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1.
J Vasc Surg ; 2024 Jul 26.
Article in English | MEDLINE | ID: mdl-39069016

ABSTRACT

OBJECTIVE: Sustained clinical and hemodynamic benefit after revascularization for chronic limb-threatening ischemia (CLTI) is needed to resolve symptoms and prevent limb loss. We sought to compare rates of clinical and hemodynamic failure as well as resolution of initial and prevention of recurrent CLTI after endovascular (ENDO) vs bypass (OPEN) revascularization in the Best-Endovascular-versus-best-Surgical-Therapy-in-patients-with-CLTI (BEST-CLI) trial. METHODS: As planned secondary analyses of the BEST-CLI trial, we examined the rates of (1) clinical failure (a composite of all-cause death, above-ankle amputation, major reintervention, and degradation of WIfI stage); (2) hemodynamic failure (a composite of above-ankle amputation, major and minor reintervention to maintain index limb patency, failure to an initial increase or a subsequent decrease in ankle brachial index of 0.15 or toe brachial index of 0.10, and radiographic evidence of treatment stenosis or occlusion); (3) time to resolution of presenting CLTI symptoms; and (4) incidence of recurrent CLTI. Time-to-event analyses were performed by intention-to-treat assignment in both trial cohorts (cohort 1: suitable single segment great saphenous vein [SSGSV], N = 1434; cohort 2: lacking suitable SSGSV, N = 396), and multivariate stratified Cox regression models were created. RESULTS: In cohort 1, there was a significant difference in time to clinical failure (log-rank P < .001), hemodynamic failure (log-rank P < .001), and resolution of presenting symptoms (log-rank P = .009) in favor of OPEN. In cohort 2, there was a significantly lower rate of hemodynamic failure (log-rank P = .006) favoring OPEN, and no significant difference in time to clinical failure or resolution of presenting symptoms. Multivariate analysis revealed that assignment to OPEN was associated with a significantly lower risk of clinical and hemodynamic failure in both cohorts and a significantly higher likelihood of resolving initial and preventing recurrent CLTI symptoms in cohort 1, including after adjustment for key baseline patient covariates (end-stage renal disease [ESRD], prior revascularization, smoking, diabetes, age >80 years, WIfI stage, tissue loss, and infrapopliteal disease). Factors independently associated with clinical failure included age >80 years in cohort 1 and ESRD across both cohorts. ESRD was associated with hemodynamic failure in cohort 1. Factors associated with slower resolution of presenting symptoms included diabetes in cohort 1 and WIfI stage in cohort 2. CONCLUSIONS: Durable clinical and hemodynamic benefit after revascularization for CLTI is important to avoid persistent and recurrent CLTI, reinterventions, and limb loss. When compared with ENDO, initial treatment with OPEN surgical bypass, particularly with available saphenous vein, is associated with improved clinical and hemodynamic outcomes and enhanced resolution of CLTI symptoms.

2.
J Vasc Surg ; 78(3): 711-718.e5, 2023 09.
Article in English | MEDLINE | ID: mdl-37201761

ABSTRACT

OBJECTIVES: The use of optimal medical therapy (OMT) in patients with chronic limb-threatening ischemia (CLTI) has not been well-studied. The Best Endovascular vs Best Surgical Therapy in Patients with CLTI study (BEST-CLI) is a multicenter, randomized, controlled trial sponsored by the National Institutes of Health comparing revascularization strategies in patients with CLTI. We evaluated the use of guideline-based OMT among patients with CLTI at the time of their enrollment into the trial. METHODS: A multidisciplinary committee defined OMT criteria related to blood pressure and diabetic management, lipid-lowering and antiplatelet medication use, and smoking status for patients enrolled in BEST-CLI. Status reports indicating adherence to OMT were provided to participating sites at regular intervals. Baseline demographic characteristics, comorbid medical conditions, and use of OMT at trial entry were evaluated for all randomized patients. A linear regression model was used to identify the relationship of predictors to the use of OMT. RESULTS: At the time of randomization (n = 1830 total enrolled), 87% of patients in BEST-CLI had hypertension, 69% had diabetes, 73% had hyperlipidemia, and 35% were currently smoking. Adherence to four OMT components (controlled blood pressure, not currently smoking, use of one lipid-lowering medication, and use of an antiplatelet agent) was modest. Only 25% of patients met all four OMT criteria; 38% met three, 24% met two, 11% met only one, and 2% met none. Age ≥80 years, coronary artery disease, diabetes, and Hispanic ethnicity were positively associated, whereas Black race was negatively associated, with the use of OMT. CONCLUSIONS: A significant proportion of patients in BEST-CLI did not meet OMT guideline-based recommendations at time of entry. These data suggest a persistent major gap in the medical management of patients with advanced peripheral atherosclerosis and CLTI. Changes in OMT adherence over the course of the trial and their impact on clinical outcomes and quality of life will be assessed in future analyses.


