The usefulness of Duplex Doppler ultrasound in the angiological and dermatological diagnosis of patients with blue toe syndrome.

INTRODUCTION: Peripheral microembolism is one of the most frequent causes of acute limb ischemia. In order to effectively prevent relapses it is essential to localize and eliminate the source of embolism. AIM: To evaluate the role of Duplex Doppler ultrasound examination in identifying the causes of blue toe syndrome (BTS). MATERIAL AND METHODS: The group of 165 patients with clinical symptoms of BTS on their upper limbs (n = 16) and lower limbs (n = 149) was investigated. They all underwent Duplex Doppler ultrasound of the major arteries of the extremities, where ischemic changes occurred. RESULTS: Morphological and functional changes which might be potential sources of microembolism were identified in 146 patients. These changes included significant short-length stenoses or unstable atherosclerotic plaque (n = 73), true aneurysms (n = 42) and pseudoaneurysms (n = 17). In 11 cases, pathology of vascular prostheses in the form of anastomotic aneurysms, infection and residual thrombi after fibrinolysis was detected. In all cases, Duplex diagnosis was confirmed by other imaging and intraoperative tests. CONCLUSIONS: Duplex Doppler ultrasound of the arteries in the affected limb with a full length view should be the first-line examination in diagnosing patients with BTS. In the absence of hemodynamic blood flow disturbances in the major arteries in patients with symptoms of BTS, it is advisable to start haematological tests to identify/exclude congenital or acquired thrombophilia.

Gene polymorphism -418 G/C of tissue inhibitor of metalloproteinases 2 is associated with abdominal aortic aneurysm.

OBJECTIVE: The pathogenesis of abdominal aortic aneurysm (AAA) is connected with abnormal extracellular matrix remodeling, with the assistance of extracellular matrix metalloproteinases and tissue inhibitors of metalloproteinases (TIMPs). A decrease in tissue inhibitor of metalloproteinases 2 (TIMP2) gene expression was detected in AAA patients. Recently, a -418 G/C (rs8179090) polymorphism of the TIMP2 gene promoter, influencing the transcription rate of the gene, has been described. This study investigated whether the -418 G/C gene polymorphism is associated with AAA in the Polish population. METHODS: The TIMP2 gene promoter polymorphism was evaluated by polymerase chain reaction, followed by restriction enzyme analysis and pyrosequencing in 128 patients affected by AAA and in 180 individuals included as references. The control group was directly matched to patients according to known risk factors for vascular diseases. RESULTS: The frequency of the C allele was significantly higher in AAA patients than in the control group (odds ratio [OR], 2.516; P = .0005). The distribution of genotypes also differed significantly between the groups (CC + CG vs GG: OR, 2.906; P = .0037) or was close to being significantly different (CC vs GG + GC: OR, 2.144; P = .0501). A similar trend was observed in men but not in women. The multivariate logistic regression analysis indicated the TIMP2 gene promoter polymorphism is risk factor of AAA in the Polish population, with an adjusted OR of 4.99, when applied to a dominant inheritance model. CONCLUSIONS: Our study supports the hypothesis that TIMP2 and the -418G/C polymorphism located in the promoter of the TIMP2 gene are important in AAA pathophysiology.

Effects of Intermittent Pneumatic Compression on Reduction of Postoperative Lower Extremity Edema and Normalization of Foot Microcirculation Flow in Patients Undergoing Arterial Revascularization.

BACKGROUND In patients with chronic leg ischemia, the beneficial effect of arterial revascularization can be significantly decreased due to postoperative leg swelling. The aim of this study was to assess the effects of intermittent pneumatic compression (IPC) on skin flow normalization in patients undergoing revascularization procedures due to chronic leg ischemia. MATERIAL AND METHODS We evaluated 116 patients with chronic leg ischemia. The patients were divided into groups according to the performed treatment (endovascular or surgical) and implementation of IPC postoperatively. The leg edema assessment and microcirculation flow assessment were performed pre- and postoperatively, using percutaneous O2 pressure (TcpO2), cutaneous blood perfusion (CBP) measurements, and skin flow motion assessment. RESULTS In patients who did not receive IPC, a decrease in CBP value was observed in the 1st postoperative assessment. Among patients receiving IPC, the CBD value increased at the 1st and 2nd postoperative measurements, especially in the surgical group. The lowest TcpO2 values were observed in by-pass surgery group without IPC postoperatively. CONCLUSIONS The benefits of the by-pass procedure in patients with leg ischemia can be significantly reduced by postoperative edema. Among patients with postoperative leg edema, local tissue blood perfusion can be improved by the use of IPC, which can result in decreased local leg swelling, as well as improved skin blood perfusion and TcpO2.

