RESUMEN
BACKGROUND: Femoropopliteal (FP) artery in-stent restenosis (ISR) is associated with high rates of re-intervention and occlusion. The combined use of laser atherectomy (LA) with balloon angioplasty (BA) is superior to conventional balloon angioplasty (BA). Drug-coated balloons (DCBs) when combined with LA have provided additional efficacy for the treatment of FP-ISR. The aim of this study was to investigate the combination of DCBâ¯+â¯LA with the recently approved Turbo-Power™ (Spectranetics Inc., Colorado Springs, CO, USA) LA device. METHODS: This was a dual-center retrospective study enrolling 78 consecutive patients with Tosaka type II (nâ¯=â¯18) or III (nâ¯=â¯60) FP-ISR. The lesions were treated with either Turbo-Power™ LA followed by DCB (nâ¯=â¯27) or with other LA devices followed by plain BA (LAâ¯+â¯BA; nâ¯=â¯51) from 2015 to 2017. A Cox regression analysis was performed to examine the association between the two groups in terms of target lesion revascularization (TLR) and occlusion rates over a follow up period of 12â¯months. Kaplan-Meier survival curves were estimated and compared with the log-rank test. RESULTS: The overall procedural success was 90%. Eight periprocedural complications occurred without any difference between the two groups (Turbo-Power™â¯+â¯DCB: 7.4% vs LAâ¯+â¯BA: 11.8%, pâ¯=â¯.7). The 12-month KM estimates for freedom from TLR were 90.9% in the Turbo-Power™â¯+â¯DCB group vs 55.7% in the LAâ¯+â¯BA group (pâ¯=â¯.005). Among Toasaka III lesions, the 12â¯m-KM survival estimates for freedom from TLR were 88.9% in the Turbo-Power™â¯+â¯DCB group vs 54.2% in the LAâ¯+â¯BA group (pâ¯=â¯.009). The 12â¯m-KM estimates for freedom from re-occlusion were 89.0% in the Turbo-Power™â¯+â¯DCB group vs 58.9% in the LAâ¯+â¯BA group (pâ¯=â¯.070). CONCLUSIONS: Turbo-Power™ laser atherectomy combined with DCB exerted synergistic mechanism of actions and improved 12-month TLR rates for the treatment of complex FP-ISR lesions.
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Angioplastia de Balón/instrumentación , Aterectomía/instrumentación , Fármacos Cardiovasculares/administración & dosificación , Materiales Biocompatibles Revestidos , Arteria Femoral , Terapia por Láser/instrumentación , Paclitaxel/administración & dosificación , Enfermedad Arterial Periférica/terapia , Arteria Poplítea , Stents , Dispositivos de Acceso Vascular , Anciano , Anciano de 80 o más Años , Angioplastia de Balón/efectos adversos , Aterectomía/efectos adversos , California , Fármacos Cardiovasculares/efectos adversos , Colorado , Constricción Patológica , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Humanos , Terapia por Láser/efectos adversos , Masculino , Persona de Mediana Edad , Paclitaxel/efectos adversos , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Recurrencia , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
PURPOSE: To examine whether an antegrade or retrograde crossing strategy for treatment of iliac artery chronic total occlusions (CTOs) is associated with differences in procedural or midterm outcomes. MATERIALS AND METHODS: A dual-center retrospective cohort study was conducted in 168 patients (mean age 66.4±10.6 years; 116 men) treated for CTOs in 110 common iliac arteries (CIA), 52 external iliac arteries (EIA), and 26 combined CIA/EIAs. Logistic regression models were developed to determine the association between crossing strategy and procedural complications, 1- and 3-year target lesion revascularization (TLR), and major adverse limb events (MALE). Results are presented as the odds ratio (OR) and 95% confidence interval (CI). RESULTS: An initial antegrade strategy was more common for EIA CTOs (p<0.005), and an initial retrograde strategy was more often used in CIA (p<0.005) and combined CIA/EIA (p<0.005) CTOs. Crossover to an alternate approach was required in 27.6% of initial antegrade attempts and 9.6% of initial retrograde attempts. EIA CTOs were the most likely lesions to be treated successfully with the initial attempt (either strategy). In all, 123 (65.4%) lesions were successfully crossed with a final retrograde approach and 65 with a final antegrade approach. Overall target lesion success