Endovascular recanalization of infra-popliteal TASC C and TASC D lesions in patients with critical limb-threatening ischemia: a single-center experience.

PURPOSE: The present study aims to (1) assess the technical success and limb salvage rates of endovascular therapy in patients with critical limb-threatening ischemia (CLTI) and infra-popliteal Trans-Atlantic Inter-Society Consensus (TASC) C/D lesions according to the updated 2015 TASC II classification and (2) to present our institutional experience. METHODS: A single-center retrospective study was conducted on patients with TASC C/D CLTI who underwent endovascular treatment between 2012 and 2017. The follow-up protocol consisted of Doppler ultrasound conduction every 3 months for the first year unless patients showed symptoms of CLTI. Patients with at least 1 year of follow-up data were included in the study, and if applicable their 3-year results were evaluated in terms of primary patency, absence of amputation, amputation-free survival, and overall survival. RESULTS: A total of 248 patients and 287 limbs (238 TASC D lesions and 49 TASC C lesions) were treated via infra-popliteal percutaneous transluminal angioplasty. The overall technical success was 87%, the primary patency rate was 41.5% in the first year, and the freedom from amputation rates were 80.8% in 1 year and 67.7% in 3 years. CONCLUSION: In patients with infra-popliteal arterial occlusive diseases, endovascular treatment methods demonstrate a high rate of technical success and favorable outcomes in limb preservation.

An International Delphi Consensus on Diagnostic Criteria for Buerger's Disease.

BACKGROUND: Buerger's disease (BD) remains a debilitating condition. Despite multiple published diagnostic criteria for BD, none is universally accepted as a gold standard. METHODS: We conducted a 2-round modified Delphi consensus study to establish a consensus on the diagnostic. The questionnaire included statements from several commonly used diagnostic criteria for BD. Qualitative and quantitative analysis methods were performed. An agreement level of 70% was applied. RESULTS: Twenty nine experts from 18 countries participated in this study. Overall, 75 statements were circulated in Round 1. Of these, 28% of statements were accepted. Following comments, 21 statements were recirculated in Round 2 and 90% were accepted. Although more than 90% of the experts did not agree that the diagnosis of BD can be based only on clinical manifestation, none of the nonclinical manifestations of BD were agreed as a part of the diagnostic criteria. There was an agreement that a history of tobacco consumption in any form, not necessarily confined to the current use, should be a part of the diagnostic criteria of BD. The history of thrombophlebitis migrans, even if not present at presentation, was accepted as a clue for BD diagnosis. It was also agreed that discoloration of the toes or fingers could be included in the diagnostic criteria of BD. Experts agreed that histology results could differentiate BD from atherosclerosis obliterans and other types of vasculitis. The presence of corkscrew collaterals on imaging and burning pain reached the agreement at the first round but not at the second. There was no consensus regarding age cut-off, the requirement of normal lipid profile, and normal blood glucose for BD diagnosis. CONCLUSIONS: The present study demonstrated discrepancies in the various published diagnostic criteria for BD and their selective utilization in routine clinical practice worldwide. We propose that all published diagnostic criteria for BD be re-evaluated for harmonization and universal use.

Dynamic Volume Perfusion CT of the Foot in Critical Limb Ischemia: Response to Percutaneous Revascularization.

OBJECTIVE. The purpose of this study was to assess the reproducibility and validity of quantitative perfusion parameters derived from dynamic volume perfusion CT in patients with critical limb ischemia (CLI) and to evaluate perfusion parameter changes before and after endovascular revascularization. SUBJECTS AND METHODS. Patients with CLI referred for unilateral extremity endovascular arterial recanalization were enrolled in this study. CT examinations obtained 1-3 days before the procedure and then within 1 week after the treatment were evaluated at two reading sessions. Blood flow (BF), blood volume (BV), and time to peak (TTP) were measured on color-coded maps and compared statistically. Intraobserver agreement was assessed using intraclass correlation coefficient (ICC) and Bland-Altman analysis. RESULTS. Endovascular treatment was technically successful for all 16 patients. The posttreatment BF and BV showed a statistically significant increase in both dermal and muscle areas (p < 0.05). The posttreatment TTP shortened at a statistically significant level (p < 0.05). In the 3-month clinical follow-up period, the limb salvage rate was 81% and the percentage change in BF and BV of patients with poor response to treatment had no statistically significant increase after treatment, consistent with the clinical assessment. The percentage change in BF and BV correlated well with the improvement of the clinical condition (r = 0.673-0.901). ICC values showed excellent agreement in the range of 0.95-0.98. CONCLUSION. As a reproducible method, dynamic volume perfusion CT of the foot may enable quantitative evaluation of the perfusion of soft tissues and also provide a novel approach to assessing response to endovascular recanalization in CLI.

