Hydration may reverse most symptoms of lower extremity intermittent claudication or rest pain.

BACKGROUND: Medical treatment of severe intermittent claudication or critical limb-threatening ischemia causing rest pain frequently achieves only partial relief or is not effective at all. METHODS: Patients with severe intermittent claudication or rest pain of the lower extremities who did not improve after control of risk factors, supervised exercises, and cilostazol medication were included in this study. All patients were treated with hydration. They were asked to drink 2500 mL of fluids (water, soup, milk) during a 24-hour period and to ingest 0.6 g/kg of albumin a day, as egg white or albumin powder. Total salt administered daily was 3.5 g. Symptoms, skin temperature, ankle-brachial index, albumin concentration in serum, and time and distance to claudication were recorded before treatment, at 6 weeks, and at 6 months. Electrolytes were measured monthly. No additional treatment was used during the study. Walking was encouraged but not supervised. The trial has continued indefinitely. For statistical analysis, SPSS software (IBM Corp, Armonk, NY) was used. The Ethical Committee approved the protocol, and an informed consent was signed by all patients. RESULTS: There were 132 patients (94 male, 38 female) included in the study. Median age was 72.5 years (range, 67-77 years); all had severe claudication of a mean of 100 meters or rest pain. Symptoms had been present for >5 months in all patients; 22 (16.8%) had rest pain. Proper hydration, determined as drinking at least 2000 mL of water during 24 hours for a period of 6 months, was achieved in 131 compliant patients. Only one patient failed to drink 2000 mL of water or more. Ankle-brachial index in 131 compliant patients improved from 0.6 to 0.75 (P < .0001) after 6 months. Skin temperature of the feet increased from 29.4°C to 31.7°C (P = .009). Distance to claudication using the treadmill improved from 100 meters to 535 meters (P < .0001) at 6 weeks and remained stable at 6 month in 65.83% of the patients; in 34.17% of them, distance to claudication increased further by 200 (100-500) meters and time to claudication improved from 1.3 to 6.3 minutes (P < .0001) at 6 weeks, but the same group of patients (34.17%) that increased the distance to claudication further prolonged the time to claudication by 2.49 (1.24-6.23) minutes. All 131 compliant patients improved their status related to lower extremity ischemia; the noncompliant patient did not have any variation of symptoms, skin temperature, ankle-brachial index, or time and distance to claudication. All patients survived the initial 6 months of treatment; afterward, three patients abandoned the treatment and four died of unrelated causes. After the 6-month control, 49% of the patients continued to improve the time and distance to claudication as well as the ankle-brachial index. The rest of the patients conserved the initial improvement. Five patients who had significantly improved the time and distance to claudication were asked to decrease water intake for 3 days. No changes in time and distance to claudication were detected. Hydration was reinitiated. CONCLUSIONS: This study suggests that proper hydration by drinking ≥2000 mL of water daily and albumin complement orally to reach 4 g/dL in serum could be included in the armamentarium of physicians treating patients with disabling claudication or rest pain caused by peripheral artery disease. Further comparative studies to assess the benefit of hydration and increasing the serum oncotic pressure are warranted.

Reversal of Lower-Extremity Intermittent Claudication and Rest Pain by Hydration.

BACKGROUND: Medical treatment of disabling intermittent claudication or critical limb-threatening ischemia causing rest pain often fails or has partial response. METHODS: In this pilot study, 36 patients (12 females) affected by disabling intermittent claudication or rest pain of the lower extremities were exposed to a daily 3-L water intake for up to 6 weeks. Cutaneous foot temperature, ankle/brachial index, time and distance of claudication, and pain intensity were recorded before and at the completion of the hydration period. RESULTS: Patients with a mean ± SE age of 71 ± 2 years (range, 40-86) had disabling claudication (less than 100 meters) for more than 5 months while 11% reported pain at rest. A 6-week water intake of more than 2,500 mL/24 hr was achieved in 35 of the 36 patients enrolled in the study. Increased water intake was associated with significant improvements in median ankle/brachial index (from 0.60 to 0.76; P < 0.0001) and skin temperature (first dorsal right toe, from 29.95°C to 30.0°C, P < 0.001). Time and distance to report claudication of supervised treadmill exercise improved from 1.25 to 6.25 min (P < 0.0001) and from 100 meters to 535 meters (P < 0.0001), respectively. CONCLUSIONS: This study suggests that hydration attained by daily water consumption of more than 2.5 L has a robust impact on reducing the symptoms of disabling claudication and rest pain caused by peripheral vascular disease.

