Acquired arteriovenous fistula of a finger.

Arteriovenous fistulae are defined as congenital or acquired abnormal direct communications between an artery and a vein leading to abnormal blood circulation. This report describes an unusual manifestation of an acquired peripheral arteriovenous fistula with a high shunt volume of 410 ml/min following a fracture of the 5th finger.

Normal values for intima-media thickness of the common carotid artery--an update following a novel risk factor profiling.

BACKGROUND: There is a widely approved influence of novel risk factors like the body fat distribution and the associated metabolic syndrome, subclinical inflammation, insulin resistance and prediabetic disturbances in glucose metabolism on the progression of atherosclerosis. Former studies examining normal values for intima-media thickness (IMT) did not consider all of these new study results in detail. We therefore aimed to assess an update on age- and gender-specific normal values for IMT accounting for these novel risk factors. PATIENTS AND METHODS: We evaluated IMT by high-resolution ultrasound (13 MHz) on the far wall of the common carotid artery in 801 subjects without cardiovascular disease (428 women aged 46.2±12.9 years; 373 men aged 47.3±13.3 years). After precise evaluation and exclusion of 14 cardiovascular risk factors, 90% limits of IMT were determined by parametric statistics. RESULTS: The reference limits of IMT according to the age classes 18-29, 30-39, 40-49 and 50-59 years were estimated as 0.47, 0.59, 0.67 and 0.70 mm in women and 0.47, 0.62, 0.72 and 0.80 mm in men. CONCLUSIONS: Age and gender-specific normal values for IMT are lower than reported in former studies after additionally accounting for novel cardiovascular risk factors. The still widely regarded upper IMT limit of 1 mm must be strictly regarded as obsolete.

Current concepts of the interventional treatment of proximal supraaortic vessel stenosis.

Interventional therapies using angioplasty and stenting of symptomatic stenosis of the proximal supraaortic vessels have evolved as safe and effective treatment strategies. The aim of this paper is to summarize the current treatment concepts for stenosis in the subclavian and brachiocephalic artery with regard to clinical indication, interventional technique including selection of the appropriate vascular approach and type of stent, angiographic and clinical short-term and long-term results and follow-up. The role of hybrid interventions for tandem stenoses of the carotid bifurcation and brachiocephalic artery is analysed. A systematic review of data for angioplasty and stenting of symptomatic extracranial vertebral artery stenosis is discussed with a special focus on restenosis rate.

Towards risk stratification in systemic atherosclerosis: value of myocardial function and viability imaging as an adjunct to MR angiography.

OBJECTIVES: To longitudinally assess the value of cardiac functional and viability imaging as a supplement to MR angiography in patients with atherosclerotic disease. METHODS: Cardiac MRI was performed in 195 consecutive patients with symptomatic peripheral arterial disease. Of these, 186 patients were followed for 22 +/- 5 months for the presence of cardiac events (cardiac death, acute coronary syndrome and hospitalisation as a result of congestive heart failure). RESULTS: Myocardial viability imaging showed a high prevalence of known (n = 31) and occult myocardial infarctions (MI) (n = 26). Cardiac events occurred more often in patients with reduced ventricular function (ejection fraction (EF) less than 40%, cardiac event in 4/8 patients; EF 40-55%, cardiac event in 10/40 patients; EF greater than 55%, cardiac event in 15/138 patients) as well as in patients with occult MI (8/25 patients) and known MI (11/30 patients). In patients with normal function, the detection of a previous MI was of high relevance to prognosis. CONCLUSIONS: Both reduced EF and the presence of MI influence patients' prognoses. Performing cardiac MRI in this patient population may influence further patient management including intensified risk factor intervention.

Imaging of primary and secondary inflammatory diseases involving large and medium-sized vessels and their potential mimics: a multitechnique approach.

OBJECTIVE: The purpose of this article is to illustrate multitechnique imaging findings in patients with primary and secondary vasculitides involving large and medium-sized vessels and their mimics. CONCLUSION: Large and medium-sized vessels are affected by many primary and secondary inflammatory disorders or mimicking conditions, often presenting similar imaging characteristics. Knowledge of distinctive imaging features such as location, length, and degree of vessel wall enhancement as well as the particular clinical settings will help the clinician in appropriately narrowing down the differential diagnosis.

