Atherosclerotic Occlusive Disease Research Articles

Lipoprotein(a) as a risk factor for atherosclerotic peripheral arterial occlusive disease

Background and Aim: Peripheral arterial occlusive disease (PAOD) commonly results from progressive narrowing of arteries in the lower extremities due to atherosclerosis. The objective of this study was to measure plasma levels of Lipoprotein (a) (Lp[a]) in patients with and without clinical evidence of PAOD and find an association (risk ratio) between Lp(a) and PAOD. Materials and Methods: This study was conducted in the Department of General Surgery at Justice K. S. Hegde Charitable Hospital, Mangalore. The age and sex of the patients, clinical symptoms were noted. The study included a total of 100 patients further divided into two groups: Fifty symptomatic patients with clinical evidence and 50 age and sex-matched asymptomatic patients without clinical evidence of PAOD. History of hypertension, diabetes mellitus, and ischemic heart disease were recorded. The diagnosis basically was made by clinical symptoms and signs. Arterial Doppler/computed tomography angiogram was done only if symptoms or signs of PAOD were present. Two ml of overnight fasting blood sample was collected, serum separated, and was analyzed for Lp(a) by immune turbidometry method. Results: In patients with PAOD, Lp(a) value was 90.06 ± 23.4 mg/dl, whereas among patients without PAOD, Lp(a) values was 48.02 ± 24.1 mg/dl and was statistically significant (P

P.63 Sarcopenia and Atherosclerotic Occlusive Disease: How Much We Know and What We Need to Know About this Association?

Purpose/BackgroundSarcopenia (decrease of muscle mass and function) has been linked with atherosclerosis [1]. The EWGSOP2 updated consensus, uses low muscle strength as the primary indicator of sarcopenia [2]. It is acknowledged that strength is better than mass for predicting adverse outcomes [2]. Handgrip strength (HGS) is a simple assessment to estimate overall muscular strength [3]. and is associated with cardiovascular mortality [4].ObjectiveAnalyze the relationship between HGS and atherosclerotic disease (carotid artery disease + lower extremity artery disease).MethodsProspective observation study was conducted from January to December 2019. The clinical and demographic data was recorded. Isometric HGS was measured with an adjustable handheld dynamometer (Jamar The higher value of each arm was used to classify the patient as sarcopenic or non-sarcopenic. Definition of sarcopenia: HGS <30 kgf in men and <20 kgf in women [5].Results94 patients (aged 44–86 years) were analyzed: 64 sarcopenic and 30 non sarcopenic. Groups differed in the prevalence of diabetes and smoking status (Table 1). No differences were found in the carotid parameters analyzed (Table 1). There was, a difference in the prevalence of chronic limb-threatening ischemia (CLTI) in sarcopenic versus non-sarcopenic group (23.44% versus 6.67% p = 0.046). Importantly, binary logistic regression showed that diabetes (p = 0.014), and HGS (p = 0.027) have a significant effect on CLTI (Table 2).ConclusionsNo relationship was found between sarcopenia (measured by HGS) and carotid atherosclerosis, differing from other authors [1,6]. In this study, sarcopenic had a higher incident of diabetes and CLTI. Sarcopenia and diabetes are reciprocally related and may share a similar pathogenetic pathway [7,8,9].Table 1Sarcopenia (n = 64)No Sarcopenia (n = 30)pAge (years)69.81 ± 8.7962.6 ± 8.61p = 0.889Male47 (73.44%)27 (90.00%)p = 0.067Hypertension51 (79.69%)21 (70.00%)p = 0.301Dyslipidemia47 (73.43%)18 (60.00%)p = 0.189Smoking load (UMA)24.42 ± 33.1437.76 ± 31.8p = 0.748Smoker/Ex-smoker33 (51.56%)24 (80.00%)p = 0.013*Diabetes28 (43.75%)7 (23.33%)p = 0.049*Coronary disease11 (17.19%)4 (13.33%)p = 0.613History of stroke11 (17.19%)3 (10.00%)p = 0.347Total cholesterol (mg/dL)158.16 ± 39.82159.6 ± 30.72p = 0.22LEAD43 (67.19%)17 (56.67%)p = 0.275Claudicants28 (43.75%)15 (50.00%)p = 0.615CLTI15 (23.44%)2 (6.67%)p = 0.046*ABI right0.83 ± 0.240.78 ± 0.29p = 0.287ABI left0.81 ± 0.280.77 ± 0.23p = 0.671Right carotid artery stenosis50–704 (6.25%)2 (6.67%)p = 0.952>70%58 (90.63%)27 (90.00%)p = 0.702Light carotid artery stenosis50–703 (4.79%)1 (3.33%)p = 0.787>70%4 (6.25%)2 (6.67%)p = 0.903Area right carotid plaque (mm2)21.22 ± 19.8120.01 ± 17.04p = 0.622Average IMT- right (mm)0.96 ± 0.410.88 ± 0.24p = 0.159Area left carotid plaque (mm2)21.46 ± 18.7321.47 ± 22.06p = 0.948Average IMT- left (mm)0.93 ± 0.250.88 ± 0.29p = 0.861Table 2Independent variablesCategoriesa95% CIpCLTIDiabetes1.4881.34–14.600.014Higher HGS−0.8880.846–0.9900.027

