The Importance of Patency in Patients with Critical Limb Ischemia Undergoing Endovascular Revascularization for Infrapopliteal Arterial Disease.

Critical limb ischemia (CLI) represents the most severe form of peripheral arterial disease (PAD) and frequently occurs in medically frail patients. CLI patients frequently exhibit multi-segmental PAD commonly including the tibial arterial segment. Endovascular therapy has been established as first-line revascularization strategy for most CLI patients. Restenosis was reported to occur in up to more than two-thirds of CLI patients undergoing angioplasty of complex tibial arterial obstructions. Nevertheless, favorable clinical outcomes were observed for infrapopliteal angioplasty when compared with bypass surgery, despite higher patency rates for the latter. Based on these observations, infrapopliteal patency was considered to be only of secondary importance upon clinical outcomes in CLI patients. In contrast to these earlier observations, however, recent findings from two randomized clinical trials indicate that infrapopliteal patency does impact on clinical outcomes in CLI patients. The purpose of the present manuscript is to provide a critical reappraisal of the present literature on the clinical importance of tibial arterial patency in CLI patients undergoing endovascular revascularization and to discuss utility and limitations of currently available anti-restenosis technologies.

Sensitivity and specificity of fluorescence microlymphography for detecting lymphedema of the lower extremity.

Fluorescence microlymphography (FML) is used to visualize the lymphatic capillaries. A maximum spread of the fluorescence dye of ≥ 12 mm has been suggested for the diagnosis of lymphedema. However, data on sensitivity and specificity are lacking. The aim of this study was to investigate the accuracy of FML for diagnosing lymphedema in patients with leg swelling. Patients with lower extremity swelling were clinically assessed and separated into lymphedema and non-lymphatic edema groups. FML was studied in all affected legs and the maximum spread of lymphatic capillaries was measured. Test accuracy and receiver operator characteristic (ROC) analysis was performed to assess possible threshold values that predict lymphedema. Between March 2008 and August 2011 a total of 171 patients (184 legs) with a median age of 43.5 (IQR 24, 54) years were assessed. Of those, 94 (51.1%) legs were diagnosed with lymphedema. The sensitivity, specificity, positive and negative likelihood ratio and positive and negative predictive value were 87%, 64%, 2.45, 0.20, 72% and 83% for the 12-mm cut-off level and 79%, 83%, 4.72, 0.26, 83% and 79% for the 14-mm cut-off level, respectively. The area under the ROC curve was 0.82 (95% CI: 0.76, 0.88). Sensitivity was higher in the secondary versus primary lymphedema (95.0% vs 74.3%, p = 0.045). No major adverse events were observed. In conclusion, FML is a simple and safe technique for detecting lymphedema in patients with leg swelling. A cut-off level of ≥ 14-mm maximum spread has a high sensitivity and high specificity of detecting lymphedema and should be chosen.

Pulmonary embolism in young males and females in Germany: data from the Federal Statistical Office.

With the introduction of diagnosis-related groups (DRG) for reimbursement in 2003, detailed description of the prevalence of pulmonary embolism in hospitalized patients in Germany was possible for the first time. Thus, we analysed the incidence of pulmonary embolism in hospitalized young people and looked for a sex-specific difference in comorbidity. Detailed lists of all pulmonary embolism coded as I26 in hospitalized patients aged 10-40 years in 2005, 2006 and 2007 were provided by the Federal Statistical Office. Beginning at the age of 12-13 years females have higher numbers of pulmonary embolism and DVT documented as principal diagnosis compared with men. This sex-specific difference disappears at the ages of 32-33 years. The total numbers of pulmonary embolism distinguishing males and females within this 20 years life period is low and varied from 318-463 in the 3 years. The sex-specific difference is highest in the group of 16 to 17-year-old people (ratio of females to males varies from 3 to 5 in 2005-2007). Specific patterns of comorbidities associated with the higher numbers of pulmonary embolism in younger females could not be detected. Pregnancies account for a maximum of 73 in 2007, which reached only less than one-fifth of the absolute difference in pulmonary embolism between males and females in the single years. The presented data derived from the most reliable data basis for the estimation of pulmonary embolism in Germany show that compared with males there is a sharp increase in hospitalization for pulmonary embolism in females beginning at the age of 12-13 years. Males catch up by the ages of 32-33 year.

Carotid plaques and their predictive value for cardiovascular disease and all-cause mortality in hemodialysis patients considering renal transplantation: a decade follow-up.

BACKGROUND: Carotid plaque formation is very common in dialysis patients. The prognostic value of plaques, both calcified and noncalcified, rarely was investigated prospectively in these patients. By using a carotid plaque score, this study aims to determine the risk for combined cardiovascular disease (CVD) events and all-cause mortality in 165 hemodialysis patients in a long-term follow-up considering phases of renal transplantation. METHODS: Baseline carotid ultrasonography was performed in 165 hemodialysis patients to screen for carotid plaques. Patients subsequently were followed up for a period up to 13 years (average, 86 months). Because of biases associated with renal transplantation, 3 methods of multivariate analysis were compared by using Cox proportional hazards regression models. RESULTS: Plaques were present in 107 of 165 patients (65%). During the observation period, 50 patients (30%) experienced a combined CVD event, 95 patients (58%) died, and 79 patients (48%) underwent at least 1 renal transplantation. Mean plaque score differed significantly between patients who reached an end point and those who did not (CVD events, 3.1 +/- 2.7 versus 2.0 +/- 2.4; P = 0.01; all-cause mortality, 3.5 +/- 2.6 versus 0.9 +/- 1.3; P < 0.001). Plaque score entered all 3 tested Cox regression models for CVD events and all-cause mortality. The lowest statistical power was associated with censoring at the time of renal transplantation. Not considering transplantation at all neglected a major change in risk. CONCLUSION: We identified carotid plaque score and treatment modality as highly significant predictors for CVD events and all-cause mortality.