[The analyze of recurrent varicose veins development after surgical treatment of lower limbs varicose veins]. / Analiza przyczyn rozwoju zylaków nawrotowych po operacyjnym leczeniu zylaków konczyn dolnych.

Possible development of recurrent varicose veins (RVV) is one of the main reasons for abandonment of patients to undergo varicose veins surgical treatment. Regardless of the increase in the number of the treatment the primary method of improving the surgical technique is to identify the causes of earlier failures. The aim of this study was to determine the mechanisms responsible for the development of recurrent varicose veins after surgical treatment of primary varicose veins. We studied 507 patients (680 limbs) with primary varicose veins of the lower limbs operated in the years 1996-2007 using the classical technique. The results of pre-and postoperative signs, duplex studies and operational protocols were analyzed. Follow-up was 36-156 months (mean 89.7 +/- 31.2 months). RVV development was observed in 36.9% of operated limbs. Irregularities of surgical techniques and neovascularization were responsible for the development of changes to 87.6% and disease progression in the development of changes in 27.4% of limbs with RVV. At 15.5% of limbs with RVV occurred more than one cause of relapse. In logistic regression combined effects of several factors shown to exist only significant relationship between development and the presence of RVV stumps in sapheno-femoral junction (SFJ) and the presence of inefficient SFJ tributaries of the stumps. The risk of development of new varicose veins was independent on the correctness of the implementation of the first treatment. The most common cause of development of RW were imperfections of surgical treatment, principally in the form of leaving the stumps with insufficient SFJ tributaries, or the development of neovascularization. It appears that improving the quality of treatment may favorably affect the development of a decreased incidence of recurrent varicose veins.

Angio PLanewave UltraSensitive Imaging (Angio PL.U.S.) as an Innovative Doppler Ultrasound Technique with a Potential to follow up Endoleaks after Endovascular Aneurysm Repair (EVAR).

The aim of the study was to evaluate the effectiveness of Angio PLanewave UltraSensitive imaging (Angio PL.U.S.) as an alternative to contrast-enhanced ultrasound (CEUS) and computed tomography angiography (CTA) for endoleak detection and classification in patients after endovascular aneurysm repair. A total of 28 patients underwent a post-endovascular aneurysm repair follow-up with color Doppler ultrasound, power Doppler ultrasound, CEUS, Angio PL.U.S and CTA examinations. CTA revealed 17 endoleaks in 14 patients (50%): 3 type Ia, 13 type II and 1 type III. There were no differences between Angio PL.U.S. and CEUS in terms of sensitivity, specificity or accuracy (93%, 100% and 97%). We did not observe any statistically significant differences between CTA, CEUS and Angio PL.U.S. in terms of the endoleak identification ability. Angio PL.U.S. may be considered as a potential tool to follow-up patients after endovascular aneurysm repair implantation, especially in patients who cannot be examined with CTA or CEUS.

Angiotensin-converting enzyme (ACE, I/D) gene polymorphism and susceptibility to abdominal aortic aneurysm or aortoiliac occlusive disease.