4D-DSA: Development and Current Neurovascular Applications.

Originally described by Davis et al in 2013, 4D-Digital Subtraction Angiography (4D-DSA) has developed into a commercially available application of DSA in the angiography suite. 4D-DSA provides the user with 3D time-resolved images, allowing observation of a contrast bolus at any desired viewing angle through the vasculature and at any time point during the acquisition (any view at any time). 4D-DSA mitigates some limitations that are intrinsic to both 2D- and 3D-DSA images. The clinical applications for 4D-DSA include evaluations of AVMs and AVFs, intracranial aneurysms, and atherosclerotic occlusive disease. Recent advances in blood flow quantification using 4D-DSA indicate that these data provide both the velocity and geometric information necessary for the quantification of blood flow. In this review, we will discuss the development, acquisition, reconstruction, and current neurovascular applications of 4D-DSA volumes.

"Modern Endovascular Therapy".

The past 25years have been witness to a revolution in how vascular care is delivered. The majority of arterial and venous interventions have converted from open surgery to minimally invasive percutaneous endovascular procedures. This surgical innovations symposium article reviews current endovascular therapy in multiple vascular beds with a primary focus on carotid artery occlusive disease, aortic pathologies, and lower extremity arterial occlusive disease. Mesenteric arterial occlusive disease and lower extremity venous endovascular therapies are also briefly discussed. Indications for intervention, treatment examples and outcomes analysis are presented. While not reviewed in this article, endovascular therapy has also become first line in the treatment of coronary artery disease, chronic mesenteric arterial occlusive disease, superficial venous reflux, central vein occlusion, and acute venous thrombus intervention when indicated. Endovascular therapies are used in all vascular beds to treat the full spectrum of vascular pathologies. Aneurysm disease, atherosclerotic arterial occlusive disease, acute arterial and venous thrombosis, ongoing hemorrhage, and venous reflux are among the issues which can be addressed by endovascular means. The minimally invasive nature of endovascular treatments in what is largely a very co-morbid patient cohort is an attractive method of avoiding major procedural related morbidity and mortality.

Features of revascularization of the lower extremity in patients with diabetic foot

Objective: To determine specific features of peripheral arterial diseases in patients with diabetic foot that influence the choice of revascularization method.&#x0D; Introduction. Peripheral arterial diseases in patients with diabetic foot (PAD/DF) have significant differences in pathogenesis, manifestations and course compared with peripheral arterial diseases (PAD). These differences cause creating classifications to access severity PAD/DF and PAD separately. But approaches to revascularizations in PAD/DF and PAD remain the same.&#x0D; The choice of revascularization method taking into account the features can significantly improve its results.&#x0D; Materials and methods. We analyzed results of 98 revascularizations of 77 lower extremities in 74 patients in the period from 2014 to 2019рр. Angioplasties were performed 72,3%, open operations – 21,4%, hybrid procedures 6,1%.&#x0D; Results. Amputation-free survival during the year was 84,6%. Healing of trophic disorders during the year was 70,5%.&#x0D; Conclusions. At the diagnostic stage, patients with PAD and PAD / DM should be separated for creating the optimal treatment plan and the choice of revascularization technique. Different approaches to the PAD/DF patients can improve the results of revascularizations.&#x0D; Abbreviations and defititions&#x0D; PAD (peripheral arterial diseases) - atherosclerotic occlusive diseases of the lower extremity arteries.&#x0D; DF (diabetic foot) - infection, ulceration or destruction of tissues of the foot associated with neuropathy and/or peripheral artery disease in the lower extremity of a person with (a history of) diabetes mellitus.&#x0D; PAD/DF - peripheral arterial diseases in persons with diabetes mellitus.