Reduced insulin clearance is linked to subclinical atherosclerosis in individuals at risk for type 2 diabetes mellitus.

Hyperglycemia and insulin resistance contribute to vascular damage and are regulated by different pathophysiological processes. The aim of the study was to systematically investigate the relative contributions of multiple fasting state- and oral glucose tolerance test (oGTT)-derived glycemic traits to carotid intima-media thickness (cIMT), a surrogate parameter of subclinical atherosclerosis, in individuals with increased risk for type 2 diabetes mellitus (T2D). 667 volunteers (417 women and 250 men, mean age 44.1 years), who were free of cardiovascular disease (CVD), were included in this cross-sectional study. Glucose tolerance, insulin sensitivity, insulin secretion and insulin clearance were assessed by frequently sampled 75 g oGTT. CIMT was measured by high-resolution ultrasound. Insulin clearance was associated with cIMT in univariate analysis (ßst = - 0.17, p < 0.0001) and in a stepwise regression analysis on 15 variables possibly affecting cIMT, age (r2 = 0.3923, p < 0.0001), insulin clearance (r2 = 0.4564, p < 0.0001), systolic blood pressure (r2 = 0.4733, p < 0.0001), body mass index (BMI) (r2 = 0.4804, p = 0.002), gender (r2 = 0.4831, p = 0.013), and fasting insulin clearance (r2 = 0.4857, p = 0.030) turned out to be significant determinants of cIMT. In a cross-validated model resulting from this analysis, insulin clearance was found to be an independent determinant of cIMT (ßst = - 0.16, p < 0.0001) even after adjusting for traditional CVD risk factors. Reduced insulin clearance may be an early marker of damage on the vasculature, independent of classical CVD risk factors. Reduced insulin clearance should be considered with regard to vascular insulin resistance.

Autoimmune thyroid disease: arterial spin-labeling perfusion MR imaging.

PURPOSE: To assess thyroid perfusion in patients with autoimmune thyroid diseases compared with that in healthy control subjects by using an arterial spin-labeling (ASL) magnetic resonance (MR) technique and to assess whether thyroid perfusion is associated with endocrine laboratory abnormalities. MATERIALS AND METHODS: This study was approved by the local institutional review board. All participants gave written informed consent. Perfusion imaging of the thyroid gland was performed in 10 patients with Graves disease (GD) and 10 patients with Hashimoto thyroiditis (HT). Ten healthy individuals served as control subjects. Perfusion imaging was performed with a 1.5-T MR unit by using a flow-sensitive alternating inversion recovery-true fast imaging with steady-state precession technique. Perfusion maps of the entire thyroid gland were calculated on the basis of extended Bloch equations. Analysis of variance with a post hoc test (Tukey honestly significant difference) was performed to assess differences in perfusion between groups. Associations between perfusion and laboratory parameters were analyzed with univariate regression analysis. RESULTS: Mean thyroid perfusion was 1596 mL/min/100 g +/- 436 (standard deviation) in patients with GD, 825 mL/min/100 g +/- 264 in patients with HT, and 491 mL/min/100 g +/- 89 in healthy control subjects. Perfusion was significantly higher in patients with GD (P < .0001) and those with HT (P < .05) than in control subjects. A significant difference in thyroid perfusion was detected between the two autoimmune entities (P < .0001). In patients with GD, significant associations were found between perfusion and serum concentrations of free thyroid hormones and anti-thyroid-stimulating hormone receptor antibodies (P < .05 for all). CONCLUSION: Quantitative ASL perfusion imaging of the thyroid gland revealed significant perfusion differences in the autoimmune thyroid diseases GD and HT. Absolute quantification of thyroid perfusion may be useful in the clinical assessment of autoimmune thyroid disorders and when monitoring therapeutic treatment in GD.

Visceral Adiposity Index as an Independent Marker of Subclinical Atherosclerosis in Individuals Prone to Diabetes Mellitus.

