stents , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Prospective single-arm study, aimed at evaluating safety and effectiveness at 12 and 24 months of the paclitaxel-eluting nitinol stent (Zilver PTX), and focused in particular on the treatment of complex lesions and/or diabetic patients. METHODS: Between May 2010 and March 2012, 67 patients (78% males) were treated by Zilver PTX, because of stenosis or occlusions of the superficial femoral artery in one of two centers. The mean age of patients was 70.1±8 years. Thirty-two of 67 (48%) were diabetics, 14 (21%) active smokers and 11 (14.6%) had chronic renal failure (end stage renal disease). The average length of lesions was 104±60 mm. Occlusion was complete in 46.3% of cases, whereas severely calcified lesions were present in 30% of patients (18.8% in diabetics and 31.4% in non-diabetics). Twenty-six patients (39%) had type C or D lesions according to TASC 2. RESULTS: One hundred-two stents were used (1.7±0.9 per patients); median 1 (range 1-4). All patients had successful stent placement. Primary patency, evaluated by Kaplan-Meier method was 88±0.06% at 12 months, and 68±0.1% at 24 months. In particular, the difference between diabetics (D) and non-diabetics (non-D) was not significant (P=0.07, Log-Rank). Patients turned from 4.2±1.3 to 1.6±1.3 Rutherford class. There were 5 deaths due to systemic comorbidities. There also were 3 major amputations, all of them also in the D group. Among the other patients, differences between D and non-D patients were not significant in terms of wound healing, bipedal stay and spontaneous ambulation. The mean follow-up length was 28±5 months (range 24-36 months). There was only one patient who had fracture and stent migration (1.5%). In 13 diabetic patients, tibial PTA was also associated. Additional treatment was required in 6 D and 1 non-D. CONCLUSIONS: The use of Zilver PTX is safe and effective in the treatment of SFA lesions. In particular, both stent patency and functional results on the basis of both clinical and instrumental tools were similar in D and non-D, suggesting a particularly favorable activity of PTX in a subpopulation of diabetics. Further studies are required to confirm these results, which seem to be particularly promising in diabetic patients.
Assuntos
Fármacos Cardiovasculares/administração & dosagem , Angiopatias Diabéticas/cirurgia , Stents Farmacológicos , Procedimentos Endovasculares/instrumentação , Artéria Femoral , Paclitaxel/administração & dosagem , Doença Arterial Periférica/terapia , Idoso , Idoso de 80 Anos ou mais , Ligas , Amputação Cirúrgica , Fármacos Cardiovasculares/efeitos adversos , Angiopatias Diabéticas/diagnóstico por imagem , Angiopatias Diabéticas/mortalidade , Angiopatias Diabéticas/fisiopatologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Humanos , Itália , Estimativa de Kaplan-Meier , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Paclitaxel/efeitos adversos , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Desenho de Prótese , Retratamento , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
Ureteral arterial fistula (UAF) is an uncommon condition characterized by a direct fistulous communication between a ureter and an iliac artery resulting in bleeding into the ureter, which can be massive and life-threatening because of hemodynamic instability, as confirmed by the high mortality rate (7-23% overall).This condition is actually increasing in frequency because of its relation to predisposing factors such as vascular pathology, previous radiation therapy, previous surgery, and necessity of ureteral stenting. Diagnosis is often challenging, as in most patients, the only symptom is hematuria and the treatment may require a multidisciplinary approach, including the expertise of the urologist, vascular surgeon, and interventional radiologist. Endovascular approach offers advantages over open surgery decreasing morbidity (reduced risk of injury to adjacent structure) and shortening hospital staying. There is no consensus regarding the safety of intentional occlusion of the hypogastric artery: proximal occlusion of a hypogastric artery typically produces little or no clinical symptoms due to well-collateralized pelvic arterial networks. On the contrary, significant complications, such as colonic ischemia, spinal cord paralysis, buttock claudication, or erectile dysfunction, are well-recognized adverse events after hypogastric artery embolization, especially in bilateral cases. We describe our experience of a bilateral UAF treated with bilateral endvascular approach.
