Alternativas de tratamiento de la obstrucción venosa retiniana: terapias combinadas y vitrectomía pars plana / Treatment Alternatives for Retinal Venous Obstruction: Combined Therapies and Pars Plana Vitrectomy

Dentro de las enfermedades vasculares de la retina, la oclusión venosa retiniana es relativamente frecuente y debido a sus complicaciones afecta de forma moderada o grave la visión. Las opciones terapéuticas aplicadas en el edema macular y los desprendimientos de retina traccionales causados por las oclusiones venosas son varias. Se realizó una revisión en la literatura científica para valorar la eficacia y seguridad del uso combinado de diferentes terapias que incluye los antiangiogénicos y esteroides intravítreos con o sin aplicación de láser, así como la vitrectomía pars plana como alternativas de tratamiento de las complicaciones de la enfermedad oclusiva venosa retiniana. Aun cuando los antiangiogénicos se consideren como primera línea de tratamiento en la oclusión venosa retiniana, en varios casos hay mejor respuesta en sus combinaciones y de los esteroides con láser. Para resolver el desprendimiento de retina traccional y hemorragia vítrea, debidas a las oclusiones venosas, se requiere, mayormente, operación de vitrectomía pars plana. Se realizó una búsqueda en bases de datos electrónicas como PubMed, Cochrane y otras publicaciones relacionadas con las alternativas de tratamiento de la obstrucción venosa retiniana en los últimos años.

Among retinal vascular diseases, retinal venous occlusion is relatively frequent and due to its complications, it moderately or severely affects vision. The therapeutic options applied in macular edema and tractional retinal detachments caused by venous occlusions are several. A review of the scientific literature was performed to assess the efficacy and safety of the combined use of different therapies including intravitreal antiangiogenics and steroids with or without laser application, as well as pars plana vitrectomy as treatment alternatives for the complications of retinal venous occlusive disease. Even when antiangiogenics are considered as first line of treatment in retinal venous occlusion, in several cases there is better response in their combinations and steroids with laser. To resolve tractional retinal detachment and vitreous hemorrhage due to venous occlusions, a pars plana vitrectomy operation is mostly required. A search was made in electronic databases such as PubMed, Cochrane and other publications related to treatment alternatives for retinal venous obstruction in recent years.

Peripheral microvascular dysfunction is also present in patients with ischemia and no obstructive coronary artery disease (INOCA).

BACKGROUND: In patients with ischemia and no obstructive coronary artery disease (INOCA), coronary microvascular dysfunction is associated with higher rate of major adverse cardiovascular events. OBJECTIVE: To demonstrate if microvascular dysfunction present in coronary microcirculation of patients with INOCA may be detected noninvasively in their peripheral circulation. METHODS: 25 patients with INOCA and 25 apparently healthy individuals (controls) were subjected to nailfold videocapillaroscopy (NVC) and venous occlusion plethysmography (VOP) to evaluate peripheral microvascular function and blood collection for biomarkers analysis, including soluble vascular cell adhesion molecule-1 (sVCAM-1), endothelin-1 (ET-1) and C-reactive protein (CRP). RESULTS: Red blood cell velocity (RBCV) before and after ischemia (RBCVmax) were significantly lower in patients with INOCA (p = 0.0001). Time to reach maximal red blood cell velocity (TRBCVmax) was significantly longer in INOCA group (p = 0.0004). Concerning VOP, maximal blood flow (p = 0.004) and its relative increment were significantly lower in patients with INOCA (p = 0.0004). RBCVmax showed significant correlations with sVCAM-1 (r = -0.38, p < 0.05), ET-1 (r = -0.73, p < 0.05) and CRP (r = -0.33, p < 0.05). Relative increment of maximal post-ischemic blood flow was significantly correlated with sVCAM-1 (r = -0.42, p < 0.05) and ET-1 (r = -0.48, p < 0.05). CONCLUSIONS: The impairment of microvascular function present in coronary microcirculation of patients with INOCA can be also detected in peripheral microcirculation.

Comparison of axillary-atrial and axillary-iliac arteriovenous grafts for hemodialysis access creation.