was high for both groups (95.1% vs 93.2%, p=0.456). Lesions treated with a final retrograde approach were shorter (75.3±34.9 vs 87.6±31.3 mm, p=0.005) and were more likely to be treated with a reentry device (34.2% vs 9.2%, p<0.001) and with balloon-expandable stents (39.2% vs 17.7%, p=0.005). The final antegrade approach was associated with a lower risk of target lesion complications (OR 0.07, 95% CI 0.01 to 0.81, p=0.034). The two crossing approaches were associated with similar estimates of 1- and 3-year TLR and MALE. CONCLUSION: A final antegrade approach was associated with lower rates for complications but the 2 approaches were similar in terms of lesion success, TLR, and MALE. The EIA CTOs were more likely to be treated with an antegrade approach and more likely to be crossed successfully with the initial approach irrespective of the crossing direction.
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Procedimientos Endovasculares , Arteria Ilíaca , Enfermedad Arterial Periférica/terapia , Anciano , California , Enfermedad Crónica , Colorado , Constricción Patológica , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/fisiopatología , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Aims Most of those with a memory problem or concern over cognition present to their General Practitioner (GP) in the first instance. Despite this, the current diagnostic and referral patterns of Irish GPs remains unclear. Methods A survey was distributed to three separate cohorts of GPs (n=692) Results Ninety-Five (14%) responded. Most personally diagnose 1-3 (69%; 65/95) or 4-6 (21%; 20/95) patients with dementia per year. Two-thirds (62%; 59/95) refer >80% of those with possible dementia for further assessment/support, most commonly to support/clarify a diagnosis (71%; 67/95) and most frequently to a geriatrician (79%; 75/95). In half of cases (51%; 48/95), referral is to a professional working as part of an established memory clinic. One-fifth reported receiving dementia-specific postgraduate training (19%; 18/95) and over four-fifths (82%; 78/95) would welcome further training. Discussion Further attention to the ongoing establishment of memory clinic services and dedicated referral pathways, as well as increasing emphasis on dementia assessment and diagnosis in medical curricula, is warranted.
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Demencia/diagnóstico , Demencia/epidemiología , Médicos Generales/estadística & datos numéricos , Derivación y Consulta/estadística & datos numéricos , Educación de Postgrado en Medicina/estadística & datos numéricos , Médicos Generales/psicología , Humanos , Irlanda/epidemiologíaRESUMEN
INTRODUCTION: While cognitive impairment is a recognised feature of Parkinson's disease (PD), few studies have evaluated the validity of brief cognitive screening measures compared to a comprehensive neuropsychological assessment. This studies aim was to evaluate the sensitivity and specificity of the Mini-Mental State Examination (MMSE), Modified Mini-Mental State Examination and Dementia Rating Scale (DRS-2) to detect cognitive impairment in individuals with PD. METHOD: Fifty-eight participants were administered the MMSE, 3MS, DRS-2 and a neuropsychological battery. ROC analyses were conducted to assess their effectiveness in classifying cognitive impairment. RESULTS: None of the three measures demonstrated good sensitivity or specificity to detect single domain cognitive impairment. For detecting impairment on two or more cognitive domains, the MMSE and DRS-2 yielded excellent sensitivity (88%) and specificity (78% and 76% respectively), at cut-off scores of 28 and 136 respectively. The 3MS demonstrated excellent sensitivity (88%) and good specificity (60%) at cut off score of 94. CONCLUSION: The MMSE and DRS-2 have excellent discriminant ability to classify multi-domain cognitive impairment in PD, however, their ability to detect more focal cognitive impairment is limited. Given that focal domain may be an indicator that could be useful in early detection of cognitive impairment for people with PD, this finding has implication for the use of these measures as screening tools in clinical practice.
