Interventional Treatment Options for the Prevention of Amputation in Patients With Lower Extremity Wounds From Peripheral Arterial Disease.

BACKGROUND: Peripheral arterial disease and related lower extremity wounds are prominent causes of amputation. Revascularization may reduce amputation rates or the amputation margin more distally in patients with peripheral arterial disease who have wounds resulting from critical limb ischemia. This study examined the association of risk factors and intervention types with amputation rates in patients with critical lower extremity arterial disease. METHODS: A total of 211 patients who underwent peripheral intervention because of foot wound were followed up for 12 months after the intervention. All patients had lower extremity wounds resulting from peripheral arterial disease. The effects of treatment approaches were compared in patients who underwent and did not undergo amputation. RESULTS: Revascularization of the anterior tibial artery reduced the amputation rate by 6.52 times compared with occlusion. Posterior tibial artery revascularization reduced the amputation rate by 49.95 times. CONCLUSION: In this study of percutaneous intervention methods for prevention of amputation, the most effective option was revascularization of the posterior tibial artery and anterior tibial artery. Considering these results, treatment of critical peripheral arterial disease can be cost-effective and efficient and may shorten procedure time.

A rare cause of acute coronary syndromes in young adults - myeloproliferative neoplasms: A case series.

INTRODUCTION: Acute coronary syndromes (ACS) mostly occur in patients with traditional risk factors. Especially in young adults without major cardiovascular (CV) risk factors, one of the less common causes of ACS is myeloproliferative neoplasms (MPNs). METHODS: We retrospectively collected data on 11 consecutive patients (nine men, two women, mean age 40.18±8.4 years) with a diagnosis of MPN who presented with ACS. The demographic characteristics of the study population, type of MPN, clinical manifestations, location of myocardial infarction (MI), coronary angiography findings, complete blood count and other related findings, and treatment strategy before and after diagnosis were analyzed. RESULTS: Six patients were diagnosed with polycythemia vera, four with essential thrombocytosis and one with primary myelofibrosis. A JAK2 mutation was found in nine patients. Mean time to diagnosis of MPN was 2.81 years after presenting ACS and mean age at first MI was 32.9±6 years. Six patients had no major CV risk factors. Ten patients had anterior MI and one had inferior MI. After initiation of specific treatment for MPN, no recurrent thrombotic events were observed in a mean follow-up of 4±2.44 years. CONCLUSIONS: In young adults presenting with ACS, MPNs should be considered, especially in the absence of atherosclerotic coronary artery lesions. It is also important to pay attention to blood cell count abnormalities seen in intracoronary thrombotic events. Early diagnosis and treatment of MPNs is essential to prevent recurrence of thrombotic events and may reduce mortality and morbidity related to thrombotic complications.

Direct stent puncture technique for recanalization of superficial femoral artery in-stent occlusion.

In-stent restenosis and occlusion are common, well-known complications of superficial femoral artery (SFA) interventions. The treatment options in such cases are re-intervention or surgery. A percutaneous antegrade approach is an effective and safe method to perform SFA stent restenosis or occlusion treatment. If an antegrade intervention fails, a retrograde transpopliteal approach may be an alternative. However, in some patients who are admitted with acute leg ischemia there is no distal vessel flow. This condition can result in the need for extremity amputation. Presently described is a case in which a direct stent puncture technique was applied to recanalize the SFA in-stent occlusion after an initially unsuccessful antegrade intervention.

Bendopnea and Its Clinical Importance in Outpatient Patients with Pulmonary Arterial Hypertension.

