Retrospective Review of Management and Overall Survival Rate of Patients With Vascular Pythiosis of the Lower Extremity: 20 Years Experience.

Pythiosis is an infectious disease in humans and animals caused by an aquatic fungus-like micro-organism, Pythium insidiosum. Vascular pythiosis is a difficult condition to treat and can lead to loss of limb in addition to being a potentially life-threatening infection. The condition is furthermore unfamiliar among healthcare workers, which often results in delayed treatment or even misdiagnosis. In this study, we report our findings, which have been gathered over a 20-year period in caring for vascular pythiosis in Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand. We made a retrospective medical review of 32 patients presented with arterial occlusion who have serum anti-Pythium insidiosum antibodies. All patients underwent computed tomography angiography to confirm the level of arterial occlusion and decided on a treatment plan. Twelve out of 22 patients with infrainguinal disease, femoropopliteal or below-knee vascular occlusion, survived. The mean survival time is 6.58 years. Eight in 10 patients presented with suprainguinal disease died during the follow-up with a mean survival time of 31.6 months. The suprainguinal extension of the disease influenced the outcome, resulting in a higher mortality rate. However, patients presented with chronic limb ischemia had a much greater rate of survival compared to other clinical presentations. Extensive surgical resection combined with antifungal treatment and immunotherapy have proven to be effective in patients with vascular pythiosis in our findings.

The Prevalence and Risk Factors for Peripheral Arterial Disease in Adults Living With Human Immunodeficiency Virus.

Adult patients with human immunodeficiency virus (HIV) appear to be at high risk of cardiovascular disease (CVD). Peripheral arterial disease (PAD) is particularly concerning as it is associated with myocardial infarction and stroke. Nevertheless, the incidence of PAD is still unknown. The authors prospectively recruited HIV-infected patients from the outpatient clinic of the Department of Internal Medicine in our center. We assessed ankle-brachial index (ABI) using the VaSera system™ (Fukuda Denshi Co., Ltd). Patients were grouped into 3 ABI levels: an ABI ≤0.90 was considered abnormal and evidence of PAD, an ABI 1.0 to 1.40 was considered normal, and 0.91 to 0.99 was considered borderline. Cardiovascular risk factors were compared across all 3 levels of ABI and were analyzed using multivariate ordinal logistic regression. Eight hundred ninety-two patients were recruited. The mean age was 42.9 ± 10.0 years and 458 (51.4%) were males. There were 704, 149, and 39 patients in the normal, borderline, and abnormal ABI groups, respectively. The latter group of 39 patients was considered to have PAD, yielding a prevalence of 4.37% (95% confidence interval [CI] 3.21-5.93). Sex ratio, age, education levels, smoking rate, body mass index (BMI), blood pressure, prevalence of comorbidities with hypertension and coronary heart disease, median triglyceride level, reduced kidney function and HIV-1 RNA undetectable ratio, duration of HIV diagnosis, and duration on antiretroviral treatment were significantly different among 3 ABI subgroups. Independent risk factors associated with PAD were being female (odds ratio [OR]: 2.86; 95% CI: 1.94-4.22), being <30 years of age (OR: 4.66; 95% CI: 2.78-7.81), being overweight (BMI 25-25.9; OR: 0.39; 95% CI: 0.20-0.76), being obese (BMI: 30; OR: 3.53; 95% CI: 1.51-8.22), having a diastolic blood pressure ≥80 mmHg (OR: 0.50; 95% CI: 0.35-0.71), and having detectable HIV-1 RNA ≥20 copies/mL (OR: 1.85; 95% CI: 1.13-3.03). In conclusion, the prevalence of PAD in HIV-infected Thais was 4.37% in infected patients on therapy attending outpatient clinics. For this population, PAD appears to be relatively poorly correlated with traditional risk factors of CVD.

Effects of short-term bisoprolol on perioperative myocardial injury in patients undergoing non-cardiac surgery: a randomized control study.