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Cognición , Disfunción Cognitiva/diagnóstico , Pruebas Neuropsicológicas/normas , Enfermedad de Parkinson/diagnóstico , Anciano , Disfunción Cognitiva/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedad de Parkinson/complicaciones , Sensibilidad y EspecificidadRESUMEN
Transcatheter aortic valve replacement (TAVR) has emerged as an effective therapy for aortic stenosis in patients who are at intermediate and high surgical risk. Vascular access remains critical to the success of the TAVR procedure. This article reviews the use of imaging in planning and executing TAVR access.
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Estenosis de la Válvula Aórtica/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/diagnóstico , Aterosclerosis/complicaciones , Aterosclerosis/diagnóstico , Protocolos Clínicos , Femenino , Fluoroscopía , Humanos , Complicaciones Intraoperatorias/etiología , Angiografía por Resonancia Magnética/métodos , Masculino , Tomografía Computarizada Multidetector , Enfermedad Arterial Periférica/complicaciones , Enfermedad Arterial Periférica/diagnóstico , Ultrasonografía Intervencional , Calcificación Vascular/complicaciones , Calcificación Vascular/diagnóstico , Lesiones del Sistema Vascular/prevención & control , Técnicas de Cierre de HeridasRESUMEN
PURPOSE: To evaluate the association between a chronic total occlusion (CTO) and long-term outcomes among patients undergoing endovascular intervention to the external iliac artery (EIA). METHODS: A 2-center retrospective study was conducted of 331 patients (mean age 64.7±12.7 years; 221 men) who underwent endovascular intervention for 481 EIA atherosclerotic lesions between 2006 and 2016. A quarter of the lesions (115, 23.9%) were CTOs. The majority of patients (184, 60.9%) were treated for claudication; 172 (38%) lesions were TransAtlantic Inter-Society Consensus type C or D. Target lesion revascularization (TLR) and major adverse limb event (MALE) rates were compared between lesions with or without an EIA CTO. A Cox proportional hazard model was subsequently developed to determine baseline variables associated with long-term outcomes after successful endovascular intervention of stented EIAs; outcomes are presented as the hazard ratio (HR) and 95% confidence interval (CI). RESULTS: The mean lesion length was longer (84 vs 50 mm, p<0.001) among patients treated for CTOs. While overall the target lesion failure rates were very low (2.8%), vessel perforation (2.7% vs 0.3%, p=0.02) and distal embolization (2.7% vs 0.9%, p=0.02) were more common in the CTO group. Among 377 successfully crossed and stented lesions (93 CTOs), the overall 1-year primary patency was 78% and secondary patency was 92%. One-year and 5-year TLR rates were 8.2% and 15.4%, respectively. CTO intervention was associated with higher 5-year TLR rates in the unadjusted analysis (HR 1.72, 95% CI 1.00 to 2.56, p=0.050), but the association did not remain significant after multivariable adjustment. CONCLUSION: Intervention to EIA CTOs is associated with increased intraprocedural complexity but with similar midterm outcomes, including high patency and low rates of TLR to 5 years.
