Contrast Induced Nephropathy and Long-term Renal Decline After Percutaneous Transluminal Angioplasty for Symptomatic Peripheral Arterial Disease.

OBJECTIVE/BACKGROUND: Administration of iodinated contrast media during endovascular procedures for peripheral arterial disease (PAD) may cause contrast induced nephropathy (CIN). The aim of the present study was to establish the incidence of CIN after these procedures and to study its association with long-term loss of kidney function, cardiovascular events, and death. METHODS: Consecutive patients first presenting with symptomatic PAD (Rutherford classification II-VI) who were treated with an endovascular procedure were included in this prospective observational cohort study. CIN was defined as >25% increase of serum creatinine concentration from baseline at 5 days after the intervention. RESULTS: Some 337 patients were included with a mean estimated glomerular filtration rate (eGFR) of 67 mL/minute. Thirteen percent (95% confidence interval [CI] 9-16) of these patients developed CIN after endovascular interventions for PAD. One year after treatment, eGFR was reduced by 12.4 mL/minute (95% CI 8.6-16.2) in patients with CIN compared with 6.2 mL/minute (95% CI 4.9-7.0) in patients without acute kidney injury (p < .01). After correction for potential confounders, CIN was associated with a 7.8 mL/minute (95% CI 4.5-11.0) reduction of eGFR at 1 year after endovascular intervention (p < .01). Furthermore, patients with CIN were at increased risk of long-term cardiovascular events and mortality. CONCLUSION: Exposure to iodinated contrast media during endovascular procedures for symptomatic PAD frequently results in CIN. Patients with CIN are at increased risk of long-term loss of renal function, cardiovascular events, and death.

Treatment of aortic graft infection by in situ reconstruction with Omniflow II biosynthetic prosthesis.

Currently available conduits for in situ reconstruction after excision of infected aortic grafts have significant limitations. The Omniflow II vascular prosthesis is a biosynthetic graft associated with a low incidence of infection that has succesfully been used in the treatment of infected infrainguinal bypass. We report on the first use of the Omniflow II prosthesis for in situ reconstruction after aortic graft infection.A bifurcated biosynthetic bypass was created by spatulating and anastomosing two 8-mm tubular Omniflow II grafts. This bypass was used for in situ reconstruction after excision of infected aortic grafts in three cases. After a mean follow-up of 2.2 years, no occlusion, degeneration, or rupture of the Omniflow II grafts was observed. Although one patient suffered from graft reinfection, the bypass retained structural integrity and no anastomotic dehiscence was observed.Treatment of aortic graft infection by in situ reconstruction with the Omniflow II vascular prosthesis is feasible. Its resistance to infection and off-the-shelf availability make this graft a promising conduit for aortoiliac reconstruction.

Duplex-guided percutaneous transluminal angioplasty in iliac arterial occlusive disease.

BACKGROUND: Chronic renal insufficiency (CRI) is a growing global problem. PTA can be performed without nephrotoxic contrast, utilizing Doppler-ultrasound (Duplex) guidance. Duplex-guided infra-inguinal interventions and access-related interventions have been reported. Duplex-guided iliac interventions have not been performed to any extent because of the anatomic location. In our study we evaluated the safety and efficacy of Duplex-guided percutaneous transluminal angioplasty (DuPTA) in iliac arteries. METHODS: From June 2012 until February 2013, 31 patients (35 iliac lesions), underwent DuPTA. Indications ranged from Rutherford 3 to 5. Preoperative evaluation included Ankle Brachial Index (ABI), Duplex and MRA. Procedural success was defined as crossing the lesion with a guidewire and dilating or stenting the lesion. Clinical success was defined as 50% reduction in peak systolic velocity (PSV) or clinical improvement. PSV was evaluated after PTA, then at 2 weeks. Clinical results were assessed 2 weeks after the procedure. RESULTS: Procedural success was achieved in 94% of patients (33/35), all of whom also had clinical success. Post-procedural PSV reduction showed an average improvement of 63% (431 cm/s to 153 cm/s). Mean preoperative ABI was 0.72 and improved to 0.88 postoperatively. CONCLUSIONS: PTA using Duplex-guidance in significant iliac stenosis is a safe method with major advantages in patients at high risk for developing contrast-induced nephropathy.

Assessment of behavioral determinants influencing success of supervised exercise therapy in patients with intermittent claudication: A cross sectional survey.