Experimental and clinical evidence supporting septectomy in the primary treatment of acute type B thoracic aortic dissection.

BACKGROUND: We reviewed the mechanics involved in the aneurysmal dilatation of the false lumen (FL) in type B aortic dissection and the experimental and clinical evidence supporting the proposition that the main agent for this dilatation is a differential of pressure between the false and true lumena. This difference in pressure is the consequence of a restricted outflow of the FL. Our aim was to study the relationship between the size of a septectomy that increases the outflow of the FL and its effect on the values of the differential of pressure. METHODS: A bench-top model of aortic dissection was used to determine the relationship between the area of the tears and the value of the pressure differential. A range of tear sizes was tested. RESULTS: The highest differential of pressure (6.77 mm Hg) was found with a single proximal tear. The addition of a distal tear decreases the pressure difference. The greater the sum of the areas of proximal and distal tears, the lower the pressure difference between true lumen and FL. This pressure difference approached zero, as the sum of the areas approached 250 mm(2). CONCLUSIONS: A septectomy of at least 250 mm(2), initiated from the distal tear to the proximal aorta of an area, should be part of the initial treatment of acute aortic dissection. Concomitant with it, the proximal tear should be occluded with either a bare stent or a stent graft.

Early endovascular grafts at Montefiore Hospital and their effect on vascular surgery.

Vascular surgery is very fortunate. It recognized the transition from open surgery to endovascular procedures as treatments for vascular disease early enough to adapt as a specialty. As a result, most vascular surgeons in North America became competent with endovascular techniques, and the survival of the specialty was assured. The endovascular graft program at Montefiore Hospital played a major role in vascular surgery's early recognition of the importance of the endovascular revolution. This article will review the history of this early endovascular graft program and how it influenced the specialty.

Sources of error in the measurement of aortic diameter in computed tomography scans.

OBJECTIVE: This study was conducted to determine the differences in the diameter of the thoracic aorta when measured from electrocardiographic (ECG)-gated and nongated computed tomography (CT) angiography. Another aim was to define the difference in the aortic diameter when it is measured at peak systole and end diastole in ECG-gated scans. METHODS: The gated and nongated CT angiograms of 27 patients (mean age, 58 ± 16 standard deviation [SD] years) obtained on a 256-slice multidetector CT scanner were used. The transverse and anteroposterior diameters and the lumen areas were measured at 1, 4, and 8 cm below the origin of the left subclavian artery. RESULTS: There was a significant difference in the aortic measurements of diameter between gated and nongated scans found in samples taken at 1, 4, and 8 cm distal to the left subclavian artery (P < .0001). We found a considerable difference between the systolic and diastolic diameters (P < .0001). The maximum change in diameter between systole and diastole was 2.9 ± 0.9 (SD) mm (14.5%, P < .0001) at 1 cm, 5.4 mm (22.6%; median, 1.7 mm; P < .0001) at 4 cm, and 4.4 mm (16.9%; median, 1.3 mm; P < .0001) at 8 cm. There was a significant difference between the transverse and anteroposterior diameters in systole and diastole at all locations (P < .0001): The maximum change in diameter between transverse and anteroposterior diameters in systole was 5.4 ± 1.1 (SD) mm (15.7%, P < .0001) at 1 cm, 5.8 mm (19%; median, 1.4 mm; P < .0001) at 4 cm, and 5 mm (15%; median, 1.02 mm; P < .0001) at 8 cm. There was also a substantial difference between measuring the transverse diameter directly and deriving it from the lumen area (P < .0001). CONCLUSIONS: Our results showed an important difference between systolic and diastolic diameters measurements in ECG-gated scans. The standard protocol for measuring aortic diameters in gated scans of the thoracic aorta uses images at end diastole because the lack of wall motion at this time provides better resolution. This is likely to result in undersizing that, in some instances, may threaten stability and the proper seal of the stent graft. The dimensions of the aorta in a gated CT should be measured at peak systole rather than the conventional end diastole used today. Most medical centers use nongated CT or gated CT scans in end diastole to calculate sizes of endografts. In view of our findings, the latter method could result in potential complications.

The value of anecdote.