PURPOSE: Bendopnea is a recently reported novel symptom in patients with heart failure (HF) defined as shortness of breath when bending forward. It has been demonstrated that bendopnea is associated with advanced symptoms and worse outcomes. The aim of this study was to assess the presence of bendopnea and its clinical importance with regards to functional status, hemodynamic and echocardiographic characteristics in outpatient pulmonary arterial hypertension (PAH) patients. METHODS: We conducted this prospective observational study of 53 patients who were admitted to our PAH clinic for routine control visits. We determined the presence of bendopnea and analyzed hemodynamic parameters, World Heart Organization (WHO) functional class, transcutaneous oxygen saturation, 6-minute walking distance (6-MWD), N-terminal pro-brain natriuretic peptide (NT-proBNP) and right ventricular (RV) function indicators in patients with and without bendopnea. RESULTS: Bendopnea was present 33.9% of the PAH patients. The mean age was higher in the patients with bendopnea than in those without bendopnea, but the difference was not significant (p = 0.201). The patients with bendopnea had a lower 6-MWD and higher NT-proBNP level (p < 0.001), and worse WHO functional class symptoms (p = 0.010). Mean right atrial pressure, pulmonary artery pressure, and pulmonary vascular resistance were higher in the patients with bendopnea. The patients with bendopnea had a more dilated RV end-diastolic diameter and lower tricuspid annular plane systolic excursion value (p < 0.001 and p = 0.001, respectively). CONCLUSIONS: Bendopnea was associated with worse functional capacity status, hemodynamic characteristics and RV function in our outpatient PAH patients.

Preprocedural Mean Platelet Volume Level Is a Predictor of In-Stent Restenosis of the Superficial Femoral Artery Stents in Follow-Up.

BACKGROUND: The mean platelet volume (MPV), the most commonly used measure of the platelet size, is a cheap and easy-to-use marker of the platelet activation. We aimed to evaluate the relationship between preprocedural MPV and other hematologic blood count parameters and in-stent restenosis in patients with superficial femoral artery (SFA) stenting. METHODS AND RESULTS: The consecutive 118 patients who successfully underwent endovascular stenting of the SFA were enrolled retrospectively in the study. The mean follow-up was 23 ± 12 months. The in-stent restenosis was observed in 42 patients (35.6%). There were no statistically significant differences between the restenosis group and no-restenosis group in terms of age, gender, and smoking (p=0.116, p=0.924, and p=0.428, resp.). In the restenosis group, the MPV level was markedly higher than that in the no-restenosis group, and it was statistically significant (p < 0.001). According to the ROC curve analysis, the optimal cutoff value of the MPV to determine the restenosis was >8.7 fL, and the level of the MPV >8.7 fL was a strong predictor of the restenosis (p < 0.001) in logistic regression analysis. CONCLUSIONS: The measurement of the preprocedural MPV levels may help to identify high-risk patients for development of the in-stent restenosis. These patients may benefit from an aggresive antiplatelet therapy and close follow-up.

Mid-Term Outcomes of Stent Overlap in Long Total Occluded Lesions of Superficial Femoral Artery.

BACKGROUND Superficial femoral artery chronic total occlusion (SCTO) is a common type of peripheral arterial disease (PAD). Endovascular therapy is a treatment approach that has a poor long-term success rate in this group. The aim of this study was to compare the mid-term results of two different uses of nitinol stents in long SCTO lesions (>100 mm): the use of one long stent or two shorter stents. MATERIAL AND METHODS Of 154 patients who underwent percutaneous infrainguinal interventions from 2011 to 2014, a total of 170 CTO lesions were selected for this retrospective study analysis. The mean age of the study population was 63.4±10.4 years (range 29-89 years); 71.8% of the patients were male. RESULTS Patients were divided into two groups according to the number of stents used. Patients treated with a single stent were placed into group A and patients treated with two stents were placed into group B. The stent fracture rate was significantly higher in group B compared to group A (29.2% vs. 42%). Type 1 and 2 fracture rates were higher in group A, but type 3 and 5 fracture rates were significantly higher in group B. The rate of stent restenosis was significantly higher in group B compared to group A (45.1% vs. 54.5%, p=0.05). CONCLUSIONS Mid-term patency rate was low in patients with long totally occluded superficial femoral artery (SFA) lesions. Using a long single stent had an acceptable mid-term patency rate compared to using a two stent strategy. Stent fracture seemed to be the main reason for in-stent restenosis in cases of multiple stenting. A long single stent strategy may be more appropriate and reasonable than a two stent strategy in the treatment of long SFA lesions.

