Repaired coarctation of the aorta does not affect four-dimensional flow metrics in bicuspid aortic valve disease.

OBJECTIVES: The objective of this study was primarily to compare four-dimensional flow magnetic resonance imaging metrics in the ascending aorta (AA) of patients with right-left fusion type bicuspid aortic valve (RL-BAV) and repaired coarctation of the aorta (CoA) to RL-BAV without CoA. Metrics of patients with RL-BAV were also compared to the matched group of patients with common tricuspid aortic valve (TAV). METHODS: Eleven patients with RL-BAV and CoA, 11 patients with RL-BAV without CoA and 22 controls with TAV were investigated. Peak velocity (cm/s), peak flow (ml/s) and flow displacement (%) were analysed at 5 pre-defined AA levels. In addition, regional wall shear stress (WSS, mN/m2), circumferential WSS (WSSc) and axial WSS (WSSa) at all levels were quantified in 6 sectors of the aortic circle. Averaged WSS values on each level (WSSavg, WSSc, avg and WSSa, avg) were calculated as well. RESULTS: Peak velocity at the proximal tubular AA was significantly lower in BAV and CoA group (P = 0.047) compared to BAV without CoA. In addition, the WSSa, avg was found to be higher for the BAV and CoA group at proximal AA respectively (P = 0.040). No other significant differences were found between these groups. BAV group's peak velocity was higher at every level (P < 0.001-0.004) compared to TAV group. Flow displacement was significantly higher for the BAV group at every level (P < 0.001) besides at the most distal level. All averaged WSS values were significantly higher in BAV patients in distal AA (P < 0.001-0.018). CONCLUSIONS: Repaired CoA does not relevantly alter four-dimensional flow metrics in the AA of patients with RL-BAV. However, RL-BAV majorly alters flow dynamics in the AA when compared to patients with TAV. CLINICAL TRIAL REGISTRATION NUMBER: https://www.clinicaltrials.gov/study/NCT05065996, Unique Protocol ID 5063566.

Toe pressure should be part of a vascular surgeon's first-line investigation in the assessment of lower extremity artery disease and cardiovascular risk of a patient.

OBJECTIVE: Toe pressure (TP) is an accurate indicator of the peripheral vascular status of a patient and thus cardiovascular risk, with less susceptibility to errors than ankle-brachial index (ABI). This study aimed to analyze how ABI and TP measurements associate with overall survival and cardiovascular death and to analyze the TP of patients with ABI of 0.9 to 1.3. METHODS: The first ABI and TP measurements of a consecutive 6784 patients treated at the Helsinki University Hospital vascular surgery clinic between 1990 and 2009 were analyzed. Helsinki University Vascular Registry and the national Cause of Death Registry provided the data. RESULTS: The poorest survival was in patients with ABI >1.3 (10-year survival, 15.3%; hazard ratio, 2.2; 95% confidence interval, 1.9-2.6; P < .0001; reference group, ABI 0.9-1.3), followed by the patients with TP <30 mm Hg (10-year survival, 19.6%; hazard ratio, 2.0; 95% confidence interval, 1.7-2.2; P < .0001; reference group, TP ≥80 mm Hg). The best 10-year survival was in patients with TP ≥80 mm Hg (43.9%). Of the 642 patients with normal ABI (0.9-1.3), 18.7% had a TP <50 mm Hg. The highest cardiovascular death rate (64.6%) was in the patients with TP <30 mm Hg, and it was significantly lower than for the patients with TP >50 mm Hg. CONCLUSIONS: Low TP is associated significantly with survival and cardiovascular mortality. Patients with a normal ABI may have lower extremity artery disease (LEAD) and a considerable risk for a cardiovascular event. If only the ABI is measured in addition to clinical examination, a substantial proportion of patients may be left without LEAD diagnosis or adequate treatment of cardiovascular risk factors. Thus, especially if ABI is normal, LEAD is excluded only if TPs are also measured and are normal.

Combination of perineural and wound infusion after above knee amputation: A randomized, controlled multicenter study.

