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1.
Vasc Endovascular Surg ; 54(2): 126-134, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31709914

RESUMEN

INTRODUCTION: Revascularization is the cornerstone of the treatment of critical limb ischemia (CLI), but the number of elderly frail patients increase. Revascularization is not always possible in these patients and conservative therapy seems to be an option. The goals of this study are to analyze the 1-year quality of life (QoL) results and mortality rates of elderly patients with CLI and to investigate if conservative treatment could be an acceptable treatment option. METHODS: Patients with CLI ≥70 years old were included in a prospective observational cohort study in 2 hospitals in the Netherlands between 2012 and 2016 and were divided over 3 treatment modalities: endovascular therapy, surgical revascularization, and conservative treatment. The World Health Organization Quality of Life (WHOQoL-Bref) instrument, a generic QoL assessment tool that includes components of physical, psychological, social relationships and environment, was used to evaluate QoL at baseline, 6 months, and 1 year. RESULTS: In total, 195 patients (56% male, 33% Rutherford 4, mean age of 80) were included. Physical QoL significantly increased after surgical (10.4 vs 14.9, P < .001), endovascular (10.9 vs 13.7, P < .001), and conservative therapy (11.6 vs 13.2, P = .01) at 1 year. One-year mortality was relatively low after surgery (10%) compared to endovascular (40%) and conservative therapy (37%). CONCLUSION: The results of this study could not be used to designate the superior treatment used in elderly patients with CLI. Conservative treatment could be an acceptable treatment option in selected patients with CLI unfit for revascularization. Treatment of choice in elderly patients with CLI is based on multiple factors and should be individualized in a shared decision-making process.


Asunto(s)
Tratamiento Conservador , Procedimientos Endovasculares , Isquemia/terapia , Enfermedad Arterial Periférica/terapia , Calidad de Vida , Procedimientos Quirúrgicos Vasculares , Factores de Edad , Anciano , Anciano de 80 o más Años , Tratamiento Conservador/efectos adversos , Tratamiento Conservador/mortalidad , Enfermedad Crítica , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Masculino , Países Bajos , Selección de Paciente , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Estudios Prospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad
2.
World Neurosurg ; 133: 314-317, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31648054

RESUMEN

BACKGROUND: The adult spinal cord is typically resistant to hypoxic-ischemic injury because of collateral blood supply; however, congenital or acquired stenosis may result in baseline maximal vasodilation, such as superimposed hemodynamic stresses, that cannot be accommodated, leaving the spinal cord vulnerable to ischemic injury. We present a rare case of spinal cord hypoxic-ischemic injury in an adult with underlying cervical spinal stenosis. CASE DESCRIPTION: A 37-year-old man with a history of morbid obesity, diabetes mellitus, hypertension, and obstructive sleep apnea presented after developing progressive weakness in the extremities. Preoperative computed tomography myelography demonstrated ossification of the posterior longitudinal ligament and severe spinal canal narrowing. Approximately 1 week after posterior decompression, the patient experienced spinal hypoxic-ischemic injury. Imaging revealed cord expansion and abnormal T2 signal intensity. Axial diffusion tensor images of the brain revealed delayed ischemic leukoencephalopathy with restricted diffusion in the cerebral cortex and deep white matter; this led to the decision to withdraw care, and the patient died. CONCLUSIONS: We hypothesize that vascular dysregulation due to cervical stenosis made the cord parenchyma vulnerable to hypoxic and/or hypoperfusion stresses.


Asunto(s)
Descompresión Quirúrgica/efectos adversos , Isquemia/etiología , Leucoencefalopatías/etiología , Osificación del Ligamento Longitudinal Posterior/cirugía , Médula Espinal/irrigación sanguínea , Estenosis Espinal/cirugía , Adulto , Resultado Fatal , Humanos , Isquemia/diagnóstico por imagen , Leucoencefalopatías/diagnóstico por imagen , Masculino , Osificación del Ligamento Longitudinal Posterior/diagnóstico por imagen , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Médula Espinal/diagnóstico por imagen , Estenosis Espinal/diagnóstico por imagen
3.
Angiology ; 71(2): 122-130, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31303025