Assuntos
Artéria Ilíaca , Doenças Ureterais , Fístula Urinária , Fístula Vascular , Feminino , Humanos , Pessoa de Meia-Idade , Doenças Ureterais/diagnóstico , Doenças Ureterais/cirurgia , Fístula Urinária/diagnóstico , Fístula Urinária/cirurgia , Fístula Vascular/diagnóstico , Fístula Vascular/cirurgiaRESUMO
Critical limb ischemia (CLI), foot ulcers, former amputation, and impaired regeneration are independent risk factors for limb amputation in subjects with diabetes. The present work investigates whether and by which mechanism diabetes negatively impacts on functional properties of muscular pericytes (MPs), which are resident stem cells committed to reparative angiomyogenesis. We obtained muscle biopsy samples from patients with diabetes who were undergoing major limb amputation and control subjects. Diabetic muscles collected at the rim of normal tissue surrounding the plane of dissection showed myofiber degeneration, fat deposition, and reduction of MP vascular coverage. Diabetic MPs (D-MPs) display ultrastructural alterations, a differentiation bias toward adipogenesis at the detriment of myogenesis and an inhibitory activity on angiogenesis. Furthermore, they have an imbalanced redox state, with downregulation of the antioxidant enzymes superoxide dismutase 1 and catalase, and activation of the pro-oxidant protein kinase C isoform ß-II (PKCßII)-dependent p66Shc signaling pathway. A reactive oxygen species scavenger or, even more effectively, clinically approved PKCßII inhibitors restore D-MP angiomyogenic activity. Inhibition of the PKCßII-dependent p66Shc signaling pathway could represent a novel therapeutic approach for the promotion of muscle repair in individuals with diabetes.
Assuntos
Isquemia/metabolismo , Músculo Esquelético/metabolismo , Pericitos/metabolismo , Proteína Quinase C beta/metabolismo , Idoso , Western Blotting , Proliferação de Células/efeitos dos fármacos , Ensaio de Imunoadsorção Enzimática , Feminino , Citometria de Fluxo , Células Endoteliais da Veia Umbilical Humana , Humanos , Imuno-Histoquímica , Técnicas In Vitro , Masculino , Microscopia Eletrônica de Transmissão , Músculo Esquelético/efeitos dos fármacos , Estresse Oxidativo/efeitos dos fármacos , Pericitos/efeitos dos fármacos , Ftalimidas/farmacologia , Espécies Reativas de Oxigênio/metabolismo , Transdução de Sinais/efeitos dos fármacosAssuntos
Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Próteses Valvulares Cardíacas , Stents , Substituição da Valva Aórtica Transcateter/instrumentação , Idoso de 80 Anos ou mais , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/etiologia , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/etiologia , Valva Aórtica/diagnóstico por imagem , Feminino , Humanos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoAssuntos
Estenose das Carótidas/terapia , Vasos Coronários/diagnóstico por imagem , Procedimentos Endovasculares/instrumentação , Tomografia de Coerência Óptica , Estenose das Carótidas/diagnóstico por imagem , Procedimentos Endovasculares/efeitos adversos , Humanos , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Stents , Resultado do TratamentoRESUMO
OBJECTIVE: Prediction of clinical outcome in diabetic patients with critical limb ischemia (CLI) is unsatisfactory. This prospective study investigates if the abundance and migratory activity of a subpopulation of circulating mononuclear cells, namely, CD45(dim)CD34(pos)CXCR4(pos)KDR(pos) cells, predict major amputation and cardiovascular death in type 2 diabetic patients undergoing percutaneous transluminal angioplasty for CLI. RESEARCH DESIGN AND METHODS: A consecutive series of 119 type 2 diabetic patients with CLI was enrolled. CD45(dim)CD34(pos)CXCR4(pos)KDR(pos) cells were assessed by flow cytometry upon isolation and also after spontaneous or stromal cell-derived factor 1α-directed migration in an in vitro assay. The association between basal cell counts and migratory activity and the risk of an event at 18-month follow-up was evaluated in a multivariable regression analysis. RESULTS: Time-to-event analysis of amputation (n = 13) showed no association with the candidate predictors. Sixteen cardiovascular deaths occurred during 18 months of follow-up. Abundance of CD45(dim)CD34(pos)CXCR4(pos)KDR(pos) cells was not associated with cardiovascular mortality. Interestingly, in vitro migration of CD45(dim)CD34(pos)CXCR4(pos)KDR(pos) cells was higher in patients with cardiovascular death compared with event-free subjects (percentage of migrated cells median value and interquartile range, 0.03 [0.02-0.07] vs. 0.01 [0.01-0.03]; P = 0.0095). Multivariable regression model analysis showed that cell migration forecasts cardiovascular mortality independently of other validated predictors, such as age, diagnosed coronary artery disease, serum C-reactive protein, and estimated glomerular filtration rate. In this model, doubling of migrated cell counts increases the cardiovascular death hazard by 100% (P < 0.0001). CONCLUSIONS: The new predictor could aid in the identification of high-risk patients with type 2 diabetes requiring special diagnostic and therapeutic care after revascularization.