BACKGROUND: The purpose of this study was to examine the role of polymorphism in angiotensin converting enzyme gene (ACE, I/D) in the development of abdominal aortic aneurysm (AAA) or aortoiliac occlusive disease (AIOD). MATERIALS AND METHODS: We investigated 829 individuals in 4 groups: AAA (n = 133), AIOD (n = 152), control (n = 152), and a random Polish population group (n = 392). ACE I/D gene polymorphism analysis was performed by polymerase chain reaction and gel electrophoresis. The genotype distribution was in Hardy-Weinberg equilibrium. RESULTS: The genotype distribution and allele frequency of ACE I/D were not significantly different between patients with AAA or AIOD and the control or the population group. Significant differences were found between the following groups: 1) hypertensive patients with AAA and normotensive patients with AAA (OR = 3.08 95% CI 1.22-7.79, P = 0.0147); 2) hypertensive patients with AAA and the population group (OR = 2.56; 95% CI 1.27-5.16, P = 0.0066). Since the majority of subjects were male, these associations were also true when only male hypertensive subjects with AAA were compared with male normotensive patients with AAA or to male population group. No relation of the ACE gene polymorphism to hypertension in the AIOD group was found. CONCLUSIONS: ACE I/D gene polymorphism is not a susceptibility factor to aortoiliac occlusive disease; however it may be an important factor in the development of AAA when coexisting with hypertension.

[Vertebral arteries dissection as a rare cause of central nervous system ischemia]. / Rozwarstwienie tetnic kregowych jako rzadka przyczyna niedokrwienia osrodkowego ukladu nerwowego.

However rare, dissection of extracranial cerebral arteries is one of the most often causes of ischemic stroke in young people. Early diagnosis and treatment promote artery recanalization that results in total symptom regression. The proper diagnosis is in many cases is difficult. The reason is the variety of causative factors, clinical symptoms and difficulty of direct dissected vertebral arteries visualisation in common Duplex-Doppler examination. In our article we present 3 causes of vertebral arteries dissection. We would like to call your attention to consider this causative factor in differentiation diagnostics of central nervous system ischemia. This complication may occur not only due to a communication accident, but also during playing tennis and bowling.

[Combined edema reducing therapy in the treatment of advanced lower limb lymphedema]. / Kompleksowa terapia przeciwobrzekowa w leczeniu zaawansowanych postaci pierwotnego obrzeku limfatycznego konczyn dolnych.

UNLABELLED: Combined edema reducing therapy is a recognized method of lymphedema treatment. However such therapy can be difficult to implement from methodological and logistic point of view in cases of advanced forms of lymphedema. The aim of the study was the presentation and discussion of intensive phase of combined treatment in patient with advanced primary lymphedema. MATERIAL AND METHODS: Therapy was conducted on 19 patients (27 limbs) with edema reducing therapy program. Procedures were conducted daily for 4-6 weeks in out-patient and in-wards conditions. RESULTS: Intensive phase of treatment succeeded in 3870-15 330 ml edema reduction, consisting of 48-65% of initial status. Chronic leg ulcers were healed completely in 2 patients. Ten patients underwent minor adverse events (AE), such as superficial skin ulceration (n = 2), popliteal fossa skin maceration (n = 2), neuropathic foot pain (n = 3) and skin scratches (n = 3). Modification of the treatment allowed the complete healing of AEs within 2-7 days, but it produced significant delay in achievement of desired therapeutic result, In 2 cases it prolonged hospital stay for 7 days. CONCLUSIONS: 1. Combined edema reducing therapy is very efficient form of treatment in advanced primary lymphedema. 2. Intensive, 4-6 week, phase of the treatment allows 3.8 to 15.3 1 edema reduction. 3. In our opinion this phase should be conducted only in specialized centers for proper final results achievement with adverse events minimization. 4. The main point of the therapy is a combination of appropriate forms of available treatment.

Superb Micro-vascular Imaging (SMI): a Doppler ultrasound technique with potential to identify, classify, and follow up endoleaks in patients after Endovascular Aneurysm Repair (EVAR).