Subject(s)
Endovascular Procedures , Peripheral Arterial Disease , Humans , Aged, 80 and over , Peripheral Arterial Disease/diagnosis , Peripheral Arterial Disease/therapy , Quality of Life , Treatment Outcome , Ischemia , Lipids , Risk Factors , Limb Salvage , Endovascular Procedures/adverse effects
3.
Cardiovasc Revasc Med ; 55: 1-5, 2023 10.
Article in English | MEDLINE | ID: mdl-37142533

ABSTRACT

OBJECTIVE: To test the hypothesis that in patients with peripheral arterial disease (PAD) and claudication, treated with maximal tolerated statin therapy, the addition of a monthly subcutaneous injection of evolocumab for 6 months improves treadmill walking performance. BACKGROUND: Lipid lowering therapy improves walking parameters in patients with PAD and claudication. Evolocumab decreases cardiac and limb adverse events in patients with PAD; however, the effect of evolocumab on walking performance is not known. METHODS: We performed a double-blind, randomized, placebo-controlled study to compare maximal walking time (MWT) and pain free walking time (PFWT) in patients with PAD and claudication treated with monthly subcutaneous injections of evolocumab 420 mg (n = 35) or placebo (n = 35). We also performed measurements of lower limb perfusion, brachial flow mediated dilatation (FMD), carotid intima media thickness (IMT), and serum biomarkers of PAD disease severity. RESULTS: After six-months of treatment with evolocumab MWT increased by 37.7 % (87.5 ± 24 s) compared to 1.4 % (-21.7 ± 22.9 s) in the placebo group, p = 0.01. PFWT increased by 55.3 % (67.3 ± 21.2 s) in the evolocumab group compared to 20.3 % (8.5 ± 20.3 s) in the placebo group, p = 0.051. There was no difference in lower extremity arterial perfusion measurements. FMD increased by 42.0 ± 73.9 % (1.01 ± 0.7 %) in the evolocumab group and decreased by 16.29 ± 20.06 % (0.99 ± 0.68 %) in the placebo group (p < 0.001). IMT decreased by 7.16 ± 4.6 % (0.06 ± 0.04 mm) in the evolocumab group and increased by 6.68 ± 4.9 % (0.05 ± 0.03 mm) in the placebo group, (p < 0.001). CONCLUSIONS: The addition of evolocumab to maximal tolerated statin therapy improves maximal walking time in patients with PAD and claudication, increases FMD, and decreases IMT. CONDENSED ABSTRACT: Peripheral arterial disease (PAD) impairs quality of life by causing lower extremity intermittent claudication, rest pain, or amputation. Evolocumab is a monthly injectable monoclonal antibody medication that reduces cholesterol. In this study, we randomly treated patients with PAD and claudication, and on background statin therapy, with evolocumab or placebo, and found that evolocumab improves walking performance on a treadmill test by increasing maximal walking time. We also found that evolocumab decreases plasma MRP-14 levels, a marker of PAD severity.


Subject(s)
Hydroxymethylglutaryl-CoA Reductase Inhibitors , Peripheral Arterial Disease , Humans , Carotid Intima-Media Thickness , Hydroxymethylglutaryl-CoA Reductase Inhibitors/adverse effects , Intermittent Claudication/diagnosis , Intermittent Claudication/drug therapy , Peripheral Arterial Disease/diagnosis , Peripheral Arterial Disease/drug therapy , Quality of Life , Walking , Double-Blind Method
4.
J Vasc Surg ; 77(4): 1099-1106.e4, 2023 04.
Article in English | MEDLINE | ID: mdl-36435274

ABSTRACT

OBJECTIVE: The WIfI (Wound, Ischemia, foot Infection) stage measures the extent of wounds, ischemia, and foot infection in patients with chronic limb threatening ischemia (CLTI) and has been associated with the risk of major amputation. Patients with CLTI have impaired health-related quality of life (HRQoL), which can be multifactorial. We hypothesized that the severity of the limb threat (WIfI stage) would be associated with poor HRQoL among patients with CLTI presenting for revascularization. METHODS: The dataset of the BEST-CLI (best endovascular versus best surgical therapy in patients with CLTI) trial, a prospective, randomized trial comparing open and endovascular revascularization strategies, was queried for HRQoL assessments at patient enrollment. The HRQoL assessments included (1) Vascular Quality of Life; (2) 12-item short form survey (SF-12), containing the utility index score (short-form six-dimension R2 utility index, incorporating physical, emotional, and mental well-being) and mental and physical components; and (3) the EQ-5D. Multivariable regression analysis was used to identify the independent associations with the baseline HRQoL assessments. RESULTS: A total of 1568 patients with complete WIfI data were analyzed, of whom 71.5% were men. The WIfI distribution was 35.5% with stage 4, 29.6% with stage 3, 28.6% with stage 2, and 6.3% with stage 1. Patients presenting with WIfI stage 4, compared with stage 1 to 3, were more often men (74.9% vs 69.6%) and current smokers (25.4% vs. 17.6%), had had end-stage renal disease (13.3% vs 8.5%) and diabetes (83.6% vs 60.2%), were not independently ambulatory (56.8% vs 38.5%), and had had higher median morbidity scores (4 vs 3; P < .05 for all). On multivariable analysis, WIfI stage 4, compared with stage 1 to 3, was associated with lower SF-12 mental component scale scores (estimate, -2.43; 95% confidence interval, -3.73 to -1.13; P < .001) and short-form six-dimension R2 utility index scores (estimate, -0.02; 95% confidence interval, -0.03 to 0.001; P = .04). The WIfI stage was not independently associated with the baseline Vascular Quality of Life, SF-12 physical component scale, or EQ-5D assessments. CONCLUSIONS: WIfI stage was independently associated with poorer quality of life because of mental, rather than physical, health for patients with CLTI. Clinicians should be aware of the burden of mental stress borne by those with the greatest limb impairment.


