Seattle Angina Pectoris Questionnaire and Canadian Cardiovascular Society Angina Categories in the Assessment of Total Coronary Atherosclerotic Burden.

The patient reported angina measurement with the Seattle Angina Questionnaire (SAQ) has shown to have prognostic implications and became an endpoint in clinical trials. Our objective was to study physician-reported and SAQ severity with the total coronary atherosclerotic burden as assessed by 4 angiographic scores. We prospectively analyzed data of consecutive patients scheduled for coronary angiography or percutaneous coronary intervention. The Canadian Cardiovascular Society (CCS) angina categories was used as physician-reported angina. SAQ domains were categorized as severe (0 to 24), moderate 25 to 75 and mild angina (>75). All angina assessments were done before coronary angiography. Gensini, Syntax, Friesinger, and Sullivan angiographic scores were used for total atherosclerotic burden quantification: 261 patients were included in the present analysis. The median age was 66.0 (59.0 to 71.8) years, 53.6% were male and 43.7% had diabetes. The median SYNTAX score was 6.0 (0 to 18.0). The worse the symptoms of CCS categories, the more severe was the atherosclerotic burden in all angiographic scores: SYNTAX (p = 0.01); Gensini (p <0.01); Friesinger (p = 0.02) and Sullivan (p = 0.03). Conversely, SAQ domains were not able to discriminate the severity of CAD in any of the scores. The only exception was the severe SAQ quality of life that had worse Gensini score than the mild SAQ quality of life (p = 0.04). In conclusion, CCS angina categories are related to the total atherosclerotic burden in coronary angiography, by all angiographic scores. SAQ domains should be used as a measure of patient functionality and quality of life but not as a measure of CAD severity.

Evolving Indications for Lower Limb Amputations in South Africa Offer Opportunities for Health System Improvement.

BACKGROUND: Rapid urbanization and westernization have precipitated dramatic changes in the profile and prevalence of surgical diseases in sub-Saharan Africa. Disease of lifestyle is now common. We aimed to review our experience with lower-limb amputations at our surgical service in South Africa. METHODS: A single-center retrospective review of a prospectively collected database was performed of all patients who underwent a lower limb amputation. Inferential and descriptive statistics were performed. Patient demographics, indication, type of amputation, and management were reviewed. The primary outcome was 30-day in-patient mortality rate. RESULTS: Over a 5-year period (2013-2018), 348 patients underwent lower limb amputations. The median age was 61.5 years. 53.7% were diabetic and 56.3% were hypertensive. 53.2% had associated peripheral vascular disease and 8% preexisting cardiac disease. 30.7% smoked. Guillotine below-knee amputation was frequently performed (44.5% of amputations). 16.1% of these patients required a further operation. The in-hospital mortality rate was 8%. Underlying renal disease was an independent risk factor for mortality (p = 0.004). CONCLUSION: Currently, the most common indications for LLA in South Africa are diabetes mellitus and atherosclerosis. This reflects the changing pattern of disease in the country. There is a major problem with access to health care in rural areas in South Africa with significant delays in getting patients to tertiary units for evaluation by specialists. Foot care and prevention at a primary health care level is also lacking. Global improvements in the healthcare system are needed to improve LLA rates in South Africa.

VARIANTS OF ENDOVASCULAR REVASCULARIZATION OF LOWER LIMBS WITH CRITICAL ISСHEMIA DOE EXTENSIVE ATEROSCLEROSIS AND ASSESSMENT OF THEIR EFFECTIVENESS.

A retrospective analysis of the results of endovascular operations on the arteries of the lower extremities was performed in 209 patients, of which 45 (21.5%) were patients with chronic ischemia of the 2nd stage, category 4, 138 (66.1%) of patients with ischemia of the lower extremities of the third stag, category 5 and 26 (12.4%) of patients with IV stage, category 6 (by classification Rutherford et al., 1997) 17, 187 men, 22 women. The average age of patients was 63.7±9.3 years. Based on clinical and angiographic data, several variants of endovascular revascularization of the lower extremities were used: the vasoballoone segmentation followed by its stenting with a self-expanding stent of Terumo Misago (Japan) or a stent of Palmas Cordis (USA), one stent or two end-to-end stents (the stenting of the artery was supplemented by vasoballoone dilatation of the segment over the stents, between stents or under stents), sub intimal angioplasty was performed under the condition of Re-Entry Outback (Cordis, USA), balloon angioplasty was used using IN cylinders. PACT Admiral (Medtronic Inc. USA) with Free Pac coating containing urea and paclitaxel, the method of SAFARI (Subintimal Arterial Flossing with Antegrade-Retrograde Intervention). After analyzing the results of restorative opera-tions, we noted that clinical success in the first 6 months was achieved in 171 (81.8%) patients. Among them, a significant improvement in the limb was reported in 94 (45.0%) patients, moderate improvement was noted in 73 (34.9%) patients, unchanged in 26 (12.4%) cases, and a moderate deterioration at 16 (7.7%) patients. Cumulative vascular passage after endovascular operations was: 1-st month - 94.5%, 2-nd month - 92.3%, 6 month - 87.4%, one year later - 78.1%, in 2 years - 69.8%. According to our observations, the highest frequency of restenosis and reocclusion occurs in the first 6 months. All patients had a successful repeated endovascular reconstruction of the lesion area. Cumulative limb preservation after endovascular surgery was: 1 month - 100%, 2 months - 94.3%, 6 months - 90.6%, in 2 years - 84.1%.

