Arterial Ischemia Research Articles

Central Retinal Artery Occlusion as a Complication in Invasive Aesthetic Cosmetology: a Clinical Case

Central retinal artery occlusion (CRAO) is a relatively rare form of acute retinal arterial ischemia that results in unilateral vision loss. The incidence of transient vision loss is estimated at approximately 14 cases per 100,000 people per year, while the incidence of CRAO is approximately 1–2 cases per 100,000 people. In the foreign literature, there are more and more publications about the development of iatrogenic vision loss after dermal cosmetic injections. We would like to present a clinical case that should be interesting for both practicing ophthalmologists and specialists of related specialties, especially for cosmetologists. Patient M., 42 years old, came to us with complaints of a sharp loss of vision to light perception in the right eye. From the anamnesis, it is known that two hours earlier, the patient was injected into the temporal region (plasma, anesthetic, epinephrine) in the cosmetology office. Lightning-fast deterioration of vision occurred at the time of the drug administration. The patient arrived at the clinic 2 hours after the onset of complaints. We conducted an ophthalmological examination of the patient, the diagnosis was made: occlusion of the central artery of the retina of the right eye, and immediately performed standard emergency therapy. After a course of conservative treatment in an ophthalmological hospital, a persistent decrease in visual functions and a violation of arterial blood circulation in the central retinal artery basin remained. The progressive increase in the number of minimally invasive cosmetic procedures in recent years, in particular, injections of dermal fillers, is associated with rare, but often fatal complications. This clinical situation should attract the attention of practicing ophthalmologists and cosmetologists to these types of complications, and improve the quality and speed of emergency medical care.

Impact of Serum Uric Acid Level on Systemic Endothelial Dysfunction in Patients with a Broad Spectrum of Ischemic Heart Disease.

Previous studies indicated that serum uric acid (SUA) level is a marker of endothelial function in subsets of ischemic heart disease (IHD). In the present study, we aimed to evaluate the relation between the SUA level and endothelial function in patients with a broad spectrum of IHD, including obstructive coronary artery disease (CAD) and ischemia with no obstructive CAD (INOCA). Three prospective studies and one retrospective study were pooled, in which the SUA level was measured, and systemic endothelial function was assessed using the reactive hyperemia index (RHI). The primary endpoint of the present study was a correlation of the SUA level with RHI. A total of 181 patients with a broad spectrum of IHD were included, among whom, 46 (25%) had acute coronary syndrome presentation and 15 (8%) had INOCA. Overall, the SUA level was negatively correlated with the RHI (r = −0.22, p = 0.003). Multivariable analysis identified the SUA level and INOCA as significant factors associated with RHI values. In conclusion, in patients with a broad spectrum of IHD, including obstructive epicardial CAD (chronic and acute coronary syndromes) and INOCA, the SUA level was significantly and negatively correlated with systemic endothelial function assessed with the RHI. INOCA, rather than obstructive CAD, was more associated with endothelial dysfunction.

Outcomes in the ISCHEMIA Trial Based on Coronary Artery Disease and Ischemia Severity.

The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) postulated that patients with stable coronary artery disease (CAD) and moderate or severe ischemia would benefit from revascularization. We investigated the relationship between severity of CAD and ischemia and trial outcomes, overall and by management strategy. In total, 5179 patients with moderate or severe ischemia were randomized to an initial invasive or conservative management strategy. Blinded, core laboratory-interpreted coronary computed tomographic angiography was used to assess anatomic eligibility for randomization. Extent and severity of CAD were classified with the modified Duke Prognostic Index (n=2475, 48%). Ischemia severity was interpreted by independent core laboratories (nuclear, echocardiography, magnetic resonance imaging, exercise tolerance testing, n=5105, 99%). We compared 4-year event rates across subgroups defined by severity of ischemia and CAD. The primary end point for this analysis was all-cause mortality. Secondary end points were myocardial infarction (MI), cardiovascular death or MI, and the trial primary end point (cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest). Relative to mild/no ischemia, neither moderate ischemia nor severe ischemia was associated with increased mortality (moderate ischemia hazard ratio [HR], 0.89 [95% CI, 0.61-1.30]; severe ischemia HR, 0.83 [95% CI, 0.57-1.21]; P=0.33). Nonfatal MI rates increased with worsening ischemia severity (HR for moderate ischemia, 1.20 [95% CI, 0.86-1.69] versus mild/no ischemia; HR for severe ischemia, 1.37 [95% CI, 0.98-1.91]; P=0.04 for trend, P=NS after adjustment for CAD). Increasing CAD severity was associated with death (HR, 2.72 [95% CI, 1.06-6.98]) and MI (HR, 3.78 [95% CI, 1.63-8.78]) for the most versus least severe CAD subgroup. Ischemia severity did not identify a subgroup with treatment benefit on mortality, MI, the trial primary end point, or cardiovascular death or MI. In the most severe CAD subgroup (n=659), the 4-year rate of cardiovascular death or MI was lower in the invasive strategy group (difference, 6.3% [95% CI, 0.2%-12.4%]), but 4-year all-cause mortality was similar. Ischemia severity was not associated with increased risk after adjustment for CAD severity. More severe CAD was associated with increased risk. Invasive management did not lower all-cause mortality at 4 years in any ischemia or CAD subgroup. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01471522.