RESUMEN

The ability of carotid intima-media thickness (IMT) to predict risk beyond plaque is controversial. In 952 participants (critical limb ischemia [CLI] or stroke, n = 473; community, n = 479), we assessed whether relationships with events for IMT complement the impact of plaque in young patients depending on the extent of thrombotic versus atherosclerotic disease. The extent of atherosclerotic versus thrombotic occlusion was determined in 54 patients with CLI requiring amputations. Thrombotic occlusion in CLI was associated with younger age (P < .0001) and less plaque (P = .02). Independent relations between plaque and CLI were noted in older (>50 years; P < .005 to <.0001) but not younger (P > .38) participants, while independent relations between plaque and stroke (P < .005 to <.0001) and between IMT and CLI (P < .0001) were noted in younger participants. Although in performance (area under the receiver operating curve) for event detection, IMT thresholds failed to add to plaque alone in older patients (0.680 ± 0.020 vs 0.664 ± 0.017, P = .27), IMT improved performance for combined stroke and CLI detection when added to plaque in younger patients (0.719 ± 0.023 vs 0.631 ± 0.026, P < .0001). Because in younger participants the high prevalence of thrombotic occlusion in CLI is associated with less plaque, IMT adds information in associations with arterial vascular events.


Asunto(s)
Grosor Intima-Media Carotídeo , Isquemia/complicaciones , Isquemia/diagnóstico por imagen , Pierna/irrigación sanguínea , Pierna/diagnóstico por imagen , Placa Aterosclerótica/complicaciones , Placa Aterosclerótica/diagnóstico por imagen , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/diagnóstico por imagen , Trombosis/complicaciones , Trombosis/diagnóstico por imagen , Factores de Edad , Anciano , Enfermedad Crítica , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas
4.
Vasc Endovascular Surg ; 54(2): 141-146, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31749415

RESUMEN

OBJECTIVES: To compare outcomes in patients randomized to infrapopliteal (IP) plain balloon angioplasty (PBA) for chronic limb-threatening ischemia within the Bypass versus Angioplasty in Severe Ischemia of the Leg (BASIL)-1 trial between 1999 and 2004 with outcomes in consecutive patients undergoing IP PBA at an academic vascular unit a decade later (2009-2013, Contemporary series [CS]). METHODS: Individual patient data were obtained from prospective BASIL-1 (48 patients) and CS databases (73 patients). All had a minimum of 3-years of follow-up. Outcomes studied were amputation-free survival (AFS), overall survival (OS), major (above ankle) limb amputation, arterial reintervention, immediate technical success, and length of hospital stay for the index procedure and during the following 12-month period. Statistical analysis was performed using SAS version 9.4. RESULTS: The BASIL and CS cohorts were well matched for gender, age, diabetes, previous stroke, myocardial infarction and arterial intervention, and presence of tissue loss. More patients in BASIL-1 underwent concomitant treatment of the superficial femoral (60% vs 37%, P = .01) and above knee popliteal (60% vs 34%, P = .005) arteries. Immediate technical success increased from 73% in BASIL-1 to 90% in the CS (P = .01). Between the two cohorts, there were no differences in AFS (hazard ratio [HR] = 1.00, 95% confidence interval [CI]: 0.65-1.54, P = 1.0), OS (HR = 1.04, 95% CI: 0.66-1.62, P = .9), major amputation (HR = 0.86, 95% CI: 0.37-1.97, P = .7), or reintervention (HR = 0.61, 95% CI: 0.29-1.27, P = .2). Contemporary series patients spent significantly fewer days in hospital following the index procedure (P = .02) and also over the following 12 months (P = .002). CONCLUSIONS: Despite improvements in the immediate technical angiographic success of IP PBA between BASIL and the CS, there were no significant improvements in survival outcomes. Results from BASIL-2 and BEST-CLI are required in order to properly define the clinical and cost-effectiveness of endovascular treatment in such patients.


Asunto(s)
Angioplastia de Balón , Isquemia/terapia , Enfermedad Arterial Periférica/terapia , Arteria Poplítea , Anciano , Anciano de 80 o más Años , Amputación , Angioplastia de Balón/efectos adversos , Enfermedad Crónica , Bases de Datos Factuales , Femenino , Humanos , Isquemia/diagnóstico por imagen , Isquemia/fisiopatología , Tiempo de Internación , Masculino , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Supervivencia sin Progresión , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Factores de Tiempo , Grado de Desobstrucción Vascular
5.
Vasc Endovascular Surg ; 54(1): 69-74, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31500525

RESUMEN

Acute limb ischemia (ALI) is an abrupt decrease of blood flow to a limb, resulting in a potential threat to that body part. In ALI, which is commonly caused by embolism or traumatic occlusion, symptoms appear quickly due to a lack of collateral blood flow and extension of the thrombus to arterial outflow. In cases with ALI presentation, urgent evaluation and management are necessary. Here, we report 3 cases with ALI due to thromboembolism. Conventional open thromboembolectomy was performed with a femoral artery cutdown and antegrade passage of the embolectomy catheter. Further, distal access was created in the dorsalis pedis artery and/or posterior tibial artery at the ankle level. After the retrograde passage of the guidewire and antegrade insertion of the embolectomy catheter, the embolus was completely removed.


