Phlegmasia cerulea dolens of the lower extremities secondary to thrombosis of an inferior vena caval aneurysm.

We present the clinical case of a 34-year-old male with an aneurysm of the inferior vena cava in which thrombosis led to a picture of bilateral phlegmasia cerulean dolens of the lower extremities. A clear and precise diagnosis was achieved by angio CT which allowed initial conservative management with good immediate and short term outcome. To our knowledge only 23 cases of aneurysm of the inferior vena cava have been reported in the literature worldwide making it difficult to establish a diagnostic and therapeutic algorithm for these cases. Nine cases were presented with thrombosis and in the other 14 the diagnosis was incidental. They mimic a pararenal mass requiring differential diagnosis with retroperitoneal neoplasms.

[Carotid stenosis in high risk patients. The SAPPHIRE study versus a decision analysis. Which is the best therapeutic option?]. / Estenosis carotídea en enfermos de alto riesgo. Estudio SAPPHIRE frente a un ánalisis de decisión. Cuál es la mejor opción terapéutica?

INTRODUCTION: In the results from the SAPPHIRE study on high surgical risk patients with carotid stenosis there are no differences between carotid stent-angioplasty (CSA) and carotid endarterectomy (CEA). AIMS: The aim of this study was to analyse the cost-effectiveness of these two interventions based on the data from the above-mentioned study and on our own experience in carotid surgery. PATIENTS AND METHODS: We evaluated 108 CSA carried out between 1999 and 2003. The morbidity and mortality rates in the subgroup of high risk patients, according to the criteria used in the SAPPHIRE study, were analysed according to whether they were symptomatic or asymptomatic. Data concerning endovascular treatment were taken from the literature. A cost-effectiveness study was conducted considering four possible perioperative events: absence of sequelae, AMI, established CVA and death. The computer software package DATAPro was used after fitting the decision to the theoretical quality of life for each of these groups. Cost-effectiveness was estimated based on the cost of each procedure. RESULTS: Of the 108 patients, 41 (37.96%) belonged to the high risk subgroup; 46.3% of them were asymptomatic and 53.7% were symptomatic. In the 30 days following the intervention, one CVA (5.2%) and one AMI (4.5%) were observed. No deaths occurred. The decision analysis for symptomatic patients showed CEA to be the most effective therapeutic option. Similar results were obtained for asymptomatic patients. The average cost for CEA was 3,963 euros and rose to 5,158 euros in the case of CSA. CONCLUSIONS: In our study, CEA is the preferred technique in high risk patients owing to its having a better cost-benefit ratio.

Polytetrafluoroethylene grafts as the first-choice arterial substitute in femoropopliteal revascularization.

We studied a series of femoropopliteal bypass operations in which polytetrafluoroethylene (PTFE) grafts were used as the first choice, regardless of the availability of saphenous vein. From Jan 1, 1979 to Dec 31, 1982, 63 PTFE femoropopliteal bypass grafts were placed in 55 patients without exploration of the saphenous vein. Forty-three grafts were placed for limb salvage, and 20 grafts were placed for disabling claudication. Patients were followed up for nine to 53 months (average, 23 months). The operative mortality was 1.8%. There were no infections. The overall patency at 30 months was 76.1%. The 30 months' cumulative patency rate for patients with claudication was 89.3%, and there were no amputations. The cumulative 30-month patency for limb salvage was 70.1%, and there was a limb salvage rate of 81.2%. Because the 30-month results were comparable with reported series using autogenous saphenous vein, we concluded that PTFE conduits may be considered the first-choice arterial substitute for femoropopliteal reconstruction. Until longer follow-ups are available, reversed autogenous saphenous vein should probably be the graft of first choice in younger patients (less than 60 years of age) without coronary artery disease who are undergoing femoropopliteal revascularizations.

Risk of renal failure after major angiography.

In 400 patients who underwent major aortography, acute renal dysfunction (ARD) occurred in 11.3%. Of the group with normal renal function before the procedure, 8.2% had ARD and 0.8% required dialysis. Patients with prior abnormal renal function had a 41.7% incidence of ARD, and 8.3% required dialysis as a result of angiography. Vigorous intravenous hydration was used in all patients but did not completely prevent renal problems. Two risk factors not previously emphasized were the injection site (higher risk with abdominal aortic studies) and presence of congestive heart failure requiring treatment with digoxin. Other notable risk factors included contrast load and age. These results emphasized that even with modern contrast agents and application of current concepts of treatment, there remains a risk of renal injury with major angiography.

Fate of aortic graft removal.

Reoperation to remove an aortic graft was performed in 18 patients. The need for removal was infection in the majority. A changing flora was seen in aortic graft infection with gram-negative organisms predominating. Despite a standardized approach with total graft removal, aortic closure, and extraanatomic reconstruction, amputation and mortality rates remain unacceptably high. A new approach to this problem is needed, and further trials with autogenous reconstruction appear warranted.