The protective role of preoperative beta-blocker in patients undergoing non-cardiac surgery is unknown. We aimed to evaluate the effects of beta-blocker on perioperative myocardial injury in patients undergoing non-cardiac surgery. We consecutively enrolled 112 patients undergoing non-cardiac surgery. They were randomly allocated to receive bisoprolol or placebo given at least 2 days preoperatively and continued until 30 days after surgery. The primary outcome was incidence of perioperative myocardial injury defined by a rise of high-sensitive troponin-T (hs-TnT) more than 99th percentile of upper reference limit or a rise of hs-TnT more than 20% if baseline level is abnormal. Baseline characteristics were comparable between bisoprolol and placebo in randomized cohort Mean age was 62.5 ± 11.8 years and 76 (67.8%) of 112 patients were male. Among 112 patients, 49 (43.8%) underwent vascular surgery and 63 (56.2%) underwent thoracic surgery. The median duration of assigned treatment prior to surgery was 4 days (2-6 days). We did not demonstrate the significant difference in the incidence of perioperative myocardial injury [52.6% (30 of 57 patients) vs. 49.1% (27 of 55 patients), P = 0.706]. In addition, the incidence of intraoperative hypotension was higher in bisoprolol group than placebo group in patients undergoing non-cardiac surgery [70.2% (40 of 57 patients) vs. 47.3% (26 of 55 patients), P = 0.017]. We demonstrated that there was no statistically significant difference in perioperative myocardial injury observed between patients receiving bisoprolol and placebo who had undergone non-cardiac surgery.

Ankle-Brachial Index and Carotid Intima-Media Thickness Progression by Using Ultrasound Among Patients With HIV Infection Versus End-Stage Renal Disease.

Human immunodeficiency virus (HIV) and end-stage renal disease (ESRD) patients contributed to accelerated cardiovascular disease. Comparing the effect on atherosclerosis of the 2 diseases has never been explored. A prospective cohort study enrolled participants who were more than 18 years of age without stroke, coronary, and peripheral arterial disease events. Each HIV-infected person had continuously used antiretroviral therapy and ESRD and required intermittent hemodialysis. We assessed patients using the ankle-brachial index (ABI) and carotid intimal media thickness (CIMT) at enrollment, and 1 year later. The main outcome was the progression of ABI and CIMT per year. Demographic, comorbidities, and serum profiles were collected on entry. A total of 789 HIV-positive and 41 ESRD with HIV-negative patients were recruited. After adjusting for potential confounders at baseline, the ESRD die not significantly decrease ABI by 0.015 in 1 year (P=0 .252). The HIV-infected group had a significantly decreased ABI by 0.020 in 1 year (P < .001), but the reduced rate in the HIV-infected group was not statistically different from those in the ESRD group (P = 0.901). When adjusted for potential confounders, the ESRD had a significant increase of CIMT by 0.111 mm in 1 year (P<0.001). The HIV patients had a significant increase of 0.250 mm CIMT in 1 year (P<0.001). This progression rate was statistically greater in the HIV-infected group versus the ESRD group. HIV infection and ESRD had comparable rates of ABI and CIMT progression in our study. Then, early prevention in asymptomatic atherosclerosis should include not only patients with ESRD but also HIV-infected patients.

Aorto-enteric Fistula After Endovascular Abdominal Aortic Aneurysm Repair for Behcet's Disease Patient: A Case Report.

INTRODUCTION: A 42 year old male with Behcet's disease (BD) had endovascular treatment of a symptomatic infrarenal abdominal aortic aneurysm (AAA). Thirteen months later he developed haematemesis and melaena. METHODS: Computed tomography (CT) and angiography showed an aorto-enteric fistula with migration and kinking of the stent graft. Explantation of the infected graft and axillobifemoral bypass, aneurysm sac debridement, and jejunal repair with omental interposition was performed on this severely contaminated patient. DISCUSSION: There are no reports of an aorto-enteric fistula secondary to endovascular repair in the literature and this case describes the potential consequences of endovascular repair of AAA in BD. The aorto-enteric fistula was associated with persistent inflammatory aortitis, stent graft kinking, and infection. Five cases of secondary aorto-enteric fistulas following open AAA repair in BD patients have been reported including this case resulting from endovascular repair.