Asunto(s)
Embolectomía , Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Trombectomía , Tromboembolia/cirugía , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Humanos , Isquemia/diagnóstico por imagen , Isquemia/fisiopatología , Masculino , Tromboembolia/diagnóstico por imagen , Tromboembolia/fisiopatología , Resultado del Tratamiento
6.
Vasc Endovascular Surg ; 54(1): 17-24, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31526118

RESUMEN

INTRODUCTION: The aim of this study is to describe our experience in the treatment of femoropopliteal occlusive disease with percutaneous transluminal angioplasty (PTA) followed by stenting with S.M.A.R.T. Flex vascular stent system. MATERIALS AND METHODS: From June 2014 to October 2018, 80 patients were treated at our Institution for intermittent claudication, critical, or acute limb ischemia due to total occlusion or long diffused lesions of the femoropopliteal segment. Main study end points are primary patency, target lesion revascularization, and stent fractures; secondary end points are major amputation rate, procedure-related bleeding, incidence of intrastent restenosis, and primary assisted patency after reintervention. RESULTS: Mean follow-up time was 21 months (range 2-48 months). Primary patency rate was 80% (64 patients of 80), with mean covered lesion length of 8.2 cm. The deployment of a single stent was obtained for 57 (89%) patients, with a mean stent length of 9.86 cm. Of 80 patients, 2 (2.5%) had early stent occlusion within first 48 hours after the procedure, while 4 (5%) of 80 patients experienced stent occlusion within first 6 months. Of 80 patients, 6 (7.5%) had an intrastent restenosis detected at duplex ultrasound with a primary-assisted patency after simple re-PTA procedures of 83.3% at 12 months. DISCUSSION: In the literature, primary patency after PTA and stenting of the femoropopliteal trunk seems to be related to several variables, such as number of stents used, specific stent length, diameters, type and length of lesions, type of pathology (if acute or chronic), and number of preoperatory patent below-the-knee vessels. In this study, we try to analyze each single factor in order to understand their role in predisposing specific stent restenosis. CONCLUSIONS: S.M.A.R.T. Flex vascular stent system has shown good results in terms of primary patency in the treatment of calcified lesions both at SFA and at popliteal level. However, in our experience, stent patency seems to be significantly poorer in patients presenting with acute limb ischemia associated with chronic atherosclerotic disease as well as for lesions located in the mid-distal part of the popliteal artery and both when number of stents increases or number of runoff vessel decreases.


Asunto(s)
Angioplastia/instrumentación , Arteria Femoral , Claudicación Intermitente/terapia , Isquemia/terapia , Enfermedad Arterial Periférica/terapia , Arteria Poplítea , Stents , Anciano , Anciano de 80 o más Años , Angioplastia/efectos adversos , Femenino , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/fisiopatología , Humanos , Claudicación Intermitente/diagnóstico por imagen , Claudicación Intermitente/fisiopatología , Isquemia/diagnóstico por imagen , Isquemia/fisiopatología , Italia , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Arteria Poplítea/diagnóstico por imagen , Arteria Poplítea/fisiopatología , Recurrencia , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular
7.
Vasc Endovascular Surg ; 54(1): 80-84, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31533547

RESUMEN

Brachial artery pseudoaneurysms (BAPs) are rare but could lead to complications of high morbidity. We report a case of a BAP presenting with hand ischemia and median nerve neuropathy nearly a decade after the inciting iatrogenic trauma, successfully treated with excision and direct repair. This report highlights that untreated pseudoaneurysms can be indolent and present late with both symptoms of embolization and local compression.