PURPOSE: The aim of the study was to assess the effectiveness of Superb Micro-vascular Imaging (SMI) as an alternative to Contrast-Enhanced Ultrasound (CEUS) and Computed Tomography Angiography (CTA) for endoleak detection and classification in patients followed up after endovascular abdominal aortic aneurysm repair (EVAR). MATERIALS AND METHODS: From May 2015 to January 2017, 30 patients underwent post-EVAR follow-up with Color Doppler Ultrasound (CDUS), CEUS, SMI, and CTA examinations. Aneurysmal sac diameter and graft patency were evaluated; endoleaks were identified and classified. Sensitivity, specificity, and accuracy values were calculated for each of the four diagnostic methods of endoleak detection. A percentage of agreement and Cohen's Kappa coefficient were calculated for comparison of methods in terms of endoleak identification. RESULTS: CTA revealed fifteen endoleaks (50%): three type Ia, nine type II, and three type III. The sensitivity of CDUS, CEUS, and SMI relative to CTA was 27%, 100%, and 100%, respectively. Specificity was 93%, 93%, and 93%, respectively. Accuracy was 60%, 97%, and 97%, respectively. There were no differences between SMI and CEUS in terms of sensitivity, specificity, or accuracy (100%, 93%, and 97%). We do not observe statistically significant differences between CTA, CEUS, and SMI concerning endoleak identification ability. The weakest method in endoleak identification was CDUS. CONCLUSIONS: The analysis showed that SMI is effective, repeatable, and comparable with the CEUS modality in identification endoleaks after EVAR; it may be considered as a potential tool to monitor patients after EVAR implantation, especially those with renal insufficiency or with an allergy to any contrast media.

[Pregnancy as a risk factor in development of varicose veins in women]. / Ciaza jako czynnik rozwoju zylaków konczyn dolnych u kobiet.

OBJECTIVES: The purpose of this study was to analyse prevalence of so called classical risk factors for VV in patients with this entity. MATERIALS AND METHODS: Study consisted of three parts. In the first part the prevalence of risk factors in 130 men and 360 women with VV was compared. In the second part the prevalence of risk factor in 360 women with VV and 162 without VV was compared. In the third part the prevalence of risk factors in pregnant women with and without VV was compared. The age of patients in all groups was comparable. The results were statistically analyzed. RESULTS: There were no differences in prevalence of classical risk factors between men and women with VV. In non pregnant women positive family history (OR 2,27, p=0,018) and previous pregnancies (OR 2,05, p=0,046) were associated with presence of VV. Premenstrual aching of lower extremities and obesity were at the border of statistical significance, OR and p, 1,9 and 0,062 and 1,4 and 0,071, respectively. As many as 47% of pregnant women had VV. Positive family history (OR 2,27, p=0,018), previous pregnancies (OR 2,56, p=0,011) and premenstrual aching of lower extremities (OR 2,03, p=0,021) were associated with presence of VV. Remaining, so called classical risk factors such as oral contraceptive, working in a sitting or standing position or constipations were not associated with occurrence of VV. CONCLUSIONS: In conclusion, positive family history and previous pregnancies seem to be principal risk factors for VV in women.

Changes in flow-mediated dilatation in patients with femoropopliteal occlusion receiving conservative and invasive treatment.

BACKGROUND: Although the beneficial effect of revascularisation on reduction of local clinical ischaemic symptoms has been well established, its effect on systemic vascular endothelial function has not been fully explained yet. AIM: To determine changes in endothelium-dependent flow-mediated dilatation in patients with unilateral femoropopliteal occlusion receiving medical and surgical treatment. METHODS: Seventy-nine patients with symptomatic atherosclerotic ischaemia of lower extremities, treated with endovascular procedures, with femoropopliteal graft, or receiving conservative treatment (21-day controlled treadmill training) were enrolled in the study. Ankle brachial pressure index (ABPI), skin blood flow on the feet, and flow-mediated dilatation (FMD) of brachial arteries were measured in each patient at baseline and after 90 days of follow-up. RESULTS: The ABPI, vasomotion in the myogenic frequency band, and FMD increased significantly in surgical patients. In patients after femoropopliteal bypass a significant increase of vasomotion in the endothelial frequency band was also observed. In patients receiving conservative treatment (treadmill training), vasomotion in the myogenic frequency band increased whereas the FMD remained unchanged. CONCLUSIONS: It seems that surgical treatment may contribute to reducing the risk of cardiovascular complications in patients with advanced peripheral artery disease, as a result of improving the systemic vascular endothelial function. Limiting treatment to just treadmill training increases pain-free walking distance but does not improve systemic vascular endothelial function.

Duplex Doppler ultrasound examination of carotid and vertebral arteries: guidelines of the Polish Society for Vascular Surgery.