Predictors of outcome in the ISCHEMIA-CKD trial: Anatomy versus ischemia

The ISCHEMIA-CKD (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches-Chronic Kidney Disease) trial found no advantage to an invasive strategy compared to conservative management in reducing all-cause death or myocardial infarction (D/MI). However, the prognostic influence of angiographic coronary artery disease (CAD) burden and ischemia severity remains unknown in this population. We compared the relative impact of CAD extent and severity of myocardial ischemia on D/MI in patients with advanced chronic kidney disease (CKD). Participants randomized to invasive management with available data on coronary angiography and stress testing were included. Extent of CAD was defined by the number of major epicardial vessels with ≥50% diameter stenosis by quantitative coronary angiography. Ischemia severity was assessed by site investigators as moderate or severe using trial definitions. The primary endpoint was D/MI. Of the 388 participants, 307 (79.1%) had complete coronary angiography and stress testing data. D/MI occurred in 104/307 participants (33.9%). Extent of CAD was associated with an increased risk of D/MI (P < .001), while ischemia severity was not (P = .249). These relationships persisted following multivariable adjustment. Using 0-vessel disease (VD) as reference, the adjusted hazard ratio (HR) for 1VD was 1.86, 95% confidence interval (CI) 0.94 to 3.68, P = .073; 2VD: HR 2.13, 95% CI 1.10 to 4.12, P = .025; 3VD: HR 4.00, 95% CI 2.06 to 7.76, P < .001. Using moderate ischemia as the reference, the HR for severe ischemia was 0.84, 95% CI 0.54 to 1.30, P = .427. Among ISCHEMIA-CKD participants randomized to the invasive strategy, extent of CAD predicted D/MI whereas severity of ischemia did not.

Measurement of capillary refill time with a handheld prototype device: a comparative validation study in healthy volunteers.

Validity and reproducibility of clinical capillary refill time (CRT) measurement depend on many factors in daily routine practice. We conducted a prospective validation study of an automatized handheld prototype device providing standardized CRT assessment (DiCART™) in 20 healthy volunteers. Three different methods of CRT measurement were compared before and during dynamic circulatory changes induced by venous and arterial occlusion tests at both upper and lower limb levels: CRTCLIN corresponding to basic clinical assessment and considered as the reference method; CRTVIDEO corresponding to off-line videos reviewed by investigators recorded by DiCART™; and CRTDiCART corresponding to on-line videos analysed by a built-in proprietary mathematical algorithm included in DiCART™. Five subjects were excluded because of a DiCART™ dysfunction. ROCAUC to detect arterial occlusion test changes at the upper limb level were 1.00 (95%CI 1.00; 1.00), 0.96 (95%CI 0.88; 1.00), and 0.92 (95%CI 0.79; 1.00) for CRTCLIN, CRTVIDEO, and CRTDiCART, respectively. Precision of CRTCLIN and CRTVIDEO were significantly better than CRTDiCART (0.18 and 0.20 vs. 0.28; P < 0.05). Percentages of error were 76% and 87% for CRTVIDEO and CRTDiCART, respectively. DiCART™ had an excellent discrimination to detect major changes in CRT induced by arterial ischemia. However, the perfectible precision, the poor agreement with clinical assessment and numerous device dysfunctions give leads to the development of a further version of the prototype before promoting its use in clinical practice.Trial registration clinicaltrial.gov. Identifier: NCT04538612.

