Circulating anti-ß2-glycoprotein I antibodies of peripheral arterial disease patients trigger a genomic overexpression of Toll-like receptor 4 in endothelial cells.

OBJECTIVE: Circulating anti-ß2-glycoprotein I (ABGPI) antibodies are associated with peripheral arterial disease (PAD) and induce the expression of leukocyte adhesion molecules and proinflammatory cytokines by endothelial cells. Our aim is to study a transcriptional activation pathway of the innate immune system through the cellular signalling cascade triggered by receptors Toll-like receptor 2 (TLR2) and Toll-like receptor 4 (TLR4) of endothelial cells after the exposure of these cells to seropositive ABGPI human serum obtained from PAD patients. METHODS: We obtained serum samples from PAD patients and controls without PAD. ABGPI serum titer was detected using indirect immunofluorescence. Our sample was stratified into three groups: group I (PAD and ABGPI titer ≥1:100; n = 15), group II (PAD and ABGPI titer <1:100; n = 15), and control participants (no PAD; n = 15). All serum samples were incubated with human aortic endothelial cell (HAEC) culture. Genomic expression of TLR2 and TLR4 receptors and their shared intracellular signalling molecules, myeloid differentiation primary response gene 88 (MyD88), and interleukin (IL)-1 receptor-associated kinase (1IRAK1), were measured after the exposure of HAECs to each serum. RESULTS: HAEC genomic expression of TLR4 was higher after the exposure to group I serum than after the exposure to group II serum (log10×10-relative quantification [RQ]: 1.80 ± 0.42 vs 1.37 ± 0.39; P = .01) or control serum (log10×10-RQ: 1.80 ± 0.42 vs 1.09 ± 0.26; P < .01). TLR4 expression was higher in group II than in the control group (log10×10-RQ: 1.37 ± 0.39 vs 1.09 ± 0.26; P = .04). TLR4 expression correlated with MyD88 (r = 0.54; P < .01) and IRAK1 (r = 0.55; P < .01) expression. We recorded a positive correlation between MyD88 and IRAK1 genomic expression (r = 0.58; P < .01). CONCLUSIONS: Our results suggest that serum from PAD patients with elevated ABGPI antibodies induces a genomic overexpression of TLR4 and its cellular signalling molecules in endothelial cells.

Carotid stenting with proximal cerebral protection in symptomatic low-grade vulnerable recurrent carotid stenosis.

BACKGROUND: Although the management of carotid disease is well established for symptomatic lesions ⩾70%, carotid revascularization for symptomatic low-grade (⩽50%) stenosis is not actually supported by data from randomized clinical trials. Such patients may occasionally have recurrent neurological symptoms despite optimal medical treatment owing to vulnerable plaques. In such cases, carotid artery stenting (CAS) may represent an option for treatment but this has not been tested in clinical trials. This study analyzed early and long-term outcomes of CAS performed in patients with low-grade symptomatic recurrent carotid stenosis. METHODS: From a prospective registry of 322 carotid revascularization in symptomatic patients, 21 consecutive patients with low-grade symptomatic recurrent carotid stenosis who underwent CAS with proximal cerebral protection device Mo.Ma, after ruling out any other source of cerebral embolization, were involved in the study.All patients had suggestive evidence of unstable plaque or plaque ulceration. RESULTS: Procedural technical success rate was 100%. No 30-day stroke or death occurred, and no patients had recurrent neurological events related to the revascularized hemisphere during follow up. No 30-day local complications were reported. No late carotid occlusions were detected. There was one late death, and no stroke-related deaths. Survival rates were 100% at 1 year and 96% at 3 years. CONCLUSIONS: This study shows that CAS is a well-tolerated, effective and durable treatment for patients with recurrent symptomatic low-grade carotid stenosis associated with a vulnerable plaque. Patients had excellent protection against further ischemic events and survived long enough.

Isquemia crítica de miembros inferiores en paciente joven: presentación atípica del síndrome de atrapamiento poplíteo / Critical lower extremity ischemia in a young patient: atypical presentation of the popliteal artery entrapment syndrome