Management of the infected aortic endograft.

Although the incidence of abdominal and thoracic aortic endograft infection is infrequent, ranging between 0.2% and 5%, stent-graft infection carries significant morbidity and mortality and exemplifies a formidable therapeutic challenge. The treatment goal is to eradicate the infectious process by endograft explantation, regional tissue debridement, and arterial reconstruction by either an extra-anatomic or in situ grafting procedure using autologous vein, cryopreserved allograft, or antibiotic-soaked prosthetic grafts. Successful treatment should maintain normal arterial perfusion to the visceral arteries and lower extremities. Important treatment adjuncts included antibiotic therapy based on cultures, specific bacterial isolates, and coverage of the repair or aortic stump using an omental wrap. Nonoperative treatment in patients with severe comorbidities that preclude endograft explantation may be appropriate in the setting of low-grade biofilm infection. Percutaneous drainage of the perigraft abscess followed by continuous antibacterial irrigation of the cavity can be utilized, but is associated with a high clinical failure rate.

Underrecognition and Undertreatment for Peripheral Arterial Disease in Diabetic Patients in Thailand.

Objective: Although several guidelines emphasized the importance of atherosclerotic risk factor management in peripheral arterial disease (PAD) in diabetic patients to reduce the cardiovascular mortality, authors do not know to what extent physicians follow these guidelines. Material and Method: Between May 2014 and August 2014, consecutive eligible outpatients, aged ≥45 years with established DM, were invited to be involved in this study. History, physical exam and laboratory test were reviewed. Ankle brachial index ≤0.9 was considered PAD. Then patients were evaluated the percentage of risk factor control according to American Heart Association (AHA) criteria. The good control was defined that patients have adequate risk factor control between 3-5 factors. Results: 2,247 diabetic patients were recruited for the study. 286 patients out of 2,247 were diagnosed PAD (12.7%). 236 PAD patients (82.5%) did not have any symptom of intermittent claudication, rest pain, gangrene or ulcer. According to AHA criteria, the percentage of adequate control in low density lipoprotein, HbA1C and systolic blood pressure in PAD patients was 18.9, 30.1 and 33.2% respectively. 49.8% in PAD patients had met our good risk factor control criteria. Conclusion: Most PAD in diabetic patients was asymptomatic. The atherosclerotic risk factor control was poor in this group.

Endovascular Aneurysm Repair in HIV Patients with Ruptured Abdominal Aneurysm and Low CD4.

We report two HIV infected patients with ruptured abdominal aneurysm by using endovascular aneurysm repair (EVAR) technique. A 59-year-old Thai man had a ruptured abdominal aortic aneurysm and a 57-year-old man had a ruptured iliac artery aneurysm. Both patients had a CD4 level below 200 µ/L indicating a low immune status at admission. They were treated by EVAR. Neither patient had any complications in 3 months postoperatively. EVAR may have a role in HIV patients with ruptured abdominal aneurysm together with very low immunity.

Acute Deep Vein Thrombosis in Venous Aneurysm following Closure of the Chronic Traumatic Arteriovenous Fistulae of the Lower Extremities.

Chronic traumatic arteriovenous fistula (AVF) commonly results from an unrecognized vascular injury. In this report, there were two cases of chronic traumatic AVF of the legs with a long history of stab (case 1) and shotgun wounds (case 2). Both cases presented with varicose veins together with hyperpigmentation around the ankle of the affected leg. Angiograms showed a single large AVF in case 1, whereas, in case 2, there was a single large AVF together with multiple small AVFs. In both cases large venous aneurysm was found next to a large AVF. An open surgical AVF closure for the large AVF was performed in case 1 successfully, but patient developed acute deep vein thrombosis (DVT) in a large venous aneurysm. In the second case, in order to prevent DVT, only closure of the large AVF was performed, which preserved arterial flow into the venous aneurysm. Case 2 did not have acute DVT. This report raised the concern about acute DVTs in venous aneurysms following the closure of chronic traumatic AVF in terms of prevention. Also chronic traumatic AVF is commonly due to misdiagnosis in the initial treatment, so complete and serial physical examinations in penetrating vascular injury patients are of paramount importance.