Asunto(s)
Aneurisma Falso/etiología , Arteria Braquial/lesiones , Enfermedad Iatrogénica , Isquemia/etiología , Flebotomía/efectos adversos , Extremidad Superior/irrigación sanguínea , Lesiones del Sistema Vascular/etiología , Anciano de 80 o más Años , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/fisiopatología , Aneurisma Falso/cirugía , Arteria Braquial/diagnóstico por imagen , Arteria Braquial/fisiopatología , Arteria Braquial/cirugía , Humanos , Isquemia/diagnóstico por imagen , Isquemia/fisiopatología , Isquemia/cirugía , Masculino , Neuropatía Mediana/etiología , Flujo Sanguíneo Regional , Factores de Tiempo , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/fisiopatología , Lesiones del Sistema Vascular/cirugía
8.
Vasc Endovascular Surg ; 54(1): 85-88, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31547785

RESUMEN

The common femoral artery (CFA) is the most widely used inflow in all types of surgical revascularization in patients with peripheral artery disease. However, the CFA cannot always be used because of calcification, obstruction, or previous dissection. Here, we report a rare case of selecting the deep circumflex iliac artery (DCIA) as a source of inflow to perform a surgical revascularization in a patient with chronic limb-threatening ischemia. A 62-year-old man was admitted to our hospital due to necrotized third and fifth toes with pain at rest. Computed tomography showed severe stenosis of the CFA, superficial femoral artery, and deep femoral artery, and an entirely stented external iliac artery. The DCIA was identified as the only patent artery. Considering the condition of the other arteries, we selected the DCIA as a source of inflow. Deep circumflex iliac-popliteal bypass was performed with a saphenous vein. The bypass graft was patent 9 months after surgery and limb salvage had been achieved.


Asunto(s)
Arteria Ilíaca/cirugía , Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/cirugía , Injerto Vascular/métodos , Enfermedad Crónica , Humanos , Arteria Ilíaca/diagnóstico por imagen , Arteria Ilíaca/fisiopatología , Isquemia/diagnóstico por imagen , Isquemia/fisiopatología , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/fisiopatología , Resultado del Tratamiento , Grado de Desobstrucción Vascular
9.
J Cardiovasc Surg (Torino) ; 60(6): 672-678, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31603293

RESUMEN

BACKGROUND: Sarcopenia, commonly determined by measuring skeletal muscle mass index (SMI) at the third lumbar level, has been identified as a predictor of clinical outcome in a variety of diseases. For patients with peripheral arterial occlusive disease (PAOD), we hypothesized that lower extremity SMI (LESMI) might be a more precise predictor of outcome and the extent of chronic ischemia than the systemic muscle mass at the L3 level. We investigated the association between complete muscle volume and muscle area derived with single-slice 2-dimensional measurements in the legs to identify at which level cross-sectional single-slice measurements are most representative of the muscle volume and investigated whether LESMI is associated with systemic sarcopenia and PAOD severity. METHODS: Muscle volumes and areas were semiautomatically segmented from computed tomography (CT) scans of the affected and contralateral legs of 50 PAOD patients with Fontaine stage IIb and 50 PAOD patients with Fontaine stage IV. The muscle mass was determined for the complete volumes of the upper and lower legs and for cross-sectional slices at 40%, 50%, and 60% of the length of the femur and tibia. Patients were determined as sarcopenic based on sex-specific cut-off values at the L3 spinal segment. Two observers segmented 20 randomly selected patients to determine the interobserver reliability with the intraclass correlation coefficient. RESULTS: The correlation between the LESMI of the complete muscle volume and the three cross-sectional slices in all 200 upper and 200 lower legs was moderately strong to strong. Interobserver reliability of cross-sectional slice segmentation was excellent. The LESMI, both measured volumetrically and cross-sectionally, were significantly lower in patients with sarcopenia compared to patients without sarcopenia. The LESMI was lower in patients with Fontaine stage IV compared to patients with Fontaine stage IIb for both volumetric and cross-sectional measurements. CONCLUSIONS: Segmentation of skeletal muscle mass from cross-sectional single-slice CT in the upper and lower leg can accurately and precisely substitute complete volume segmentations. These findings warrant the use of measurements based on cross-sectional single-slice CT for assessing the LESMI. Patients with systemic sarcopenia are also at increased risk for muscle mass loss in the lower extremities. In the current study, LESMI was lower in patients with Fontaine class IV PAOD compared to patients with Fontaine class IIb PAOD. Future studies should assess the predictive value of the LESMI on clinical outcomes in PAOD patients.