Assuntos
Movimento Celular , Diabetes Mellitus Tipo 2/mortalidade , Pé Diabético/mortalidade , Pé/irrigação sanguínea , Isquemia/mortalidade , Leucócitos Mononucleares/fisiologia , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Proteína C-Reativa/análise , Quimiocina CXCL12/farmacologia , Doença da Artéria Coronariana/etiologia , Doença da Artéria Coronariana/mortalidade , Diabetes Mellitus Tipo 2/complicações , Pé Diabético/cirurgia , Feminino , Pé/cirurgia , Humanos , Isquemia/cirurgia , Leucócitos Mononucleares/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Receptores CXCR4/análiseRESUMO
OBJECTIVES: This is a prospective evaluation of percutaneous interventions (PTAs) performed by the antegrade femoral approach in diabetic patients with critical limb ischemia (CLI) and ostial superficial femoral artery (SFA) lesions. METHODS: The puncture site was selected according to duplex scan analysis and physical examination (brachial, crossover, or antegrade). In cases of antegrade approach, a bare needle angiogram of the femoral bifurcation was performed in order to have an adequate distance (>2 cm) from the target lesion. RESULTS: Between January 2010 and August 2011, 64 diabetic patients underwent PTA for ostial SFA lesions. Crossover or brachial approach was electively adopted in 19/64 (30%) patients. The antegrade bare needle angiogram was performed in the remaining 45/64 (70%) patients. In two patients, the vascular anatomy was considered not suitable for antegrade approach, and they were treated in crossover. Technical success was achieved in 38/45 (84%) of patients. During hospital stay, one patient had SFA stent thrombosis treated with urgent bypass grafting. CONCLUSIONS: The antegrade approach can be safely performed in most patients presenting with CLI and ostial SFA lesions. The use of clinical and radiographic criteria correctly identifies patients with ostial SFA lesions suitable for an antegrade approach in 42/44 (95%) of cases.
Assuntos
Angioplastia/métodos , Arteriopatias Oclusivas/terapia , Complicações do Diabetes/terapia , Artéria Femoral , Isquemia/terapia , Perna (Membro)/irrigação sanguínea , Doenças Vasculares Periféricas/cirurgia , Arteriopatias Oclusivas/fisiopatologia , Feminino , Artéria Femoral/diagnóstico por imagem , Artéria Femoral/fisiopatologia , Humanos , Masculino , Estudos Prospectivos , Radiografia , Resultado do TratamentoRESUMO
AIMS: To evaluate the feasibility of peripheral revascularization by angioplasty (PTA) or bypass grafting (BPG) in diabetic patients with critical limb ischemia (CLI). METHODS: All diabetic patients referred to our Diabetic Foot Centre for foot lesion or rest pain were assessed for the presence of CLI as assessed by the TASC criteria. All patients underwent angiography that was evaluated jointly by an interventional radiologist, a vascular surgeon and a diabetologist of the diabetic foot care team. RESULTS: During 2009, 344 diabetics were admitted because of CLI in a total of 360 limbs. PTA was performed in 308 (85.6%) limbs, and BPG was performed in 40 (11.1%) limbs in which PTA was not feasible. Revascularization could not be carried out in 12 (3.3%) limbs due to the lack of target vessel (9 limbs) or high surgical risk (3 limbs). According to the judgement of the vascular surgeon, BPG was anatomically feasible in 180 (58.4%) of the 308 limbs that underwent PTA. Therefore, considering also the 40 limbs that underwent BPG, surgical revascularization was judged anatomically possible in a total of 220 (61.1%) limbs. At 30 days, 19 (5.3%) above-the-ankle amputations were performed: 8 (66.7%) amputations were performed in the 12 non-revascularized limbs, 8 (2.6%) amputations were performed in the 308 limbs treated with PTA and 3 (7.5%) amputations were performed in the 40 limbs treated with BPG. CONCLUSIONS: Revascularization by PTA is highly feasible in diabetics with CLI. The feasibility of revascularization by BPG is lower but nonetheless consistent. In centres where both revascularization procedures are available, it is possible to revascularize more than 96% of diabetics with CLI.
Assuntos
Isquemia/cirurgia , Salvamento de Membro/métodos , Procedimentos Cirúrgicos Vasculares/métodos , Idoso , Idoso de 80 Anos ou mais , Angioplastia , Extremidades/cirurgia , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Enxerto VascularRESUMO
Subintimal angioplasty (SAP) is frequently performed for the treatment of critical limb ischemia (CLI) and has been recognized as an effective technique for these patients. Nevertheless, this approach is limited by the lack of controlled re-entry into the true lumen of the target vessel. We describe a novel device for true lumen re-entry after subintimal recanalization of superficial femoral arteries (SFA). We report our experience with six patients treated between April 2009 and January 2010 with a novel system designed to facilitate true lumen re-entry. The device was advanced by ipsilateral antegrade approach through a 6-French sheath. Successful reaccess into the true lumen was obtained in five of six patients without complications. The patient in whom the reaccess to the true lumen was not possible underwent successful bypass surgery. At 30 days follow-up, the SFA was patent in all patients according to echo-Doppler examination. Our preliminary experience indicates that this novel re-entry device increases the success rate of percutaneous revascularization of chronically occluded SFA.