The duplex Doppler examination of carotid and vertebral arteries is the primary diagnostic method in detecting disorders leading to the brain blood supply disturbances. In many cases, in patients with carotid artery stenosis, the Doppler ultrasound plays a major role in the process of qualification to the reconstructive procedures. Regardless of the widespread availability and high sensitivity and specificity of this method it's burdened with serious drawbacks. The most important of them are evaluation subjectivity and variety of methods to assess stenosis degree and the nature of atherosclerotic plaques. They often cause difficulties in comparing the test results carried out in different centers and to find correlations with other imaging methods results. In order to overcome these drawbacks, Polish Society for Vascular Surgery has attempted to develop recommendations for uniform methodology of carotid and vertebral arteries Doppler examination. Legal terms, the manner of examination and its interpretation were presented. Proposing the way of highlights results and messages conclusion to enable the recommendationsimplementation of endovascular and surgical qualifications relating to surgical treatment. We hope that these recommendations will help to standardize examination techniques.

[Duplex Doppler ultrasound examination of extremities arteries: guidelines of the Polish Society for Vascular Surgery]. / Zalecenia dotyczace wykonywania badan USG dupleks dopler tetnic konczyn Polskiego Towarzystwa Chirurgii Naczyniowej.

The duplex Doppler examination of extremities arteries is the primary diagnostic method in detecting disorders leading to lower and upper extremities blood supply disturbances. In many cases the Doppler ultrasound plays a major role in the process of qualification to the reconstructive procedures or conservative treatment, especially to the endovascular procedures. Regardless of the widespread availability and high sensitivity and specificity of this method it's burdened with serious drawbacks. The most important of them are evaluation subjectivity and variety of methods determining the haemodynamic stenosis consequences. They often cause difficulties in comparing the test results carried out in different centres and to find correlations with other imaging methods results. In order to overcome these drawbacks, Polish Society for Vascular Surgery has attempted to develop recommendations for uniform methodology of extremities arteries Doppler examination. Legal terms, the manner of examination and its interpretation were presented. Proposing the way of highlights results and messages conclusion to enable the recommendations implementation of endovascular and surgical qualifications relating to surgical treatment. We hope that these recommendations will help to standardise examination techniques.

Risk factors in abdominal aortic aneurysm and in Polish population aortoiliac occlusive disease and differences between them [corrected].

Abdominal aortic aneurysm (AAA) and aortoiliac occlusive disease (AIOD) are multifactorial vascular disorders caused by complex genetic and environmental factors. The purpose of this study was to define risk factors of AAA and AIOD in the Polish population and indicate differences between diseases.

The use of duplex ultrasound arterial mapping (DUAM) and preoperative diagnostics in patients with atherosclerotic ischaemia of lower extremities.

UNLABELLED: In spite of the fact duplex Doppler ultrasonography is recognized as an scanning technique equivalent to other imaging methods for preoperative diagnostics of the lower extremity arteries, in many centres its use is limited to screening. THE AIM OF THE STUDY: was to the determine usefulness of arterial duplex mapping for preoperative diagnostics in patients with peripheral artery occlusive disease (PAOD). MATERIAL AND METHODS: In 2008-2009, 103 patients with PAOD symptoms (129 limbs) were examined in a prospective, non-randomized study. DUAM was performed in all limbs, DSA in 90, CT-angio in 29, and revascularisation procedures in 116 limbs. RESULTS: Problems with completing DUAM occurred in 10,1% of cases, including 1.5% of examinations of no diagnostic value. Consistency of DUAM and DSA results was found in 94.6% of cases, and consistency of DUAM results and the range of actually performed ranges was found in 97.8% of cases. Consistency of DUAM and CT-angio results was recorded in 68.0% of cases. The comparison between individual examinations and the actually performed procedures showed consistency of 96.5% for DUAM and 72.4% for CT-angio. CONCLUSIONS: DUAM usefulness for detecting and defining lesions in lower extremity arteries is similar to that of DSA and CT-angio. This examination may be successfully used in preoperative diagnostics, particularly for intravascular procedures, which makes possible to reduce exposition to radiation and minimalize diagnostics costs.

Location of femoral artery puncture site and the risk of postcatheterization pseudoaneurysm formation.