Subject(s)
Endovascular Procedures , Peripheral Arterial Disease , Male , Humans , Female , Limb Salvage/methods , Quality of Life , Risk Factors , Prospective Studies , Treatment Outcome , Peripheral Arterial Disease/diagnosis , Peripheral Arterial Disease/surgery , Ischemia/diagnosis , Ischemia/surgery , Chronic Limb-Threatening Ischemia , Retrospective Studies , Endovascular Procedures/adverse effects
5.
Food Technol Biotechnol ; 61(4): 430-438, 2023 Dec.
Article in English | MEDLINE | ID: mdl-38205048

ABSTRACT

Research background: Wine production, which is considered a major sector in food industry, often involves the use of a large amount of resources. Moreover, wine making generates a large amount of grape pomace, which is generally used for low-value applications such as fertiliser and animal feed. The aim of the present research is to explore the possibility of improving the overall sustainability of traditional winemaking. Experimental approach: A zero-waste process was developed. It includes the production of white wine and the substantial valorisation of grape pomace, which is converted into solid biofuel, tartaric acid and concentrated grape extract as feedstock for industrial baker's yeast production. Results and conclusions: We estimate that a significant surplus of renewable energy of approx. 3 MJ/kg processed grapes can be obtained during this conversion. The suitability of grape extract as a potential substrate for industrial baker's yeast production was evaluated and the feasibility of a partial replacement of molasses (up to 30 %) was demonstrated. Novelty and scientific contribution: We present a circular economy approach for the conversion of winery biowaste into high-value resources such as feedstock and solid biofuel.

6.
Article in English | LILACS-Express | LILACS | ID: biblio-1537051

ABSTRACT

In the last 30 years soils decreased 73 % of their productive capacity in the world. One of the main reasons for this decrease has been the politics implemented, as well as the absence of opportunity for the small producer to implement improvement strategies that can increase their productivity in the field. Therefore, in this research a soil measurement system is proposed for small farmers, based on the design of two sensors of low cost: (i) Apparent electrical conductivity (ECa) sensor and (ii) moisture sensor. These measurement variables have the particularity that their characteristics can be associated with the physical properties of the soil for decision-making. The sensors developed in this work employ two techniques: Wenner's method for ECa and electrical impedance measurement to identify the dielectric permittivity associated with the water content of the soil. The system is controlled by the Raspberry Pi 3 board through developed software that allows correlating data with its geolocation. The device was tested in controlled laboratory measurements with calibrated instruments, obtaining a coefficient of . Finally, on-site tests were made to validate their use for small farmers.


Durante los últimos 30 años, los suelos han disminuido un 73 % su capacidad productiva, a nivel mundial. Una de las principales razones para esta cifra a la baja son las políticas implementadas, así como la falta de oportunidad para que el pequeño productor adopte estrategias de mejora, con lo cual, pueda aumentar la productividad. Por lo anterior, en esta investigación, se propone un sistema de medición de suelo para pequeños productores, a partir del diseño de dos sensores de bajo costo: (i) sensor de conductividad eléctrica aparente (CEa) y (ii) sensor de humedad. Estas variables de medición tienen la particularidad que sus características se pueden asociar a las propiedades físicas del suelo, para tomar decisiones. Los sensores desarrollados en este trabajo usan dos técnicas: el método de Wenner, para la CEa y la medición de impedancia eléctrica, para identificar la permitividad dieléctrica asociada con el contenido de agua del suelo. El sistema es controlado mediante la tarjeta Raspberry Pi 3, a través de un software desarrollado, que permite correlacionar los datos con su geolocalización. El dispositivo, se probó en mediciones controladas en laboratorio, con instrumentos calibrados, obteniendo un coeficiente . Finalmente, se hicieron pruebas in situ, con el fin de validar su uso por pequeños agricultores.

7.
N Engl J Med ; 387(25): 2305-2316, 2022 12 22.
Article in English | MEDLINE | ID: mdl-36342173

ABSTRACT

BACKGROUND: Patients with chronic limb-threatening ischemia (CLTI) require revascularization to improve limb perfusion and thereby limit the risk of amputation. It is uncertain whether an initial strategy of endovascular therapy or surgical revascularization for CLTI is superior for improving limb outcomes. METHODS: In this international, randomized trial, we enrolled 1830 patients with CLTI and infrainguinal peripheral artery disease in two parallel-cohort trials. Patients who had a single segment of great saphenous vein that could be used for surgery were assigned to cohort 1. Patients who needed an alternative bypass conduit were assigned to cohort 2. The primary outcome was a composite of a major adverse limb event - which was defined as amputation above the ankle or a major limb reintervention (a new bypass graft or graft revision, thrombectomy, or thrombolysis) - or death from any cause. RESULTS: In cohort 1, after a median follow-up of 2.7 years, a primary-outcome event occurred in 302 of 709 patients (42.6%) in the surgical group and in 408 of 711 patients (57.4%) in the endovascular group (hazard ratio, 0.68; 95% confidence interval [CI], 0.59 to 0.79; P<0.001). In cohort 2, a primary-outcome event occurred in 83 of 194 patients (42.8%) in the surgical group and in 95 of 199 patients (47.7%) in the endovascular group (hazard ratio, 0.79; 95% CI, 0.58 to 1.06; P = 0.12) after a median follow-up of 1.6 years. The incidence of adverse events was similar in the two groups in the two cohorts. CONCLUSIONS: Among patients with CLTI who had an adequate great saphenous vein for surgical revascularization (cohort 1), the incidence of a major adverse limb event or death was significantly lower in the surgical group than in the endovascular group. Among the patients who lacked an adequate saphenous vein conduit (cohort 2), the outcomes in the two groups were similar. (Funded by the National Heart, Lung, and Blood Institute; BEST-CLI ClinicalTrials.gov number, NCT02060630.).