Early Thrombosuction and Tirofiban Use in Knee and Below-Knee Arterial Thrombosis.

BACKGROUND Acute limb ischemia (ALI) is a clinical entity with a high rate of morbidity and mortality. Despite advances and variety of its management, there is still no criterion standard treatment. The goal of this study was to evaluate the effect of tirofiban use on the early and 6-month prognosis of patients with knee and below-knee arterial thrombosis who were treated with percutaneous thrombosuction (PT) within 24 h. MATERIAL AND METHODS Data of consecutive ALI patients who were diagnosed with popliteal and infra-popliteal arterial thrombosis and underwent PT procedure within 24 h between January 2010 and September 2015 were evaluated retrospectively. Patients were separated into 2 groups according to tirofiban usage. RESULTS A total of 105 patients (mean age 67±16; 53% men) were included in the study. Atrial fibrillation (n 64, 61%) and hypertension (n 60, 57%) were the most frequent comorbidities in patients with thromboembolic events. A significantly higher rate of distal embolization (6% vs. 16%; p=0.01) and slow-flow (17% vs. 30%; p<0.01) developed in patients who were not treated with tirofiban after the PT procedure. Although major and minor bleeding were more frequent in the tirofiban group, only the rate minor bleeding was statistically significant (29% vs. 9%, p=0.001). Reverse embolic event ratio was similar in both groups. Although there was a higher rate of amputation in patients not treated with tirofiban, the difference was not significant. CONCLUSIONS Adding tirofiban to PT reduces angiographic thromboembolic complications. Usage of tirofiban in patients prone to thromboembolic events may be useful for improving success of the PT procedure, with a reasonable bleeding ratio.

Effect of thrombus aspiration on postprocedural outcomes in elderly patients with acute ST-elevation myocardial infarction.

AIM: The effects of thrombus aspiration (TA) during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) have been evaluated in several studies. The aim of the present study was to evaluate postprocedural outcomes in elderly STEMI patients who have a tendency for vasoconstruction and decreased coronary flow reserve. METHODS: A total of 124 patients (aged ≥65 years) with STEMI who underwent primary PCI (71.2% men, 29.8% women, mean age 74 ± 7 years) were enrolled in the study. Patients were divided into two groups according to intervention with and without TA. Acute angiographic, electrocardiographic and echocardiographic results were compared between the two groups. RESULTS: TA was carried out in 42 patients (33.8%). Baseline clinical characteristics and predischarge echocardiographic features did not differ between TA(+) and TA(-) patients (ejection fraction 37.26 ± 8.91 vs 38.53 ± 11.18, P = 0.558, wall motion index 1.69 ± 0.38 vs 1.76 ± 0.37, P = 0.316, septal E' 0.058 ± 0.022 vs 0.053 ± 0.015, P = 0.267, E/E' 11.82 ± 4.30 vs 13.12 ± 5.09, P = 0.370). Acute angiographic and electrocardiographic results did not differ between the two groups, but were slightly better in the thrombectomy group than those without TA corrected TIMI frame count (31.63 ± 16.33 vs 34.97 ± 15.81, P = 0.197, TIMI-3 88.1% vs 79.3%, P = 0.223, ST segment resolution 81.3% vs 70.3%, P = 0.250). CONCLUSIONS: Thrombectomy during primary PCI has no effect on postprocedural outcomes in an elderly group with STEMI. Geriatr Gerontol Int 2015; ●●: ●●-●●.

A young patient with coronary artery anomaly, whose left anterior descending artery originated from the pulmonary artery, underwent cardiac arrest.