[Acute aortic syndromes: an assessment]. / Il punto sulle sindromi aortiche acute.

The term "acute aortic syndrome" describes a range of severe, painful, potentially life-threatening abnormalities of the aorta. This review discusses the pathophysiology and risk factors, classification schemes, epidemiology, clinical presentations, diagnostic modalities, management options, and outcomes of various aortic conditions, including acute aortic dissection (AD) and its variants intramural hematoma and penetrating atherosclerotic ulcer. The common denominator of acute aortic syndromes is disruption of the media layer of the aorta, with bleeding within the layers (intramural hematoma), along the aortic media resulting in separation of the layers (AD), or transmurally through the wall in the case of ruptured penetrating atherosclerotic ulcer or trauma. The incidence of AD ranges from 2 to 3.5 cases per 100 000 person-years; hypertension and a variety of genetic disorders with altered connective tissues are the most prevalent risk conditions. Recent advances in imaging techniques have helped in understanding the natural history and dynamics of this condition. Prognosis is clearly related to undelayed diagnosis and appropriate surgical repair in case of proximal involvement of the aorta; the advent of endovascular treatment has opened new perspectives in the management of acute aortic syndromes affecting the descending aorta, since this can modify its natural history and improve prognosis.

Atherosclerotic renovascular disease in the United States.

Atherosclerotic renovascular disease (ARVD) is an increasingly recognized clinical condition that is diagnosed predominantly in older patients. Here we used annual United States Medicare 5% Denominator Files and studied 16,036,904 patients, 66 years of age and older, to quantify trends in diagnostic rates, associations, treatment, and outcomes of ARVD over a 13-year period. Overall, there was an ARVD rate of 3.09 per 1000 patient-years, which rose progressively with an adjusted hazard ratio of 3.35, comparing data from 1992 to 2004. Within 6 months of disease diagnosis, 13.4% of patients had undergone revascularization. A biphasic pattern of revascularization was found where the adjusted hazard ratios significantly increased in a progressive manner until 1999, following which there was a decline through 2004, which was not significant. The method of revascularization changed markedly over time with endovascular intervention steadily replacing direct surgical revascularization. As a time-dependent variable, ARVD was associated with excess mortality in each calendar year, albeit with declining hazard ratio estimates in more recent years. Among patients with this disease, revascularization was associated with mortality adjusted hazard ratios <1 in each year. Our study shows the diagnosis of ARVD has substantially risen in the United States but the survival implications were not fully explained by other comorbid vascular diseases.

Virtual histology-intravascular ultrasound in assessment of carotid plaques: ex vivo study.

OBJECTIVE: Virtual histology-intravascular ultrasound (VH-IVUS) has been reported to be useful in detecting the components of coronary plaques in vivo. Recently, the application of VH-IVUS to peripheral interventions has been evaluated. The aim of this study was to examine the extent to which the necrotic core of carotid plaques could be assessed accurately by VH-IVUS compared with histopathology. METHODS: A total of 37 carotid plaques underwent ex vivo VH-IVUS within 24 hours after endarterectomy. Ninety-five segments of virtual histological images were matched to histological sections. The area of the necrotic core on histological sections was compared with that on virtual histological images. Intraplaque hemorrhage (IPH) was histopathologically graded by its severity using immunohistochemical staining for glycophorin A as a marker. The relationship of the severity of the IPH to the necrotic core was histopathologically evaluated. The correlation between the necrotic core or IPH with symptomatology was also evaluated. RESULTS: The area of the necrotic core on virtual histological images (median, 8.0%; interquartile range, 5.0%-13%) was significantly smaller compared with that of the histological sections (median, 50%; interquartile range, 40%-63%) (P < 0.0001). The Bland-Altman analysis showed poor agreement in the necrotic core measurement between virtual histological images and histological sections (mean difference, 39.8%; 95% confidence interval, 35.8%-43.8%). Severe IPH was significantly associated with a larger necrotic core and symptomatology (P < 0.0001 and P = 0.0039, respectively). The area of necrotic core on the virtual histological analysis did not correlate with symptomatology (P = 0.70), but that on pathological analysis tended to correlate with symptomatology (P = 0.059). CONCLUSION: In the present virtual histological algorithm, the underestimation of the necrotic core was revealed. The lack of a hemorrhage component in the virtual histological algorithm is a leading cause of its underestimation.