Comparative Analysis of Short-Term Outcomes in in Patients with Lower Extremity Atherosclerotic Occlusive Disease Undergoing a Hybrid Approach vs Open Revascularization

Comparative Analysis of Short-Term Outcomes in in Patients with Lower Extremity Atherosclerotic Occlusive Disease Undergoing a Hybrid Approach vs Open Revascularization

Comparative Analysis of Outcomes in Patients Undergoing Femoral Endarterectomy plus Endovascular (Hybrid) or Bypass for Femoropopliteal Occlusive Disease

The gold-standard for management of combined common femoral artery (CFA) and superficial femoral artery (SFA) atherosclerotic occlusive disease has traditionally been open femoral endarterectomy and femoral-popliteal bypass. Hybrid approaches involving an open and endovascular component are increasingly common. The aim of this study was to compare perioperative outcomes in patients who underwent an open versus hybrid revascularization. NSQIP data, years 2012-2017, were queried for patients who underwent nonemergent CFA endarterectomy with either SFA transluminal intervention or bypass. The primary outcome of interest was a composite of cardiovascular, pulmonary, and renal complications (systemic) and mortality. Two propensity-weight adjusted analyses were performed: 1) comparing hybrid and prosthetic bypass 2) comparing hybrid and vein bypass. There were 4,478 patients included (1,537 hybrid, 1,408 prosthetic, 1,533 vein); 64.8% were men, and the mean age was 67.8±9.7years; 29.9% had claudication, 38.8% had tissue loss, and 31.3 were unspecified. In the propensity-weighted analysis comparing hybrid to prosthetic bypass, there was no difference in systemic complications (OR=1.29 for prosthetic vs. hybrid; 95% CI: 0.95-1.76; P=0.107) or mortality (OR=1.54; 95% CI: 0.71-3.33; P=0.275). Prosthetic bypass was associated with more deep surgical-site infections (OR=2.02; 95% CI: 1.19-3.45; P=0.010), postoperative sepsis (OR=2.07; 95% CI: 1.13-3.76; P=0.018), unplanned 30-day readmission (OR=1.28; 95% CI: 1.04-1.58; P=0.021), and the composite of any complication (OR=1.38; 95% CI: 1.18-1.61; P<0.001). In the propensity-weighted analysis comparing hybrid to vein bypass, there was no difference in systemic complications (OR=1.10 for vein vs. hybrid; 95% CI: 0.81-1.49; P=0.552) or mortality (OR=0.91; 95% CI: 0.42-2.00; P=0.819). Vein bypass was associated with more superficial surgical-site infections (OR=1.45; 95% CI: 1.04-2.02; P=0.028), and the composite of any complication (OR=1.32; 95% CI: 1.13-1.54; P=0.001). Overall mortality was significantly higher patients with systemic complications (13.9% vs 0.1%; P<0.001). Systemic complications were less common in patients with claudication undergoing hybrid revascularization than vein or prosthetic bypass. Claudicants undergoing bypass experienced more systemic complications than those undergoing hybrid procedures, but there appears to be no increased risk of systemic complications or mortality with open reconstruction when compared to hybrid procedures for other indications. Other complications, such as infection, postoperative transfusion, and readmission, were more common in the bypass groups.