Effect of picroside II on hind limb ischemia reperfusion injury in rats.

INTRODUCTION: Many structural and functional damages are observed in cells and tissues after reperfusion of previously viable ischemic tissues. Acute ischemia reperfusion (I/R) injury of lower extremities occurs especially when a temporary cross-clamp is applied to the abdominal aorta during aortic surgery. Research regarding the treatment of I/R injury has been increasing day-by-day. In this study, we aimed to investigate the effect of picroside II on skeletal muscle of rats experiencing simulated I/R. MATERIALS AND METHODS: Twenty-four male Wistar albino rats weighing between 210 and 300 g were used in this study. Rats were randomly divided into 4 groups of 6 rats each (control, I/R, control + picroside II, and I/R + picroside II). The infrarenal section of the abdominal aorta was occluded with an atraumatic microvascular clamp in I/R group. The clamp was removed after 120 minutes and reperfusion was provided for a further 120 minutes. Picroside II (10 mg kg-1) was administered intraperitoneally to the animals in control + picroside II and I/R + picroside II groups. At the end of the study, skeletal muscle tissue was obtained for the determination of total oxidant status (TOS) and total antioxidant status (TAS) levels. Apoptosis was evaluated by TUNEL experiment. RESULTS: TOS levels were significantly higher in I/R group than that of control and I/R + picroside II groups (P=0.014, P=0.005, respectively). TAS levels were significantly higher in I/R group than that of control and I/R + picroside II groups (P=0.007 P=0.005, respectively). TUNEL assay revealed that picroside II reduced cell necrosis. CONCLUSION: The results of this study demonstrated that picroside II plays a critical role to prevent I/R injury. Even though our results were found to be satisfactory, it should be encouraging to those who want to conduct future research on this topic.

Effect of picroside II on erythrocyte deformability and lipid peroxidation in rats subjected to hind limb ischemia reperfusion injury.

BACKGROUND: Ischemia reperfusion injury (I/R) in hind limb is a frequent and important clinical phenomenon. Many structural and functional damages are observed in cells and tissues in these kinds of injuries. In this study, we aimed to evaluate the effect of picroside II on lipid peroxidation and erythrocyte deformability during I/R in rats. METHODS: Rats were randomly divided into four groups - each containing six animals (sham, I/R, sham + picroside II, and I/R + picroside II). The infrarenal section of the abdominal aorta was occluded with an atraumatic microvascular clamp in I/R groups. The clamp was removed after 120 minutes and reperfusion was provided for a further 120 minutes. Picroside II (10 mg·kg(-1)) was administered intraperitoneally to the animals in the appropriate groups (sham + picroside II, I/R + picroside II groups). All rats were euthanized by intraperitoneal administration of ketamine (100 mg·kg(-1)) and taking blood from the abdominal aorta. Erythrocytes were extracted from heparinized complete blood samples. Buffer (PT) and then erythrocytes (PE) were passed through the filtration system and the changes in pressure were measured to investigate the role of serum malondialdehyde and nitric oxide (NO) in lipid peroxidation and erythrocyte deformability index. RESULTS: Deformability index was significantly increased in the I/R group compared to groups sham, sham + picroside-II, and I/R + picroside-II (P<0.0001, P<0.0001, and P=0.007). Malondialdehyde (MDA) and NO levels were evaluated. MDA level and NO activity were also higher in the I/R group than in the other groups. Picroside II treatment before hind limb I/R prevented these changes. CONCLUSION: These results support that deformability of erythrocytes is decreased in I/R injury and picroside II plays a critical role to prevent these alterations. Further experimental and clinical studies are needed to evaluate and clarify the molecular mechanisms of action and clinical importance of these findings.

Early postoperative results for females undergoing isolated coronary artery bypass surgery: comparison of the pre- and postmenopausal periods.

