Society for Vascular Surgery appropriate use criteria for management of intermittent claudication.

The Society for Vascular Surgery appropriate use criteria (AUC) for the management of intermittent claudication were created using the RAND appropriateness method, a validated and standardized method that combines the best available evidence from medical literature with expert opinion, using a modified Delphi process. These criteria serve as a framework on which individualized patient and clinician shared decision-making can grow. These criteria are not absolute. AUC should not be interpreted as a requirement to administer treatments rated as appropriate (benefit outweighs risk). Nor should AUC be interpreted as a prohibition of treatments rated as inappropriate (risk outweighs benefit). Clinical situations will occur in which moderating factors, not included in these AUC, will shift the appropriateness level of a treatment for an individual patient. Proper implementation of AUC requires a description of those moderating patient factors. For scenarios with an indeterminate rating, clinician judgement combined with the best available evidence should determine the treatment strategy. These scenarios require mechanisms to track the treatment decisions and outcomes. AUC should be revisited periodically to ensure that they remain relevant. The panelists rated 2280 unique scenarios for the treatment of intermittent claudication (IC) in the aortoiliac, common femoral, and femoropopliteal segments in the round 2 rating. Of these, only nine (0.4%) showed a disagreement using the interpercentile range adjusted for symmetry formula, indicating an exceptionally high degree of consensus among the panelists. Post hoc, the term "inappropriate" was replaced with the phrase "risk outweighs benefit." The term "appropriate" was also replaced with "benefit outweighs risk." The key principles for the management of IC reflected within these AUC are as follows. First, exercise therapy is the preferred initial management strategy for all patients with IC. Second, for patients who have not completed exercise therapy, invasive therapy might provide net a benefit for selected patients with IC who are nonsmokers, are taking optimal medical therapy, are considered to have a low physiologic and technical risk, and who are experiencing severe lifestyle limitations and/or a short walking distance. Third, considering the long-term durability of the currently available technology, invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitations and a short walking distance. Fourth, in the common femoral segment, open common femoral endarterectomy will provide greater net benefit than endovascular intervention for the treatment of IC. Finally, in the infrapopliteal segment, invasive intervention for the treatment of IC is of unclear benefit and could be harmful.

Clinical impact of sacroplasty on patient mobility.

PURPOSE: To evaluate the effect of sacroplasty on patient mobility and pain when performed as a treatment for sacral insufficiency fractures. MATERIALS AND METHODS: Imaging with computed tomography (CT), magnetic resonance imaging, or bone scan confirmed the diagnosis of sacral insufficiency fractures. Baseline clinical mobility scale (CMS) score and visual analog scale (VAS) pain score were recorded. Sacroplasty was performed under CT guidance. Follow-up CMS and VAS scores were assessed at 4, 24, and 48 weeks. RESULTS: Eighteen elderly patients (age 80 y ± 8.5; 17 women) were treated. Repeated-measures analysis of variance was conducted to assess changes in CMS and VAS scores over time. Pairwise comparisons revealed a significant increase in average CMS score between baseline and all three follow-up points-4 weeks (P < .001), 24 weeks (P < .001), and 48 weeks (P < .001)-indicating improvement in mobility over time. Pairwise comparisons revealed significant differences in mean VAS scores between baseline and all three follow-up time points-4 weeks (P < .001), 24 weeks (P < .001), and 48 weeks (P < .001)-indicating improvement in overall pain level over time. CONCLUSIONS: Treatment with CT-guided sacroplasty for sacral insufficiency fractures in this elderly population resulted in significant improvement in patient mobility.

Trends in Percutaneous Device Use for the Treatment of Venous Thromboembolism Over Time in the PINC AI Healthcare Database and the National Inpatient Sample.

The number of different methods of reperfusion therapy to treat venous thromboembolism (VTE) has increased substantially. Nevertheless, investigation of data representativeness and device-level use in administrative databases has been limited. Using the National Inpatient Sample (NIS) and the PINC AI Healthcare Database (PHD), all hospital encounters with a diagnosis code of VTE were identified between January 1, 2016 and December 31, 2020. Patient demographics and trends in treatment modalities were evaluated over time. An algorithm was developed to identify specific devices used for VTE treatment in the PHD cohort. A total of 145,870 patients with VTE treated with reperfusion therapy were identified in the NIS (pulmonary embolism [PE] 88,725, isolated deep vein thrombosis [iDVT] 57,145) and 39,311 in the PHD (PE 25,383, iDVT 13,928). Patient demographics were qualitatively similar in the NIS and PHD. Over time, there was a significant increase in the use of mechanical thrombectomy in the PE and iDVT populations (p <0.05 in both databases), with catheter-directed thrombolysis use plateauing in PE (p = 0.83 and p = 0.14 in NIS and PHD, respectively) and significantly decreasing for the iDVT population (p <0.05 in both databases). In the PHD cohort, specific reperfusion devices were identified in 14,105 patients (PE 9,098, iDVT 5,007). In conclusion, the use of mechanical thrombectomy for the treatment of VTE has increased over time, whereas the rates of catheter-directed thrombolysis therapy have remained stagnant or decreased. Further research is needed to understand the uptake of these treatment modalities and the unique abilities of the PHD to study specific device therapy in the VTE population.