AIM: The visceral adiposity index (VAI) has been proposed as an estimate of visceral adipose tissue (VAT) mass and as an indicator of VAT dysfunction. Both parameters are associated with cardiometabolic risk, including insulin resistance. In this study, we investigated whether VAI is associated with subclinical atherosclerosis in subjects who were free of cardiovascular disease but were at risk of developing diabetes mellitus. METHODS: A total of 731 adults with a median age of 47 years old without diabetes mellitus were included in this cross-sectional study. The anthropometric data, blood pressure, and lipid profiles of 398 women and 333 men were measured. All subjects underwent an oral glucose tolerance test, and carotid intima-media thickness (cIMT) was evaluated by ultrasound. Insulin resistance was estimated using the homeostatic model assessment of insulin resistance (HOMA-IR). RESULTS: VAI and HOMA-IR (ßst=0.44, p＜0.0001), VAI and cIMT (ßst=0.17, p＜0.0001), and HOMA-IR and cIMT (ßst=0.09, p=0.0127) were correlated with each other. After adjusting for cofounding variables, VAI is still correlated with HOMA-IR (ßst=0.42, p＜0.0001). Furthermore, VAI (ßst=0.07, p=0.0392) but not HOMA-IR (ßst=0.03, p=0.37) was correlated with cIMT independently of other established cardiovascular risk factors. CONCLUSION: The calculation of VAI may provide a better estimation of subclinical atherosclerosis than the calculation of HOMA-IR.

Periaortic Adipose Tissue Compared With Peribrachial Adipose Tissue Mass as Markers and Possible Modulators of Cardiometabolic Risk.

Increased perivascular fat mass contributes to cardiometabolic risk (CMR). High peribrachial adipose tissue (PBAT) associates with insulin resistance independently of established CMR parameters. It is unknown to what extent periaortic adipose tissue (PAAT) may have a similar impact. In 95 participants, precise quantification of total adipose tissue, PBAT, PAAT, visceral adipose tissue (VAT), and liver fat (LF) content was performed by whole-body magnetic resonance imaging. Insulin sensitivity was determined by oral glucose tolerance test and carotid intima-media thickness (cIMT) by high-resolution ultrasound. In univariate analyses, PAAT correlated with PBAT (ß = .65, P < .0001). A negative correlation of PAAT (ß = -.35, P = .0002) and PBAT (ß = -.43, P < .0001) with insulin sensitivity was observed. While in a stepwise forward regression analysis the relationship of PAAT with insulin sensitivity was no longer significant after adjustment for VAT, LF content, and other CMR factors ( P = 0.42), PBAT still correlated with insulin sensitivity ( r2 = .35, P = .01). The association between PAAT and cIMT (ß = .49, P < .0001) remained significant after adjustment for these variables ( r2 = .42, P = .0001). Although PAAT and PBAT strongly correlate, PAAT is not associated with insulin resistance, but with cIMT. Therefore, PAAT and PBAT may act differently as possible modulators of insulin resistance and subclinical atherosclerosis.

Rapid effects of rosiglitazone treatment on endothelial function and inflammatory biomarkers.

BACKGROUND: Antidiabetic thiazolidinediones (TZDs), like rosiglitazone or pioglitazone, improve endothelial function in patients with type 2 diabetes or metabolic syndrome, but it is currently unknown, whether these beneficial effects of TZDs depend on their metabolic action or may be caused by direct effects on the endothelium. Therefore, the present study examined whether short-term rosiglitazone treatment influences endothelium-dependent vasodilation as well as serum levels of vascular disease biomarkers in healthy, nondiabetic subjects. METHODS AND RESULTS: Short-term treatment (21 days) of healthy subjects (n = 10) did not significantly change blood glucose levels or lipid profile. In contrast, rosiglitazone significantly increased flow-mediated, endothelium-dependent vasodilation already within the first day from 5.3+/-2.7% at baseline to 7.8+/-2.6%, further increasing it to 9.4+/-3.0% at day 21. In addition, the early improvement of endothelium-dependent vasodilation was paralleled by a rapid reduction of serum levels of the biomarkers C-reactive protein (CRP), serum amyloid A (SAA), and sE-selectin. Moreover, after drug withdrawal all markers remained suppressed for the whole follow-up period of 7 days. In contrast, rosiglitazone treatment did not significantly affect tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, sICAM-1, sVCAM-1, and sCD40L levels. CONCLUSIONS: Our study suggests a direct effect of TZD treatment on endothelial function and inflammatory biomarkers of arteriosclerosis, promoting the concept that TZDs, independent of their metabolic action, may exhibit protective effects in the vessel wall.