A rare congenital anomaly of the coronary arteries, in which the left coronary arterial system starts from the arteria pulmonalis, is known as Bland-White-Garland (BWG) syndrome. Isolated left anterior descending (LAD) or circumflex (Cx) arteries originating from the pulmonary artery are even more rare. These anomalies may cause myocardial ischaemia, myocardial infarction, arrhythmia and sudden death. Even if the patient is asymptomatic, he/she should undergo corrective surgery. Here we present the case of an 18-year-old male who survived sudden cardiac arrest during exercise. We identified intra-myocardial blood flow from transthoracic echocardiography, and performed coronary and computed tomographic (CT) angiography, which showed that all the coronary arteries were ectatic and curly and there were disseminated collaterals among the coronary arteries. We diagnosed 'anomalous left coronary artery from the pulmonary artery' (ALCAPA) syndrome, as additionally, the LAD originated from the pulmonary artery. We treated the patient with a left internal mammarian artery - left anterior descending artery (LIMA-LAD) graft.

Relationship between endothelial functions and acetylsalicylic acid resistance in newly diagnosed hypertensive patients.

BACKGROUND: We aimed to investigate the effects and dose dependency of aspirin on endothelial functions and prevalence of aspirin resistance in newly diagnosed hypertensive patients without previous drug therapy and development of cardiac complications. HYPOTHESIS: Acetylsalicyclic acid improves endothelial function. METHODS: Fifty-eight hypertensive patients and 61 healthy subjects in the control group were included in the study. Endothelial functions of the patient and control groups were evaluated with brachial artery examination. Patient and control groups were divided into 2 groups. A total of 100 mg and 300 mg of aspirin were given to the separate groups for 1 week. After 1 week, endothelial functions were reevaluated and aspirin resistance examined with a platelet function analyzer (PFA-100; Dade Behring, Marbourg, Germany). RESULTS: Baseline flow-mediated dilatation (FMD) change percent in hypertensive patients was 9.8%, and it was significantly lower than in the control group (12%) (P < 0.001). Frequency of acetylsalicylic acid (ASA) resistance was 20% and 26% in control and hypertensive patient groups, respectively (P = not significant). ASA resistance was 28% and 24% in 100 mg and 300 mg in hypertensive patients, respectively (P = not significant). FMD change percent increased both in the control and hypertensive groups after ASA treatment from 12.4% to 13.3% and 9.8 % to 11.9 %, respectively. FMD percentage change was significantly increased in hypertensive patients irrespective of ASA resistance (P = 0.02, for ASA resistance [+]; P < 0.012, for ASA resistance [-]). CONCLUSIONS: Endothelial functions were impaired more in hypertensive patients compared to the control group. Endothelial functions were improved with all ASA doses in hypertensive patients irrespective of ASA resistance.

Diabetic cardiomyopathy.

Diabetic individuals are at significantly greater risk of developing heart failure (HF) independent from other risk factors such as coronary artery disease (CAD) and hypertension. Diabetic cardiomyopathy (DCP) is defined as ventricular dysfunction in the absence of hypertension, coronary artery and valvular heart disease, which increases the risk of HF. Due to better understanding of its pathophysiology and clinical importance, DCP is more frequently recognized in daily practice. The most important mechanisms of DCP are hyperglycemia, insulin resistance/hyperinsulinemia, abnormal fatty acid metabolism, increased apoptosis, cardiac autonomic neuropathy and local renin-angiotensin-aldosterone system (RAAS) overactivation. Echocardiography is the most frequently used diagnostic method for the detection of this pathology. Currently, although there is no specific treatment for DCP, strict glycemic and concomitant risk factor controls seems to be the most important target strategy for prevention of the progression and treatment of DCP. In this article, we aim to provide an extensive review on the pathophysiology, diagnosis, management of DCP.

Ischemic stroke history predicts increased cardiovascular mortality in chronic heart failure.