Subject(s)
Chronic Limb-Threatening Ischemia , Limb Salvage , Vascular Surgical Procedures , Humans , Chronic Limb-Threatening Ischemia/surgery , Chronic Limb-Threatening Ischemia/therapy , Endovascular Procedures/adverse effects , Endovascular Procedures/methods , Limb Salvage/adverse effects , Limb Salvage/methods , Retrospective Studies , Risk Factors , Treatment Outcome , Vascular Surgical Procedures/adverse effects , Vascular Surgical Procedures/methods , Saphenous Vein/transplantation
8.
J Med Eng Technol ; 46(3): 179-197, 2022 Apr.
Article in English | MEDLINE | ID: mdl-35172686

ABSTRACT

There is a lack of medical simulation tools that can be understood and used, at the same time, by researchers, teachers, clinicians and students. Regarding this issue, in this work we report a virtual simulator (developed in OpenModelica) that allow to experiment with the fundamental variables of the cardiovascular and respiratory system of a neonate. We extended a long-tested lumped parameter model that represents the cardiovascular and respiratory physiology of a neonate. From this model, we implemented a physiological simulator using Modelica. The fidelity and versatility of the reported simulator were evaluated by simulating seven physiological scenarios: two of them representing a healthy infant (newborn and 6-months old) and five representing newborns affected by different heart diseases. The simulator properly and consistently represented the quantitative and qualitative behaviour of the seven physiological scenarios when compared with existing clinical data. Results allow us to consider the simulator reported here as a reliable tool for researching, training and learning. The advanced modelling features of Modelica and the friendly graphical user interface of OpenModelica make the simulator suitable to be used by a broad community of users. Furthermore, it can be easily extended to simulate many clinical scenarios.


Subject(s)
Lung , Respiratory Physiological Phenomena , Computer Simulation , Humans , Infant , Infant, Newborn , User-Computer Interface
9.
BMC Pulm Med ; 21(1): 77, 2021 Mar 05.
Article in English | MEDLINE | ID: mdl-33663424

ABSTRACT

BACKGROUND: The purpose of this study was to assess the safety and efficacy of percutaneous transcatheter embolization (TCE) for the treatment of pulmonary arteriovenous malformations (PAVMs). METHODS: Forty-three consecutive patients (n = 17 males; n = 26 females) with 72 untreated PAVMs underwent coil and/or plug embolization between January 2010 and February 2018. The mean patient age was 42 ± 14 years (range 19-71 years). The median size of the feeding artery was 7.9 ± 2.9 mm (range 3.5-14.0 mm). The arterial blood gas level and cardiac function of all patients were analysed. The technical success rate, recanalization rate, and complications were evaluated. Computed tomography angiography (CTA) examinations were scheduled for 12 months after treatment and every 2-4 years thereafter. RESULTS: Twenty-five PAVMs were treated with coils alone, twenty-one were treated with plugs alone, and twenty-six were treated with both coils and plugs. The technical success rate was 100%. There were no complications during operation. However, one patient (2.3%) had pulmonary thrombosis and embolism post-operation. The patients' pre-operative and post-operative PaO2 and SaO2 levels were significantly different (p < 0.01). A comparison of the New York Heart Association (NYHA) grade before and after embolization in all patients showed a significant decrease in the post-operative grade (p < 0.01). The 72 PAVMs were divided into three groups (coils only group [n = 25], plugs only group [n = 21], and coils/plugs combined group [n = 26]). After 12 months of follow-up, there were seven reperfusion PAVMs in the coil group, seven reperfusion PAVMs in the plug group, and 1 reperfusion PAVM in the combined group. There were significant differences between the two groups and the combined group. CONCLUSION: Percutaneous TCE is safe and effective for the treatment of PAVMs. A combination of coils and vascular plugs may be useful for preventing recanalization after the embolization of PAVMs.


Subject(s)
Arteriovenous Malformations/complications , Arteriovenous Malformations/therapy , Blood Vessel Prosthesis , Embolization, Therapeutic/methods , Adult , Aged , Arteriovenous Malformations/diagnostic imaging , Computed Tomography Angiography , Female , Humans , Male , Middle Aged , Pulmonary Artery/abnormalities , Pulmonary Artery/diagnostic imaging , Pulmonary Veins/abnormalities , Pulmonary Veins/diagnostic imaging , Retrospective Studies , Treatment Outcome , Young Adult
10.
Cardiovasc Revasc Med ; 21(12): 1489-1492, 2020 12.
Article in English | MEDLINE | ID: mdl-32448777

ABSTRACT

BACKGROUND: Drug eluting stents (DES) are used in the majority of patients undergoing percutaneous coronary intervention (PCI). Factors associated with the use of bare metal stents (BMS) for patients undergoing primary PCI for ST elevation myocardial infarction (STEMI) have not been adequately explored. The objective of this study was to evaluate factors associated with BMS use in STEMI patients undergoing primary PCI. METHODS: Patients undergoing primary PCI for STEMI between January 2008 and February 2015 were retrospectively identified. Patients who received both a DES and BMS were included in the DES group and patients receiving balloon angioplasty only were excluded. Baseline demographics, angiographic variables, procedure related variables and in-hospital events were collected. Multivariate analysis was performed to identify factors associated with BMS use. RESULTS: Eight hundred and sixty-five patients underwent primary PCI for STEMI during the study period. Seventy-two patients (8.3%) received balloon angioplasty only and were excluded, yielding 793 patients for the study cohort. Three hundred fifty-two patients (44%) received BMS and 441 patients (56%) received DES. Patients receiving DES had a higher prevalence of diabetes mellitus, prior myocardial infarction, prior PCI, left anterior descending artery culprit location and Medicaid Insurance compared to those receiving BMS. Patients receiving BMS had a higher prevalence of cardiogenic shock and right coronary artery culprit location. Unadjusted in-hospital mortality was significantly higher for patients receiving BMS compared to patients receiving DES, 11.1% vs 3.2%, respectively, p < 0.0001. Multivariate predictors of BMS use were cardiogenic shock (OR 30.3; 95% CI 11.25 to 81.73) and diabetes mellitus (OR 2.99; 95% CI 1.04 to 8.64). CONCLUSION: In a contemporary series of patients undergoing primary PCI for STEMI, BMS were used in 44% of patients and independent factors associated with BMS use were cardiogenic shock and diabetes mellitus.