Anecdote is defined as "a usually short narrative of an interesting, amusing, or biographical incident" and are not often deemed scientifically valuable (www.merriam-webster.com). Anecdotes can be analyzed, however, and those observations can become the initiation of important and groundbreaking work. In this article, we describe aecdotes of several cases which by themselves had seemingly little value. The value was added later, when these concepts were extrapolated to important projects, which expanded into series of experiences, which were reproducible and able to be analyzed and judged as valuable devices and/or methods. The authors recognize that some of the images are old and not of great quality but the information provided is as complete as possible and reliable.

TEVAR and EVAR, the unknown knowns of the cardiovascular hemodynamics; and the immediate and long-term consequences of fabric material on major adverse clinical outcome.

This review discusses the impact of endovascular aneurysm repair on cardiovascular (CV) hemodynamics and the role of stent-graft material, i.e., polytetrafluoroethylene (PTFE) vs. polyester in post-procedural outcomes. Endovascular aneurysm repair has been widely employed in the last decades for thoracic and abdominal aneurysm repair. However, aortic endografts are stiff and alter the native flow hemodynamics. This failure to simulate the native aorta could lead to added strain on the heart, manifesting as increased left ventricular strain, higher pulse pressure, and congestive heart failure later. This could result in adverse CV outcomes. Also, evidence is mounting to support the implication of stent-graft materials, i.e., PTFE vs. polyester, in adverse post-procedural outcomes. However, there is an absence of level one evidence. Therefore, the only way forward is to plan and perform a randomised controlled trial to demonstrate the alterations in the CV hemodynamics in the short and long run and compare the available stent-graft materials regarding procedural and clinical outcomes. We believe the best solution, for now, would be to reduce the stented length of the aorta. At the same time, in the longer term, encourage continuous improvement in stent-graft materials and design.

Two decades of experience in explantation and graft preserving strategies following primary endovascular aneurysm repair and lessons learned.

Objectives: We aim to scrutinize our evolving re-intervention strategies following primary endovascular aortic aneurysm repair (EVAR) - EVAR GORE SalvAge Fabric Technique (ARAFAT), aortic sac double breasting with endograft preservation, and stent-graft explantation. Methods: We performed 1,555 aortic interventions over the study period, including 910 EVARs. Factors associated with the need for reintervention and the likelihood of chronic fabric fatigue failure (CFFF) were investigated. Using conventional and innovative diagnostic modalities with Prone contrASt enHanced computed tomography Angiography (PASHA), 136 endoleaks (ELs) were identified (15 type I, 98 type II; 18 type III; 5 type IV). Results: Forty-four (4.84%) patients underwent re-intervention post-primary EVAR; 18 ARAFATs, 12 double breastings, and 14 explantations. Choice of re-intervention was based on patient fitness and mode of failure. Mean EL detection duration following primary EVAR was 53.3 ± 6.82 months, while mean time to re-intervention was 70.20 ± 6.98 months. The mean sac size before the primary EVAR and re-intervention was 6.00 ± 1.75 cm and 7.51 ± 1.94 cm, respectively. Polyester (61.40%) was the most commonly employed stent-graft material. Use of more than three modular stent-graft components (3.42 ± 1.31, p = 0.846); with the proximal stent-graft diameter of 31.6 ± 3.80 cm (p = 0.651) and the use of iliac limbs more than 17 mm (p = 0.364), all added together are contributing factors. We had one peri-operative mortality following explantation due to sepsis-induced multiorgan failure. Conclusions: Our re-intervention strategies matured from stent graft explantation to graft preservation with endovascular relining of the stent-graft. Graft preservation with aortic sacotomy and double breasting were used to manage concealed ELs due to aortic hygroma.

Combined thoracic endovascular aortic repair and endovascular aneurysm repair and the long-term consequences of altered cardiovascular haemodynamics on morbidity and mortality: case series and literature review.