The short-term safety and effectiveness of a new distal perforating stent graft in Type B aortic dissection: a retrospective study

BackgroundSpinal artery ischemia (SCI) events can result from over coverage of the descending thoracic aorta with a coated stent during Thoracic Endovascular Aortic Repair (TEVAR). The aim of this study was to determine whether a new distal perforating stent could reduce the incidence of spinal cord ischemia while remodeling the true lumen.MethodsTBAD patients treated with Talos stent in the vascular surgery Department of Yan 'an Hospital affiliated to Kunming Medical University between December 2017 and October 2019 were retrospectively analyzed to investigate the short-term safety and effectiveness of Talos stent.ResultsA total of the 20 patients, including 14 males and 6 females, with an average age of 52.65 ± 8.98 years (range 37–68 years), were included in the analysis. Stent-grafts were successfully implanted in all patients under local anesthesia, with a technical success rate of 100%. The average operation time was 50.75 ± 13.01 min. A total of 2 cases (10%) presented chest pain associated with intercostal artery ischemia that was relieved on the 3rd and 5th postoperative day, respectively. Postoperative mean follow-up was 16.15 ± 3.99 months. No paraplegia or other complications occurred. And stenting did not induce new tears. No migration, deformation, or fracture of the stents occurred. There was a significant difference in the remolding of the true lumen preoperatively and at 12 months postoperatively (P < 0.05).ConclusionsTalos stent has achieved satisfactory clinical treatment results in short term.

Cardiovascular immunotoxicities associated with immune checkpoint inhibitors: a safety meta-analysis

The risk and incidence of cardiovascular (CV) immune-related adverse events (irAEs) associated with immune checkpoint inhibitors (ICIs) in cancer patients remain unknown. We systematically reviewed all randomized clinical trials (RCTs) including at least one ICI-containing arm and available CV adverse event (CVAE) data in cancer patients in the ClinicalTrials.gov registry, Medline, and the Cochrane CENTRAL Register of Controlled Trials, up to 31 August 2020 (CRD42020165672). The primary outcome was the summary risk of 16 different CVAEs associated with ICI exposure vs. controls (placebo and non-placebo) in RCTs. CVAEs with an increased risk associated with ICI exposure were considered as CV irAEs. Summary incidences of CV irAEs identified in our primary outcome analyses were computed using all RCTs including at least one ICI-containing arm. We used a random-effects meta-analysis to obtain Peto odds ratios (ORs) with 95% confidence intervals (CIs) and logit transformation and inverse variance weighting to compute summary incidences. Sixty-three unique RCTs with at least one ICI-containing arm (32 518 patients) were retrieved, among which 48 (29 592 patients) had a control arm. Among the 16 CVAEs studied, ICI use was associated with an increased risk of 6 CV irAEs including myocarditis, pericardial diseases, heart failure, dyslipidemia, myocardial infarction, and cerebral arterial ischaemia with higher risks for myocarditis (Peto OR: 4.42, 95% CI: 1.56-12.50, P < 0.01; I2 = 0%, P = 0.93) and dyslipidemia (Peto OR: 3.68, 95% CI: 1.89-7.19, P < 0.01; I2 = 0%, P = 0.66). The incidence of these CVAEs ranged from 3.2 (95% CI 2.0-5.1) to 19.3 (6.7-54.1) per 1000 patients, in studies with a median follow-up ranging from 3.2 to 32.8 months. In RCTs, ICI use was associated with six CV irAEs, not confined to myocarditis and pericarditis.

A Case Report of Mesenteric Ischemia After COVID-19 Vaccination

The United States has vaccinated almost 200 million citizens in the first 7 months of 2021. During that period adverse events have been described from minor complaints of redness, pain and swelling at the injection site to more serious events such as Guillain Barre Syndrome and thrombosis. As vaccination distribution continue to move forward, more side effects and complications will become evident. This case report is of a patient presenting in shock 4 days after receiving her second COVID-19 vaccination with altered mental status, dyspnea, and an acute abdomen with a bowel perforation. After resuscitation, the patient was taken to surgery where an additional diagnosis of embolic mesenteric arterial ischemia was made on exploratory laparotomy. While a causal relationship between the vaccine and the findings in this particular patient cannot be proven, there certainly is a temporal relationship between her receiving the Pfizer-BioNTech (BNT162b2) COVID-19 vaccine, the presentation of this patient to our institution, and the findings during emergency surgery. Thromboses are known adverse events from the COVID-19 vaccines however to our knowledge, there has not been a published case report of embolic mesenteric arterial ischemia after receiving a COVID-19 vaccine. Appreciating the association between COVID-19 vaccines and embolic mesenteric arterial ischemia should alert physicians to keep this diagnosis high on their differential in the setting of unusual abdominal pain and recent vaccination.