OBJECTIVE: To investigate comorbidities that predict cardiac mortality and re-hospitalization in chronic heart failure (CHF) patients. METHODS: Five hundred eighty patients (mean age 63 ± 13 years, 373 male, 207 female, mean ejection fraction (EF) 26 ± 9%) with mild, moderate or severe CHF [NYHA class II-IV] were included in this prospective observational study. We evaluated all comorbidities such as history of ischemic stroke, coronary artery disease, peripheral arterial disease, chronic obstructive lung disease, hypertension, diabetes mellitus and chronic kidney disease in CHF patients who were hospitalized due to decompensated heart failure in Kocaeli University, Faculty of Medicine's Hospital between January 2003 and July 2009. Cox regression and Kaplan-Meier survival analyses were used to establish predictors of unfavorable outcomes. RESULTS: Of 580 patients 207 (36%) patients died due to cardiovascular reasons. In multivariable Cox regression analysis age (HR-1.06, 95% CI 1.04-1.08, p<0.001), NYHA functional class (HR-3.20 95% CI, 1.90-5.41, p<0.001), history of ischemic stroke (HR-2.48, 95% CI 1.14-5.37, p=0.022), high-sensitive C-reactive protein (HR-1.09, 95% CI, 1.04-1.15, p=0.001), brain natriuretic peptide (HR-1.00, 95% CI 1.00-1.00, p=0.01) and hemoglobin (HR-0.90, 95% CI 0.81-0.99, p=0.038) were independent predictors of cardiac death in the present study. History of ischemic stroke was demonstrated as an important comorbidity that predicts cardiovascular mortality beyond other co-morbidities in CHF patients. NYHA functional class (HR-2.85, 95% CI 1.80-4.65, p<0.001), left ventricular EF [(HR-0.98, 95% CI 0.95-0.99, p=0.039) and ischemic stroke history (HR-2.41, 95% CI 1.15-5.05, p=0.019) were independent predictors for recurrence hospitalization. The stroke history was only predictor showing recurrent hospitalization at least in one year among the other comorbid conditions, which were evaluated during study. CONCLUSION: History of ischemic stroke may be an important risk factor for increased cardiac mortality and recurrence hospitalization in CHF patients.

Association between documented coronary artery disease and urinary albumin, albumin to creatinine ratio.

BACKGROUND: The aim of this study was to investigate whether the amount of urinary albumin concentration (UAC) or urinary albumin to creatinine ratio (UACR) is more strongly associated with angiographically documented coronary artery disease (CAD). MATERIAL/METHODS: A total of 199 consecutive patients [11 9(60%) male, 80 (40%) female, mean age =57±10] undergoing diagnostic coronary angiography were included in the study. Significant coronary artery disease was defined as a stenosis equal to or above 50% in the main coronary artery or in one of the other branches. UAC and UACR were calculated from the urine. Baseline clinical parameters, UAC and UACR were compared between subjects with and without CAD. Factors predicting CAD were evaluated by multivariate analysis. RESULTS: Baseline clinical and laboratory characteristics of patients with and without CAD were not different except for a slightly male predominance in patients with CAD. Patients with CAD had significantly higher UACs and UACRs than patients without CAD (32.14±31.27 mg/day vs. 15.61±16.70 mg/day, p=0.01; 9.11±7.42 mg/g vs. 4.80±3.28 mg/g, p=0.009). A positive correlation was found between Gensini score and UACR (p=0.01), whereas no correlation was found between Gensini and UAC. UACR was the only significant parameter for the presence of CAD in the multivariate analysis adjusted for age, sex, other well known CAD risk factors, UAC and UACR. CONCLUSIONS: Our preliminary results suggest that UACR is more closely associated with angiography documented CAD than is the level of UAC itself, but UACR maybe more significantly associated with angiography documented CAD than with the levels of UAC.

Diagnostic value of poor R-wave progression in electrocardiograms for diabetic cardiomyopathy in type 2 diabetic patients.