Noninvasive Arterial Testing: What and When to Use.

Peripheral arterial disease (PAD) represents a growing public health issue that continues to be underdiagnosed. In its most severe form, critical limb ischemia, it contributes to expanding morbidity with minor and major limb amputations. PAD is strongly associated with increased mortality, as it is known to be concomitant with coronary and cerebrovascular disease. Diagnosis of PAD relies on noninvasive arterial testing, a class of tests that can provide physiologic or morphologic information. Physiologic tests such as ankle-brachial index, toe-brachial index, pulse volume recordings, and arterial duplex evaluation are the mainstay of gateway evaluation and surveillance. Morphologic exams such as computer tomographic angiography and magnetic resonance angiography are appropriate for preprocedural anatomic evaluation in patients with established vascular disease. This review focuses on physiologic exams.

Peripheral Atherectomy: Applications and Techniques.

Peripheral atherectomy is a class of procedures that is rapidly increasing in volume. Multiple classes of devices exist, and newer variants are added to the market annually. The devices see wide application for de novo lesions, in-stent restenosis, and adjunctive therapy for drug-coated balloons. The body of evidence supporting atherectomy is less robust than for many other peripheral therapies. The frequency and severity of complications from atherectomy can be significant compared with angioplasty and stenting, and familiarity with preventative and bailout techniques is essential for the interventionalist.

Phylogenetic relationships of methionine aminopeptidase 2 among Encephalitozoon species and genotypes of microsporidia.

This report describes the characterization and phylogenetic analysis of the deduced amino acid sequences of methionine aminopeptidase 2 (MetAP-2) enzymes from microsporidian species and genotypes of the genus Encephalitozoon. Fragments of DNA encoding 318 to 335 amino acid residues of the MetAP-2 genes were isolated from genomic DNA prepared from cultured spores of Encephalitozoon hellem, Encephalitozoon intestinalis, and Encephalitozoon cuniculi genotypes I-III. Sequence comparisons of the deduced amino acid residues indicated that the microsporidian sequences are MetAP-2-like rather than MetAP-1-like. Alignments demonstrated that the new Encephalitozoon sequences included sequences and structures conserved in eukaryotic MetAP-2s, including the five conserved, active site residues, Asp, Asp, His, Glu, and His, considered to be critical for catalysis and for coordinating the cation (e.g., cobalt) co-factor, and included residues known to interact with the antibiotic, fumagillin. The primary structure of the Encephalitozoon MetAP-2s, however, showed some dissimilarity with human and yeast MetAP-2s, including the absence of the NH2-terminal polylysine tract. Phylogenetic comparison of these Encephalitozoon MetAP-2s with orthologues from related species and from other informative taxa confirmed that the MetAP-2s of these Encephalitozoon species and strains are closely related to each other and cluster with MetAP-2s.

Antimicrosporidial activity of (fluoro)quinolones in vitro and in vivo.

Microsporidia are a cause of emerging and opportunistic infections in humans and animals. Although two drugs are currently being used to treat microsporidiosis, concerns exist that albendazole is only selective for inhibiting some species of microsporidia that infect mammals, and fumagillin appears to have been found to be toxic. During a limited sequence survey of the Vittaforma corneae genome, a partial gene encoding for the ParC topoisomerase IV subunit was identified. The purpose of this set of studies was to determine if fluoroquinolones, which target topoisomerase IV, exert activity against Encephalitozoon intestinalis and V. corneae in vitro, and whether these compounds could prolong survival of V. corneae-infected athymic mice. Fifteen fluoroquinolones were tested. Of these, norfloxacin and ofloxacin inhibited E. intestinalis replication by more than 70% compared with non-treated control cultures, while gatifloxacin, lomefloxacin, moxifloxacin, and nalidixic acid (sodium salt) inhibited both E. intestinalis and V. corneae by at least 60% at concentrations not toxic to the host cells. These drugs were tested in vivo also, where gatifloxacin, lomefloxacin, norfloxacin, and ofloxacin prolonged survival of V. corneae-infected athymic mice (P < 0.05), whereas moxifloxacin and nalidixic acid failed to prolong survival. Therefore, these results support continued studies for evaluating the efficacy of the fluoroquinolones for treating microsporidiosis and for characterizing the target(s) of these fluoroquinolones in the microsporidia.

Retrograde Tibiopedal Access for the Treatment of Critical Limb Ischemia.