Unusual Cases of Hypothenar Hammer Syndrome.

OBJECTIVE: Hypothenar hammer syndrome (HHS) is a rare occupational disease. The risk group of HHS is patient whose dominate hand used as a hammer. Our study report unusually cases in Chiang Mai University Hospital. RESULT: 19 year-old basketball player had right ulnar artery aneurysm for two months. After operation, his symptom was relieved and returned to play basketball again. 65 year-old housekeeper had non-dominated hand ulnar artery aneurysm for two years. After operation she still had hand claudication due to poor run-off vessel. CONCLUSION: HHS is previously state in risk group. But from our report there was a risk in different occupation.

Vascular Pythiosis of the Lower Extremity in Northern Thailand: Ten Years' Experience.

Pythiosis is a disease caused by Pythium insidiosum, a fungus-like organism. P. insidiosum is pathogenic in mammals, particularly in horses, dogs, and humans. Human pythiosis can be classified into 4 types: (1) cutaneous/subcutaneous, (2) ocular, (3) vascular, and (4) disseminated pythiosis. Vascular pythiosis is a rare disease but a serious limb- and life-threatening infection. We reviewed 22 cases over a 10-year period in Maharaj Nakorn Chiang Mai/Chiang Mai University Hospital. The survival rate was around 63.6% during our follow-up period. The only effective treatment was complete excision of the infected tissue, which was done mainly by major amputation, such as above-knee amputation. This report raises awareness of this disease, which needs preemptive diagnosis and appropriate treatment.

Case series of isolated primary persistent sciatic vein.

Our study aimed to present a short series on the persistent sciatic vein, a rare venous variation, without Klippel-Trenaunay-Weber syndrome and to review the anatomical consideration of deep venous systems. Four cases of lower-type persistent sciatic vein were found. A combination of May-Thurner syndrome and persistent sciatic vein was found in 2 cases. Non-hypoplastic femoral veins, normal and duplicated, were found in 3 cases. This study concluded that in this persistent sciatic vein, the associated non-hypoplastic femoral vein is not uncommon, and care must be taken about this condition during ultrasonographic examination. Unusual causes of chronic venous insufficiency and other venous anomalies should not be overlooked.

Mycotic abdominal aortic aneurysm due to Streptococcus suis: a case report.

BACKGROUND: Streptococcus suis is a common infection of pigs. Human infection is often related to accidental inoculation through skin injuries during occupational exposure to pigs and pork. The disease may present as meningitis, bacteremia, and less commonly endocarditis, arthritis, or bronchopneumonia. METHODS: Case report and review of the literature. RESULTS: We report a case of bacteremia and severe sepsis caused by S. suis serotype 2 complicated by septic arthritis in a 56-year-old male with history of a prior contact with unprocessed pork. The causative agent was isolated from blood cultures and aspirated synovial fluid. The patient's condition improved after treatment with penicillin, but he was found subsequently to have an abdominal aortic aneurysm, confirmed by computed tomography (CT) scan. The mycotic aneurysm was successfully repaired using an in situ graft reconstruction. Tissue samples analyzed using polymerase chain reaction identified S. suis serotype 2 as the causative organism. After completion of two weeks of parenteral antibiotics, an oral form of ciprofloxacin (0.25 g twice a day) was continued for one month. The patient was discharged from our institution after uncomplicated recovery. Clinical review, a CT scan, and inflammatory markers nine months after surgery revealed no evidence of infection. CONCLUSION: This is the first report of mycotic aneurysm caused by S. suis, which may be an etiologic agent of mycotic aneurysms, especially when complicated by bacteremia in adults with a recent history of contact with pigs or unprocessed pork.