Subject(s)
Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction , Drug-Eluting Stents , Humans , Retrospective Studies , Treatment Outcome
11.
Ann Vasc Surg ; 66: 614-620, 2020 Jul.
Article in English | MEDLINE | ID: mdl-32027986

ABSTRACT

BACKGROUND: Management of patients with chronic limb-threatening ischemia (CLTI) and extensive foot necrosis presents a challenge for limb salvage. Our study evaluates preoperative risk factors that contributed to durability and efficacy of limb salvage after open transmetatarsal amputation (TMA) in patients with critical limb-threatening ischemia. METHODS: We abstracted data from patients who underwent open TMA at Los Angeles County-University of Southern California Medical Center and Keck Hospital of University of Southern California from 2009 to 2018. Multivariable logistic regression analysis, adjusting for preoperative risk factors, was used to examine predictors of major adverse limb events (MALE). The aim was to evaluate outcomes following open TMA with MALE as the primary outcome. Our hypotheses were that outcomes would be worse for patients with foot infections and renal failure. RESULTS: Forty-three open TMAs were done in 39 patients during the study period. The cohort had a mean age of 63 ± 11.6 years, 89% had a history of diabetes, 95% hypertension (HTN), 54% had end-stage renal disease (ESRD), and 26% were current smokers. MALE occurred in 39% of the cohort. Sex, race, indication, HTN, smoking status, and history of prior ipsilateral revascularization or minor amputations were not associated with MALE (P > 0.05). Multivariate logistic regression found ESRD to be an independent predictor of MALE (odds ratio 7.43, 95% confidence interval 1.12-49.17, P = 0.038) after adjusting for clinically significant covariates. CONCLUSIONS: Open TMA provides acceptable rates of limb salvage for complex patients with CLTI. ESRD is an independent risk factor for MALE following open TMA in these patients. Vigilant follow-up is essential for this morbid patient population given poorer outcomes after forefoot amputation.


Subject(s)
Amputation, Surgical/adverse effects , Forefoot, Human/blood supply , Forefoot, Human/surgery , Ischemia/surgery , Peripheral Arterial Disease/surgery , Aged , Chronic Disease , Female , Humans , Ischemia/diagnostic imaging , Ischemia/physiopathology , Limb Salvage , Los Angeles , Male , Middle Aged , Peripheral Arterial Disease/diagnostic imaging , Peripheral Arterial Disease/physiopathology , Reoperation , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome
12.
Cardiovasc Revasc Med ; 21(1): 118-121, 2020 01.
Article in English | MEDLINE | ID: mdl-31575468

ABSTRACT

BACKGROUND: Patients with chronic limb threatening ischemia (CLTI) and end-stage renal disease (ESRD) have greater risk of limb loss compared to those with CLTI alone. We investigated angiographic patterns in patients with CLTI and evaluated for differences based on ESRD status. METHODS: We reviewed lower extremity angiograms of 152 CLTI patients at a single academic medical center from 2011 to 2017 and analyzed them based on the Graziani and Bollinger classification systems. We used these classification systems to evaluate for angiographic patterns and arterial disease severity categorized by the presence or absence of ESRD. RESULTS: The analysis included 152 CLTI patients (161 angiograms). Patients' mean age was 63.4 ±â€¯11.3 years and 20 (12.4%) patients had ESRD. In our study population, infrapopliteal arterial disease was more severe than femoropopliteal disease. Disease of the arteries providing direct flow to the plantar arch was more severe in ESRD patients compared to non-ESRD patients, evident by higher Graziani Class VII disease (20% vs. 4.9%, p = .03). ESRD patients also had higher rates of concurrent significant stenosis of the posterior tibial and lateral plantar arteries (70% vs. 23%, p < .0001). CONCLUSION: In people with CLTI, infrapopliteal arteries are more severely affected than proximal femoropopliteal arteries. ESRD patients exhibit a pattern of arterial disease, we termed the "renal foot," that frequently involves arteries providing direct flow to the plantar arch.


Subject(s)
Angiography , Femoral Artery/diagnostic imaging , Foot/blood supply , Ischemia/diagnostic imaging , Kidney Failure, Chronic/complications , Peripheral Arterial Disease/diagnostic imaging , Popliteal Artery/diagnostic imaging , Aged , Chronic Disease , Databases, Factual , Female , Femoral Artery/physiopathology , Humans , Ischemia/physiopathology , Kidney Failure, Chronic/diagnosis , Kidney Failure, Chronic/physiopathology , Male , Middle Aged , Peripheral Arterial Disease/complications , Peripheral Arterial Disease/physiopathology , Popliteal Artery/physiopathology , Predictive Value of Tests , Prognosis , Regional Blood Flow , Retrospective Studies , Severity of Illness Index
13.
J Cardiovasc Pharmacol Ther ; 25(2): 158-163, 2020 03.
Article in English | MEDLINE | ID: mdl-31550912