BACKGROUND: Thoracic and abdominal aortic stent grafts are firmer and more rigid than the native aorta. Aortic implanted devices have been implicated in the development of acute systolic hypertension, elevated pulse pressure, and reduced coronary perfusion. CASE SUMMARY: We report four cases of staged thoracic endovascular aortic repair (TEVAR) and then endovascular aneurysm repair (EVAR). All patients had TEVAR first for thoracic aortic aneurysm and later on developed infra-renal abdominal aortic aneurysm (AAA) that required EVAR. There were three males and one female with a median age of 74.5 years (range 67.5-78.5). None of the patients developed aortic-related major clinical adverse effects or required any aortic intervention during their follow-up. However, within 2 years, all patients developed symptomatic left ventricular hypertrophy with diastolic dysfunction. All patients had bilateral lower limb oedema, with on and off chest pain and shortness of breath (SOB), necessitating coronary angiograms, which showed no evidence of coronary artery disease. Three patients died from cardiovascular-related morbidities, and the fourth patient is still complaining of SOB despite a normal coronary angiogram. DISCUSSION: Aortic-endograft compliance mismatch is an invisible enemy, with troubling consequences for the aorta proximal and distal to the endograft. Aortic stiffness due to vascular endograft could lead to cardiovascular adverse events, even in the absence of direct aortic-related complications. After combined TEVAR and EVAR, the compliance mismatch and elasticity loss are even more pronounced than with TEVAR alone, which necessitates patient monitoring for the development of cardiovascular complications.

The history of proximal carotid protection and flow reversal to prevent stent angioplasty embolization.

Innovation in medicine is often driven by the observations of imaginative physicians who are blessed with insatiable curiosity, coupled with the inability to accept technical boundaries, the status quo of patient care, or the acceptance of procedural morbidity. Few examples illustrate this truism better than the physician-originated clinical research that transformed the safety of carotid stent angioplasty over the last 2 decades. Initial clinical application of carotid stenting suggested that proximal protection may be a better approach to prevent embolic stroke during the angioplasty procedure. The history of how this innovation was developed is particularly relevant as vascular surgeons adopt new endovascular therapies. It has been more than 15 years since Dr Juan Parodi put together a multidisciplinary team of scientists and clinicians to test the "proximal protection" hypothesis. The goal of this overview was to provide Dr Parodi team's perspective on the development of the proximal protection and flow reversal concept to minimize plaque embolization during carotid stent angioplasty procedures.

Complications of carotid artery stenting are largely preventable: a retrospective error analysis.

Procedure-related complications with carotid artery stenting must be minimized for it to be a valid treatment for carotid stenosis. Failure analysis was done for 207 carotid stent procedures. All complications were reviewed and technical errors were identified. The procedure-related stroke rate was 2.9%, technical failure rate was 1.9%, and no patients died. Two strokes resulted from protocol deviations. A third stroke occurred while crossing a long, irregular lesion with a protection device instead of establishing flow reversal. Excessive instrumentation of the aortic arch resulted in 2 strokes. Distal embolization occurred after open-cell stenting a friable lesion in 1 patient. The majority of neurologic events and technical complications that occur during carotid stenting are preventable. By adhering to technical protocols, avoiding excessive instrumentation in the aortic arch, using flow reversal in selected lesions, and matching the appropriate anatomy and stent, results of carotid artery stenting can be exceptional.

Heme oxygenase-1 is expressed in carotid atherosclerotic plaques infected by Helicobacter pylori and is more prevalent in asymptomatic subjects.

BACKGROUND AND PURPOSE: It is not well established what are the features, if any, that distinguish symptomatic from asymptomatic carotid atherosclerotic plaques. Inducible heme oxygenase-1 (HO-1) is a component of cellular defense mechanisms against oxidative stress. We aimed to assess the presence of Helicobacter pylori (H pylori) and the expression of HO-1 in carotid atherosclerotic plaques of patients with and without prior neurologic symptoms attributable to the operated artery. METHODS: We examined 25 symptomatic and 23 asymptomatic carotid atherosclerotic plaques removed during endarterectomy and 7 normal carotid arteries obtained at autopsy. We investigated the presence of H pylori DNA in the vessel wall and performed immunohistochemical detection of HO-1. RESULTS: H pylori DNA was present in 28 plaques and HO-1 was expressed in 30 plaques. HO-1 was found in 27 H pylori-positive specimens but in only 3 H pylori-negative specimens (P<0.001). All 7 normal carotid arteries were negative for both H pylori and HO-1. Although 82% of asymptomatic specimens were positive for H pylori and 87% for HO-1, only 36% of symptomatic specimens were positive for both H pylori and HO-1 (P<0.01). CONCLUSIONS: This study suggests a strong association between H pylori infection and expression of HO-1 in carotid atherosclerotic plaques. There was a substantial prevalence of these features in specimens obtained from asymptomatic subjects.