BACKGROUND: Supervised exercise therapy is the first step in treatment of intermittent claudication. However, adherence to supervised exercise therapy is low. Limited access and reimbursement issues are known reasons, though lack of motivation is often leading. Behavioral determinants influencing motivation and thus adherence to supervised exercise therapy remain to be investigated. In this study we sought to determine which behavioral determinants would be of influence on the long-term adherence of supervised exercise therapy. METHODS: 200 patients, newly diagnosed with peripheral arterial disease Rutherford classification II-III, were sent a questionnaire to assess motivation and behavior with regard to supervised exercise therapy. The questionnaire was constructed using the I-CHANGE model for explaining motivational and behavioral change. Baseline characteristics were acquired from medical records. Alpha Cronbach's was calculated to test reliability of the questionnaire. RESULTS: 108 (54%) patients returned their questionnaire. A total of 79% patients followed supervised exercise therapy. Patients who increased their walking distance after supervised exercise therapy have significantly greater knowledge (p = 0.05), positive attitude (p = 0.03) and lower negative attitude (p = 0.01). Patients with a higher self-efficacy remained significantly more active after participating in supervised exercise therapy (p = 0.05). CONCLUSION: Increasing the determinants knowledge, attitude and self-efficacy will improve adherence to supervised exercise therapy and result in delayed claudication onset time.

Acute arterial occlusion after deployment of the Angio-Seal closure device: is it as uncommon as we think?

Angio-Seal is a frequently used vascular closure device after arterial catheterisation. Major complications are infrequently reported. We present four cases occurring within a 2-month period in our hospital with dislodgement of an Angio-Seal causing acute arterial occlusion, resulting in loss of limb in one case. Surgical intervention was necessary in all cases. Acute arterial occlusion after deployment of the Angio-Seal in patients with peripheral arterial disease might be less uncommon than the literature suggests.

A randomised controlled trial comparing compression therapy after radiofrequency ablation for primary great saphenous vein incompetence.

BACKGROUND: Optimal duration of leg compression after venous ablation remains unclear. This randomised controlled trial evaluates 4 h compared to 72 h of leg compression. METHODS: Patients were randomised to 4 or 72 h of leg compression after radiofrequency ablation of the great saphenous vein. Primary outcome was change in leg volume after 14 days. Secondary outcomes were postoperative pain, complications and time to full recovery. RESULTS: Patients wearing compression stockings for 4 h after treatment had a 64 mL (95%CI: - 23 to + 193) reduction in leg volume, compared to an increase of 21 mL (95%CI: 8.33-34.5) in patients wearing compression stockings for 72 h (P = 0.12). Patients wearing compression stockings for 4 h experienced fewer complications (16% vs. 33%, P = 0.05). Postoperative pain and time to full recovery did not differ significantly. CONCLUSION: Wearing compression stockings for 4 h is non-inferior in preventing leg oedema as wearing compression stockings for 72 h.

Vascular replacement using a layered elastin-collagen vascular graft in a porcine model: one week patency versus one month occlusion.

A persistent clinical demand exists for a suitable arterial prosthesis. In this study, a vascular conduit mimicking the native 3-layered artery, and constructed from the extracellular matrix proteins type I collagen and elastin, was evaluated for its performance as a blood vessel equivalent. A tubular 3-layered graft (elastin-collagen-collagen) was prepared using highly purified type I collagen fibrils and elastin fibers, resembling the 3-layered native blood vessel architecture. The vascular graft was crosslinked and heparinised (37 ± 4 µg heparin/mg graft), and evaluated as a vascular graft using a porcine bilateral iliac artery model. An intra-animal comparison with clinically-used heparinised ePTFE (Propaten®) was made. Analyses included biochemical characterization, duplex scanning, (immuno)histochemistry and scanning electron microscopy. The tubular graft was easy to handle with adequate suturability. Implantation resulted in pulsating grafts without leakage. One week after implantation, both ePTFE and the natural acellular graft had 100% patencies on duplex scanning. Grafts were partially endothelialised (Von Willebrand-positive endothelium with a laminin-positive basal membrane layer). After one month, layered thrombi were found in the natural (4/4) and ePTFE graft (1/4), resulting in occlusion which in case of the natural graft is likely due to the porosity of the inner elastin layer. In vivo application of a molecularly-defined tubular graft, based on nature's matrix proteins, for vascular surgery is feasible.