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Procedimientos Endovasculares , Arteria Ilíaca , Enfermedad Arterial Periférica/terapia , Anciano , California , Colorado , Constricción Patológica , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/fisiopatología , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: Patients with history of cryptogenic stroke are more likely to have a patent foramen ovale (PFO) and should be managed with antithrombotic agents, while the alternative option is percutaneous closure of PFOs. Our aim was to perform a meta-analysis of randomized controlled trials (RCTs) comparing percutaneous closure vs. medical treatment for patients with PFO and prior cryptogenic stroke. METHODS: Medline, Scopus and Cochrane databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. New ischemic stroke was defined as the primary endpoint. A sensitivity analysis was performed for Amplatzer device. Subgroup analyses were performed for different patient and PFO characteristics for the composite endpoints as defined by the included RCTs. RESULTS: In total of 3440 patients were included in this meta-analysis. Closure devices were superior to medical therapy for prevention of recurrent ischemic strokes (HRâ¯=â¯0.29; CI: 0.02-0.56), but were associated with increased risk of new onset of atrial fibrillation (AF) and atrial flutter (RRâ¯=â¯4.67; CI: 2.22-9.81). However, in the sensitivity analysis for Amplatzer device, there was no difference between the two groups in new onset of atrial arrhythmias. Closure devices were superior across all different subgroups when compared to medical treatment with the exception of patients with a small shunt. CONCLUSION: This meta-analysis shows that closure devices for patients with PFO and history of cryptogenic stroke can significantly decrease the risk of a new ischemic stroke. The use of Amplatzer device was not associated with increased risk of newly diagnosed atrial arrhythmias.
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Isquemia Encefálica/prevención & control , Cateterismo Cardíaco/instrumentación , Fibrinolíticos/uso terapéutico , Foramen Oval Permeable/terapia , Accidente Cerebrovascular/prevención & control , Adulto , Arritmias Cardíacas/etiología , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiología , Cateterismo Cardíaco/efectos adversos , Femenino , Fibrinolíticos/efectos adversos , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Ensayos Clínicos Controlados Aleatorios como Asunto , Recurrencia , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/etiología , Resultado del TratamientoRESUMEN
OBJECTIVE: To examine the impact of re-entry device (RED) use on 1- and 5-year outcomes after endovascular treatment of common iliac artery (CIA) chronic total Occlusions (CTOs). BACKGROUND: There are not enough data regarding the long-term safety and efficacy of RED. METHODS: We performed a two-center retrospective study of 115 patients (140 lesions) undergoing CIA CTO endovascular intervention between 2006 and 2016. Baseline characteristics and long-term outcomes were described. A Cox proportional hazard model was developed to determine if REDs were associated with target lesion revascularization (TLR) or major adverse limb events (MALE) after 1 and 5 years. RESULTS: Among 140 lesions, 43 (31%) required use of a RED. The mean age was 63.9 years and the majority (n = 80) of patients were male. An antegrade crossing approach and treatment of restenotic lesions were less common in the RED group (10% vs. 29%, P < .05 and 0% vs. 21%, P < .05, respectively). There were no significant differences in Rutherford class, pre-procedure ABI, or patient presentation. The procedural complication rates were similar between the two groups. The 1- and 5-year TLR rates for lesions treated with re-entry device vs. standard approaches were 11% vs. 9%; P = 0.8 and 29% vs. 29%; P = 0.9 respectively. The 1 and 5-year MALE rates for lesions treated with re-entry device were 5% vs. 6%; P = 0.8 and 11% vs. 11%; P = 0.9 respectively. CONCLUSIONS: This retrospective analysis found that recanalization of CIA occlusions using a RED is safe and is associated with long-term clinical outcomes similar to that of standard crossing techniques.