BACKGROUND: Diabetic cardiomyopathy (DCMP) is a common complication of diabetes and is associated with increased mortality. It has been suggested that a poor R-wave progression in a resting electrocardiogram (ECG) could be a sign of cardiomyopathy. HYPOTHESIS: The aim of this study was primarily to analyze the relationship between poor R-wave progression and DCMP, and the effect of poor R-wave progression on cardiac functions in long-term follow-up. METHODS: Seventy type 2 normotensive diabetics (33 female, 37 male; mean age, 52.9 ± 10.4 years) were included in the study. Poor R-wave progression in an ECG was defined as an R wave < 3 mm in V1-3 derivations. The patients were randomized in 2 groups, which were those without (group I, n = 34) and those with poor R-wave progression (group II, n = 36). All patients underwent conventional and tissue Doppler echocardiography and were followed in an outpatient clinic setting for 4 years. RESULTS: Demographic variables were similar between the 2 groups. In group II, left ventricular (LV) relaxation abnormality was more prevalent, the Tei index was higher, and in tissue Doppler mitral annulus Em velocities were significantly lower and Am velocities were higher than those with normal R-wave progression. At the end of the 4-year follow-up period, LV ejection fraction was decreased in group II, whereas LV mass index and Tei index were significantly increased. CONCLUSIONS: LV diastolic dysfunction is more frequently observed in diabetic patients with poor R-wave progression in ECG, which may be an early sign of LV dysfunction and DCMP in diabetics.

Right atrial appendage function in different etiologies of permanent atrial fibrillation: a transesophageal echocardiography and tissue Doppler imaging study.

OBJECTIVES: Several studies exist on the left atrial appendage function (LAA) in permanent atrial fibrillation (AF). However, knowledge about the right atrial appendage (RAA) function is limited. We investigated RAA function with TEE and tissue Doppler imaging (TDI) in permanent AF patients with different etiologies and evaluated predictive parameters of right atrial spontaneous echo contrast (SEC) and thrombi. METHODS: Patients with permanent AF developed due to three different etiologies (20 mitral stenosis, 44 hypertension, 20 hyperthyroidism) and 23 subjects with sinus rhythm were included into the study. RAA was examined with TEE and pulsed-wave and TDI velocities of RAA were measured. RESULTS: Both PW-Doppler and TDI velocities were significantly impaired in all AF groups compared to controls. The lowest velocities were recorded in mitral stenosis patients. Right atrial moderate-severe SEC was observed in 75% of the mitral stenosis patients, in 25% of hypertensive patients, and in 30% of hyperthyroidism patients. Right atrial thrombus was observed in 25% of mitral stenosis, 4.5% of hypertension, and in none of the hyperthyroidism patients. In the multivariate analysis, the most important parameter associated with the severity of RAA SEC was the percent change in RAA area (B =-0.034, P = 0.03). CONCLUSION: In patients with permanent AF, impairment of RAA function and development of right atrial SEC-thrombus are closely related to the underlying etiology. These results suggested that evaluation of RAA functions may have an incremental value over the assessment of the LAA for determining thromboembolic risk.

Dilated cardiomyopathy, spontaneous echo contrast in the aorta and embolic events.

BACKGROUND: Spontaneous echocardiographic contrast (SEC) is a frequent finding in patients with dilated cardiomyopathy (DCM). In this study, we have investigated the frequency and clinical correlates of aortic-SEC (Ao-SEC) in patients with DCM. METHODS: Ninety-two consecutive DCM patients (63 men, 29 women, mean age 60 +/- 11 years) underwent transthoracic and transoesophageal echocardiography. RESULTS: Ao-SEC was found in 53 patients (58%). It was associated with: (i) a lower cardiac index (P < 0.001); (ii) left atrial-SEC (P < 0.001); (iii) left ventricular-SEC (P = 0.008); (iv) a larger aortic root (P = 0.02); (v) the presence of complex aortic atherosclerotic plaques (P < 0.001).The significant determinant of thromboembolism was left-atrial SEC (P = 0.03).We did not find a significant correlation between Ao-SEC and thromboembolism. CONCLUSION: Most of the patients who developed embolic events in the follow-up period had Ao-SEC.Thromboembolism is rather associated with left-atrial SEC than with Ao-SEC.