[Successful surgical management of arterio-mesenterial duodenal compression]. / Arteriomesenterialis duodenum leszorítás sikerrel operált esete]

A 17 year old female patient developed in 6 month a gradually exacerbating stomach passage disturbance not responding to conservative treatment. Clinical and radiological examinations verified that the compression of the duodenum was caused by irregular position of the arteria mesenterica superior. The patient was operated on and a dissection and transposition of the duodenum was performed using an end-to-end anastomosis before the arteria mesenterica superior. This method has never been seen in Hungary before. The good result of the operation was verified by the control examinations.

Controlled fabrication of triple layered and molecularly defined collagen/elastin vascular grafts resembling the native blood vessel.

There is a consistent need for a suitable natural biomaterial to function as an arterial prosthesis in achieving arterial regeneration. Natural grafts are generally obtained by decellularization of native blood vessels, but batch to batch variations may occur and the nature/content of remaining contaminants is generally unknown. In this study we fabricated a molecularly defined natural arterial graft from scratch resembling the native three layered architecture from the fibrillar extracellular matrix components collagen and elastin. Using casting, moulding, freezing and lyophilization techniques, a triple layered construct was prepared consisting of an inner layer of elastin fibres, a middle (porous) film layer of collagen fibrils and an outer scaffold layer of collagen fibrils. The construct was carbodiimide cross-linked and heparinized. Characterization included biochemical/biophysical analyses, scanning electron microscopy, micro-computed tomography, (immuno)histology and haemocompatibility. Burst pressures were up to 400mm Hg and largely conferred by the intermediate porous collagen film layer. The highly purified type I collagen fibrils and elastin fibres used did not evoke platelet aggregation in vitro. Suturability of the graft in end to side anastomosis was successful and considered adequate for in vivo application.

Observations on the failure of stent-grafts in the aortic arch.

INTRODUCTION: The results of endovascular stent-grafts in the abdominal aorta and descending thoracic aorta have been encouraging. Expanding the use of thoracic stent-grafts in to the aortic arch has been associated with increasing numbers of complications. Recently isolated cases of stent-graft collapse have been reported. METHODS: This was a multi-centre European case series. Data was collected retrospectively on seven patients from five experienced endovascular centres with thoracic stent-graft collapse. RESULTS: Of the seven patients four were treated for traumatic aortic rupture. Six were male, median age 33 (range 17-54) years. During the ensuing 2 months all patients suffered stent-graft collapse. This was symptomatic in 3 patients and the rest were identified on CT. Endovascular management was possible in 6/7 patients using either a balloon expandable stent (n=6) or further stent-graft (n=1). Two patients had persistent type I endoleak despite treatment. Two of the 7 patients died, both of which presented with symptomatic thoracic stent-graft occlusion. Both deaths were a direct result of stent-graft collapse. CONCLUSIONS: Thoracic stent-graft collapse may be asymptomatic underscoring the importance of stent-graft surveillance. Endovascular management of collapse is possible in most cases using a large balloon expandable stent. Symptomatic collapse is associated with high morbidity and mortality.

[Postoperative changes in free fatty acid levels in serum]. / Postoperative Anderungen des freien Fettsäurespiegels im Serum.

The serum free fatty acid levels were stuied under the influence of various operations. During surgery, the FFA level rose significantly in patients with arteriosclerosis and cholelithiasis, and also in obese ones, and decreased in hyperfunctional struma patients. Individual fatty acids too showed characteristic changes in these diseases. Under the influence of surgery, saturated fatty acid levels too rose significantly in arteriosclerotic patients.

Lymphocyte glucocorticoid receptors in cancer patients.

Glucocorticoid receptor concentration was determined in circulating lymphocytes of patients with benign and malignant tumors. It was not different from control values in case of benign tumors. However, it was increased significantly in case of operable colorectal adenocarcinoma and decreased, sometimes to very low levels, when the tumor (gastric or colorectal adenocarcinoma) was inoperable.

Effects of operations on lymphocyte glucocorticoid receptors.

The changes in the glucocorticoid receptor count of lymphocytes was studied in diseases requiring various surgical treatments. Based on their studies, authors established that the number of receptors increased in most cases after operation. The increase in receptor count depends on operative stress. As a result, the stimulated receptor count increased to double or triple that of the normal value, decreasing then to normal during the postoperative phase. The change in receptor count can be used in assessing the reactivity of the organism and prognosis.