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Angioplastia/instrumentación , Arteria Ilíaca , Enfermedad Arterial Periférica/terapia , Dispositivos de Acceso Vascular , Anciano , Angioplastia/efectos adversos , California , Enfermedad Crónica , Colorado , Constricción Patológica , Diseño de Equipo , Femenino , Humanos , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/fisiopatología , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularAsunto(s)
Anticoagulantes/administración & dosificación , Fibrilación Atrial/diagnóstico , Toma de Decisiones Clínicas/métodos , Índice de Severidad de la Enfermedad , Administración Oral , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/fisiopatología , Humanos , Ensayos Clínicos Pragmáticos como Asunto/métodosRESUMEN
PURPOSE: To examine whether laser atherectomy combined with drug-coated balloons (laser + DCB) can improve the outcomes of femoropopliteal (FP) in-stent restenosis (ISR). METHODS: A dual-center retrospective study was conducted of 112 consecutive patients (mean age 70.3±10.6 years; 86 men) with Tosaka class II (n=29; diffuse stenosis) or III (n=83; occlusion) FP-ISR lesions. Sixty-two patients (mean age 68.5±10 years; 51 men) underwent laser + DCB while the other 50 patients (mean age 72.5±10.8 years; 35 men) had laser atherectomy plus balloon angioplasty (laser + BA). Critical limb ischemia was the indication in 33% of the interventions. The average lesion length was 247 mm. A Cox regression hazard model was developed to examine the association between laser + DCB vs laser + BA; the results are presented as the hazard ratio (HR) and 95% confidence interval (CI). One-year target lesion revascularization (TLR) and reocclusion were estimated using the Kaplan-Meier method. RESULTS: Overall procedure success was 98% and was similar between groups. Bailout stenting was less often required in the laser + DCB group (31.7% vs 58%, p=0.006). The combination of laser + DCB was associated with improved 12-month estimates for freedom from TLR (72.5% vs 50.5%, p=0.043) and freedom from reocclusion (86.7% vs 56.9%, p=0.003). Among patients with Tosaka III FP-ISR, combination therapy with laser + DCB was also associated with increased freedom from reocclusion (87.1% vs 57.1%, p=0. 028). On multivariable analysis, treatment with laser + DCB was associated with a significantly reduced risk of reocclusion (HR 0.08, 95% CI 0.17 to 0.38; p=0.002). CONCLUSION: When used for treatment of complex FP-ISR lesions, DCB angioplasty combined with laser atherectomy is associated with significantly reduced 1-year TLR and reocclusion rates.
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Angioplastia de Balón Asistida por Láser , Procedimientos Endovasculares/instrumentación , Arteria Femoral , Enfermedad Arterial Periférica/terapia , Arteria Poplítea , Stents , Anciano , Anciano de 80 o más Años , Angioplastia de Balón Asistida por Láser/efectos adversos , Procedimientos Endovasculares/efectos adversos , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Recurrencia , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Grado de Desobstrucción VascularRESUMEN
AIM: Novel biomarkers have been proposed for identification of patients at greater risk of future adverse events among those presenting with chest pain. In this review, we aim to elucidate the ability of pregnancy associated plasma protein-A (PAPP-A) to predict mortality and other cardiovascular events in this patient population. METHODS: A literature search of the electronic databases Medline, Scopus, Cochrane Library and ClinicalTrials.gov was performed in order to identify studies investigating the utility of PAPP-A to predict mortality and adverse cardiovascular events in patients with chest pain. RESULTS: Eight studies met our inclusion criteria. Five of these studies pertained to patients with confirmed ischemic chest pain, while the rest included patients presenting with chest pain possibly due to acute coronary syndrome, irrespectively of the underlying cause. Although the results for long-term events were inconclusive in both groups of patients, higher PAPP-A concentrations were found to be a significant predictor of short-term adverse events in patients with confirmed ischemic chest pain. CONCLUSIONS: PAPP-A appears to be a potentially useful biomarker for short-term risk stratification of patients presenting with chest pain of ischemic origin. However, there is an eminent need for more standardized clinical studies investigating the prognostic value of this biomarker.