OBJECTIVE: The aim of this study was to compare two complex vascular access techniques that utilize the axillary artery as inflow and accesses were created with early cannulation grafts: the axillary-atrial arteriovenous graft versus axillary-iliac arteriovenous graft. METHODS: This is a retrospective study of end-stage renal disease patients with occluded intrathoracic central veins that underwent complex hemodialysis access creation in our institution after failed endovascular recanalization attempts. Patients' demographics, comorbidities, number and types of previous accesses, intraoperative variables, and clinical outcomes were collected and compared. RESULTS: Four patients underwent axillary-atrial arteriovenous graft creation with Flixene™ (Atrium™, Hudson, NH, USA) grafts, through a midline sternotomy to expose the right atrium; all were successfully implanted and used for hemodialysis within the first 72 h; one patient developed a pseudoaneurysm in the mid-graft portion, requiring surgical repair, and it is currently functional. Eight axillary-iliac arteriovenous grafts were created; all grafts were patent and were utilized within 96 h after placement. At 6 months of follow-up period, five (62 %) of our patients underwent graft thrombectomy, one (12 %) balloon angioplasty at the vein anastomosis secondary to stenosis, and two (25 %) grafts were removed due to infectious complications. Axillary-atrial arteriovenous graft and axillary-iliac arteriovenous graft primary patency rates at 6 months were 75% and 48%, respectively; 6-month secondary patency of the axillary-atrial arteriovenous graft compares favorably against that of axillary-iliac arteriovenous graft (100% vs 75%, respectively). CONCLUSION: Despite the invasiveness, direct atrial outflow procedures remain a valid alternative in carefully selected patients with adequate cardiopulmonary reserve.

Vascular Parameters for Ambulatory Monitoring of Congestive Heart Failure Patients: Proof of Concept.

PURPOSE: Prompt detection of congestion is an essential target in order to prevent heart failure (HF) related hospitalization, being ambulatory monitoring a promising strategy to do so. A successful non-invasive ambulatory monitoring system requires automatic devices for physiological data recording; these data must give information about HF deterioration early enough to predict HF-related adverse events. This work aims to evaluate seven vascular parameters for the ambulatory monitoring of congestive heart failure patients. METHODS: Seven vascular parameters are proposed as indicators of HF deterioration. These parameters are obtained using venous occlusion plethysmography; a technique that uses hardware able of being miniaturized and easily integrated into wearables for ambulatory monitoring. The ability of the proposed vascular parameters to detect congestion is evaluated in eight healthy volunteers and ten congestive heart failure patients with different congestion levels-mild, moderate and severe. RESULTS: Most parameters distinguish between healthy volunteers and heart failure patients, and some of them present significant differences between volunteers and low levels of congestion-mild or moderate. CONCLUSION: Home monitoring of some of the proposed parameters could detect HF deterioration on its onset and alert to health personnel.

Vascular Function at Baseline in the Hemodialysis Fistula Maturation Study.

BACKGROUND: End-stage renal disease is accompanied by functional and structural vascular abnormalities. The objective of this study was to characterize vascular function in a large cohort of patients with end-stage renal disease, using noninvasive physiological measurements, and to correlate function with demographic and clinical factors. METHODS AND RESULTS: We analyzed cross-sectional baseline data from the Hemodialysis Fistula Maturation Study, a multicenter prospective observational cohort study of 602 patients with end-stage renal disease from 7 centers. Brachial artery flow- and nitroglycerin-mediated dilation, carotid-femoral and -radial pulse wave velocity, and venous occlusion plethysmography were performed prior to arteriovenous fistula creation. Relationships of these vascular function measures with demographic, clinical, and laboratory factors were evaluated using linear mixed-effects models. Arterial function, as assessed by flow- and nitroglycerin-mediated dilation and carotid-femoral pulse wave velocity, worsened with increasing age and diabetes mellitus. Venous capacitance decreased with diabetes mellitus but not with age. Flow-mediated dilation was higher among patients undergoing maintenance dialysis than for those at predialysis, and a U-shaped relationship between serum phosphorus concentration and flow-mediated dilation was evident. Partial correlations among different measures of vascular function, adjusting for demographic factors, diabetes mellitus, and clinical center, were modest or essentially nonexistent. CONCLUSIONS: Multiple demographic and clinical factors were associated with the functions of vessels of different sizes and types in this large cohort of patients with end-stage renal disease. Low correlations between the different measures, controlling for demographic factors, diabetes mellitus, and center, indicated that these different types of vascular function otherwise vary heterogeneously across patients.