Factors Affecting Mortality in Acute Arterial Mesenteric Ischemia: A Single-Center Experience

Background : Acute mesenteric ischemia (AMI) is a life-threatening pathology that often requires urgent surgical intervention. It is frequently faced in elderly patients. Despite advances in the diagnosis of AMI morbidity, and mortality rates are still high. The presence of comorbidities delayed surgical intervention due to diagnostic difficulties, and in most cases, older patients with heart problems may be remarkable factors for higher mortality rates. Diagnostic challenges are tried to be overcome with both imaging methods and laboratory findings. Unfortunately, to date, no clear laboratory parameters have been described in diagnosing or predicting mortality of mesenteric ischemia. Materials and Methods : The patients diagnosed with acute arterial mesenteric ischemia between the dates 2010-2019 were enrolled in the study. Demographic characteristics, diagnostic biochemical parameters (lymphocyte, neutrophil, albumin, C-reactive protein, lactate, lactate dehydrogenase, Di-Dimer, troponin, white blood count, platelet, fibrinogen, creatine kinase-MB) levels, as well as comorbidities of the patients, were evaluated. Results : A total of 149 patients was enrolled in the study, with a mean age of 66.11 . In the non-survivor group, neutrophil, RDW, lactate, DDM, Fibrinogen, and CK-MB levels, furthermore albumin levels were defined as significantly elevated in the survivor group (p0.05). Hypertension was the major comorbidity by far in both groups. Conclusion : High levels of fibrinogen, lactate, DDM, CK-MB levels and low levels of albumin levels may be predictors of mortality in mesenteric ischemia.

An Update on COVID-19 Vaccine Induced Thrombotic Thrombocytopenia Syndrome and Some Management Recommendations.

The thrombotic thrombocytopenia syndrome (TTS), a complication of COVID-19 vaccines, involves thrombosis (often cerebral venous sinus thrombosis) and thrombocytopenia with occasional pulmonary embolism and arterial ischemia. TTS appears to mostly affect females aged between 20 and 50 years old, with no predisposing risk factors conclusively identified so far. Cases are characterized by thrombocytopenia, higher levels of D-dimers than commonly observed in venous thromboembolic events, inexplicably low fibrinogen levels and worsening thrombosis. Hyper fibrinolysis associated with bleeding can also occur. Antibodies that bind platelet factor 4, similar to those associated with heparin-induced thrombocytopenia, have also been identified but in the absence of patient exposure to heparin treatment. A number of countries have now suspended the use of adenovirus-vectored vaccines for younger individuals. The prevailing opinion of most experts is that the risk of developing COVID-19 disease, including thrombosis, far exceeds the extremely low risk of TTS associated with highly efficacious vaccines. Mass vaccination should continue but with caution. Vaccines that are more likely to cause TTS (e.g., Vaxzevria manufactured by AstraZeneca) should be avoided in younger patients for whom an alternative vaccine is available.

Memo for a patient with ischemic heart disease

Angina pectoris is not an independent disease, but a syndrome that is a manifestation of ischemic heart disease (IHD). Ischemic artery disease occurs due to insufficient blood supply to the heart muscle and is an acute or chronic heart dysfunction resulting from a relative or absolute decrease in the supply of the myocardium with arterial blood. In more than 90% of cases, the anatomical basis of ischemic heart disease is the lesion of the coronary arteries of the heart. Angina pectoris is a kind of heart signal about oxygen deficiency. The signal is felt in the form of attacks of short-term sudden acute compressive, pressing, burning pains in the heart region. In some patients, the pain is accompanied by a state of general discomfort, a feeling of lack of air, and interruptions in the work of the heart.

Acute arterial ischemia due to SARS-CoV-2 infection

Acute arterial ischemia due to SARS-CoV-2 infection

Effect of Surgical Technique on the Microstructure and Microcirculation of the Small Intestine Stump during Delayed Anastomosis: Multimodal OCT Data.