Reporting standards for angioplasty and stent-assisted angioplasty for intracranial atherosclerosis.

BACKGROUND AND PURPOSE: Intracranial cerebral atherosclerosis causes ischemic stroke in a significant number of patients. Technological advances over the past 10 years have enabled endovascular treatment of intracranial atherosclerotic stenosis. The number of patients treated with angioplasty or stent-assisted angioplasty for this condition is increasing. Given the lack of universally accepted definitions, the goal of this document is to provide consensus recommendations for reporting standards, terminology, and written definitions when reporting clinical and radiological evaluation, technique, and outcome of endovascular treatment using angioplasty or stent-assisted angioplasty for stenotic and occlusive intracranial atherosclerosis. SUMMARY OF REPORT: This article was written under the auspices of Joint Writing Group of the Technology Assessment Committee, Society of NeuroInterventional Surgery, Society of Interventional Radiology; Joint Section on Cerebrovascular Neurosurgery of the American Association of Neurological Surgeons and Congress of Neurological Surgeons; and the Section of Stroke and Interventional Neurology of the American Academy of Neurology. A computerized search of the National Library of Medicine database of literature (PubMed) from January 1997 to December 2007 was conducted with the goal to identify published endovascular cerebrovascular interventional data in stenotic intracranial atherosclerosis that could be used as benchmarks for quality assessment. We sought to identify those risk adjustment variables that affect the likelihood of success and complications. This document offers the rationale for different clinical and technical considerations that may be important during the design of clinical trials for endovascular treatment of intracranial stenotic and occlusive atherosclerosis. Included in this guidance document are suggestions for uniform reporting standards for such trials. These definitions and standards are primarily intended for research purposes; however, they should also be helpful in clinical practice and applicable to all publications. CONCLUSIONS: In summary, the definitions proposed represent recommendations for constructing useful research data sets. The intent is to facilitate production of scientifically rigorous results capable of reliable comparisons between and among similar studies. In some cases, the definitions contained here are recommended by consensus of a panel of experts in this writing group for consistency in reporting and publication. These definitions should allow different groups to publish results that are directly comparable.

The utility of quantitative magnetic resonance angiography in the assessment of intracranial in-stent stenosis.

BACKGROUND AND PURPOSE: Noninvasive screening for intracranial in-stent stenosis is often limited by artifact because of the stent or associated coils. We aimed to determine the utility of quantitative MRA (QMRA) as a screening tool for detecting intracranial in-stent stenosis. METHODS: We reviewed 14 patients who had intracranial stent placement with follow-up QMRA and conventional angiography at our institution. Socio-demographic, medical, clinical, and imaging data were abstracted from medical charts. A blinded interventional neurologist reviewed all angiograms for presence of >50% in-stent stenosis. We tested QMRA (mL/min) at varying thresholds as a predictor of angiographic results. RESULTS: Among 14 patients (mean age, 62 years; 12 female, 2 male), 13 patients had Neuroform stents placed for wide-neck cerebral aneurysms and 1 patient had a Wingspan stent placement for atherosclerotic stenosis. Lesions were located in the intracranial internal carotid artery in 57.2% (n=8), the middle cerebral artery in 14.3% (n=2), and vertebrobasilar arteries in 28.6% (n=4). On follow-up angiography, 2 patients (14.3%) had >50% in-stent stenosis on angiography. Time-of-flight MRA was nondiagnostic in each case because of artifact from the stent or coils. A >20% reduction in vessel-specific blood flow by QMRA was associated with presence of >50% in-stent stenosis on angiography (P=0.033). As a screening tool to predict >50% angiographic in-stent stenosis, the sensitivity, specificity, positive predictive value, and negative predictive value of QMRA were 100%, 92%, 67%, and 100%, respectively. CONCLUSIONS: We found that QMRA is a promising screening tool to detect intracranial in-stent stenosis. Future prospective studies should focus on whether QMRA has a role in the detection of radiographic restenosis and prediction of clinical events.

Meta-analysis of the diagnostic accuracy of transesophageal echocardiography for assessment of atherosclerosis in the ascending aorta in patients undergoing cardiac surgery.