Critical limb ischemia (CLI) is associated with high rates of morbidity and mortality. Many patients with CLI are poor surgical candidates. Endovascular therapy has been shown to be an effective technique to improve arterial perfusion for patients with CLI. In patients with isolated infrapopliteal occlusive disease, endovascular therapy may be more effective than conventional bypass surgery. When antegrade endovascular revascularization fails, an understanding of tibiopedal access and retrograde crossing techniques is essential to re-establish flow to aid in tissue healing, provide symptomatic relief, and avoid amputation.

Renal cell carcinoma initially presenting as an arteriovenous malformation: a case presentation and a review of the literature.

We describe a case of a patient who presented with hematuria and was diagnosed with a renal arteriovenous malformation (AVM). Transcatheter arterial embolization subsequently was performed on this lesion multiple times. Follow-up imaging demonstrated that the AVM was masking an underlying, rapidly growing renal cell carcinoma (RCC). We describe the pathological and radiographic characteristics of AVMs and RCC. We describe the strengths and weaknesses of computed tomography (CT) and magnetic resonance imaging (MRI) to detect and characterize RCC and AVM. We recommend initial and follow-up MR imaging in patients with an AVM to establish a baseline, monitor treatment response, and survey lesions for underlying and obscured malignancy.

Asymptomatic isolated celiac artery dissection after a fall.

Isolated injury to mesenteric vessels in blunt trauma is uncommon. Most patients with these injuries present with abdominal pain, shock, or laboratory evidence of bowel and/or liver ischemia. We report herein the case of a man with asymptomatic isolated celiac artery dissection after blunt trauma suspected by screening abdominal computed tomography and confirmed by catheter-based angiography. The patient was treated with 3 months of oral anticoagulation alone.

Percutaneous thrombin injection of a femoral artery pseudoaneurysm with simultaneous venous balloon occlusion of a communicating arteriovenous fistula.

An 82-year-old woman developed acute occlusion of her right coronary artery. She underwent percutaneous coronary stent placement and aortic balloon pump installation. In the postprocedural period, she developed a common femoral artery pseudoaneurysm (PSA) that communicated with the common femoral vein via an arteriovenous fistula (AVF). After unsuccessful ultrasound-guided compression, ultrasound-guided thrombin injection of the PSA was performed, with simultaneous balloon occlusion of the common femoral vein at the level of the AVF. There was complete thrombosis of the PSA and AVF.

Retrograde cannulation of the thoracic duct and embolization of the cisterna chyli in the treatment of chylous ascites.

The authors offer a previously undescribed technique for cisterna chyli embolization in the treatment of chylous ascites. After the failure of conventional percutaneous direct cisterna chyli cannulation, the authors accessed the thoracic duct directly from the subclavian vein. Retrograde microcatheter access through the thoracic duct enabled embolization of the cisterna chyli. Embolization materials included fibered endovascular coils, gelatin sponge, and doxycycline. The patient's symptoms returned 10 days after embolization. This technique provided short-term success in the treatment of the patient's chylous ascites.

Sequence survey of the genome of the opportunistic microsporidian pathogen, Vittaforma corneae.

The microsporidian Vittaforma corneae has been reported as a pathogen of the human stratum corneum, where it can cause keratitis, and is associated with systemic infections. In addition to this direct role as an infectious, etiologic agent of human disease, V. corneae has been used as a model organism for another microsporidian, Enterocytozoon bieneusi, a frequent and problematic pathogen of HIV-infected patients that, unlike V. corneae, is difficult to maintain and to study in vitro. Unfortunately, few molecular sequences are available for V. corneae. In this study, seventy-four genome survey sequences (GSS) were obtained from genomic DNA of spores of laboratory-cultured V. corneae. Approximately, 41 discontinuous kilobases of V. corneae were cloned and sequenced to generate these GSS. Putative identities were assigned to 44 of the V. corneae GSS based on BLASTX searches, representing 21 discrete proteins. Of these 21 deduced V. corneae proteins, only two had been reported previously from other microsporidia (until the recent report of the Encephalitozoon cuniculi genome). Two of the V. corneae proteins were of particular interest, reverse transcriptase and topoisomerase IV (parC). Since the existence of transposable elements in microsporidia is controversial, the presence of reverse transcriptase in V. corneae will contribute to resolution of this debate. The presence of topoisomerase IV was remarkable because this enzyme previously had been identified only from prokaryotes. The 74 GSS included 26.7 kilobases of unique sequences from which two statistics were generated: GC content and codon usage. The GC content of the unique GSS was 42%, lower than that of another microsporidian, E. cuniculi (48% for protein-encoding regions), and substantially higher than that predicted for a third microsporidian, Spraguea lophii (28%). A comparison using the Pearson correlation coefficient showed that codon usage in V. corneae was similar to that in the yeasts, Saccharomyces cerevisiae (r = 0.79) and Shizosaccharomyces pombe (r = 0.70), but was markedly dissimilar to E. cuniculi (r = 0.19).