[Thromboembolic complication after ovarian stimulation]. / Thromboembolische Komplikation nach ovarieller Stimulation--Fall 1/2016.

HISTORY AND ADMISSION FINDINGS: We report on two pregnant women with dyspnoe and thoracic pain in the context of an ovarian hyperstimulation syndrome. INVESTIGATIONS: Both patients had pleural effusions. The first patient was diagnosed with pulmonary embolism via computer tomography. In the second patient, thrombosis of the upper part of the body including intracranial thrombosis was revealed via magnetic resonance and ultrasound imaging. In both cases, thrombosis was caused by ovarian hyperstimulation. DIAGNOSIS, TREATMENT AND COURSE: Therapy included anticoagulation with low molecular weight heparin and a drainage of the pleural effusions. One patient had an abortion in the 8th week of pregnancy, the second patient gave birth to two healthy children. CONCLUSIONS: Ovarian hyperstimulation syndrome is a potentially life-threatening disease, which should be considered as a differential diagnosis of causes of thromboembolic events in early pregnancy.

[A rare cause of pulmonary embolism]. / Seltene Ursache einer Lungenarterienembolie - Fall 8 / 2016.

HISTORY AND ADMISSION FINDINGS: We report on a patient with acute dyspnea after several vertebral body interventions, among others a kyphoplasty, that was performed a few days earlier. INVESTIGATIONS: In the computed tomography we prove a bilateral pulmonary embolism (cement and thrombus). There is no right heart failure. A deep vein thrombosis can be excluded by color-coded vascular ultrasound. DIAGNOSIS, TREATMENT AND COURSE: The pulmonary embolism is due to bone cement. The cement material is also found paravertebral, intraspinal and intraneuroforaminal. By conservative treatment using therapeutic anticoagulation and analgesic medication, the patient showed a rapid clinical improvement. CONCLUSIONS: In patients with cardiopulmonary symptoms after vertebroplasty and kyphoplasty, pulmonary embolism due to bone cement should be considered as a possible cause. The therapy depends on the extent of the cement embolism and the symptoms of the patient.

Relationship of Serum Trimethylamine N-Oxide (TMAO) Levels with early Atherosclerosis in Humans.

Circulating trimethylamine N-Oxide (TMAO) levels predict cardiovascular disease (CVD), possibly by impacting on cholesterol metabolism and oxidative stress. Because hepatic TMAO production is regulated by insulin signalling and it is unclear whether and to what extent circulating TMAO levels associate with CVD risk, independently of insulin resistance and its important determinants fatty liver and visceral obesity, we have now addressed this question in 220 subjects who participated in the Tübingen Lifestyle Intervention Program. Visceral fat mass (r = 0.40, p < 0.0001), liver fat content (r = 0.23, p = 0.0005) and TMAO levels (r = 0.26, p < 0.0001) associated positively, and insulin sensitivity associated negatively (r = -0.18, p = 0.009) with carotid intima-media thickness (cIMT). Higher TMAO levels (std.-Beta 0.11, p = 0.03) predicted increased cIMT, independently of age, sex and visceral fat mass. While during the lifestyle intervention most cardiovascular risk parameters improved, mean TMAO levels did not change (p = 0.18). However, cIMT decreased significantly (p = 0.0056) only in subjects in the tertile with the largest decrease of TMAO levels (>20%). We provide novel information that increased serum TMAO levels associate with increased cIMT, independently of established cardiovascular risk markers, including insulin resistance, visceral obesity and fatty liver. Furthermore, the decrease of cIMT during a lifestyle intervention may be related to the decrease of TMAO levels.