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Síndrome Coronario Agudo/sangre , Biomarcadores/sangre , Dolor en el Pecho/sangre , Proteína Plasmática A Asociada al Embarazo/análisis , Síndrome Coronario Agudo/complicaciones , Síndrome Coronario Agudo/mortalidad , Causas de Muerte , Dolor en el Pecho/complicaciones , Femenino , Humanos , Pronóstico , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
BACKGROUND: The relative benefit of higher statin dosing in patients with peripheral artery disease has not been reported previously. We compared the effectiveness of low- or moderate-intensity (LMI) versus high-intensity (HI) statin dose on clinical outcomes in patients with peripheral artery disease. METHODS AND RESULTS: We reviewed patients with symptomatic peripheral artery disease who underwent peripheral angiography and/or endovascular intervention from 2006 to 2013 who were not taking other lipid-lowering medications. HI statin use was defined as atorvastatin 40-80 mg or rosuvastatin 20-40 mg. Baseline demographics, procedural data, and outcomes were retrospectively analyzed. Among 909 patients, 629 (69%) were prescribed statins, and 124 (13.6%) were treated with HI statin therapy. Mean low-density lipoprotein level was similar in patients on LMI versus HI (80±30 versus 87±44 mg/dL, P=0.14). Demographics including age (68±12 versus 67±10 years, P=0.25), smoking history (76% versus 80%, P=0.42), diabetes mellitus (54% versus 48%, P=0.17), and hypertension (88% versus 89%, P=0.78) were similar between groups (LMI versus HI). There was a higher prevalence of coronary artery disease (56% versus 75%, P=0.0001) among patients on HI statin (versus LMI). After propensity weighting, HI statin therapy was associated with improved survival (hazard ratio for mortality: 0.52; 95% confidence interval, 0.33-0.81; P=0.004) and decreased major adverse cardiovascular events (hazard ratio: 0.58; 95% confidence interval 0.37-0.92, P=0.02). CONCLUSIONS: In patients with peripheral artery disease who were referred for peripheral angiography or endovascular intervention, HI statin therapy was associated with improved survival and fewer major adverse cardiovascular events compared with LMI statin therapy.
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Atorvastatina/administración & dosificación , Dislipidemias/tratamiento farmacológico , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Claudicación Intermitente/tratamiento farmacológico , Isquemia/tratamiento farmacológico , Enfermedad Arterial Periférica/tratamiento farmacológico , Rosuvastatina Cálcica/administración & dosificación , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Angiografía , Atorvastatina/efectos adversos , Biomarcadores/sangre , Enfermedad Crítica , Progresión de la Enfermedad , Supervivencia sin Enfermedad , Prescripciones de Medicamentos , Dislipidemias/sangre , Dislipidemias/diagnóstico por imagen , Dislipidemias/mortalidad , Procedimientos Endovasculares , Femenino , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Claudicación Intermitente/sangre , Claudicación Intermitente/diagnóstico por imagen , Claudicación Intermitente/mortalidad , Isquemia/sangre , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Estimación de Kaplan-Meier , Lípidos/sangre , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Pautas de la Práctica en Medicina/tendencias , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Rosuvastatina Cálcica/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
PURPOSE: To analyze the relationship between the new TransAtlantic Inter-Society Consensus (TASC II) infrapopliteal classification and limb outcomes among patients with critical limb ischemia (CLI). METHODS: A single-center retrospective study was performed on 166 consecutive CLI patients (mean age 71 years; 113 men) undergoing endovascular treatment of 244 infrapopliteal lesions from 2006 to 2013. Patient, procedural, angiographic, and limb outcomes were compared for the new TASC A/B vs C/D classification for infrapopliteal lesions. Binary restenosis was determined by a peak systolic velocity ratio >2.0 by duplex ultrasound on follow-up at 1, 3, 6, and 12 months. RESULTS: Seventy-two (43.4%) patients had TASC A/B lesions, while 94 (56.6%) had TASC C/D patterns of infrapopliteal disease. Baseline demographics and tissue loss (93% vs 94%, p=0.59) were similar between the groups. TASC A/B lesions were shorter (53±35 vs 170±83 mm, p<0.001), less severely stenosed (77%±24% vs 93%±14%, p<0.001), had a larger target vessel diameter (2.9±0.5 vs 2.6±0.5 mm, p<0.001), and were less frequently chronic total occlusions (24% vs 64%, p<0.001) compared with the TASC C/D group. Three-year freedom from both amputation (85% vs 67%, p=0.02) and major adverse limb events (79% vs 61%, p=0.02) were significantly higher in the TASC A/B group. Technical success rates (95% vs 80%, p<0.001) and 1-year primary patency (58% vs 51%, p=0.04) were higher in the A/B group. Overall 3-year survival was similar between the groups (96% A/B vs 88% C/D, p=0.2). CONCLUSION: TASC C/D infrapopliteal lesions are associated with higher amputation and major adverse limb events rates and lower primary patency compared with TASC A/B infrapopliteal lesions. Further studies are needed to assess the association between TASC C/D infrapopliteal lesions and clinical outcomes in patients with CLI.