Assessment of transcutaneous oxygen tension in ischaemic legs by means of using an electric blanket and 40% O2.

This work was done to evaluate the transcutaneous oxygen tension (TcPO2) in ischaemic legs introducing two variables: O2 breathed at 40% and heating with an electric blanket (HEB). Forty nine legs were studied and divided into three different groups: Normal (N) 19 legs, Intermittent Claudication (IC) 12, and Rest Pain (RP) 13. The transcutaneous sensor was placed on the Anterior Chest Wall (AChW), High thigh (HT), Anterior Tibial Compartment (ATC) and Dorsum of the Foot (DF). Measurements were done at each area with and without 40% O2 and with and without HEB. The TcPO2 readings increased significantly (P less than 0.05) in the three groups (N, IC, RP) at all leg levels (HT, ATC, DF) when the patient breathed 40% O2 with and without HEB. In the N group no significant differences were noted between the three leg levels whether the 40% O2 or the HEB was used or not (P less than 0.05). In the RP group significant differences were obtained when the HEB was used whether the patient was breathing ambient O2 or at 40%. On the contrary, when the HEB was not used, the differences between HT and ATC disappeared but persisted at the DF (P less than 0.05). There was a good correlation at the DF and at the AChW (DF/AChW) (r: 0.8012; P less than 0.001). From these results, we conclude that the TcPO2 is a good method of differentiating different degrees of leg ischemia in vascular patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemangiopericytoma ischiorectal. Report of a case.

Hemangiopericytoma (HP) is a rare tumoral neoplasm of the soft tissues. Here, we report a case of HP that appeared in a young woman in a very uncommon location (perianal). Initially it was considered as a perianal abscess: arteriography, CT-scan and, eventually, histological studies, confirmed the diagnosis of HP. The tumoral mass was first embolized and thereafter was resected through a double approach (abdominal and perineal). One and a half years after surgery, the patient remains asymptomatic.

Abdominal aortic aneurysms. Results of surgical treatment.

One hundred and twenty-one aneurysms of the abdominal aorta were operated on during a ten year period (1971-1981). Elective surgery was carried out in 89 patients (73.5%). Thirty-two patients were operated on for impending or frank rupture. Most of the patients treated electively had no symptoms on admission. The mortality of this group of patients was 6.7% (6 patients). All the patients treated as emergencies had acute abdominal or back pain. Six cases presented with shock and acute renal failure. The hospital mortality was high in this group of 11 patients (34.3%). Nine of them were operated on because of suspected rupture but this was not confirmed at operation. Only one patient in this group died after the operation (11.1%). The hospital mortality of the 23 patients with ruptured aneurysms was 43.4% (10 patients). Six of them died in the operating room. While elective surgery carries an acceptable mortality, the emergency procedure involves a high risk. All the aneurysms must be resected electively in spite of the absence of symptoms.

Intraoperative assessment of carotid endarterectomy.

In our experience intraoperative arteriography in carotid endarterectomy is very effective in detecting residual small lesions after surgery. There were no neurosurgical complications due to arteriography. The interpretation of the surgical results is objective since the criteria are the same as those used to assess preoperative arteriography. Different intraoperative assessment methods to control carotid endarterectomy are also analysed.

Multifunctional targets of dietary polyphenols in disease: a case for the chemokine network and energy metabolism.

Chronic, non-acute inflammation is behind conditions that represent most of the disease burden in humans and is clearly linked to immune and metabolic mechanisms. The convergence of pathways involving the immune response, oxidative stress, increased circulating lipids and aberrant insulin signaling results in CCL2-associated macrophage recruitment and altered energy metabolism. The CCL2/CCR2 pathway and the energy sensor AMP-activated protein kinase (AMPK) are attractive therapeutic targets as a part of preventive management of disease. Several effects of polyphenols are useful in this scenario, including a reduction in the activities of cytokines and modulation of cellular metabolism through histone deacetylase inhibitors, AMPK activators, calorie-restriction mimetics or epigenetic regulators. Research is currently underway to develop orally active drugs with these effects, but it is convenient to examine more closely what we are eating. If a lack of relevance in terms of toxicity and substantial effectiveness are confirmed, plant-derived components may provide useful druggable components and dietary supplements. We consider therapeutic actions as a combination of synergistic and/or antagonistic interactions in a multi-target strategy. Hence, improvement in food through enrichment with polyphenols with demonstrated activity may represent a major advance in the design of diets with both industrial and sanitary value.

The role of combined assessment of defense against oxidative stress and inflammation in the evaluation of peripheral arterial disease.