ABSTRACT

BACKGROUND: Critical limb-threatening ischemia (CLTI) is associated with an increased risk of major adverse limb events and mortality. High on-treatment platelet reactivity (HPR) is associated with an increased risk of ischemic events, while low on-treatment platelet reactivity (LPR) is associated with an increased risk of bleeding. This study investigates the frequency with which patients with CLTI on clopidogrel or ticagrelor achieve a "therapeutic window" (TW) of platelet inhibition. METHODS: Data from the "Switch To Ticagrelor in Critical Limb Ischemia Anti-Platelet Study" were assessed retrospectively to determine the incidence of TW of on-treatment platelet reactivity in 50 consecutive patients with CLTI (mean age: 65.2 ± 10.5 years, 54% male). The data included 4 measurements of patients' platelet reactivity using the VerifyNow P2Y12 Assay: baseline and steady state platelet reactivity on clopidogrel 75 mg daily and on ticagrelor 90 mg twice daily. RESULTS: At baseline, 46% of patients on clopidogrel were within TW of on-treatment platelet reactivity compared to 10% of patients on ticagrelor (P < .0001). At steady state, 42% of patients on clopidogrel were within the TW compared to 10% of patients on ticagrelor (P < .0001). Patients on ticagrelor exhibited higher rates of LPR compared to those on clopidogrel at baseline as well as at steady state (baseline 88% vs 18%, steady state 88% vs 28%; P < .0001). CONCLUSION: Although ticagrelor has been proposed as an alternative for patients with HPR on clopidogrel, the current study observes an excess of platelet inhibition with ticagrelor in most patients with CLTI at a dose of 90 mg twice daily.


Subject(s)
Clopidogrel/administration & dosage , Ischemia/drug therapy , Peripheral Arterial Disease/drug therapy , Platelet Aggregation Inhibitors/administration & dosage , Platelet Aggregation/drug effects , Purinergic P2Y Receptor Antagonists/administration & dosage , Ticagrelor/administration & dosage , Aged , Clopidogrel/adverse effects , Critical Illness , Drug Administration Schedule , Drug Monitoring , Female , Humans , Ischemia/blood , Ischemia/diagnosis , Male , Middle Aged , Peripheral Arterial Disease/blood , Peripheral Arterial Disease/diagnosis , Platelet Aggregation Inhibitors/adverse effects , Platelet Function Tests , Purinergic P2Y Receptor Antagonists/adverse effects , Ticagrelor/adverse effects , Time Factors , Treatment Outcome
14.
J Am Podiatr Med Assoc ; 109(2): 174-179, 2019 Mar.
Article in English | MEDLINE | ID: mdl-31135194

ABSTRACT

Emergency department visits for lower extremity complications of diabetes are extremely common throughout the world. Surprisingly, recent data suggest that such visits generate an 81.2% hospital admission rate with an annual bill of at least $1.2 billion in the United States alone. The likelihood of amputation and other subsequent adverse outcomes is strongly associated with three factors: 1) wound severity (degree of tissue loss), 2) ischemia, and 3) foot infection. Using these factors, this article outlines the basic principles needed to create an evidence-based, rapid foot assessment for diabetic foot ulcers presenting to the emergency department, and suggests the establishment of a "hot foot line" for an organized, expeditious response from limb salvage team members. We present a nearly immediate assessment and referral system for patients with atraumatic tissue loss below the knee that has the potential to vastly expedite lower extremity triage in the emergency room setting through greater collaboration and organization.


Subject(s)
Clinical Protocols , Diabetic Foot/diagnosis , Diabetic Foot/therapy , Emergency Service, Hospital , Triage/methods , Adult , Humans , Male , Severity of Illness Index
15.
J Investig Med High Impact Case Rep ; 7: 2324709619846575, 2019.
Article in English | MEDLINE | ID: mdl-31053036

ABSTRACT

We report a case of a 23-year-old female with a history of unrepaired ventricular septal defect and pulmonary arterial hypertension with Eisenmenger's syndrome (ES) presenting with chest pain. Electrocardiography demonstrated new anterior Q waves and anterolateral ST elevations, and coronary angiography revealed a large organized thrombus in the mid-left anterior descending artery consistent with paradoxical coronary embolism. Patient was treated with percutaneous coronary intervention and aggressive anticoagulation management. Intensive care unit course was complicated by respiratory failure requiring intubation due to hospital-acquired pneumonia in the setting of severe pulmonary hypertension. Patient was emergently initiated on veno-venous extracorporeal membrane oxygenation support (ECMO) as a bridge to heart-lung transplantation. After initiation of ECMO, patient displayed significant clinical improvement and underwent successful heart-lung transplantation. This case highlights veno-venous ECMO as a bridge to heart-lung transplantation in acutely decompensated patients with ES, and is the first reported case of paradoxical coronary embolism in a patient with ES.


Subject(s)
Eisenmenger Complex/surgery , Embolism, Paradoxical/complications , Extracorporeal Membrane Oxygenation , Heart-Lung Transplantation , ST Elevation Myocardial Infarction/surgery , Coronary Angiography , Eisenmenger Complex/physiopathology , Electrocardiography , Embolism, Paradoxical/diagnostic imaging , Female , Hemodynamics , Humans , Hypertension, Pulmonary/physiopathology , Hypertension, Pulmonary/surgery , Respiratory Insufficiency/physiopathology , Respiratory Insufficiency/surgery , ST Elevation Myocardial Infarction/diagnostic imaging , Treatment Outcome , Young Adult
16.
J Invasive Cardiol ; 31(4): 101-106, 2019 04.
Article in English | MEDLINE | ID: mdl-30643039