Abstract 260: Aortic Pulse Wave Characteristics and Coronary Blood Flow Responses to Plantar Flexion in Peripheral Arterial Diseases Patients

Peripheral arterial diseases (PAD) is an atherosclerotic occlusive disease in the periphery affecting 8-12 million U.S.adults. It has been reported that the PAD patients have attenuated coronary blood flow response to stress, however how the diseases influence aortic arterial pulse wave properties during exercise, and its relationship with coronary perfusion in this patient population is unknown. Accordingly, the primary aim of this study was to examine myocardial supply and demand relationship by investigating aortic pulse wave properties and their relationship with coronary perfusion during exercise in PAD. Methods: 13 PADpatients and 13 healthy (age, sex, BMI-matched) control subjects performed rhythmic plantar flexion for 14 minutes or until fatigue (30 contractions per minute). The workload started at 2 kg and increased by 1 kg every minute up to12 kg. Brachial (oscillometric cuff) and aortic (SphygmoCor, utilizing transfer function and brachial blood pressures) blood pressures were measured during supine rest and plantar flexion exercise as well as aortic pulse wave properties from derived-aortic pulse waveforms. On a separate visit, coronary blood flow velocity was measured non-invasively during rest and exercise. Results: Due to earlier arrival of reflected wave (140.9± 2.3 vs. 150.5± 3.4 ms; P =0.0289), baseline augmented pressure (15.9± 2.4 vs. 9.3± 1.7 mmHg; AP, P =0.0380), augmentation index (27.2± 2.7 vs. 19.1± 2.2 %; AI, P =0.0263), and cardiac wasted energy (4625± 590 vs. 2875± 491 s· dyne· cm 2 ; E w , P =0.0321) were greater compared to healthy control. During exercise, changes in aortic mean arterial pressure(21.90± 5.04 vs. 9.36± 2.20 mmHg; ΔaMAP, P =0.0041), end-systolic pressure (133.38± 4.85 vs. 111.46± 4.97 mmHg; ΔESP, P =0.0043), and the tension time index (1027± 216 vs. 504± 117 mmHg· S -1 · min -1 ; ΔTTI, P =0.0035) were significantly greater in PAD while ΔAI was not different. Intriguingly, despite the augmented TTI, the first and second peaks of CBV during exercise were not different between the groups leading to significantly attenuated subendocardial viability ratio responses to exercise (-34.66± 4.19 vs. -23.03± 3.37 %; ΔSEVR, P =0.0164). Conclusions: At this peak workload for PAD patients, the patients had a greater myocardial demand compared to healthy control. However, despite the increase in the myocardial demand and the accompanying increase in initial coronary perfusion pressure (ESP), CBV of PAD patients was not different from that seen in healthy control indicating limited myocardial supply during exercise in PAD. Consequently, PAD exhibited a greater mismatch of myocardial demand and supply at the peak workload. This suggests that, in PAD patients, there are mechanisms aside from changes in coronary perfusion pressure that limit myocardial supply during exercise (i.e. a greater coronary vascular tone and diastolic dysfunction).

Long-Term Patency of Open and Endovascular Internal Iliac Artery Revascularization for Atherosclerotic Occlusive Disease

Long-term outcome of internal iliac artery (IIA) revascularization for occlusive disease has not been extensively reported in the literature. The aim of this study was to evaluate the long-term patency of open and endovascular IIA revascularization performed for atherosclerotic occlusive disease.

Extracranial-intracranial bypass surgery for occlusive atherosclerotic disease of the anterior cerebral circulation: protocol for a systematic review and meta-analysis

BackgroundOcclusive atherosclerotic disease of the anterior cerebral circulation is one of the most common causes of anterior circulation ischemia and stroke. Treatment options include medical therapies (including antiplatelet use, blood pressure control, lipid reduction, and lifestyle modification) and extracranial-intracranial bypass surgery (such as superficial temporal artery-middle cerebral artery bypass). However, the optimal treatment remains unclear. The objective of this study will be to compare the efficacy of and extracranial-intracranial bypass surgery with that of other medical therapy in adult patients with occlusive atherosclerotic disease of the anterior cerebral circulation.MethodsThis is the study protocol for a systematic review. We will search MEDLINE, EMBASE, Web of Science, and the Cochrane Library (from January 1980 onwards). We will include randomized controlled trials, quasi-experimental studies (non-randomized, interrupted time series), and observational studies (e.g., cohort studies and case-control studies), examining the efficacy of extracranial-intracranial bypass surgery compared to other treatments for adult patients with occlusive atherosclerotic disease of anterior cerebral circulation. Two team members will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The primary outcome will include stroke or death. The secondary outcomes will include intracranial hemorrhage, transient ischemic attack, and myocardial infarction. The study methodological quality (or bias) will be appraised using appropriate tools. If feasible, we will conduct random effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., study design, geographical location, or risk of bias).DiscussionThis review will evaluate the evidence on the efficacy of extracranial-intracranial bypass surgery for adult patients with occlusive atherosclerotic disease of the anterior cerebral circulation. We anticipate that our findings will be of interest to patients, their families, caregivers, healthcare professionals, and in making optimal treatment selection. Implications for future clinical and epidemiological research will be discussed.Systematic review registrationPROSPERO CRD42018105513