Introducción. El síndrome de atrapamiento poplíteo es una entidad infrecuente, cuya incidencia oscila entre 0,17 y 3,5 %, representando una de las principales causas de isquemia en miembros inferiores en adultos jóvenes. Suele manifestarse con claudicación intermitente (69 %) o isquemia aguda (26 %), siendo muy rara su presentación con isquemia crítica de miembros inferiores. Caso clínico. Paciente de 30 años quien presentó úlcera subungueal en primer dedo de pie derecho con dolor intenso. En la exploración física no se palpaban pulsos distales y se observó palidez cutánea intensa y frialdad. Se realizó arteriografía donde se observó defecto de repleción de bordes regulares y desplazamiento medial de la arteria poplítea. La resonancia magnética mostró una inserción anómala del gastrocnemio medial, con lo que se hizo diagnóstico de síndrome de atrapamiento poplíteo tipo I. Mediante abordaje posterior se realizó reconstrucción vascular con injerto venoso y sección tendinosa del gastrocnemio medial. En el postoperatorio inmediato el paciente recupera pulso pedio y en el seguimiento a un año el paciente no presenta clínica de isquemia de miembros inferiores, encontrándose el baipás permeable. Discusión. A pesar de su baja incidencia, es importante incluir el síndrome de atrapamiento poplíteo en el diagnóstico diferencial de isquemia en miembros inferiores en adultos jóvenes. Su presentación con isquemia crítica es excepcional, encontrando muy pocos casos publicados en la literatura. La reconstrucción arterial precoz mediante injerto o plastia con material autólogo constituye el tratamiento de elección

Introduction. The popliteal entrapment syndrome is an infrequent entity, whose incidence ranges between 0.17 and 3.5%, representing one of the main causes of lower limb ischemia in young adults. It usually manifests with intermittent claudication (69%) or acute ischemia (26%), being very rare its presentation with critical ischemia of the lower limbs.Clinical case. A 30-year-old patient with a history of smoking, with no other risk factors, who presented with a subungual ulcer on the first right toe. On physical examination, distal pulses are not palpated, intense skin paleness and coldness are observed. Magnetic resonance imaging showed an anomalous insertion of the medial gastrocnemius with extrinsic compression of the popliteal artery, confirming a diagnosis of popliteal entrapment syndrome type I. Vascular reconstruction with venous graft and tendon section of the medial gastrocnemius was performed through a posterior approach. In the immediate postoperative period, the patient recovers a pediatric pulse and in the one-year follow-up the patient does not present symptoms of lower limb ischemia, finding the bypass patent. Discussion. Despite its low incidence, it is important to include popliteal impingement syndrome in the differential diagnosis of lower limb ischemia in young adults. Its presentation with critical ischemia is exceptional, finding very few cases published in the literature. Early arterial reconstruction by graft or plasty with autologous material is the treatment of choice

Lesión pancreática aislada tras traumatismo abdominal cerrado: a propósito de un caso / Isolated pancreatic injury after blunt abdominal trauma: a case report

Introducción. La incidencia de lesiones traumáticas del páncreas es baja debido a su localización retroperitoneal, y las lesiones aisladas son excepcionales debido a la proximidad del páncreas a otros órganos y estructuras vasculares. Caso clínico. Presentamos el caso de un varón de 21 años con lesión aislada del páncreas tras traumatismo abdominal cerrado, que precisó manejo quirúrgico. Discusión. Las lesiones pancreáticas aisladas secundarias a traumatismo son raras, pero debemos tenerlas en cuenta en un paciente politraumatizado. Su diagnóstico precoz y manejo adecuado son cruciales para evitar el desarrollo de complicaciones

Introduction. The incidence of traumatic injuries to the pancreas is low due to its retroperitoneal location, and isolated injuries are rare due to the proximity of the pancreas to other vascular organs and structures. Clinical case. We present the case of a 21-year-old man with an isolated lesion of the pancreas after blunt abdominal trauma, which required surgical management.Discussion. Isolated pancreatic injuries secondary to trauma are rare but must be taken into account in a multiple trauma patient. Its early diagnosis and proper management are crucial to avoid the development of complications

Results of infrapopliteal endovascular procedures performed in diabetic patients with critical limb ischemia and tissue loss from the perspective of an angiosome-oriented revascularization strategy.

Our aim was to describe our experience with infrapopliteal endovascular procedures performed in diabetic patients with ischemic ulcers and critical ischemia (CLI). A retrospective study of 101 procedures was performed. Our cohort was divided into groups according to the number of tibial vessels attempted and the number of patent tibial vessels achieved to the foot. An angiosome anatomical classification of ulcers were used to describe the local perfusion obtained after revascularization. Ischemic ulcer healing and limb salvage rates were measured. Ischemic ulcer healing at 12 months and limb salvage at 24 months was similar between a single revascularization and multiple revascularization attempts. The group in whom none patent tibial vessel to the foot was obtained presented lower healing and limb salvage rates. No differences were observed between obtaining a single patent tibial vessel versus more than one tibial vessel. Indirect revascularization of the ulcer through arterial-arterial connections provided similar results than those obtained after direct revascularization via its specific angiosome tibial artery. Our results suggest that, in CLI diabetic patients with ischemic ulcers that undergo infrapopliteal endovascular procedures, better results are expected if at least one patent vessel is obtained and flow is restored to the local ischemic area of the foot.