Asunto(s)
Composición Corporal , Isquemia/diagnóstico por imagen , Extremidad Inferior/irrigación sanguínea , Músculo Esquelético/diagnóstico por imagen , Atrofia Muscular/diagnóstico por imagen , Enfermedad Arterial Periférica/diagnóstico por imagen , Sarcopenia/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Anciano , Femenino , Humanos , Isquemia/fisiopatología , Masculino , Persona de Mediana Edad , Músculo Esquelético/fisiopatología , Atrofia Muscular/fisiopatología , Variaciones Dependientes del Observador , Enfermedad Arterial Periférica/fisiopatología , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Sarcopenia/fisiopatología , Índice de Severidad de la Enfermedad
10.
J Cardiovasc Surg (Torino) ; 60(6): 642-651, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31603294

RESUMEN

INTRODUCTION: The aim of this article is to systematically review the literature on medical adjunctive therapy for patients with chronic limb-threatening ischemia (CLTI). EVIDENCE ACQUISITION: MEDLINE, Embase, and Cochrane Database of Systematic Reviews were searched for studies published between January 1st, 2009, and June 1st, 2019. Articles that studied medical treatment of CLTI patients and reported clinical outcomes were eligible. Main exclusion criteria were case reports <20 patients, incorrect publication type, and CLTI caused by Buerger disease. The primary end point was major amputation (above the ankle) in studies with a follow-up of ≥6 months. Secondary end points were other clinical end points such as death and wound healing. Study quality was assessed according to the Downs and Black checklist. EVIDENCE SYNTHESIS: Included were 42 articles: four focused on antiplatelet therapy, five on antihypertensive medication, 6 on lipid-lowering therapy, 16 on stem cell therapy, three on growth factors, five on prostanoids, and one study each on cilostazol, glucose-lowering therapy, spinal cord stimulation, sulodexide, and hemodilution. Calcium channel blockers, iloprost, cilostazol, and hemodilution showed significant improvement of limb salvage, but data are limited. Stem cell therapy showed no significant improvement of limb salvage but could potentially improve wound healing. Antiplatelets, antihypertensives, and statins showed significantly lower cardiovascular events rates but not evident lower major amputation rates. The quality of the studies was fair to good. CONCLUSIONS: Certain medical therapies serve to improve limb salvage next to revascularization in CLTI patients, whereas others are important in secondary prevention. Because high quality evidence is limited, further research is needed.


Asunto(s)
Fármacos Cardiovasculares/uso terapéutico , Isquemia/tratamiento farmacológico , Enfermedad Arterial Periférica/tratamiento farmacológico , Amputación , Fármacos Cardiovasculares/efectos adversos , Enfermedad Crítica , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Factores de Riesgo , Resultado del Tratamiento
11.
J Cardiovasc Surg (Torino) ; 60(6): 686-692, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31603296

RESUMEN

BACKGROUND: In patients requiring infrageniculate surgical revascularization a single-segment great saphenous vein (SS-GSV) is the optimal conduit. In the absence of a SS-GSV, the small saphenous vein and arm veins can also be used to obtain an all-autologous bypass. The aim of this study was to compare the long-term results of infrageniculate SS-GSV bypasses and spliced vein bypasses in patients with chronic limb-threatening ischemia (CLTI). METHODS: A total of 308 consecutive CLTI patients who underwent a primary infragenicular, autologous bypass between January 2000 and December 2016 were included. The definition of a spliced vein bypass was a graft consisting of at least two venous segments. RESULTS: A SS-GSV graft was used in 235 patients, and a spliced vein graft was used in 73 patients. Significantly more infrapopliteal bypasses were performed in the spliced vein group (P=0.024), and in this group the mean operation time was almost 60 minutes longer (P<0.001). The overall morbidity rate was 44%. The overall 30-day mortality was 3.2%, and overall in-hospital mortality was 4.9%. No significant differences were observed between the groups in mortality, overall morbidity or any specific complication. Comparing the SS-GSV group with the spliced vein group, no significant differences were observed between overall survival (53.2% vs. 45.7%), primary patency (55.5% vs. 53.2%), assisted primary patency (78.5% vs. 76.5%), secondary patency (87.9% vs. 90.6%) and limb salvage (83.3% vs. 82.0%). CONCLUSIONS: The use of infrageniculate spliced vein bypasses for the treatment of CLTI patients results in similar results compared with infrageniculate SS-GSV bypass grafts. A strict surveillance protocol in the first 2 years and a liberal reintervention strategy may result in excellent long-term patency rates.


