The vascular and biochemical effects of cilostazol in diabetic patients with peripheral arterial disease.

OBJECTIVES: Cilostazol improves walking in patients with peripheral arterial disease (PAD). We hypothesized that cilostazol reduces diabetic complications in PAD patients. METHODS: Diabetic PAD patients were prospectively recruited to a randomized double-blinded, placebo-controlled trial, using cilostazol 100mg twice a day. Clinical assessment included ankle-brachial index, arterial compliance, peripheral transcutaneous oxygenation, treadmill walking distance and validated quality of life (QoL) questionnaires. Biochemical analyses included glucose and lipid profiles. All tests were at baseline, 6, and 24 weeks. RESULTS: 26 diabetic PAD patients (20 men) were recruited. Cilostazol improved absolute walking distance at 6 and 24 weeks (86.4% vs. 14.1%, P = .049; 143% vs. 23.2%, P = .086). Arterial compliance and lipid profiles improved as did some QoL indices for cilostazol at 6 and 24 weeks. Blood indices were similar at baseline and at follow-up points for both treatment groups. CONCLUSIONS: Cilostazol is a well-tolerated and efficacious treatment, which improves claudication distances in diabetic PAD patients with further benefits in arterial compliance, lipid profiles, and QoL.

Advantages and pitfalls of abdominal aortic aneurysm screening in high-risk patients.

Screening for abdominal aortic aneurysm (AAA) has been suggested for older men. Our aim was to determine the effect of participant selection on prevalence and treatment suitability. Men aged 65 to 75 years attending cardiology clinics composed the high-risk group; the control group was from the community. AAA screening was performed, with follow-up or surgery arranged. Four hundred eight of 651 (62.7%) high-risk men and 109 of 908 (45.0%; p< .0001) men attended from the community. In the high-risk patients, 40 AAAs were diagnosed, with a mean diameter of 41.4 mm (+/-10.4 mm). In the control group, 22 new AAAs were found, with an average size of 40.9 mm (+/-10.4 mm). Higher polypharmacy existed in the high-risk group (4.6+/-2.2 vs 2.3+/-2.0; p< .0001). More aneurysm patients were on dual-antiplatelet therapy (32.5% vs 15.4%; p= .048) compared with the overall high-risk group. In this group, three underwent surgery; one was anatomically unsuitable for endovascular repair and medically unfit for open repair. Two in the control group had surgery. A higher prevalence of AAA is encountered in high-risk men. Most aneurysms are small; however, a significant proportion of the aneurysms detected were of a size that would warrant repair. The decision to perform surgical repair is likely to be influenced by the comorbid medical conditions, which placed the patients in the high-risk category.

Effect of preoperative renal dysfunction on mortality and postoperative renal failure following endovascular abdominal aortic aneurysm repair.

This study was aimed to assess the effect of preoperative renal dysfunction on mortality and postoperative renal failure in patients undergoing elective endovascular repair of abdominal aortic aneurysm. A total of 155 patients with a mean age of 74.9 years (+/-6.4) were included. In all, 31 patients (20%) had a preoperative creatinine level of >1.5 mg/dL, whereas 66 patients (42.6%) had an estimated glomerular filtration rate of <60 mL/min. Perioperative mortality was 2.6% with no significant difference between those with and without abnormal renal indices. Long-term survival at 4 years was 30% in patients with creatinine >1.5 mg/dL compared to over 60% in those with normal creatinine (P < .02). The difference in long-term survival was not as significant in patients with normal or reduced glomerular filtration rate (P = .13). However, neither creatinine nor glomerular filtration rate were found to accurately predict survival even though both demonstrated strong predictivity for postoperative renal failure in patients undergoing elective endovascular repair of abdominal aortic aneurysm.

Inflammatory infrarenal abdominal aortic aneurysm in a young woman.

Inflammatory abdominal aortic aneurysm is a rare cause of abdominal pain in young adults that may be difficult to diagnose in the Emergency Department. This case highlights the significance of this condition as a possible diagnosis in young patients presenting with abdominal symptoms. A 32-year old woman presented with lower abdominal and back pain. She had four previous visits to the Emergency Department and one hospital admission with similar symptoms and had been discharged without a definite diagnosis. Her vascular risk factors included hypercholesterolemia and smoking. A computed tomography (CT) scan showed a non-leaking infrarenal saccular abdominal aortic aneurysm and para-aortic lymphadenopathy. A transthoracic echocardiogram excluded endocarditis. There was no evidence of bacterial, viral, or fungal infection on blood and serum assays, and her autoimmune screen was negative. She underwent urgent open repair using a synthetic graft. The aneurysmal wall and para-aortic lymph node histology confirmed the diagnosis of inflammatory aneurysm with periaortitis. She remained asymptomatic at 8 months after surgery with no evidence of additional aneurysmal disease. Inflammatory abdominal aortic aneurysm is an unusual cause of abdominal pain in young adults. It is more likely in patients with persistent or recurrent abdominal symptoms.

Prosthetic stent graft infection after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: The purpose of this report is to discuss the incidence, diagnosis, and management of stent graft infections after endovascular aneurysm repair (EVAR). METHODS: Data were collected from the hospital database and medical case notes for all patients with infected endografts after elective or emergency EVAR for abdominal aortic aneurysm (AAA) during the last 8 years in two university teaching hospitals in Northern Ireland. The data included the patient's age, gender, presentation of sepsis, treatment offered, and the ultimate outcome. The diagnosis of graft-related sepsis was established by a combination of investigations including inflammatory markers, labelled white cell scan, computed tomography (CT) scan, microbiology cultures, and postmortem examination. RESULTS: Graft-related septic complications occurred in six of 509 patients, including 433 elective repairs and 76 emergency endografts for ruptured AAA. Two patients presented with left psoas abscess and were treated successfully with extra-anatomic bypass and removal of the infected stent graft. Two more patients presented with infected graft without other evidence of intra-abdominal sepsis: one underwent successful removal of the infected prosthesis with extra-anatomical bypass, and the other was treated conservatively and died of progressively worsening sepsis. The fifth patient presented with unexplained fever and died suddenly, with a postmortem diagnosis of aortoenteric fistula and ruptured aneurysm. The last patient presented with an aortoenteric fistula, was treated conservatively in view of concurrent myelodysplasia, and died of possible aneurysm rupture. CONCLUSION: This report emphasizes the need for continued awareness of potential graft-related septic complications in patients undergoing EVAR of AAA. Attention to detail with regard to sterility and antibiotic prophylaxis during stent grafting and during any secondary interventions is vital in reducing the risk of infection. In addition, early recognition and prompt treatment are essential for a successful outcome.

Successful surgical management of a ruptured true pancreaticoduodenal artery aneurysm following failed transcatheter embolization.

A ruptured splanchnic artery aneurysm is a rare clinical entity. Its diagnosis requires a high index of clinical suspicion, and management usually requires a multidisciplinary approach. We present a case of ruptured true pancreaticoduodenal artery aneurysm in an 83-year-old woman who was initially treated with transcatheter embolization, but it failed to arrest the bleeding, and she subsequently required laparotomy and surgical ligation. The clinical course and management are discussed with a review of the literature.