Safety of urgent carotid endarterectomy following thrombolysis.

Acute ischemic stroke is a leading cause of morbidity and mortality worldwide, and the incidence of ischemic stroke is predicted to increase in coming years. Carotid atherosclerotic occlusive disease accounts for up to 20% of all ischemic strokes, and mounting evidence suggests that, in the setting of an acute ischemic stroke due to carotid disease, earlier treatment with carotid intervention results in better outcomes. In patients with acute ischemic stroke, systemic or intravenous thrombolysis (IVT) has revolutionized ischemic stroke therapy, and intravenous tissue plasminogen activator (tPA) has become the principal treatment for acute ischemic stroke when administered within 3 to 4.5 hours of neurologic symptom onset. Given these trends in acute ischemic stroke therapy, vascular specialists are increasingly asked to perform carotid intervention following IVT, but reports in the literature examining outcomes in this circumstance are scarce, and the data regarding the appropriate interval from IVT to carotid endarterectomy (CEA) remains controversial. Literature searches were performed in PubMed (MEDLINE) and Ovid examining journal articles published between January 1st, 1998 and September 30th, 2019. The search terms used were: "urgent carotid endarterectomy," "carotid endarterectomy" AND "thrombolysis," "acute stroke and thrombolysis," "timing of carotid endarterectomy," and various combinations of these terms. A total of 21 published reports detailing outcomes in 1165 patients have been published to date, with an average interval from IVT to CEA of 7.1 days, a cumulative 30-day stroke and death rate of 4.1% (0-18%) and a mean frequency of intracranial hemorrhage of 2.6% (0-18%). The aggregate data from the 21 reported series suggest that CEA can be performed safely within the first 14 days after the onset of neurologic symptoms in patients receiving antecedent IVT, however, data regarding the safety of urgent CEA within 48 to 72 hours of thrombolysis is conflicting, with some series reporting excellent results and others showing an increased risk of ICH, stroke, and/or death in these select patients. Given the trend toward expedited treatment of acute ischemic stroke with subsequent transfer to regional referral centers, vascular specialists will be confronted with an increasing number of patients who may require urgent CEA after antecedent IVT. Further study is warranted to clearly delineate the appropriate interval from IVT to CEA and, specifically, to establish the safety of CEA with 72 hours of tPA administration.

Midterm outcomes of subclavian artery revascularization in the setting of thoracic endovascular aortic repair

ObjectiveThe outcomes of subclavian artery revascularization (SAR) have been examined extensively in the setting of atherosclerotic occlusive disease but have been poorly characterized in the setting of thoracic endovascular aortic repair (TEVAR). As trials for branched thoracic endovascular stent grafts materialize, the outcomes of the subclavian artery branched prosthesis will need to be compared with TEVAR with SAR by carotid-subclavian bypass or subclavian transposition. MethodsA database of 1516 patients undergoing TEVAR from 2000 to 2015 was queried. Of those undergoing TEVAR, 19% (282 patients) also underwent SAR. Patient demographics, TEVAR indication, 30-day morbidity and mortality, and midterm patency and survival were analyzed. ResultsDuring the study period, 282 patients underwent 288 SARs in the setting of TEVAR. A total of 269 (93%) carotid-subclavian bypasses and 19 (7%) subclavian artery transpositions were performed; 76% of the SARs occurred before TEVAR, 14% occurred concurrently with TEVAR, and 10% occurred after TEVAR. The most common indications for TEVAR was aortic aneurysm (56%), chronic aortic dissection with aneurysmal degeneration (23%), and aortic dissections (13%). The 30-day ipsilateral stroke rate was 3.5%. Eight patients (2.8%) underwent an unplanned return to the operating room (2.1% for hematoma evacuation and 0.7% for management of chyle leak). Six patients (2.1%) sustained a nerve injury. The mean follow-up was 4.2 years. All-cause 30-day mortality was 4.6%. The overall survival rates at 1 year, 5 years, and 10 years were 82%, 60%, and 42%, respectively. The median survival was 7.2 years. Four patients were found to have a failure in primary patency during follow-up. All four patients had undergone a carotid-subclavian bypass. The 1-, 2-, and 5-year primary patency rates were 99.5%, 98.9%, and 98.0%, respectively, for carotid-subclavian bypass and 100% for carotid-subclavian transposition. ConclusionsDuring our 16-year study, we found SAR in the setting of TEVAR to be associated with low morbidity, durable long-term patency, and infrequent need for reintervention.

