External validation of Villalta score in high-middle income country patients with deep vein thrombosis.

ABSTRACT: Post-thrombotic syndrome (PTS) is a late complication that does not have a cure yet, with a prevalence estimated between 20 to 75%, associated with previous deep vein thrombosis event. Although the Villalta score (VS) is the gold-standard clinical tool for diagnostic and prognostic evaluation of PTS, there are currently no VS intra-rater agreement established and no validation studies for VS' application into Brazilian Portuguese. We sought to translate and validate VS reliability systematically; and, secondarily, to compare the ultrasound findings with the severity of PTS.We systematically translated the original VS into Brazilian Portuguese (BP). Fifty participants who underwent two outpatient visits were evaluated using the translated VS. We assessed its intra-rater and inter-rater agreement and compared BP VS versus CEAP clinical component (CEAP C), and the clinical PTS severity versus the duplex ultrasound (DUS) findings. The study and its report followed the Guidelines for Reporting Reliability and Agreement Studies.The intra-rater evaluation of VS grades had a simple Kappa coefficient of 0.73, and the simple Kappa coefficient inter-rater for VS grades was 0.67. When VS was compared to CEAP C, it established a remarkably high correlation over 0.9. There was difference among VS values compared to DUS initial deep vein thrombosis territory, with femoropopliteal showing higher values than distal veins. Higher VS values were correlated to DUS venous recanalization and reflux.There was a substantial inter-rater and intra-rater agreement when the BP VS was applied; and when compared to CEAP C, VS showed a high correlation. When VS grading was compared to DUS characteristics, there were significant statistical and clinical correlation, with presence of reflux and recanalization showing higher VS values. This external VS validation also changes the clinical practice allowing the VS use in a different population and establishes the VS intra-rater agreement.

Angioplasty and stenting for below the knee ulcers in diabetic patients: protocol for a systematic review.

BACKGROUND: The worldwide incidence and prevalence of diabetes mellitus (DM) are increasing. DM has a high social and economic burden due to its complications and associated disorders. Peripheral arterial disease (PAD) is closely related to DM. More than 85% of patients with DM will develop PAD in their lifetime, and between 10 and 25% of patients with DM will have a foot ulcer. In such cases, it is important to determine for each patient whether it is necessary and feasible to revascularise the affected limb as well as the optimal technique. Percutaneous transluminal angioplasty (PTA) is designed to restore blood flow through the vessel lumen by various devices including balloons, drug-coated balloons, bare stents, drug-eluting stents and endovascular atherectomes. This systematic review aims to evaluate the effects of PTA in the treatment of lower limb arterial ulcers in diabetic patients. METHODS: We will search randomised controlled trials (RCTs) and quasi-RCTs in the following databases (e.g., MEDLINE via PubMed, EMBASE, Lilacs, Cochrane Central Register of Controlled Trials, Ibecs, CINAHL, AMED, World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov , and OpenGrey). Our search strategy will use the following free-text terms and controlled vocabulary (e.g., Emtree, MeSH) for 'foot ulcer', 'leg ulcer', 'diabetic foot', 'Peripheral Arterial Disease', 'Diabetes Complications', 'Peripheral Vascular Diseases', 'critical limb ischemia', 'below the knee ulcer', 'angioplasty', 'stents', 'stenting', and 'endovascular procedures'. There will be no limits on date or language of publication. Two authors will, independently, select studies and assess the data from them. Risks of bias (RoB) of included studies will be evaluated using the Cochrane's RoB tool. If possible, we will perform and report structured summaries of the included studies and meta-analyses. Results are not available as this is a protocol for a systematic review, and we are currently in the phase of building a sensitive search strategy. DISCUSSION: While there are several available endovascular techniques for revascularisation, it is unclear which technique has better outcomes for ulcers below the knee in diabetic patients. A systematic review is required to validate and demonstrate these techniques and their outcomes to allow an evidence-based clinical decision. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017065171.

Popliteal Artery Entrapment Syndrome: A Case Report and Review of the Literature.