Asunto(s)
Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/cirugía , Vena Safena/trasplante , Injerto Vascular/métodos , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Femenino , Mortalidad Hospitalaria , Humanos , Isquemia/diagnóstico por imagen , Isquemia/mortalidad , Isquemia/fisiopatología , Masculino , Persona de Mediana Edad , Países Bajos , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Flujo Sanguíneo Regional , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidad , Grado de Desobstrucción Vascular
12.
Invest Ophthalmol Vis Sci ; 60(13): 4310-4318, 2019 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-31622467

RESUMEN

Purpose: To evaluate whether retinal capillary nonperfusion is found predominantly adjacent to arteries or veins in eyes with diabetic retinopathy (DR). Methods: Sixty-three eyes from 44 patients with proliferative DR (PDR) or non-PDR (NPDR) were included. Images (12 × 12-mm) foveal-centered optical coherence tomography (OCT) angiography (OCTA) images were taken using the Zeiss Plex Elite 9000. In 37 eyes, widefield montages with five fixation points were also obtained. A semiautomatic algorithm that detects nonperfusion in full-retina OCT slabs was developed, and the percentages of capillary nonperfusion within the total image area were calculated. Retinal arteries and veins were manually traced. Based on the shortest distance, nonperfusion pixels were labeled as either arterial-side or venous-side. Arterial-adjacent and venous-adjacent nonperfusion and the A/V ratio (arterial-adjacent nonperfusion divided by venous-adjacent nonperfusion) were quantified. Results: Twenty-two eyes with moderate NPDR, 16 eyes with severe NPDR, and 25 eyes with PDR were scanned. Total nonperfusion area in PDR (median: 8.93%) was greater than in moderate NPDR (3.49%, P < 0.01). Arterial-adjacent nonperfusion was greater than venous-adjacent nonperfusion for all stages of DR (P < 0.001). The median A/V ratios were 1.93 in moderate NPDR, 1.84 in severe NPDR, and 1.78 in PDR. The A/V ratio was negatively correlated with the total nonperfusion area (r = -0.600, P < 0.0001). The results from the widefield montages showed similar patterns. Conclusions: OCTA images with arteries and veins traced allowed us to estimate the nonperfusion distribution. In DR, smaller nonperfusion tends to be arterial-adjacent, while larger nonperfusion tends toward veins.


Asunto(s)
Retinopatía Diabética/fisiopatología , Isquemia/fisiopatología , Arteria Retiniana/fisiopatología , Vena Retiniana/fisiopatología , Anciano , Capilares/fisiopatología , Estudios Transversales , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 2/complicaciones , Retinopatía Diabética/diagnóstico por imagen , Femenino , Angiografía con Fluoresceína , Humanos , Isquemia/diagnóstico por imagen , Edema Macular/diagnóstico por imagen , Edema Macular/fisiopatología , Masculino , Persona de Mediana Edad , Arteria Retiniana/diagnóstico por imagen , Vena Retiniana/diagnóstico por imagen , Estudios Retrospectivos , Tomografía de Coherencia Óptica/métodos
14.
J Med Vasc ; 44(5): 350-353, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31474347

RESUMEN

Penetrating injuries of axillary artery are uncommon and associated with high mortality and morbidity rate. Clinical presentation of these injuries may vary; therefore, a high index of suspicion is essential. We are reporting a case of late presentation of axillary arterial ischemia, 10 days after a gunshot wound, which occurred to a 20-year-old male. The patient was treated successfully with open surgical intervention.


Asunto(s)
Arteria Axilar/lesiones , Isquemia/etiología , Lesiones del Sistema Vascular/etiología , Heridas por Arma de Fuego/etiología , Arteria Axilar/diagnóstico por imagen , Arteria Axilar/cirugía , Humanos , Isquemia/diagnóstico por imagen , Isquemia/cirugía , Masculino , Factores de Tiempo , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/cirugía , Heridas por Arma de Fuego/diagnóstico por imagen , Heridas por Arma de Fuego/cirugía , Adulto Joven
15.
J Pak Med Assoc ; 69(8): 1216-1218, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31431784

RESUMEN

Peripartum cardiomyopathy (PPCM) is a condition of unknown etiology that presents as heart failure due to left ventricular systolic dysfunction in the last of month of pregnancy and up to six months after giving birth. PPCM predisposes towards thrombo-embolism and an acute limb ischaemia can be a manifestation of this disease. We present a case of a 23-year-old lady presenting an acute lower limb ischaemia four months post-partum. Doppler ultrasound showed bilateral femoral emboli and cardiac ECHO showed a 24% ejection fraction. Amputation was performed on both limbs, below her right knee and above her left knee. The patient was started on heart failure medication and her symptoms improved with diuretic therapy, confirming the diagnoses of PPCM. It is important to recognise acute limb ischaemia as a rare manifestation of PPCM, as a timely diagnosis and effective treatment of the disease can improve the prognosis. We believe this is the first case to be reported in medical literature from Pakistan of a patient presenting PPCM with bilateral acute limb ischaemia and gangrene.