ABSTRACT

BACKGROUND: Severe coronary artery calcification is a challenge for percutaneous coronary intervention (PCI), particularly in left main coronary artery disease (LM-CAD). Rotational atherectomy (RA) is a useful tool for modification of calcified plaque prior to PCI. We report our experience with RA for severely calcified LM-CAD. METHODS: From January 2008 to January 2017, all patients who underwent RA-assisted LM-PCI were evaluated. The study population included both protected and unprotected LM-CAD patients. Clinical characteristics and in-hospital outcomes were collected retrospectively. In-hospital outcomes included post-PCI myocardial infarction, stroke, death, emergency coronary artery bypass graft surgery, and urgent repeat PCI. Angiographic success was defined by residual stenosis <20% and presence of TIMI 3 flow. RESULTS: Fifty-five consecutive patients who underwent RA-assisted PCI of LM-CAD were identified (mean age, 73.0 ± 10 years; 64% male). Mean left ventricular ejection fraction was 37.5 ± 15.7%. Fifty-one patients (93%) had multivessel disease and 39 patients (71%) underwent RA-assisted LM-PCI with use of a mechanical support device. The median largest burr size used was 1.5 mm. The mean number of LM stents implanted was 0.95 ± 0.3. The mean LM stent diameter and length were 3.7 ± 0.3 mm and 15.8 ± 7.5 mm, respectively. Intravascular ultrasound was used to assess vessel size and stent apposition in 20 patients (36.0%). Angiographic success was obtained in all patients (100%). CONCLUSION: Despite technical challenges, RA of the LM coronary artery can be performed safely and is associated with a high rate of angiographic success.


Subject(s)
Atherectomy, Coronary , Coronary Artery Disease , Coronary Vessels , Inpatients/statistics & numerical data , Percutaneous Coronary Intervention , Vascular Calcification , Aged , Aged, 80 and over , Atherectomy, Coronary/adverse effects , Atherectomy, Coronary/methods , Coronary Angiography/methods , Coronary Artery Disease/metabolism , Coronary Artery Disease/pathology , Coronary Artery Disease/surgery , Coronary Vessels/diagnostic imaging , Coronary Vessels/pathology , Coronary Vessels/surgery , Female , Humans , Male , Middle Aged , Outcome Assessment, Health Care , Percutaneous Coronary Intervention/methods , Percutaneous Coronary Intervention/statistics & numerical data , Reoperation/methods , Reoperation/statistics & numerical data , Risk Adjustment , Severity of Illness Index , United States
17.
J Innov Card Rhythm Manag ; 10(8): 3785-3789, 2019 Aug.
Article in English | MEDLINE | ID: mdl-32477745

ABSTRACT

A common dilemma facing physicians treating patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) is the management of oral anticoagulation (OAC) therapy, because there is also an indication for dual antiplatelet therapy in these patients. The purpose of this study was therefore to evaluate anticoagulation patterns in this patient population in an attempt to identify patterns of risk factors that may influence OAC prescribing habits. This retrospective study entailed a review of a total of 4,648 patients from two academic hospitals who underwent PCI between 2008 and 2016. We ultimately included 211 patients who had AF and an indication for OAC. Chart review revealed patients' risk factors, CHA2DS2-VASc and HAS-BLED scores, and antithrombotic regimens. Only 105 (49.8%) patients who met the indications for OAC were actually placed on OAC post-PCI. There was no significant relationship between discharge on OAC and HAS-BLED score (t = 0.14; p = 0.44) or CHA2DS2-VASc score (t = 0.76; p = 0.22). Patients younger than 65 years of age were prescribed more triple therapy (56% versus 33%; p < 0.01) or any OAC (69% versus 41%; p < 0.01) on discharge in comparison with patients 65 years of age or older. The older patient group had a significantly higher average CHA2DS2-VASc score (4.4 versus 3.2; p < 0.01) and a higher average HAS-BLED score (2.8 versus 2.4; p < 0.01). Ultimately, this study indicated that less than half of AF patients with an indication for OAC were placed on OAC post-PCI. There was no association between discharge on OAC and CHA2DS2-VASc score, HAS-BLED score, or any other individual risk factor, with the exception of age.

18.
J Invasive Cardiol ; 30(10): 367-371, 2018 10.
Article in English | MEDLINE | ID: mdl-30279292

ABSTRACT

BACKGROUND: Patients with massive and submassive pulmonary embolism (PE) require rapid identification, triage, and consideration for reperfusion therapy. Use of an existing ST-segment elevation myocardial infarction (STEMI) team and activation protocol may be an effective means to care for these patients. OBJECTIVE: The objective of this analysis was to evaluate a pilot study using the STEMI team and a dedicated PE protocol for treatment of patients with massive and submassive PE. METHODS: From June 2014 to April 2016, a total of 40 patients with massive and submassive PE were evaluated. Baseline demographics, mode of hospital entry (transfer-in, in-hospital, and emergency department [ED] arrival), treatment time intervals (door to computed tomography PE protocol [CTPE], CTPE to invasive pulmonary angiogram, door to treatment time), procedures performed, and in-hospital clinical events were collected. RESULTS: Mean age was 56 ± 14 years, 17 (42%) were male, and 12 (30%) had a prior history of deep venous thrombosis or PE. Twenty-three patients (57%) had massive PE and 17 patients (43%) had submassive PE. Mode of hospital entry was transfer-in (38%), in-hospital (20%), and ED arrival (42%). Four patients (10%) presented with cardiac arrest, 8 patients (20%) required intubation, and 5 patients (12%) required extracorporeal membrane oxygenation. Ten patients (25%) received anticoagulation therapy or placement of inferior vena cava filter, 3 patients (7.5%) received diagnostic pulmonary angiography alone, and 27 patients (67.5%) received endovascular treatment. For patients arriving via the ED, door to CTPE was 4.9 ± 3.6 hours, CTPE to diagnostic pulmonary angiography was 7.8 ± 8.5 hours, and door to treatment time was 10.2 ± 9.0 hours. Endovascular devices utilized included combinations of rheolytic and other thrombectomy devices as well as catheter-directed fibrinolysis. Length of hospital stay was 15 ± 15 days and in-hospital survival rate was 90%. CONCLUSIONS: Use of an existing STEMI team and activation protocol is a feasible method to care for patients with massive and submassive PE. This pilot study demonstrated rapid treatment times with low in-hospital mortality.