BACKGROUND Popliteal artery entrapment syndrome (PAES) results from an anomalous relationship between the popliteal artery and the myofascial structures of the popliteal fossa. The most common presenting symptoms include intermittent pain in the feet and calves on exercise, resulting in lameness. PAES can lead to popliteal artery thrombosis, stenosis, distal arterial thromboembolism, or arterial aneurysm. The treatment of PAES includes surgical exploration with fasciotomy, myotomy, or sectioning of fibrous band formation, to release the popliteal artery. However, in cases with thrombotic occlusion, thromboendarterectomy with venous patch arterioplasty, or venous graft arterial bypass surgery may be required. This report describes the presentation and surgical management of a case of PAES presenting with limb pain and includes a review of the literature on this condition. CASE REPORT A previously healthy 47-year-old woman presented with a 20-day history of sudden pain in the left lower limb, associated with pallor and a loss of arterial pulses below the knee. Angiography of the affected limb showed occlusion of the left supragenicular popliteal artery, with arterial occlusion, suggestive of arterial thrombus. Imaging of the right popliteal artery, which was not occluded, showed that it was medially deviated. An ipsilateral saphenous vein graft was used to bypass the left supragenicular popliteal artery to the infragenicular popliteal artery, resulting in resolution of the patient's symptoms. CONCLUSIONS PAES is rare and can be under-diagnosed, possibly due to lack of knowledge of this condition. However, if the diagnosis is made early, the prognosis is usually favorable, following appropriate surgical treatment.

Systematic Literature Review on Evaluation and Management of Isolated Spontaneous Celiac Trunk Dissection.

BACKGROUND: The purpose of this study is to perform a systematic literature review of isolated spontaneous celiac trunk dissection (ISCTD), to evaluate initial clinical and diagnostic aspects, treatment modalities, and outcomes. METHODS: A retrospective search of MEDLINE, Cochrane, and SciELO databases was performed, using the terms celiac artery dissection, celiac trunk dissection, hepatic artery dissection, splenic artery dissection, or left gastric artery dissection to identify instances of ISCTD. Patients with associated aortic and/or other visceral artery dissection were excluded. When available, the following information was collected from each case: gender, age, associated risk factor, symptoms, diagnostic method, treatment modality, and outcome. RESULTS: A total of 60 publications were identified between 1987 and 2015, with 11 cases series and 49 case reports, achieving a total of 169 patients identified with ISCTD. Such information was collected: 99 patients were male and 17 female, with an average age of 53.1 years and the most common symptom was abdominal pain. Diagnosis was mainly made with computed tomography. The most common associated conditions were hypertension and smoking in 31% and 23% of the cases, respectively. Conservative treatment was performed in 79% of the cases. CONCLUSIONS: The profile of patients with ISCTD is male, middle aged, and almost all suffer from abdominal pain. Initial conservative treatment seems adequate for most cases, but a few patients will require interventional treatment. Clinical and radiological long-term follow-up is mandatory, owing to the risk of later progression to aneurysm.

Evaluation and management of symptomatic isolated spontaneous celiac trunk dissection.

The purpose of this study is to describe 10 cases of symptomatic isolated spontaneous celiac trunk dissection (ISCTD) in order to evaluate the initial clinical presentation, diagnosis, treatment modalities and outcomes. A retrospective search was performed from 2009 to 2014 and 10 patients with ISCTD were included in the study. Patients with associated aortic and/or other visceral artery dissection were excluded. The following information was collected from each case: sex, age, associated risk factors, symptoms, diagnostic method, anatomic dissection pattern, treatment modality and outcome. Most patients were male (90%), with an average age of 44.8 years, and the most common symptom was abdominal pain (100%). Hypertension and vasculitis (polyarteritis nodosa) were the most frequent risk factors (40% and 30%, respectively). Diagnosis was made in all patients with computed tomography. Dissection was limited to the celiac trunk in three patients and extended to celiac branches in the other seven. Initial conservative treatment was attempted in every case and was successful in nine patients. In one case, initial conservative treatment was unsuccessful and arterial stenting with coil embolization of the false lumen was performed. After successful initial treatment, late progression of the dissection to aneurysmal dilatation was observed in two patients and it was decided to perform endovascular treatment. Mean follow-up was 19 months, ranging from 2 to 59 months. In conclusion, initial conservative treatment seems adequate for most patients with ISCTD. Long-term follow-up is mandatory, owing to the risk of later progression to aneurysm.

Endovascular stenting of brachial artery occlusion in critical hand ischemia.

Critical upper limb ischemia caused by atherosclerosis is uncommon. Endovascular treatment, with angioplasty or stenting, has been successfully performed for subclavian and below the elbow diseases; however, there's a lack of report regarding the treatment of brachial artery disease causing critical hand ischemia. In this article, we describe the treatment of a brachial artery occlusion with endovascular stenting in a patient with chronic upper limb ischemia.