Arterial reconstruction with human bioengineered acellular blood vessels in patients with peripheral arterial disease

ObjectiveVascular conduit is essential for arterial reconstruction for a number of conditions, including trauma and atherosclerotic occlusive disease. We have developed a tissue-engineered human acellular vessel (HAV) that can be manufactured, stored on site at hospitals, and be immediately available for arterial vascular reconstruction. Although the HAV is acellular when implanted, extensive preclinical and clinical testing has demonstrated that the HAV subsequently repopulates with the recipient's own vascular cells. We report a first-in-man clinical experience using the HAV for arterial reconstruction in patients with symptomatic peripheral arterial disease. MethodsHAVs were manufactured using human vascular smooth muscle cells grown on a biodegradable scaffold. After the establishment of adequate cell growth and extracellular matrix deposition, the vessels were decellularized to remove human cellular antigens. Manufactured vessels were implanted in 20 patients with symptomatic peripheral arterial disease as above-knee, femoral-to-popliteal arterial bypass conduits. After HAV implantation, all patients were assessed for safety, HAV durability, freedom from conduit infection, and bypass patency for 2 years. ResultsTwenty HAVs were placed in the arterial, above-knee, femoral-to-popliteal position in patients with rest pain (n = 3) or symptomatic claudication (n = 17). All HAVs functioned as intended and had no evidence of structural failure or rejection by the recipient. No acute HAV infections were reported, but three surgical site infections were documented during the study period. Three non-HAV-related deaths were reported. One vessel developed a pseudoaneurysm after suspected iatrogenic injury during a balloon thrombectomy. No amputations of the HAV implanted limb occurred over the 2-year period, and no HAV infections were reported in approximately 34 patient-years of continuous patient follow-up. ConclusionsHuman tissue engineered blood vessels can be manufactured and readily available for peripheral arterial bypass surgery. Early clinical experience with these vessels, in the arterial position, suggest that they are safe, have acceptable patency, a low incidence of infection, and do not require the harvest of autologous vein or any cells from the recipient. Histologic examination of tissue biopsies revealed vascular remodeling and repopulation by host cells. This first-in-man arterial bypass study supports the continued development of human tissue engineered blood vessels for arterial reconstruction, and potential future expansion to clinical indications including vascular trauma and repair of other size-appropriate peripheral arteries.

Novel Geometry of an Extended Length Chimeric Scapular Free Flap for Hemimandibular Reconstruction: Nuances of the Technique Streamlined by In-House Virtual Surgical Planning and 3D Printing for a Severely Vessel-Depleted Neck

Subscapular-based flaps have historically maintained an unparalleled ability to provide a multitude of bone and soft tissue components based on a single vascular pedicle. However, these flaps are often not thought of as an ideal choice for composite defects requiring extended lengths of bone for reconstruction. The ability to harvest long segments of bone and reliably perform multiple contouring osteotomies is fundamental to long-span composite mandibular reconstruction, and microvascular surgeons are often met with significant reconstructive challenges when fibular free flaps cannot be used owing to variant vascular anatomy or occlusive atherosclerotic disease in these specific clinical scenarios. This challenge is further compounded by treatment-related vessel depletion in the neck, which reduces the availability of suitable recipient vessels in close proximity to the reconstruction. We present a case in which all of the aforementioned challenges presented in a single individual, who concomitantly required hemimandibular reconstruction with treatment related vessel depletion in the neck and unsuitable bilateral vascular anatomy in the legs precluding the use of a fibular free flap. This case demonstrates a previously unreported flap component geometry for hemimandibular reconstruction using an extended-length chimeric scapular free flap with scapular tip, lateral scapular border, and parascapular fasciocutaneous skin paddle components.