The aim of the study was to use multimodal optical coherence tomography (MM OCT) to evaluate microstructure and microcirculation in the proximal and distal sections of the intestine relative to the resected area in acute mesenteric ischemia.Materials and MethodsThe study was carried out using three groups of male Wistar rats weighing 270–435 g (n=18). Acute occlusive arterial ischemia of the small intestine was initiated in all animals. After 80–90 min, the ischemic non-viable part of the intestine was resected, and the operation was completed by stoma exteriorization (group 1, n=6), by applying purse-string sutures (group 2, obstructive resection, n=6), or by internal drainage of the proximal and distal ends of the small intestine (group 3, bypass, n=6). Relaparotomy and anastomosis formation were performed 2 days later.With the help of MM OCT at each stage of the surgical intervention, images were obtained from the serous membrane side: the intestinal wall microstructure (layers) was viewed using cross-polarization OCT (CP OCT) and the intramural circulation — using optical coherent angiography (OCA). The MM OCT images obtained from the terminal intestine sections immediately after resection and 2 days later (before the anastomosis formation) were compared between the experimental groups, as well as with the pre-ischemic data (norm). All resected sections of the intestine were then histologically examined. The MM OCT data were compared with the histological and intravital macroscopy data.ResultsAs a result of studying the intestinal wall microstructure by in vivo CP OCT, it was found that during ostomy (group 1) and obstructive resection (group 2), the images showed signs of tissue edema and destructive changes in the mucous membrane that were confirmed histologically, while with bypass surgery (group 3), there were minimal changes as compared with the norm.According to the OCA data, on day 2 of ostomy in the proximal and distal segments of the intestine, there was a noticeable disappearance of small and medium blood vessels; mainly large arteries and veins could be visualized. Following obstructive resection (purse-string suturing) or bypass surgery, the most noticeable changes (a decrease in the number of visualized blood vessels) were observed in the distal part of the intestine. The L index calculated from OCA images and characterizing the total length of the intramural perfused vasculature, showed a statistically significant decrease during ostomy: 12.18 [10.40; 14.20] μm — in the proximal and 10.67 [7.98; 13.05] μm — in the distal section; for comparison, the L index before ischemia was 18.90 [17.98; 19.73] μm and 18.74 [17.46; 19.90] μm, respectively (p=0.0001). In obstructive resection (group 2), statistically significant differences in the L parameter were found only for the distal bowel section: 16.39 [12.37; 18.10] μm compared with 18.74 [17.46; 19.90] μm before ischemia (p=0.041). After bypass surgery (group 3), there were no significant deviations in the L index.ConclusionBy using MM OCT, we found that in treating the remaining sections of the intestine after its emergency resection for acute mesenteric ischemia, the type of surgical technique determines the tissue structure in the period before the delayed anastomosis is applied.The least pronounced and most balanced changes occur in the proximal and distal segments of the intestine when operated using the bypass technique. However, to recommend this type of surgery, the development of reliable, safe, and effective bypass instruments is needed.

The Heart Shape-Sign in Bilateral Medial Medullary Infarction; Complicated with Quadriparesis and Respiratory Failure

20% of ischemic strokes involve posterior circulation. The most common causes of posterior circulation large artery ischemia are atherosclerosis, embolism, and dissection. The most common location of atherosclerotic occlusive disease within the posterior circulation is the proximal portion of the vertebral artery in the neck within the first inches. Basilar artery occlusive disease most often presents as ischemia in the pons. Occlusion of the rostral portion of the basilar artery can cause ischemia of the midbrain, thalami, temporal, and occipital lobe. The most frequent finding in patients with PCA territory infarction is a hemianopia.