Asunto(s)
Cardiomiopatías/complicaciones , Embolia/etiología , Arteria Femoral/diagnóstico por imagen , Gangrena/etiología , Isquemia/etiología , Trastornos Puerperales/diagnóstico por imagen , Amputación , Cardiomiopatías/diagnóstico por imagen , Ecocardiografía , Embolectomía , Embolia/diagnóstico por imagen , Embolia/cirugía , Femenino , Gangrena/cirugía , Humanos , Isquemia/diagnóstico por imagen , Extremidad Inferior , Volumen Sistólico , Insuficiencia del Tratamiento , Ultrasonografía Doppler , Adulto Joven
17.
Saudi J Kidney Dis Transpl ; 30(4): 985-988, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31464261

RESUMEN

Cramps are very common in hemodialysis (HD) patients. A high ultrafiltration rate and volume contraction have been implicated in the pathogenesis, but the underlying mechanism is not yet fully elucidated. We present a male HD patient with cramps during his session, attributed to acute limb ischemia due to thrombosis of a common femoral artery aneurysm (CFAA). The true CFAAs are extremely rare, but the pseudoaneurysms (or false aneurysms) are less uncommon resulting after femoral catheterization for diagnostic and therapeutic procedures. This aneurysm was eccentric in shape which in conjunction with the patient's history of femoral catheterization strongly suggests us to consider it a pseudoaneurysm. Although the patient was operated with the clinical suspicion of arterial embolism due to atrial fibrillation and the subtherapeutic anticoagulation, no embolus was found in the aneurysm. We want to emphasize that the presence of cramps is not always innocent, simply attributed to HD. Rarely, it may result from or mask severe and devastating acute leg ischemia caused by thrombosis of a CFAA. Notably, the thrombosis of a CFAA (true or false) is an extremely rare condition. We suggest all the HD patients with a history of femoral cannulation to undergo a vascular ultrasound in the related femoral artery at least once, to manage and to prevent the complications.


Asunto(s)
Aneurisma Falso/etiología , Cateterismo Periférico/efectos adversos , Arteria Femoral/lesiones , Isquemia/etiología , Extremidad Inferior/irrigación sanguínea , Calambre Muscular/etiología , Diálisis Renal , Trombosis/etiología , Lesiones del Sistema Vascular/etiología , Anciano , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/cirugía , Implantación de Prótesis Vascular , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/cirugía , Humanos , Isquemia/diagnóstico por imagen , Isquemia/cirugía , Masculino , Calambre Muscular/diagnóstico , Diálisis Renal/efectos adversos , Trombosis/diagnóstico por imagen , Trombosis/cirugía , Factores de Tiempo , Resultado del Tratamiento , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/cirugía
19.
Vasc Endovascular Surg ; 53(7): 606-608, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31272303

RESUMEN

Hydrophilic polymer coatings are now widely applied to catheters and other intravascular devices used in neurovascular, cardiovascular, and peripheral vascular procedures. Emboli consisting of these materials have been previously identified in biopsies and autopsies following pulmonary infarction, stroke, gangrene, or death. We report a case involving a nonhealing foot ulcer that appeared following cardiac catheterization, stenting, and automatic implanted cardiac defibrillator (AICD) implantation in a patient without other evidence of significant peripheral artery disease. An 85-year-old woman with chronic atrial fibrillation, aortic valve stenosis, and coronary artery disease underwent coronary stenting and AICD implantation for ventricular tachycardia and syncope. She developed a toe ulcer shortly thereafter, which did not respond to standard treatment. A histological examination following amputation of the toe found amorphous basophilic material in capillaries adjacent to the edge of the ulcer, which was similar to material associated with hydrophilic polymer coatings. Ischemia and infarcts following endovascular procedures should not be presumed to result from thrombus or vascular disease, even if intravascular devices appear intact or properly placed after the procedure. To help establish the incidence of ischemia caused by hydrophilic polymer device coatings, if excision of ischemic or infarcted tissue after endovascular procedures using coated devices becomes necessary, the tissue should be evaluated microscopically. Surgeons should also consider the tolerance of distal organs to infarct or ischemia when selecting coated intravascular devices.