A rare case report of extensive extracranial internal carotid artery aneurysm and its endovascular management

Aneurysms of the extracranial carotid arteries can occur as a result of atherosclerotic degeneration, traumatic injury, dissection, or local infection or as a complication after carotid endarterectomy. Extracranial carotid artery aneurysm (ECAA) is an uncommon but important clinical entity. Carotid aneurysms are extremely rare in comparison with atherosclerotic occlusive disease of the same location. These aneurysms are also rare in comparison with aneurysms involving the intracranial carotid arteries and their branches. The reported incidence of incidental intracranial aneurysms discovered in autopsy studies ranges from 0.8% to 18%. The incidence of ECAA is largely unknown, but it represents only 1%–1.5% of procedures performed for extracranial cerebrovascular disease at major referral centers.

Endovascular and Surgical Management of Subclavian Artery Occlusive Disease: Early and Long-Term Outcomes

The aim of the study was to report early and late outcomes of surgical and endovascular management of subclavian artery atherosclerotic disease (SAAD). Data about consecutive patients treated for subclavian artery atherosclerotic occlusive disease between 2001 and 2018 either by open surgical repair (OSR) or by endovascular repair (ER) were retrospectively collected and analyzed. Primary outcomes included 30-day death, as well as cardiac and neurologic events, reported separately for occlusion and stenosis. Secondary outcomes included primary patency in the long term, reported separately for occlusive and stenotic lesions. The Kaplan-Meier analysis with the logrank test was used to estimate long-term primary patency. Chi-squared and t-tests were used as appropriate to compare the outcomes of the 2 groups. A P value<0.05 was considered statistically significant. Sixty-eight patients were treated using ER (49 patients) and OSR (19). Technical success rate was 100% in both groups. During in-hospital stay, 1 brachial hematoma and 2 acute upper limb ischemia occurred in the ER group and in the OSR group, respectively. At 30days, no deaths or neurological/cardiac events were recorded in both ER and OSR groups. Symptoms resolution and upper limb salvage were 100% in both groups. In the ER group, primary patency was 100% at 7years in patients who had been treated for stenotic lesions and 62.5±21.3% in patients who had been treated for occlusive lesions (P=0.0035). In the OSR group, primary patency was 100% at 7years in patients treated for stenotic lesions and 25±21.6% in patients who had been treated for occlusive lesions (P<0.0001). Overall, long-term primary patency in the OSR group was 76.9±11.7% at 7years, being lower than that reported after ER (93.4±4.5%, P=0.02). Both ER and OSR proved to be safe, effective, and durable in the treatment of SAAD. In particular, the primary patency rates at long term for both ER and OSR showed better outcomes for stenotic lesions.

Role of Adipose Tissue and Skeletal Muscle in Atherosclerotic Occlusive Disease (Peripheral Arterial Disease and Carotid Arterial Disease) and in Central Hemodynamics

Role of Adipose Tissue and Skeletal Muscle in Atherosclerotic Occlusive Disease (Peripheral Arterial Disease and Carotid Arterial Disease) and in Central Hemodynamics

A Cohort Study of Upper Critical Limb Ischemia Secondary to Atherosclerotic Occlusive Disease

