New Directions in the Management of Peripheral Artery Disease.

BACKGROUND: Peripheral artery disease represents an important chapter of cardiovascular pathology in which atherosclerosis (promoted by major risk factors-hypertension, smoking, dyslipidemia, and diabetes mellitus) is the major etiology. The severity of this pathology is not only due to local injury but also due to frequent association with atherosclerotic disease with other localizations, thus increasing cardiovascular morbidity and mortality in these patients. Diagnosis is based on clinical data, functional tests (the ankle-brachial index is very useful in these cases) and imagistic methods (Doppler ultrasonography, computed tomography angiography, magnetic resonance angiography, and digital subtraction angiography). Therapeutic options vary depending on the location and severity of the lesions but also on the chronic or acute nature of the disease. Thus, in addition to pharmacological treatment and nonpharmacological measures (related to lifestyle), revascularization therapy is a very important step. AREAS OF UNCERTAINTY: There are still many things that need to be clarified in this pathology: importance of developing national registries (because epidemiological data are often poor), role of drug-eluting stents/drug-eluting balloons in femoropopliteal lesions, optimal duration of double antiplatelet treatment after stenting, and more. Current guidelines for the management of peripheral artery disease are built from the results of many trials and research groups regarding to the evaluation and therapy of these patients. THERAPEUTIC ADVANCES: Endovascular therapy is particularly targeted for cases with short lesions/occlusions or in patients with high surgical risk; instead, surgical revascularization (bypass) brings benefits in patients with long or distal stenoses/occlusions or where anatomy does not allow for interventional intervention. Anticoagulant and thrombolytic treatment plays an important role in acute limb ischemia. CONCLUSIONS: So, in the patients with peripheral artery disease (especially acute limb ischemia), early diagnosis and prompt application of therapeutic measures are the cornerstone of management in these cases.

Some Perspectives on Hypersensitivity to Coronary Stents.

The development of coronary stents has represented a revolution in the treatment of coronary heart disease. Beyond their many advantages, stents also have their limitations and complications. Allergic reactions to coronary stents are more common than acknowledged. These stented patients are exposed to foreign substances inserted in direct contact with the coronary intima. Hypersensitivity to stent components and drugs prescribed after stent insertion together with any environmental exposure seem to contribute to these adverse reactions. Patients can present to the hospital with a wide range of symptoms and multiple complications, the most important ones being instent restenosis and stent thrombosis. Although not very common (and not always easy to identify), allergic reactions after coronary or peripheral stents should be taken into account. Careful selection of patients (for elective stent implantation) depending on the propensity to allergies, although hard to achieve, represents a key factor in reducing the number of these complications.

Anaesthesia for Liver Transplantation: An Update.

Liver transplantation (LT) is a challenging surgery performed on patients with complex physiology profiles, complicated by multi-system dysfunction. It represents the treatment of choice for end-stage liver disease. The procedure is performed under general anaesthesia, and a successful procedure requires an excellent understanding of the patho-physiology of liver failure and its implications. Despite advances in knowledge and technical skills and innovations in immunosuppression, the anaesthetic management for LT can be complicated and represent a real challenge. Monitoring devices offer crucial information for the successful management of patients. Hemodynamic instability is typical during surgery, requiring sophisticated invasive monitoring. Arterial pulse contour analysis and thermo-dilution techniques (PiCCO), rotational thromboelastometry (RO-TEM), transcranial doppler (TCD), trans-oesophageal echocardiography (TEE) and bispectral index (BIS) have been proven to be reliable monitoring techniques playing a significant role in decision making. Anaesthetic management is specific according to the three critical phases of surgery: pre-anhepatic, anhepatic and neo-hepatic phase. Surgical techniques such as total or partial clamping of the inferior vena cava (IVC), use of venovenous bypass (VVBP) or portocaval shunts have a significant impact on cardiovascular stability. Post reperfusion syndrome (PRS) is a significant event and can lead to arrhythmias and even cardiac arrest.

Myocardial bridging-an unusual cause of Wellens syndrome: A case report.

RATIONALE: Coronary chest pain is usually ischemic in etiology and has various electrocardiographic presentations. Lately, it has been recognized that myocardial bridging (MB) with severe externally mechanical compression of an epicardial coronary artery during systole may result in myocardial ischemia. Such a phenomenon can be associated with chronic angina pectoris, acute coronary syndromes (ACS), coronary spasm, ventricular septal rupture, arrhythmias, exercise-induced atrioventricular conduction blocks, transient ventricular dysfunction, and sudden death. PATIENT CONCERNS: We report the case of a 58-year-old woman presenting with recurrent episodes of constrictive chest pain during exercise within the last 2 weeks. Except for obesity, general and cardiovascular clinical examination on admission were normal. DIAGNOSES: The resting 12 lead electrocardiogram (ECG) revealed changes typically for Wellens syndrome. High-sensitive cardiac troponin I was normal. We established the diagnosis of low-risk non-ST-segment elevation acute coronary syndrome with a Global Registry of Acute Coronary Events risk score of 92 points. INTERVENTIONS: The patient underwent coronary angiography, who showed subocclusive dynamic obstruction of the left anterior descending artery due to MB. OUTCOMES: The patient was managed conservatively. Her hospital course was uneventful and she was discharged on pharmacological therapy (clopidogrel, bisoprolol, amlodipine, atorvastatin, and metformin) with well-controlled symptoms on followup. LESSONS: MB is an unusual cause of myocardial ischemia. Wellens syndrome is an unusual presentation of ACS. We present herein a rare case of Wellens syndrome caused by MB. This case highlights the importance of subtle and frequently overseen ECG findings when assessing patients with chest pain and second, the importance of considering nonatherosclerotic causes for ACS.

Fast Progressing His-Purkinje Conduction Disturbances in a Myotonic Dystrophy Pacient.

Myotonic dystrophy leads to multiple systemic complications and the age of death is earlier in myotonic dystrophy patients than in the general population. These patients have a high frequency of sudden death related to respiratory failure, cardiac arrhythmias and in particular to cardiac conduction disturbances. Prophylactic pacemaker implantation should be considered in asymptomatic myotonic dystrophy patients, which in the early stages of disease present minor conduction disturbances in 12-leads ECG. Even if the rate of progression of conduction abnormalities is usually slow, fast progression has been often observed thus making the clinical course of individual patients rather unpredictable.

Advanced Atherosclerosis with Leriche Syndrome, in a Patient with Carney Complex.

Carney complex (CNC) is a rare autosomal dominant syndrome. Spotty skin pigmentation is the major clinical manifestation of CNC, followed by cardiac myxomas, benign tumors that usually present with features from the classical triad of obstructive cardiac, embolic and non-specific constitutional symptoms (NCS). NCS are caused by the overproduction of interleukin-6 (IL-6), a pro-inflammatory cytokine which mediates the induction of intercellular adhesion molecule 1 (ICAM-1) and promotes endothelial dysfunction and atherosclerosis. Thus, myxomas may be directly linked to an increased risk of atherosclerotic events. We report here a case of a 74-year-old woman with left atrial myxoma, skin pigmentary abnormalities, thyroid disorder and extensive atherosclerosis, with non-embolic occlusion of infrarenal abdominal aorta.