English

BACKGROUND Central retinal artery occlusion (CRAO) was first described by Van Graefe in 1859 as an embolic event to the central retinal artery in a patient with endocarditis. CRAO has various causes, but patients typically present with sudden, severe, and painless loss of vision. Retinal arterial occlusions are a cause for profound visual loss in the population. Carotid atherosclerosis is common in elderly people. Dyslipidaemia, hypertension, and diabetes mellitus are factors which accelerate the development of carotid atheromatous plaques. Embolism from the carotid bifurcation is the most common cause of retinal artery occlusions. In retinal arterial occlusion carotid arterial occlusion is usually assessed using radiological techniques. The purpose of this study was to evaluate carotid atherosclerotic disease in patients with arterial occlusions in the eye and determine the relation between arterial occlusions in the eye &amp; carotid artery occlusive disease. METHODS This retrospective study included patients aged thirty and above, who had come with symptoms suggestive of arterial occlusions in the eye and carotid doppler was done. The inclusion criteria included patients diagnosed with the following conditions CRAO, branch retinal artery occlusion (BRAO), ophthalmic artery occlusion, anterior ischaemic optic neuropathy (AION) and cilioretinal artery occlusion. Patients usually present with sudden loss of vision in one eye. After taking a detailed history, all patients were subjected to a thorough ocular examination. Patient’s vision is assessed using Snellen’s visual acuity chart, pupillary assessment done, and fundus examination to look for retinal arterial occlusion is also done. Fundus imaging is also done. Carotid doppler was done to rule out carotid artery occlusive disease. RESULTS Patients presenting with retinal arterial occlusion should be investigated thoroughly for both systemic and local causes of CRAO. The risk of developing arterial occlusions were 1.7 - 9.15 times more in patients with carotid artery occlusion than in patients with normal carotids. Arterial occlusion was more found in patients with 70 % occlusion of the carotid artery. CONCLUSIONS There was a strong association between retinal arterial occlusions and carotid artery occlusion. KEYWORDS Central Retinal Artery Occlusion (CRAO), Carotid Artery Occlusive Disease, Carotid Doppler

Partial Flap Loss in Gender Affirming Phalloplasty.

Flaps used in phalloplasty are larger than described for other indications, with a design that is tubularized up to two times. While the incidence of partial flap loss (PFL) is well described, current literature lacks granularity comparing donor sites and techniques with minimal discussion of etiology and management. The purpose of this study was to review our experience with PFL in phalloplasty. This was a retrospective cohort study of patients who underwent phalloplasty by a single surgeon at a single institution between 2016 and 2020. PFL was defined as any patient requiring sharp excision of necrotic tissue and reconstruction. Patient variables (demographics, body mass index, American Society of Anesthesiologists physical status classification, comorbidities), flap variables (donor site, design, dimensions, perforator number) and intraoperative variables (use of vasopressors, intraoperative fluid volume) were collected. Of 76 phalloplasties, 6 patients suffered PFL (7.9%). 5/6 patients were radial forearm free flap tube-within-tube (TWT) and 1/5 patients were pedicled anterolateral thigh TWT. 4/6 cases involved the shaft only and were treated with excision ± Integra and full-thickness skin grafting. 2 cases of PFL involved the urethral extension requiring excision of the necrotic segment. PFL occurred in 7.9% of cases and was solely found in the TWT cohort. The majority of cases involved the shaft, sparing the urethral segment. Cases in the acute postoperative period appeared to be related to macrovascular venous congestion, while cases in the subacute period appeared to be due to microvascular arterial ischemia.

ISQUEMIA AGUDA DE LA EXTREMIDAD INFERIOR COMO POSIBLE COMPLICACION DE COVID-19.

Introduction Acute arterial ischemia in lower extremities is a vascular emergency with a high risk of limb loss and elevated morbidity and mortality associated. SARS-COV2 virus infection is usually not related to acute arterial ischemia and its incidence is unknown. World references have been documented such as superficial and deep vein thrombosis and peripheral arterial thrombosis. Case description We present the case of a 69-year-old patient, previous smoker for 15 years, who presented with acute pain in the left lower limb followed by absence of distal and popliteal pulses. Complementary imaging studies demonstrated the absence of left arterial patency from the left femoral artery, raising a diagnosis of acute arterial ischemia of the left lower limb. Threatening acute marginal ischemia (Rutherford IIA) associated with SARS-COV2 infection was considered, for which selective femoral and popliteal embolectomy was performed with further control arteriography. The patient recovers arterial patency in the left lower extremity and was discharged with anticoagulation and analgesia. Postsurgical popliteal wound developed lymphorrhea that subsides with compression measures. In follow-up, the patient has a satisfactory evolution, without signs of ischemia. Conclusion In the medical literature of our country, this is our first case of acute arterial ischemia located in the lower extremities. Diagnosis requires a high degree of clinical suspicion and correct identification. Recommended treatment are surgical and/or pharmacological.