Subject(s)
Cardiologists , Patient Care Team , Pulmonary Embolism/therapy , Thrombectomy/methods , Emergency Service, Hospital , Female , Fibrinolytic Agents/therapeutic use , Humans , Male , Middle Aged , Pilot Projects , Retrospective Studies , ST Elevation Myocardial Infarction , Thrombolytic Therapy/methods
19.
Cardiovasc Revasc Med ; 19(8): 951-955, 2018 12.
Article in English | MEDLINE | ID: mdl-30078629

ABSTRACT

BACKGROUND: The optimal stent for use in saphenous vein graft (SVG) intervention is still debatable. Multiple randomized trials have compared drug-eluting stents (DES) to bare metal stents (BMS) in SVG interventions with conflicting results. METHODS: Authors searched the online databases for randomized controlled trials (RCTs) comparing DES to BMS in SVG percutaneous coronary interventions (PCI). We performed a meta-analysis using a random effects model to calculate the odds ratio for outcomes of interest. RESULTS: Authors studied six RCTs that included 1592 patients undergoing PCI of SVG. The mean follow up was 42 months. Patients mean age was the same in both groups: 70.3 years in the DES group (approximately 93.3% male) and 70.3 years in the BMS group (approximately 93.8% male). Vein graft age was 13.4 years in the DES PCI arm vs. 13.4 years in the BMS PCI arm. Four of the six trials reported data on embolic protection device use: 67% (303/452) in the DES arm vs. 67.9% (309/455) in the BMS arm. The primary outcome of long-term all-cause mortality was not different between DES vs. BMS (15.2% vs. 14.1%, OR 1.12, 95% CI 0.67-1.88; P = 0.66). Secondary outcomes were also similar between DES and BMS: major adverse cardiovascular events (31.6% vs. 33.1%, OR 0.79, 95% CI 0.45-1.38; P = 0.41); cardiac death (9% vs. 8.6%, OR 1.12, 95% CI 0.55-2.30; P = 0.75); myocardial infarction (8% vs. 9.5%, OR 0.84, 95% CI 0.47-1.51; P = 0.57); target lesion revascularization (16.4% vs. 14.4%, OR 0.98, 95% CI 0.50-1.92; P = 0.95); and target vessel revascularization (19% vs. 19.4%, OR 0.75, 95% CI 0.41-1.34; P = 0.33). CONCLUSION: At a mean follow-up of 42 months, no difference was observed in clinical outcomes between DES and BMS in SVG interventions.


Subject(s)
Coronary Artery Disease/surgery , Drug-Eluting Stents , Percutaneous Coronary Intervention/methods , Randomized Controlled Trials as Topic , Saphenous Vein/transplantation , Follow-Up Studies , Humans , Time Factors , Treatment Outcome
20.
Cardiovasc Revasc Med ; 19(8): 960-963, 2018 12.
Article in English | MEDLINE | ID: mdl-30060923

ABSTRACT

BACKGROUND: Mitral regurgitation (MR) is a common valvular disorder, occurring in up to 10% of the general population. Although surgery is the established treatment for primary MR, many patients do not receive appropriate therapy. The objective of this study was to determine the incidence and treatment pattern of patients with severe MR evaluated at a tertiary medical center and determine factors associated with receiving surgery. METHODS: All patients with moderate-severe and severe MR undergoing transthoracic echocardiography from 2011 to 2016 were identified. Patients with prior mitral valve surgery were excluded. Treatment recommendations were classified as referral to cardiology, referral to cardiothoracic surgery (CTS), receiving mitral valve surgery or receiving MitraClip. A multivariate logistic regression model was used to evaluate factors associated with referral to CTS or receiving surgery. RESULTS: During the study period, 1918 transthoracic echocardiogram were performed and 412 patients with moderate-severe or severe MR were identified. One hundred sixty-six patients (40%) had primary MR and 246 patients (60%) had secondary MR. For those with primary MR, 75 patients (45%) received treatment (surgery, n = 60 and MitraClip, n = 15) and 91 patients (55%) did not receive treatment. One hundred patients (60%) were referred to CTS and 128 patients (77%) were referred to cardiology. Patients undergoing surgery were younger (62.6 ±â€¯14.2 years vs 72.0 ±â€¯14 years, p < 0.001), with a higher prevalence of heart failure (57% vs 40%, p = 0.044) and a lower prevalence of stroke (3% vs 24%, p < 0.001) and hypertension (54% vs 74%, p = 0.012), compared to patients not undergoing surgery, respectively. Ejection fraction (60.4 ±â€¯10.9% vs 56.3 ±â€¯11.6%, p = 0.034), left ventricular end diastolic diameter (53.2 ±â€¯10.3 mm vs 48.7 ±â€¯10.9 mm, p = 0.040) and effective regurgitant orifice area (0.5 ±â€¯0.4 cm2 vs 0.3 ±â€¯0.1 cm2) were higher in patients undergoing surgery, compared to patients not undergoing surgery, respectively. The most common reason for not receiving surgery was that MR was not addressed by the treating physician and lost to clinical follow-up. Over 50% of patients that did not receive surgery had at least 1 indication based upon current practice guidelines. CONCLUSIONS: In contemporary clinical practice, less than half of patients with moderate-severe and severe primary MR received surgery and many were not referred for surgical consultation.


Subject(s)
Cardiac Surgical Procedures/methods , Mitral Valve Insufficiency/epidemiology , Adult , Aged , Aged, 80 and over , Echocardiography , Female , Follow-Up Studies , Humans , Incidence , Male , Middle Aged , Mitral Valve Insufficiency/diagnosis , Mitral Valve Insufficiency/surgery , Retrospective Studies , Severity of Illness Index , United States/epidemiology , Young Adult
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