Asunto(s)
Materiales Biocompatibles Revestidos/efectos adversos , Embolia/etiología , Úlcera del Pie/etiología , Migración de Cuerpo Extraño/etiología , Isquemia/etiología , Polímeros/efectos adversos , Dedos del Pie/irrigación sanguínea , Anciano de 80 o más Años , Amputación , Angiografía , Biopsia , Embolia/diagnóstico por imagen , Embolia/cirugía , Femenino , Úlcera del Pie/diagnóstico por imagen , Úlcera del Pie/fisiopatología , Úlcera del Pie/cirugía , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/cirugía , Humanos , Interacciones Hidrofóbicas e Hidrofílicas , Isquemia/diagnóstico por imagen , Isquemia/fisiopatología , Isquemia/cirugía , Flujo Sanguíneo Regional , Dedos del Pie/cirugía , Resultado del Tratamiento
20.
Pediatr Rheumatol Online J ; 17(1): 39, 2019 Jul 10.
Artículo en Inglés | MEDLINE | ID: mdl-31291964

RESUMEN

BACKGROUND: Deficiency of adenosine deaminase 2 (DADA2) is a rare autosomal recessive autoinflammatory condition. Recognised features include vasculitis predominantly affecting medium sized vessels, livedoid skin rash, central and peripheral nervous system involvement, variable degrees of immunodeficiency, and marrow failure, amongst other clinical presentations. We present the case of a six year old male with DADA2 who presented with acute testicular ischaemia secondary to vasculitis, the first such description in DADA2. CASE PRESENTATION: A six year old male presented acute right-sided testicular pain. His history included transient infantile neutropenia, resolved hepatosplenomegaly, and longstanding livedo racemosa, leading to screening and confirmation of DADA2 caused by homozygous c.139G > C (p.G47R) mutation of ADA2. As his only clinical feature was that of mild livedo racemosa with normal laboratory parameters at diagnosis, he was being actively monitored prior to starting any treatment. At a routine clinic follow-up a 24 h history of testicular pain was noted on systems review. He was afebrile, and his only physical signs were that of moderate livedo racemosa, and tenderness of the right testicle. Laboratory parameters revealed C-reactive protein (CRP) 8 mg/L (reference range [RR] < 20 mg/L); erythrocyte sedimentation rate (ESR) 28 mm/hr. (RR < 10); and serum amyloid A (SAA)5 mg/L (RR < 10). Ultrasound-scan of the scrotum revealed significantly reduced perfusion of the right testes, without torsion. Surgical scrotal exploration confirmed testicular ischaemia without torsion. Histology demonstrated ischaemic seminiferous tubules with intervening haemorrhage and acute inflammatory cells, consistent with vasculitis of the testis as the cause. He was treated with high dose intravenous methyl-prednisolone followed by a weaning course of oral prednisolone, and subcutaneous adalimumab (anti-tumour necrosis factor alpha, anti-TNFα). Repeat ultrasound-scan 3 weeks later revealed good testicular perfusion, with a small area of focal infarction. At last follow-up (11 months post-event) he remained asymptomatic, on treatment with adalimumab. CONCLUSION: The phenotype of DADA2 continues to expand, and we add testicular infarction to the features of DADA2. CRP and SAA cannot be relied on as reliable biomarkers to predict tissue ischaemia and hence who to target for anti-TNFα therapy in DADA2, since these remained steadfastly normal before, during, and after testicular infarction in this case.


Asunto(s)
Adenosina Desaminasa/deficiencia , Infarto/patología , Péptidos y Proteínas de Señalización Intercelular/deficiencia , Enfermedades Testiculares/patología , Vasculitis/patología , Adenosina Desaminasa/genética , Niño , Enfermedades Autoinflamatorias Hereditarias/complicaciones , Enfermedades Autoinflamatorias Hereditarias/genética , Humanos , Infarto/diagnóstico por imagen , Infarto/etiología , Péptidos y Proteínas de Señalización Intercelular/genética , Isquemia/diagnóstico por imagen , Isquemia/etiología , Isquemia/patología , Masculino , Enfermedades Testiculares/diagnóstico por imagen , Enfermedades Testiculares/etiología , Testículo/irrigación sanguínea , Testículo/diagnóstico por imagen , Testículo/patología , Vasculitis/diagnóstico por imagen , Vasculitis/etiología
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