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Procedimientos Endovasculares , Isquemia/terapia , Enfermedad Arterial Periférica/terapia , Arteria Poplítea , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Angiografía , California , Constricción Patológica , Enfermedad Crítica , Supervivencia sin Enfermedad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Femenino , Humanos , Isquemia/diagnóstico por imagen , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Modelos de Riesgos Proporcionales , Recurrencia , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Doppler Dúplex , Grado de Desobstrucción VascularRESUMEN
PURPOSE: To assess the intraprocedural and mid-term outcomes of orbital atherectomy (OA) combined with drug-coated balloon (DCB) angioplasty for the treatment of calcified femoropopliteal disease. METHODS: In this single-center cohort, 89 patients (139 lesions) were treated with DCB angioplasty for claudication or critical limb ischemia (CLI). Angiographic characteristics and procedural outcomes were reviewed for patients treated with or without adjunctive OA. Lesion calcification was graded using two previously published scoring systems, the angiographic calcium score (ACS) and the peripheral artery calcification scoring system (PACSS). RESULTS: Among 139 lesions, 40 (29%) were treated with OA + DCB. Mean lesion length was 135 ± 100 mm for lesions treated with OA + DCB and 139 ± 100 mm for DCB alone (P = 0.9). Moderate to severe calcification was present in 83% of patients treated with OA, compared to 42% of patients treated with DCB alone (P < 0.001). Lesions treated with OA + DCB were less likely to require bailout stenting (18% vs. 39%, P =0.01). Rates of embolization (0% in OA + DCB vs. 2% in DCB only, P = 0.4), dissection (13% vs. 14%, P = 0.8), and perforation (0%) did not differ significantly between groups. The freedom from TLR at 1 year was 82% in both groups (P = 0.6) while primary patency was 81% in-patients treated with DCB alone and 77% in-patients treated with DCB with concomitant OA (P = 0.8). CONCLUSION: In this single-center analysis of patients undergoing DCB angioplasty for claudication or CLI, OA was most often used for the treatment of severely calcified lesions. These lesions were more likely to be treated with scoring balloons and less likely to require bailout stenting. At 1 year, target lesion revascularization and primary patency was similar in patients treated with and without adjunctive OA, despite the higher lesion complexity among those receiving the combination procedure. © 2017 Wiley Periodicals, Inc.
Asunto(s)
Angioplastia de Balón/instrumentación , Aterectomía , Materiales Biocompatibles Revestidos , Arteria Femoral , Claudicación Intermitente/terapia , Isquemia/terapia , Enfermedad Arterial Periférica/terapia , Arteria Poplítea , Dispositivos de Acceso Vascular , Calcificación Vascular/terapia , Anciano , Angiografía , Angioplastia de Balón/efectos adversos , Aterectomía/efectos adversos , Colorado , Enfermedad Crítica , Supervivencia sin Enfermedad , Diseño de Equipo , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Humanos , Claudicación Intermitente/diagnóstico por imagen , Claudicación Intermitente/fisiopatología , Isquemia/diagnóstico por imagen , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/fisiopatología , Grado de Desobstrucción VascularRESUMEN
Cavitation clusters and streamers are characterised in lipid materials (specifically sunflower oil) and compared to water systems. The lipid systems, which are important in food processing, are studied with high-speed camera imaging, laser scattering and pressure measurements. In these oils, clusters formed at an aged (roughened) tip of the sound source (a piston like emitter, PLE) are shown to collapse with varied periodicity in relation to the drive amplitude employed. A distinct streamer (an area of increased flow emanating from the cavitation cluster) is seen in the lipid media which is collimated directly away from the tip of the PLE source whereas in water the cavitation plume is visually less distinct. The velocity of bubbles in the lipid streamer near the cluster on the order of 10 m s-1. Local heating effects, within the streamer, are detected using a dual thermocouple measurement at extended distances. Viscosity, temperature and the outgassing within the oils are suggested to play a key role in the streamer formation in these systems.