Acute effect of rheopheresis on peripheral endothelial dysfunction in patients suffering from sudden hearing loss.

Single low density lipoprotein (LDL) fibrinogen apheresis has shown beneficial effects in the treatment of patients with sudden sensorineural hearing loss (SSHL). Pathophysiologically, a microcirculatory disorder of the inner ear, probably caused by disturbed endothelial function, is discussed as a final common pathway of a variety of SSHL etiologies. Thus, we carried out a prospective pilot study on the efficacy of Rheopheresis on vascular function in these patients, embedded into an ongoing randomized controlled multicenter trial investigating the efficacy of Rheopheresis for the treatment of SSHL. Potential modulation of systemic endothelial dysfunction by Rheopheresis was examined by measuring flow-associated vasodilatation of the brachial artery (according to the criteria of the American College of Cardiology) in a small group of patients suffering from SSHL (N=6, 5m/1f, mean age 56+/-11 years) within the last 3 days. At baseline, five of the six patients with acute hearing loss showed endothelial dysfunction as evidenced by diminished flow-mediated vasodilatation (FMD<5%). After a single Rheopheresis treatment, flow-mediated vasodilatation improved significantly (from 3.9+/-3.6% to 7.2+/-2.4%, P=0.05, mean+/-SD, two-sided paired T-test). This was paralleled by a reduction in fibrinogen (364+/-216 mg/dL to 142+/-96 mg/dL, P=0.03), total cholesterol (228+/-23 to 98+/-10, P<0.0001) and LDL cholesterol levels (153+/-8 mg/dL to 83+/-23 mg/dL, P<0.01). Based on this case series we conclude that single Rheopheresis treatment might have an acute beneficial effect on endothelial dysfunction in patients suffering from SSHL.

Insulin resistant young subjects at risk of accelerated atherosclerosis exhibit a marked reduction in peripheral endothelial function early in life but not differences in intima-media thickness.

Reduced bio-availability of nitric oxide leading to disturbed flow mediated (endothelial dependent) vasodilation (FMD) has been shown to be an early functional abnormality of the vascular system in insulin resistant individuals and other subjects at high risk for accelerated atherosclerosis. In addition, an increase of the intima-media thickness (IMT) is regarded as an early marker of morphological alterations of the vessel wall. Whether endothelial dysfunction (ED) is evident already at an early stage when morphological changes of the vessel wall are not apparent is still an open question. We, therefore, examined IMT and peripheral endothelial function in a group of young insulin resistant subjects in a cross-sectional study and compared these results with a metabolically healthy (insulin sensitive) control group. We measured IMT (distal common carotid arteries), endothelium-dependent and endothelium-independent vasodilation (flow mediated and glyceroltrinitrate induced vasodilation of the brachial artery) non-invasively with high resolution ultrasound (13 MHz) in 91 young normoglycemic subjects (40/51 M/F, median: 31 years, range 18-50 years). Insulin sensitivity was measured with a euglycemic, hyperinsulinemic glucose clamp. Despite a marked reduction in flow-mediated vasodilation in insulin resistant (IR) subjects (FMD: median 3.4%, range -4.0 to 12.5 in IR versus 6.6%, range -1.2 to 20.1% in insulin sensitive subjects; P = 0.017), there was no difference in endothelial independent vasodilation (16.3%, range 5.7-41.0% versus 16.1%, range 0.5-39.2%) and in IMT (0.50 mm, range 0.39-0.66 and 0.51, 0.40-0.70 mm, respectively). These data suggest that ED can be detected very early in the life of insulin resistant subjects whereas no significant structural changes, indicated by a thickening of the intima-media layer, could be found. We therefore conclude that for identification of subjects with a high risk for accelerated atherosclerosis at an early stage, measurement of flow mediated vasodilation of the brachial artery may be more helpful than measuring thickness of the vascular wall.

[Urinary albumin excretion and noninvasive assessment of peripheral endothelial dysfunction with high-resolution ultrasound in type 2 diabetic subjects and nondiabetic controls]. / Renale Albuminausscheidung und nichtinvasive Endothelfunktionstestung mit hochauflösendem Ultraschall bei Typ-2-Diabetikern und Nichtdiabetikern.