Introduction - Introduction: upper critical limb ischaemia (UCLI) secondary to atherosclerotic occlusive disease is rare. Accordingly, revascularisation indications and outcomes remain unclear. In this relatively large series, we review our experience in managing this condition. Methods - Patients and Methods: This is a cohort study of patients presenting to a tertiary referral centre with UCLI (rest pain and/or tissue loss) between January 2012 and December 2016. Patients with acute upper limb ischaemia or arm claudication were excluded. All patients underwent full imaging (CT/MR or CO2 angiography). Results - Results: during the study period, 20 male patients with 25 ischaemic limbs and 7 female patients with 8 ischaemic limbs, met the inclusion criteria. Median (range) age was 59 (17-71) years and 44% were smokers. 93% of patients were diabetic and 80% of those had elevated HBA1c. 89% were hypertensive and 52% had concurrent or previous history of lower CLI. In addition, 74% had end-stage renal disease and 41% had haemoglobin levels <110g/l. 78% of patient were on antiplatelets and statins at the time of presentation. In the affected limbs, the distribution of significant arterial occlusive disease was: 15% subclavian, 0% axillary, 9% brachial, 45% ulnar, 58% radial and 73% palmar/digital. 52% of limbs underwent revascularisation (12 via angioplasty and 5 via vein bypass surgery). 21% (7) limbs were deemed non-reconstructible. 9 patients had significant concomitant circulatory failure secondary to cardiac or septic pathologies. These were managed expectantly. 18% of limbs required digit and/or partial palm amputation. None required major amputation. Overall 1 year mortality was 30%, however, mortality was twice as much in the no-intervention group (40% vs. 20%). Conclusion - Conclusion: In our experience, UCLI secondary to diabetic arteriopathy is fast increasing. Characteristically, the disease is infra-cubital with particular affinity to palmar and digital vessels. Although major amputation is rarely required, these patients tend to have significant comorbidities and poor survival.

Vitamin D as A Protector of Arterial Health: Potential Role in Peripheral Arterial Disease Formation.

Atherosclerotic occlusive diseases and aneurysms that affect large and medium-sized arteries outside the cardiac and cerebral circulation are collectively known as peripheral arterial disease (PAD). With a rise in the rate of aging population worldwide, the number of people diagnosed with PAD is rapidly increasing. The micronutrient vitamin D is an important steroid hormone that acts on many crucial cellular mechanisms. Experimental studies suggest that optimal levels of vitamin D have beneficial effects on the heart and blood vessels; however, high vitamin D concentrations have been implicated in promoting vascular calcification and arterial stiffness. Observations from various clinical studies shows that deficiency of vitamin D has been associated with a greater risk of PAD. Epidemiological studies have often reported an inverse relation between circulating vitamin D status measured in terms of 25-hydroxivitamin D [25(OH)D] levels and increased cardiovascular disease risk; however, randomized controlled trials did not show a consistent positive effect of vitamin D supplementation on cardiovascular disease risk or events. Even though PAD shares all the major risk factors with cardiovascular diseases, the effect of vitamin D deficiency in PAD is not clear. Current evidence suggests a strong role of vitamin D in promoting genomic and epigenomic changes. This review summarises the current literature that supports the notion that vitamin D deficiency may promote PAD formation. A better understanding of underlying pathological mechanisms will open up new therapeutic possibilities which is the main unmet need in PAD management. Furthermore, epigenetic evidence shows that a more holistic approach towards PAD prevention that incorporates a healthy lifestyle, adequate exercise and optimal nutrition may be more effective in protecting the genome and maintaining a healthy vasculature.

Clinical Applications for Radiotracer Imaging of Lower Extremity Peripheral Arterial Disease and Critical Limb Ischemia.

Peripheral arterial disease (PAD) is an atherosclerotic occlusive disease of the non-coronary vessels that is characterized by lower extremity tissue ischemia, claudication, increased prevalence of lower extremity wounds and amputations, and impaired quality of life. Critical limb ischemia (CLI) represents the severe stage of PAD and is associated with additional risk for wound formation, amputation, and premature death. Standard clinical tools utilized for assessing PAD and CLI primarily focus on anatomical evaluation of peripheral vascular lesions or hemodynamic assessment of the peripheral circulation. Evaluation of underlying pathophysiology has traditionally been achieved by radiotracer-based imaging, with many clinical investigations focusing on imaging of skeletal muscle perfusion and cases of foot infection/inflammation such as osteomyelitis and Charcot neuropathic osteoarthropathy. As advancements in hybrid imaging systems and radiotracers continue to evolve, opportunities for molecular imaging of PAD and CLI are also emerging that may offer novel insight into associated complications such as peripheral atherosclerosis, alterations in skeletal muscle metabolism, and peripheral neuropathy. This review summarizes the pros and cons of radiotracer-based techniques that have been utilized in the clinical environment for evaluating lower extremity ischemia and common pathologies associated with PAD and CLI.