PURPOSE: In this retrospective study, we investigated the demographic data and evaluated our early postoperative results of premenopausal and postmenopausal females who underwent coronary artery bypass graft surgery (CABG). METHODS: A total of 730 female patients who underwent CABG between April 2004 and January 2012 were included in the study. Patients were divided into two groups based on whether they were pre- (group 1) or postmenopausal (group 2). The groups were compared in terms of the demographic and peri-operative parameters. RESULTS: Smoking and the preoperative hematocrit levels were higher in group 1, whereas the incidence of hypertension and obesity and the European system for cardiac operative risk evaluation values were higher in group 2 (p values <0.01; <0.01; <0.01; 0.004 and <0.01 respectively). The utilization of a left internal mammary artery graft and the postoperative drainage volumes were higher in group 1; however, the number of grafts per patient, cardiopulmonary bypass duration, number of patients who needed inotropic support, blood transfusion volumes, the duration of ventilatory support and the hospital stay were higher in group 2 (p values 0.038; 0.040; 0.026; 0.032; 0.014; 0.001; <0.01 and <0.01, respectively). CONCLUSIONS: Although the mortality rates were not significantly different, postmenopausal patients require more intensive postoperative care in comparison to premenopausal patients following CABG.

Single-stage repair of the anterior chest wall following sternal destruction complicated by mediastinitis.

PURPOSE: Although various techniques have been described, the ideal reconstructive procedure for treating massive sternal fragmentation and necrosis is still a matter of debate. Sometimes, reconstruction is so challenging that repetitive operations are required, particularly when complicated by mediastinitis and sternal osteomyelitis. METHODS: Five patients (three males, two females, median age 66) with severe osteomyelitis and sternal destruction after receiving myocardial revascularization underwent partial or radical sternal resection, omental flap transposition, titanium mesh implantation and rectus abdominis muscle flap transposition. The final procedure involved single-stage closure. RESULTS: One patient died 9 days after the final procedure due to pneumonia and septicemia. The other patients received antibiotics for at least 6 weeks postoperatively. The mean hospital stay was 36 days. Optimal wound healing was observed, with acceptable cosmetic disorders. CONCLUSIONS: Although lateral sternal support is the first-line surgical treatment for sternal dehiscence, performing primary closure of complicated defects is often impossible. Aggressive treatment modalities are required in such cases for anterior chest wall defects. This technique provides the ability to perform rigid and stable sternal closure in complicated cases.

Differential identification of atypical pneumonia pathogens in aorta and internal mammary artery related to ankle brachial index and walking distance.

BACKGROUND: We studied the existence of agents in aorta biopsies, such as Chlamydia pneumoniae, cytomegalovirus, and Mycoplasma pneumoniae, that are thought to have a role in atherosclerosis etiopathogenesis role, and their association with peripheral artery disease. MATERIALS AND METHODS: We examined aorta wall and internal mammarian artery (IMA) biopsies taken from two different places in 63 patients in whom coronary artery bypass was performed. In these biopsies, we evaluated the deoxyribonuclease (DNA) of these microorganisms using polymerase chain reaction. From the same patients, we recorded the ankle brachial index, road walking distance information, lipid profile, C-reactive proteins, blood parameters such as fibrinogen, and the patient's operation data. RESULTS: In the nine aorta biopsies taken from 63 patients, we isolated C pneumoniae DNA. In IMA biopsies taken from the same patients, we detected no microorganism DNA (P < 0.001). In the same aorta biopsies, we found no cytomegalovirus or M pneumoniae DNA. We examined 12 patients using an index value of 0.9 in the ankle brachial index evaluation; eight had C pneumoniae in the aorta biopsies (P < 0.001). CONCLUSIONS: We found a significant relationship between C pneumoniae DNA and the existence of peripheral artery disease. In the development of atherosclerosis with C pneumoniae, there may be a determinant pathogen in both the aorta and the peripheral arteries. The nonexistence of C pneumoniae DNA in the IMA biopsies may indicate infectious agents because of the predominant endothelial functions in this artery, and thus its resistance to atherosclerosis.

Effect of iloprost on renal function in patients undergoing coronary artery bypass grafting: a clinical study.