BACKGROUND: Recent theory in pathogenesis of atherosclerosis has focused on the pathobiology of the artery wall including the emerging influence of the nitric oxide (NO) system on thrombogenicity and trigger mechanisms leading to morphologic changes culminating in the stenotic plaque. Therefore, diagnostic evaluation of disturbances in NO bioavailability might be of prognostic relevance regarding primary prevention of cardiovascular disease. Disturbances in NO production can be measured noninvasively with conventional high-resolution ultrasound. On the other hand, particularly in individuals with diabetes, microalbuminuria is thought to be associated with an increased risk of cardiovascular events. Thereby it is still unknown, whether an increase in renal albumin excretion can be regarded as an indicator of global endothelial dysfunction, or whether other partial functions such as the nitric oxide system might be disturbed earlier. PROBANDS AND METHODS: Therefore, the NO system and renal albumin excretion were examined in 129 subjects (56 with type 2 diabetes and 73 nondiabetics). Nitric oxide production was assessed by measuring flow-mediated vasodilatation (FMD) of the brachial artery using a 13-MHz linear array. Comparison was done between subjects with disturbed endothelial NO production (FMD < 5%) and subjects with normal regulation of the vascular tone (FMD > 5%). RESULTS: In normoalbuminuric individuals (< 20 microg/min, and < 20 mg/l, respectively), neither for the group of subjects with type 2 diabetes nor in the group of nondiabetics, relevant differences could be found in renal albumin excretion (RAE) rate between subjects with disturbed and normal FMD (RAE in diabetics 4.8 +/- 5.5 vs. 4.6 +/- 5.1 mg/l and in nondiabetics 5.1 +/- 2.6 vs. 4.9 +/- 2.7 microg/min). Both groups were well balanced regarding other risk factors of the metabolic syndrome (systolic/diastolic blood pressure, glucose and lipid metabolism). Furthermore, comparison of FMD in subjects with microalbuminuria (20-200 microg/min and 20-200 mg/l, respectively, n = 18) versus normoalbuminuric individuals (n = 111) again did not reveal a significant difference for the diabetic group (FMD median 4.3% [range 1.8-7.6%] vs. 5.0% [range 1.1-9.1%]) nor for the nondiabetic group (FMD median 4.7% [range 3.1-13.3%] vs. 5.2% [range -1.2-31.6%]). However, this analysis underlined the considerable influence of the classic cardiovascular risk factors. Particularly in the nondiabetic group, individuals with microalbuminuria showed higher blood pressure (p = 0.05) and a higher body mass index (p < 0.01). CONCLUSION: From these results, it is concluded that both procedures (renal albumin excretion rate and the measurement of endothelium-dependent vasodilatation) investigate two independent disturbances of the vascular wall. Furthermore, these results lead to the hypothesis that disturbances in endothelial NO production occur early and may already be operative before renal albumin excretion increases. Thus, for the purpose of actually identifying cardiovascular high-risk subjects early, peripheral endothelial dysfunction should be measured in addition to renal albumin excretion rate.

[Rare cause of an abdominal emergency--case 6/2014]. / Seltene Ursache eines akuten Abdomens--Fall 6/2014.

HISTORY AND ADMISSION FINDINGS: We report on a 58-year-old male patient with abdominal and right-sided flank pain, who presented with the picture of an acute abdominal emergency. INVESTIGATIONS: Laboratory tests revealed evidence of an inflammation and a hematuria. In the Doppler duplex ultrasound and computed tomography, chronic idiopathic periaortitis was diagnosed. The inflammatory-fibrosing disease resulted in urine retention and rupture of the fornix of the right kidney. DIAGNOSIS, TREATMENT AND COURSE: After surgical implementation of an ureteral stent and initiation of immunosuppressive therapy, it came to an improvement of the symptoms. CONCLUSIONS: In the differential diagnosis of an acute abdominal emergency, diseases of the aorta should be taken into account. Especially in male patients with anatomical complications it is important to exclude an inflammatory-fibrosing disease.