Relationship of superior mesenteric artery thrombus density with transmural intestinal necrosis on multidetector computed tomography in acute mesenteric ischemia.

Acute arterial occlusive mesenteric ischemia with transmural intestinal necrosis (TIN) is a fatal disease, which is difficult to diagnose on multidetector computed tomography (MDCT). The aim of the present study was to determine the relationship of superior mesenteric artery (SMA) thrombus density with TIN on MDCT in patients with acute mesenteric ischemia (AMI) due to SMA thromboembolism. In this retrospective study, 33 patients who underwent abdominal MDCT and angiography for AMI due to SMA thromboembolism were divided into two groups: the AMI with TIN group and the AMI without TIN group. We analyzed the relationships of clinical characteristics, qualitative MDCT signs, and SMA thrombus density with TIN. The SMA thrombus density was measured on non-contrast MDCT. Univariate and multivariate analyses were performed to determine the risk factors for predicting TIN. The diagnostic performances of risk factors were evaluated by receiver-operating characteristic (ROC) curve analysis. Of the patients with AMI enrolled in this study, 33.3% (11/33) were diagnosed with TIN. Peritonitis (P=0.042), bowel wall thinning (P=0.033), and pneumatosis/portomesenteric gas (P=0.010) were significantly associated with TIN. AMI patients with TIN exhibited a higher SMA thrombus density than AMI patients without TIN [41.2±6.1 vs. 34.2±3.0 Hounsfield unit (HU), P=0.003]. Multivariate analysis showed that SMA thrombus density was an independent predictor of TIN [P=0.044, hazard ratio (HR): 1.82, 95% confidence interval (CI): 1.02-3.25]. For diagnosing AMI with TIN, the area under the ROC curve (AUC) of SMA thrombus density (0.83) was larger than those of peritonitis (0.68), bowel wall thinning (0.66), and pneumatosis/portomesenteric gas (0.71). In patients with AMI, erythrocyte-rich thrombus blocking the SMA trunk which has a higher density on MDCT is prone to the occurrence of TIN compared with erythrocyte-scarce thrombus with a lower density. SMA thrombus density could be an independent risk factor for TIN in patients with AMI due to SMA thromboembolism.

Adipose-Derived Stem Cells and Their Derived Microvesicles Ameliorate Detrusor Overactivity Secondary to Bilateral Partial Iliac Arterial Occlusion-Induced Bladder Ischemia.

(1) Background: We established a new bladder ischemia rat model through bilateral partial iliac arterial occlusion (BPAO) and investigated the therapeutic effect of adipose-derived stem cells (ADSCs) and ADSC-derived microvesicles (MVs); (2) Methods: The study included four groups: (1) sham, (2) BPAO, (3) BPAO + ADSCs, and (4) BPAO + ADSC-derived MVs. Female Wistar rats with BPAO were injected with ADSCs or ADSC-derived MVs through the femoral artery. Doppler flowmetry and real-time laser speckle contrast imaging were performed to quantify blood flow in the common iliac arteries and bladder microcirculation. A 24-h behavior study and transcystometrogram were conducted after 2 weeks. Bladder histology, immunostaining, and lipid peroxidation assay were performed. The expressions of P2X2, P2X3, M2, and M3 receptors and nerve growth factor (NGF) were evaluated; (3) Results: BPAO significantly reduced bladder microcirculation, intercontraction interval (ICI), and bladder volume and increased the amplitude of nonvoiding contraction, neutrophil infiltration, and malondialdehyde and NGF levels. ADSCs and ADSC-derived MVs significantly ameliorated these effects. The results of Western blot showed that the BPAO group exhibited the highest expression of M3 and P2X2 receptors. ADSCs significantly attenuated the expressions of M2 and P2X2 receptors. ADSC-derived MVs significantly attenuated the expressions of M3 and P2X2 receptors; (4) Conclusions: ADSCs and ADSC-derived MVs ameliorated the adverse effects of BPAO including bladder overactivity, bladder ischemia, and oxidative stress. Inflammation, muscarinic signaling, purinergic signaling, and NGF might be involved in the therapeutic mechanism.