Atherosclerosis in symptomatic peripheral arterial disease affects wide portions of numerous arteries in lower extremities. The resulting active inflammation in a considerable amount of arterial tissue facilitates systemic detection via measurement of inflammation-related variables. We reasoned that the combined assessment of defense against oxidative stress, in the form of paraoxonase-1 (PON1), and monocyte migration measured as circulating (C-C motif) ligand 2 (CCL2), may play a role in the evaluation of these patients. Plasma CCL2 and serum PON1-related variables, assessed by their interaction with functional genetic variants, were measured in a cross-sectional study in patients with symptomatic PAD. We found that PON1 activity and concentration were significantly lower and CCL2 concentration higher in PAD patients compared to controls, that the combination of plasma CCL2 and PON1- related values, especially PON1 concentration differentiated, almost perfectly, controls from patients and that the expression of CCL2 and PON1 generally co-localized in the atherosclerotic lesion. Since no association with genetic variants was found, such a relationship is probably the result of the disease. Our data suggest a coordinated role between CCL2 and PON1 that may be detected in blood with simple measurements and may represent an indicator of the extent of atherosclerosis.

Progressive renovascular hypertension by increasing aortic constriction in rats.

Moderate and progressive hypertension was produced experimentally in rats by progressive aortic constriction. The progression of the stenosis was assessed by the differences of pressure across the stenosis. Haemodynamic studies were performed 15, 30 and 60 days after the ligature was placed or after sham operation. Fifteen days after surgery, when the ligated rats did not show any increase in carotic pressure, they showed augmented cardiac output (50.3 +/- 5.4 v. 29.7 +/- 2.0 ml min-1 100 g-1; mean +/- -SEM) and a decreased total peripheral resistance (2.23 +/- 0.21 v. 3.67 +/- 0.20 mmHg ml-1 min 100 g). They also had decreased vascular resistance in both kidneys and in skeletal muscle samples above and below the ligature as well as increased plasma renin content and normal values of plasma volume and extracellular volume. Later in the evolution of hypertension, carotic pressure and the pressure gradient across the stenosis increased (51.8 +/- 4.5 v. 0.9 +/- 1.6 mmHg in controls), cardiac output decreased to control values, total peripheral resistance as well as renal and muscular vascular resistances increased. Plasma and extracellular volume remained unchanged in ligated rats in contrast to controls where they decreased. Perfusion pressure of the kidney below the ligature did never fall below control values (97.2 +/- 3.4 v. 100.4 +/- 2.4 mmHg). A small but constant degree of elastosis and a double layer of myocytes in the renal arterioles above the ligature was the only histological finding.

Effect of captopril infusion on systemic and renal haemodynamics in conscious hypertensive rats with chronic, progressive aortic ligation.

The effect of the converting enzyme inhibitor captopril (5 mg (kg bwt)-1) on systemic and renal haemodynamics has been studied in conscious rats in which a progressive hypertension has been induced by progressive aortic ligation (AL) between the renal arteries, and in a sham-operated (SO) group. Cardiac output (CO), organ blood flow and vascular resistances have been measured using radioactive microsphaeres. Captopril infusion caused increases in CO in both groups of rats, but the increase was higher in SO (9.2 +/- 0.7%) than in AL rats (5.2 +/- 0.6%; P less than 0.005). Plasma renin concentrations were similar in both groups but increased more in AL (10.3 microIU +/- 1.0) than in SO (5.81 microIU +/- 0.62; P less than 0.05) after captopril. Captopril induced also a larger decrease in arterial pressure (36 +/- 4 mmHg), and of the pressure gradient across the stenosis (19 +/- 3) mmHg in AL than in SO rats (5.6 +/- 1.4 and 1.1 +/- 1.3 mmHg, P less than 0.005 for both cases). Vascular resistance of the kidney above the ligature decreased more in AL than in SO rats, but this difference was not observed in the other kidney. From these data it can be concluded that captopril has an acute hypotensive effect despite the normal renin levels of this model of chronic hypertension. In addition, blood flow to the high-pressure perfused kidney seems to be dependent on the increased renin production by the contralateral kidney.

Role of glucagon in the splanchnic and systemic hemodynamic changes induced by portal-systemic blood shunting.

Portal-systemic blood shunting is often accompanied by hyperglucagonemia and hemodynamic changes. To determine this causal relation, splanchnic and systemic hemodynamics (radioactive microspheres) and plasma glucagon levels (radioimmunoassay) were assessed in conditions of total portal-systemic shunting in portacaval-shunted (PCS) rats and in sham-operated (SO) normal rats. To compare these results, another hemodynamic study was undertaken basally and during glucagon infusion in nonoperated normal rats. PCS rats showed a threefold greater plasma glucagon concentration than SO animals (924 +/- 134 vs. 309 +/- 18 pg/ml, p less than 0.01), and they developed a hyperdynamic splanchnic circulation with higher portal venous inflow than SO rats (8.29 +/- 1.1 vs. 5.09 +/- 0.4 ml/min/100 g, p less than 0.05). Infusion of a pharmacological dose of glucagon in normal rats increased portal venous inflow (from 4.92 +/- 0.33 to 6.24 +/- 0.48 ml/min/100 g, p less than 0.05) so as to imply this hormone in the development of the hyperdynamic splanchnic circulation in conditions of portal-systemic shunting. However, the discrepancies in systemic hemodynamics between PCS and glucagon-infused rats may be a result of the different plasma glucagon levels reached in the two groups.