RESUMEN
A new method to detect the uncompensated resistance, the capacitance and the Faradaic current at an electrode exposed to ultrasonic cavitation is presented. The method enables these parameters to be resolved with a 2 microsecond resolution and relies on the detection of the impedance of an electrode recorded as a function of time with a suitable AC excitation signal (here 500 kHz). Data obtained from an aluminium electrode, held under potentiostatic control, is used to illustrate the technique with particular relevance to the effects of cavitation bubbles generated by ultrasound. Analysis of the data recorded shows that the cavitation bubbles form close to the surface of the electrode and collapse, causing damage to the passive film formed at the aluminium surface. The capacitance, uncompensated resistance and Faradaic signals are used to explore the dynamic processes and show expansion and collapse of bubbles prior to erosion/corrosion. The close proximity of the bubbles to the surface is deduced from the reductions in capacitance and increases in resistance prior to bubble collapse, which is then shown to trigger the onset of a Faradaic signal, thus confirming the erosion/corrosion mechanism previously assumed.
RESUMEN
Peripheral artery disease (PAD) includes atherosclerosis of the aorta and lower extremities. Affecting a large segment of the population, PAD is associated with impaired functional capacity and reduced quality of life as well as an increased risk of stroke, myocardial infarction and cardiovascular death. The evaluation of PAD begins with the physical examination, incorporating non-invasive testing such as ankle-brachial indices to confirm the diagnosis. Therapeutic interventions are aimed at alleviating symptoms while preserving limb integrity and reducing overall cardiovascular risk. With this in mind, risk factor modification with exercise and medical therapy are the mainstays of treatment for many patients with PAD. Persistent symptoms or non-healing wounds should prompt more aggressive therapies with endovascular or surgical revascularisation. The following manuscript provides a comprehensive review on the contemporary evaluation and management of PAD.
Asunto(s)
Fármacos Cardiovasculares/uso terapéutico , Procedimientos Endovasculares , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/terapia , Conducta de Reducción del Riesgo , Procedimientos Quirúrgicos Vasculares , Amputación Quirúrgica , Fármacos Cardiovasculares/efectos adversos , Dieta Saludable , Procedimientos Endovasculares/efectos adversos , Ejercicio Físico , Humanos , Recuperación del Miembro , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Valor Predictivo de las Pruebas , Factores de Riesgo , Cese del Hábito de Fumar , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
OPINION STATEMENT: Peripheral artery disease (PAD) comprises atherosclerosis of the aorta and lower extremities. Many patients with PAD are asymptomatic, while others present with intermittent claudication (IC) or critical limb ischemia (CLI). Defined as rest pain or tissue loss that persists for >2 weeks, CLI represents the most severe clinical manifestation of PAD and is associated with an increased risk of limb loss and death. Patients with PAD, including those with CLI, are underdiagnosed and undertreated. In addition to smoking cessation, medical therapy with an antiplatelet agent and statin is recommended for all patients with PAD. Regular exercise has been shown to improve walking distance and quality of life in patients with symptomatic PAD and should be incorporated into each patient's treatment plan. In patients who have CLI and in those with persistent lifestyle-limiting claudication despite optimal medical therapy and an exercise program, revascularization is indicated for limb salvage and symptom relief, respectively. Consensus guidelines currently support an endovascular first approach to revascularization in the majority of cases. Surgical procedures provide an alternative to endovascular therapy in select cases.