PURPOSE: Renal dysfunction remains a serious complication of coronary artery bypass grafting (CABG) surgery and is associated with increased mortality and morbidity. To date, a number of different strategies, including new pharmacologic agents, off-pump and cardiopulmonary bypass techniques have been used to avoid it, but none of them proves the excellent result. METHODS: Between April 2009 to September 2011, 185 consecutive patients with multivessel coronary artery disease undergoing elective CABG were included the study. Iloprost was given with the onset of rewarming period at a dose of 1.25-2.5 ng/kg/min and it was ended together with the ending of CPB in 94 patients and remaining were in the control group. Creatinine clearance (CCr) and GFR were measured at the time of hospitalisation and on day first and fifth postoperatively. Serum potassium level was determined every 6 hours, during the first 24 hours postoperatively, and every 12 hours for the next 72 hours, and glomerular filtration rate was estimated. RESULTS: There was no statistically significant difference in preoperative comorbidity. There were no significant differences in postoperative morbidity or mortality between either of the two groups that completed the study. However, urine output during the operation was significantly higher in the study group. An increase in creatine levels was more common in the control group. Development of a new CCr less than 50 ml/min was also significantly higher in the control group, postoperatively. CONCLUSION: Our study demonstrates that prophylactic intravenous iloprost administration after initiation of a rewarming period during CPB in patients undergoing CABG surgery is associated with improved renal function, compared with conventional treatment in well-hydrated patients. It also has a good safety profile and is generally well tolerated.

Detection of Helicobacter pylori DNA in aortic and left internal mammary artery biopsies.

We investigated the relationship between acute coronary ischemia and the presence of Helicobacter pylori DNA in aortic regions that were absent macroscopic atheromatous plaques. The study group (Group 1) consisted of 42 patients who underwent coronary artery bypass grafting. Biopsy samples were obtained from 2 different locations: from regions of the aorta that were free (macroscopically) of atheromatous plaque (Group 1A), and from the internal mammary artery (Group 1B). The control group (Group 2) of 10 patients who had no atherosclerotic vascular disease provided aortic tissue samples for comparison. The real-time polymerase chain reaction method was used to detect H. pylori DNA in all biopsy samples. Eleven of 42 aortic tissue samples (26%) in Group 1A were positive for H. pylori DNA. Neither biopsies from the left internal mammary arteries of those patients nor biopsies from the aortas of the control group (Group 2) were positive for H. pylori DNA. There was a statistically significant difference between 1A and 1B in terms of H. pylori positivity (P=0.001). In Group 1 as a whole, acute coronary ischemia was more prevalent in the H. pylori-positive patients than in the H. pylori-negative patients (P=0.001). To our knowledge, this is the 1st study to investigate the detection of H. pylori DNA in aortic biopsy samples that are macroscopically free of atheromatous plaque. Such detection in patients who have atherosclerotic coronary artery disease could be an important indication of the role of microorganisms in the pathogenesis of atherosclerosis.

Effects of atypical pneumonia agents on progression of atherosclerosis and acute coronary syndrome.

BACKGROUND: The aim of this study was to investigate the presence of various atypical pneumonia agents (Chlamydia pneumoniae, cytomegalovirus, Mycoplasma pneumoniae), which are considered to have a role in the ethiopathogenesis of atherosclerosis, in aortic biopsies without macroscopically visible plaque and in internal thoracic artery biopsies. MATERIAL AND METHODS: Thirty-three patients (group 1), who had undergone coronary bypass operation and 10 non-atherosclerotic patients (group 2), were included in the study. Seventy-six tissue biopsies were taken. Biopsies from the patients in group 1 a were obtained from the atheroma plaque-free aortic tissue and 33 biopsies (group Ib) were obtained from their internal thoracic arteries. Following DNA extraction, nested PCR was used to detect Chlamydia pneumoniae DNA, and real time PCR was used to detect cytomegalovirus and Mycoplasma pneumoniae DNA. Blood parameters (lipid profile, CRP, fibrinogen) of the patients and operation characteristics were recorded. RESULTS: Chlamydia pneumoniae DNA was detected in 5 of 33 biopsy samples from coronary bypass patients, whereas none of the control patients (group 1b and group 2) were positive for this agent (P = 0.001). Neither CMV nor Mycoplasma pneumoniae was detected in IMA and aortic biopsies of both bypass and control patients. Elevated total cholesterol levels (P = 0.02) and positive CRP (P = 0.001) was found in C. pneumoniae positive patients. Prevalence of acute coronary syndrome was significantly higher in C. pneumoniae detected patients compared (P = 0.00 1). CONCLUSIONS: Detection of C. pneumoniae DNA in the atheroma free aortic biopsies might indicate that this micro-organism intervened in the progression of atheroma plaque. There was a strong relationship between the detection of this micro-organism in the aortic wall and acute coronary syndrome. The absence of DNA of the corresponding micro-organisms in the IMA wall may show its resistance to infective agents and in turn to atherosclerosis, which is a result of the prevailing endothelial functions of this artery.