Assuntos
Angioplastia/instrumentação , Arteriopatias Oclusivas/terapia , Artéria Femoral , Isquemia/terapia , Doenças Vasculares Periféricas/terapia , Idoso de 80 Anos ou mais , Angiografia , Desenho de Equipamento , Feminino , Humanos , Masculino , Radiografia Intervencionista , Resultado do Tratamento , Ultrassonografia DopplerRESUMO
BACKGROUND: To evaluate the survival after major lower limb amputation, at a level either below (BKA) or above (AKA) the knee, in diabetic patients admitted to hospital because of critical limb ischemia (CLI). METHODS: From January 1999 to December 2003, 564 diabetic patients were consecutively admitted to our Foot Center because of CLI and followed up until December 2005. A revascularization procedure was performed in 537 patients (95.2%): in 420 with peripheral angioplasty, in 117 with peripheral bypass graft. Neither endoluminal nor surgical revascularization was practicable in 27 (4.8%) patients. RESULTS: Major amputation was performed in a total of 55 (9.8%) patients. Among the clinical and demographic variables evaluated, age was significantly lower (67.3+/-10.1 vs. 76.7+/-10.4, P<.001), duration of diabetes was higher (17.1+/-11.1 vs. 13.4+/-10.0, P=.013), and current smoking was more frequent (38.5% vs. 25.0%, P<.001) in revascularized amputees. The amputation free median time for revascularized patients was 5.11 months, and for nonrevascularized patients, 0.33 months. The log-rank test for equality of survivor function without amputation between amputees with or without revascularization was 31.76 (P<.001). Among the 55 amputees, 11 (28.2%) out of the 39 revascularized patients and 13 (81.2%) out of the 16 nonrevascularized patients died. The log-rank test for equality of survivor function was 6.83 (P=.009). The Cox model performed to evaluate the association between the recorded variables and the mortality showed a significant hazard ratio only with age (hazard ratio for 1 year 1.11, P=.003, confidence interval 1.04-1.19). CONCLUSIONS: Our data suggest that the revascularization allows to postpone the major amputation, and that the survival of revascularized amputees is better than that of nonrevascularized amputated patients. All these data offer further encouragement to revascularize all diabetic patients with CLI.
Assuntos
Amputação Cirúrgica/mortalidade , Diabetes Mellitus Tipo 2/cirurgia , Pé Diabético/mortalidade , Pé Diabético/cirurgia , Pé/irrigação sanguínea , Isquemia/cirurgia , Procedimentos Cirúrgicos Vasculares , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Diabetes Mellitus Tipo 2/complicações , Extremidades/irrigação sanguínea , Extremidades/patologia , Extremidades/cirurgia , Feminino , Seguimentos , Pé/patologia , Pé/cirurgia , Humanos , Isquemia/complicações , Salvamento de Membro/métodos , Salvamento de Membro/mortalidade , Salvamento de Membro/reabilitação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Cirúrgicos Vasculares/mortalidade , Procedimentos Cirúrgicos Vasculares/reabilitaçãoRESUMO
OBJECTIVE: To evaluate the long-term prognosis of critical limb ischemia (CLI) in diabetic patients. RESEARCH DESIGN AND METHODS: A total of 564 consecutive diabetic patients were hospitalized for CLI from January 1999 to December 2003; 554 were followed until December 2007. RESULTS: The mean follow-up was 5.93 +/- 1.28 years. Peripheral angioplasty (PTA) was performed in 420 (74.5%) and bypass graft (BPG) in 117 (20.6%) patients. Neither PTA nor BPG were possible in 27 (4.9%) patients. Major amputations were performed in 74 (13.4%) patients: 34 (8.2%) in PTA, 24 (21.1%) in BPG, and 16 (59.2%) in a group that received no revascularization. Restenosis occurred in 94 patients, bypass failures in 36 patients, and recurrent ulcers in 71 patients. CLI was observed in the contralateral limb of 225 (39.9%) patients; of these, 15 (6.7%) required major amputations (rate in contralateral compared with initial limb, P = 0.007). At total of 276 (49.82%) patients died. The Cox model showed significant hazard ratios (HRs) for mortality with age (1.05 for 1 year [95% CI 1.03-1.07]), unfeasible revascularization (3.06 [1.40-6.70]), dialysis (3.00 [1.63-5.53]), cardiac disease history (1.37 [1.05-1.79]), and impaired ejection fraction (1.08 for 1% point [1.05-1.09]). CONCLUSIONS: Diabetic patients with CLI have high risks of amputation and death. In a dedicated diabetic foot center, the major amputation, ulcer recurrence, and major contralateral limb amputation rates were low. Coronary artery disease (CAD) is the leading cause of death, and in patients with CAD history the impaired ejection fraction is the major independent prognostic factor.