Effect of portacaval surgical anastomosis on systemic and splanchnic hemodynamics in portal hypertensive, cirrhotic rats.

The effect of surgical end-to-side portacaval anastomosis (PCSA) on systemic and splanchnic circulation has been studied in cirrhotic rats with portal hypertension (CCl4-phenobarbital method) and in control animals. Hemodynamics have been measured using the microsphere technique, with a reference sample for the systemic hemodynamic measurements, and intrasplenic injection for portal systemic shunting rate measurements. Compared with controls, sham-operated (SO) cirrhotic rats showed a hyperdynamic circulation with increased cardiac output (CO) and decreased mean arterial pressure and peripheral resistances. PCSA in control rats induced only a small change in systemic hemodynamics, with parallel decreases in arterial pressure and peripheral resistances, and a small, nonsignificant increase in CO. In cirrhotic rats, PCSA induced a decrease of CO to values similar to those of control rats, with an increase in total peripheral resistances. PCSA induced an increase in hepatic arterial blood flow in control and in cirrhotic rats, portal pressure becoming in this latter group not different from that of control rats. Blood flow to splanchnic organs was higher in SO cirrhotic than in SO control animals. Thus portal venous inflow was also increased in SO cirrhotic rats. PCSA induced an increase in portal venous inflow in control rats, which was only significant in cirrhotic rats when expressed as a percentage of CO. In SO control animals, a significant correlation was observed between total peripheral resistances and splanchnic arteriolar resistances and between CO and splanchnic blood flow. These correlations were not observed in cirrhotic rats. These results do not support the hypothesis that hyperdynamic circulation shown by cirrhotic rats is based on increases in splanchnic blood flow and (or) massive portal systemic shunting.

Hepatic haemodynamic changes after portacaval anastomosis in normal, cirrhotic and chronic prehepatic portally hypertensive rats.

Radioactive microspheres were used to determine the hepatic haemodynamic response to portacaval anastomosis in normal, cirrhotic and chronic prehepatic portally hypertensive rats 20 days after operation, and in normal rats 2 months after operation. After 20 days portacaval anastomosis caused a decrease in liver mass only in normal and cirrhotic animals, whereas hepatic arterial blood flow per unit of mass increased in normal (+488 per cent), cirrhotic (+191 per cent) and prehepatic portally hypertensive rats (+133 per cent). Despite these facts, animals with portacaval anastomosis showed a reduced hepatic total perfusion (arterial plus portal inflow) per unit of mass with respect to controls in normal (-53 per cent) and cirrhotic rats (-68 per cent), but not in those with prehepatic portal hypertension. Comparing studies carried out at 2 months with those performed 20 days after portacaval anastomosis in normal rats, some recovery of liver mass and total liver blood flow was observed. In conclusion, portacaval anastomosis produced a limited increase in hepatic arterial blood flow which was unable to preserve liver mass and its total perfusion in normal and cirrhotic animals. In contrast, portacaval anastomosis did not significantly alter liver mass or its perfusion in animals with chronic prehepatic portal hypertension, as both values were previously diminished in controls. Thus, the risk of liver failure after portacaval anastomosis is higher in normal and cirrhotic rats than in those with chronic prehepatic portal hypertension.

Renal function derangements induced by portacaval anastomosis in normal rats.

The purpose of this study was to determine the renal function derangements that portacaval shunting caused in previously normal rats. Eight rats suffered a surgical portacaval shunt (PCS) and another 8 a sham operation (SHAM). Renal function was investigated by determining urinary volume, sodium, potassium, creatinine and aldosterone excretion, in basal conditions and after sodium overload. Plasma renin concentration and urinary excretion of PGE2, 6-keto-PGF1 alpha and TXB2 were also determined in basal conditions. PCS rats showed increased urinary volume, creatinine excretion and endogenous creatinine clearance, either in basal conditions or after sodium load. After the latter, PCS animals also showed sodium retention and hyperaldosteronuria. PCS caused in basal conditions a striking diminution in urinary excretion of all prostaglandins and no changes in plasma renin. In conclusion, PCS in the normal rat caused a renal dysfunction consisting of polyuria, possibly related to ADH disfunction and an inability to manage a sodium load.