BACKGROUND: Post-operative pain after an above-knee amputation is often severe, and in the elderly patients the adverse effects of post-operative opioids are evident. We hypothesized that continuous perineural local anesthetic infusion (CPI) combined to a wound infusion will reduce acute pain and opioid consumption compared to placebo after above knee amputation. METHODS: Ninety-three patients going through an above knee amputation were recruited for this randomized, controlled trial. Two catheters were placed, one to the sciatic nerve sheath and one under the fasciae during the amputation. After two 10 mL boluses of ropivacaine 0.75% a post-operative infusion of ropivacaine 0.2% or placebo (NaCl 0.9%) at 2 mL/h was administered for 72 hours to both catheters. The primary outcome was average stump pain during the first 5 days. RESULTS: The mean intensity of stump pain during the first five post-operative days was 1.4 (0.8) in the CPI group and 1.9 (0.9) in the placebo group on VRS, mean (SD), P = .006. The opioid consumption on first five post-operative days did not differ between the groups. CONCLUSION: A combination of continuous perineural and wound local anesthetic infusion seems to diminish the intensity of stump pain after above knee amputation.

Quality Control of the Foot Revascularization Using Indocyanine Green Fluorescence Imaging.

OBJECTIVES: Critical limb ischemia (CLI) is a clinical diagnosis, confirmed by objective tests, usually ankle-brachial index (ABI), toe pressure (TP) and TcPO2. Furthermore, the anatomical lesions in patients affected by CLI were visualized by ultrasound, angiography, CTA, or MRA. Indocyanine green fluorescence imaging (ICG-FI) is a diagnostic modality for assessing foot perfusion. We aimed to study the usefulness of ICG-FI in the quality control of revascularization. MATERIALS AND METHODS: One hundred and four CLI limbs in 101 patients were studied with ICG-FI using SPY Elite before and after open or endovascular revascularization. ABI and TP were also measured. After ICG-FI, assessment of circulation was done using time-intensity curve derived from the two regions of interest the one being in the plantar side of the foot and the other in the dorsal side of the foot. Three parameters were derived from the curves: maximum intensity (the absolute value of the maximum intensity); intensity rate (the value from the time-intensity curve describing the increase in maximum intensity/s) and SPY10 (the intensity achieved during the first 10 s after the foot starts to gain intensity). RESULTS: Sixty-two limbs presented category 3 of Rutherford classification, 12 limbs category 4, and 30 limbs category 5. Ninety-five technically successful procedures were achieved, 63 (66.3%) endovascular and 32 (33.7%) surgical revascularizations. In 9 (9.5%) patients, an in-line flow from the aorta to the foot was not achieved due to a failure to recanalize the occlusion (n = 7) or due to distal embolization (n = 2). ABI was not reliable in 58 patients (57.4%) mostly due to pseudohypertension and TPs in 49 (48.5%) patients mostly due to previous minor amputations. ICG-FI was successful in all patients. The mean intensity values before and after the procedure in patients who underwent successful revascularization were 81 ± 47 units and 120 ± 5 units of intensity (p < .001) and intensity rates 4.2 ± 4 and 8.0 ± 6.2 units/s (p = .001), respectively. In the PTA patients in whom the revascularization was unsuccessful, no changes were seen in the hemodynamic parameters. In 6 (8.8%) patients who underwent technically successful revascularization, the SPY values were worse after the revascularization than at the baseline. CONCLUSIONS: ICG-FI with SPY Elite provides reliable information on the increase in perfusion after revascularization, in addition to implicating possible failure if there is no improvement in the ICG-FI variables. Unlike ABI and TP, it can be performed in all patients. It gives valuable information to complement traditional assessment methods.

Diagnosis and treatment of dyslipidemia are neglected in patients with peripheral artery disease.

OBJECTIVE: Our aim was to investigate how dyslipidemia was diagnosed and treated in patients with peripheral artery disease (PAD) in a university vascular clinic. DESIGN: Our analysis included all 1 843 PAD patients (median age 71 years, interquartile range 63-79, M/W 975/868) who attended the clinic in 2002-2003 either for diagnostic angiography or for revascularization. The charts of patients tested for dyslipidemia were reviewed closer. RESULTS: Serum lipids were measured in only 214 PAD patients (11.6%). Of them 37.9% smoked, 59.8% had antihypertensive medication, 35.0% diabetes, and 30.8% a history of coronary heart disease. Mean serum cholesterol concentration was 4.5 mmol/l (SD 1.3), LDL-cholesterol 2.54 (0.48), HDL-cholesterol 1.25 (0.48), and triglycerides 1.62 (0.84). Only 40 patients (19.7%) were using statins, this was increased to 72 (33.6%) after clinic visit. Consequently, 50.0% and 53.2% met the current total cholesterol (<4.5 mmol/l) and LDL-cholesterol (<2.5 mmol/l) goals, respectively. CONCLUSIONS: Dyslipidemia was highly under-diagnosed among PAD patients. Serum lipids were measured only in a minority and among them serum lipid values and the use of hypolipidemic drugs were not optimal according to guidelines.