Iatrogenic causes constitute increasingly frequent sources of pseudoaneurysms due to endovascular interventions. However, till now, all analyses focused on evaluating different risk factors contributing to the development of pseudoaneurysm, overlooking the issue of localization of femoral puncture. The aim of this study was to assess the influence of position of femoral artery puncture on the risk of pseudoaneurysm formation. 116 patients were evaluated for the site of catheter insertion into femoral arteries. Another group of 273 patients, suspected of vascular complications after endovascular procedures, were diagnosed with pseudoaneurysms which were analyzed for the location of arterial wall disruption. Puncture sites of groin arteries, i.e. EIA (2.7%), CFA (77.5%), SFA and DFA (19.8%), correlated with pseudoaneurysm location reaching 7.6% (EIA), 54.3% (CFA) and 38.1% (SFA, DFA). Type of procedure influenced these values. Duplex ultrasound mapping of CFA before the endovascular intervention eliminated discrepancies between the incidence of pseudoaneurysm formation and the frequency of arterial puncture in the selected vascular segments. Pseudoaneurysms formed in 4.5% of patients undergoing traditional palpation-guided vessel cannulation and in 2.6% of patients after ultrasound-guided puncture of the femoral artery. Upon further analysis, we concluded that the likelihood of the development of pseudoaneurysm depends on the artery punctured in the groin. This risk increases dramatically for external iliac artery, superficial and deep femoral arteries. A simple means of prevention of this dangerous complication of femoral artery puncture is duplex ultrasound mapping of the groin arteries.

[Application of the percutaneuos thrombin injection in treatment of iatrogenic femoral pseudoaneurysms]. / Zastosowanie przezskórnego ostrzykiwania trombina w leczeniu jatrogennych tetniaków rzekomych tetnic udowych.

Pseudoaneurysms are not a common complication of the endovascular procedures but can present a serious therapeutic problem. Both, the application of compression therapy and surgical operation can lead to the development of subsequent complications. The aim of this study was analysis of the treatment results of iatrogenic pseudoaneurysms managed with percutaneous thrombin injection. Treated group consisted of 69 patients diagnosed with iatrogenic femoral pseudoaneurysms. The indication for injection technique was ineffective compression therapy as well as necrotic changes or bacterial skin infection in the groin area or a large diameter of pseudoanurysm's chambers. Thrombin was injected percutaneously during 1-3 sessions in the dose of 100-1200 U into the centre of the chamber under ultrasound control. Primary and secondary success rate was 88% and 94% respectively. The following factors significantly decreased effectiveness of the method: complex pseudoaneurysms (with treatment efficacy 82% and 88% respectively vs 90% and 96% for simple pseudoaneurysms), and large chamber volume. Early and late recanalization of the thrombotic changes appeared in 7% and 3% of treated cases. The most frequent complication was appearance of non-elastic tumor (71%) or pain (64%) in the groin area. The most serious complication was acute lower limb ischemia detected in one case (2%) as a result of femoral artery compression by the thrombosed pseudoaneurysm. Percutaneous thrombin injection should be a preferred method of pseudoaneurysms treatment, especially in cases of ineffective compression therapy or its contraindications due to low cost of the therapy, simplicity of the technique and relatively low percentage of the complications.

Current options in prosthetic vascular graft infection: comparative analysis of 63 consecutive cases.

PURPOSE: The study was conducted to compare the results of two different techniques of vascular reconstruction in patients after the removal of infected vascular prostheses. METHODS: Sixty-three patients with vascular prostheses infections underwent treatment. Either the infected fragments or the entire prosthesis was removed in all of the patients. Extra-anatomical grafts were implanted in 19 cases. Cryopreserved allogenic arterial grafts were applied for reconstruction in 44 patients. RESULTS: In a 19-patient group with extra-anatomical grafts, two patients died (10.5%). In seven patients (36.8%) relapse symptoms of infection appeared. Primary and secondary patencies of the grafts after 3 years were 31.6% and 52.6% respectively. In a group of 44 patients with allogenic grafts no recurrence of infection was observed. Six patients died (13.6%). Primary and secondary patencies after 3 years were 63.6% and 81.8% respectively. CONCLUSIONS: The results reveal the benefits of the allogenic arterial grafts in revascularization in patients with major vascular prostheses infections. The differences in secondary patencies of the implanted allogenic grafts indicate the necessity of an early selection of patients for the complete removal of the infected prosthesis, during a time when patients are in general good health.