Outpatients with Lymphoma on Chemotherapy: Specific Thromboembolic Risk Factors and Venous Thrombosis Incidence

INTRODUCTIONIncidence of venous thrombotic events (VTE) in patients with lymphomas is approximately 4%. There are a number of thrombotic risk factors (TRF) identified in this group of patients in general, like leukocytosis, dexamethasone, central nervous system lymphoma and primary mediastina large b-cell lymphoma and poor performance status. These TRF have not been evaluated specifically in patients with lymphoma under non-hospitalization chemotherapy regimen. OBJETIVES•To evaluate the prevalence of general and specific TRF in patients with lymphomas under out hospital chemotherapy regimen in our center.•To describe the incidence of thrombosis and ischemic events in this group of patients during treatment in our area.•To describe the characteristics of vascular events.•To evaluate the safety of antiplatelet and anticoagulant treatment during chemotherapy treatment in this group. MATERIAL AND METHODSThis is a retrospective, one center study and single physician for the treatment and follow-up of patients. Patients with lymphoma diagnosed at our center and under out-hospitalization chemotherapy schemes of treatment, between January 2014 and December 2016, were included. We analyzed age at diagnosis, histology, stage, chemotherapy schemes, vascular events prior lymphoma diagnosis, antiplatelet or antithrombotic prophylaxis, use of erythropoietin, Hb<10g/dl, platelets (Plat)>350x109/L, leucocyte (LEU)>11x109/L, immobilization, Charlson, IMC >35, use of dexamethasone, doxorrubicine, radiotherapy, catheters and incidence and characteristics of vascular events. A descriptive analysis was performed, using absolute and relative frequencies for qualitative variables and measures of central tendency and dispersion for continuous variables. The study was carried out according to the Declaration of Helsinki and was approved by the Ethics Committee of the Regional University Hospital of Málaga. RESULTSWe included 137 subjects, median age 54.3+/-18 years old, 51% of group were males. The most frequent types of lymphoma were diffuse large B-cell lymphoma (LDCGB) (30,6%), follicular Lymphoma (FL) (24,8%) and Hodgkin lymphoma (HL) (22,6%). Most of patients presented advance disease, 61,6% were stages III or IV, and 87.4% did not presented B symptoms. Schemes of treatment were R-CHOP or bortezomid-R-CHOP for LDCGB, R-Bendamustine or R-FC in FL and AVBD +/- radiotherapy in HL. Most of them got complete remission, 74,5% with only 17.5% con stable disease or progression. Median follow up of the serie was 20,3+/-16 months.The 40,9% of patients had 3 or more TRF, incidence of each TRF: use of erythropoietin 4,4%, Hb<10g/dl 14%, platelets (Plat)>350x109/L 19%, leucocyte (LEU)>11x109/L 19%, immobilization 3,6%, Charlson 41%, IMC >35 2,9%, use of dexamethasone 5,1%, doxorrubicine 32,8%, radiotherapy 8%, catheters 3,6%.Three patients (2,2%) patients presented VTE: •Female 19 years old, EH 2B, plat>350x109/L, Hb <10gr/L, leu 11x109/L, doxorubicin. Upper limb thrombosis 22 months after diagnosis. Treatment LMWH 3 months.•Patient 2: Female 74 years old, LDCGB 2A, plat>350x109/L, Hb <10gr/L, charlson 4. Lower limb thrombosis 8 months after diagnosis. Treatment antivitamin-K 6 months.•Patient 3: Male 40 years old, LDCGB 1A, plat>350x109/L, doxorubicin. Upper limb thrombosis 8 months after lymphoma. Treatment LMWH 3 months.Three patients were under secondary antiplatelet prophylaxis for prior arterial ischemia. One of them presented a gastrointestinal bleeding after 8 months under chemotherapy and concomitant antiplatelet secondary prophylaxis. Of the 3 patients who develop VTE events after lymphoma diagnosis, one presented an upper gastrointestinal bleed, 20 days after anticoagulation started. Coagulation test were normal and Platelets number higher than 100x109/L at bleeding event. According to these data, 2 of 6 patients under chemotherapy and antiplatelet o anticoagulant treatment presented grade 3 bleedings (30%). CONCLUSIONSPrevalence of VTE in patients with outpatient with lymphoma looks lower than global lymphoma. Three VTE affected patients presented 3 or more TRF. Upper limb thrombosis was the most frequent one, probably related with the local administration of chemotherapy. Bleeding risk in patients with chemotherapy treatment and concomitant antiplatelet or anticoagulant drugs has to be carefully evaluated. DisclosuresNo relevant conflicts of interest to declare.