BACKGROUND: Stroke after cardiac surgery may be caused by emboli emerging from an atherosclerotic ascending aorta (AA). Epiaortic ultrasound scanning (EUS), the current 'gold' standard for detecting AA atherosclerosis, has not gained widespread use because there is a lack of optimized ultrasound devices, it lengthens the procedure, it endangers sterility, and there is a false belief by many surgeons that palpation is as sensitive as EUS. Furthermore there is no clear evidence proving that the use of epiaortic scanning changes outcome in cardiac surgery. Various researchers investigated the ability of transesophageal echocardiography (TEE) to discriminate between the presence and absence of AA atherosclerosis. It is acknowledged that TEE has limited value in this, but it has never been supported by a meta-analysis estimating the true diagnostic accuracy of TEE based on all quantitative evidence. We aimed to do this using state-of-the-art methodology of diagnostic meta-analyses. METHODS: We searched multiple databases for studies comparing TEE vs. EUS for detection of atherosclerosis. A random-effects bivariate meta-regression model was used to obtain summary estimates of sensitivity and specificity, incorporating the correlation between sensitivity and specificity as well as covariates to explore heterogeneity across studies. RESULTS: We extracted six studies with a total of 346 patients, of whom 419 aortic segments were analyzed, including 100 segments with atherosclerosis [median prevalence 25% (range 17-62%)]. Summary estimates of sensitivity and specificity were 21% (95% CI 13-32%) and 99% (96-99%), respectively. CONCLUSIONS: Because of the low sensitivity of TEE for the detection of AA atherosclerosis, a negative test result requires verification by additional testing using epiaortic scanning. In case of a positive test result, AA atherosclerosis can be considered as present, and less manipulative strategies might be indicated.

Energy cost of walking measurements in subjects with lower limb amputations: a comparison study between floor and treadmill test.

Measuring the energy cost of walking (ECW) is a valid way of assessing the walking efficiency of subjects who were prosthetic users following lower limb amputation. The aim of this study was to determine whether, in these subjects, treadmill and floor ECW measurements are comparable. We tested 24 subjects who had undergone unilateral lower limb amputations for vascular diseases as they walked at a self-selected comfortable speed on the floor and on a treadmill. The tests were conducted at the end of rehabilitative treatment to fit prosthesis. Eight subjects underwent transtibial and 16 transfemoral amputation. The measurements were taken with a portable gas analyzer. The self-selected comfortable speed on the treadmill was significantly lower than that on the floor, where the patients adopted the aid they normally used for walking; oxygen consumption was the same in the two tests. Therefore, for both transtibial and transfemoral patients, ECW was greater during walking on the treadmill. Steady-state heart rate did not differ in the two tests. The data show that the ECW values of the amputated subjects obtained on the treadmill at the end of rehabilitation did not correspond with those they obtained on the floor. The floor test is the one that may better reflect walking with prostheses and aids in everyday life, in subjects with dysvascular lower limb amputation, using the prosthesis for a short time.

Vascular assessment and reconstruction of the ischemic diabetic limb.

Peripheral artery disease (PAD) is a common finding among diabetic patients and is usually secondary to atherosclerosis. PAD in diabetic patients tends to be more malignant, presenting with diffuse involvement and more complications. Unless the ischemia is addressed concomitantly with local problems in the foot, resulting problems can lead to extensive tissue loss and major amputation. Lower extremity atherosclerotic complications in diabetic patients require considerable dedication and aggressiveness if limb loss is to be avoided.

Aortic assessment for cardiac surgical procedures.

Aortic atheromatous disease is associated with stroke in both the ambulatory and perioperative setting. In addition to atheromatous deposits, a reduction in the compliance of the aorta takes place as elastin fibers are replaced by collagen fibers. Both of these distinct processes, termed atherosclerosis, can easily be measured using transesophageal echocardiography during cardiac surgery. A review of the literature demonstrates many studies supporting the benefit of transesophageal echocardiography examination of the aorta for reducing stroke following cardiac surgery, through modification of surgical techniques. There have also been attempts by surgeons to remove atheromatous lesions from the aorta during cardiac surgery. Unfortunately, these procedures currently have a high perioperative mortality. Finally, medical therapy such as warfarin or statins may help reduce the incidence of stroke following heart surgery.

Carotid artery stenting versus carotid endarterectomy: current status.

As operator experience and device technology continue to improve, the theoretic advantages of endovascular approaches to treat carotid occlusive disease may be closer to realization. Currently, data from controlled trials of CAS is minimal, but several multicenter RCTs comparing CAS to CEA are recruiting patients actively and preliminary results show procedural morbidity and mortality rates for CAS that compare favorably to CEA. Community-based experience with CAS continues to grow and further refinements in patient selection based on plaque morphology and other variables offer further hope that endovascular approaches to carotid occlusive disease may benefit selected patients. Given the proved efficacy and durability of CEA for treatment of extracranial carotid stenosis, surgical revascularization remains the recommended standard of care for most patients. CAS will have to be proved equivalent or superior to surgery and as cost-effective to facilitate its widespread acceptance as a treatment alternative for carotid occlusive disease.