Large-vessel Arterial Disease Research Articles

Straight Sinus Thrombosis with Bilateral Internal Watershed Infarcts Mimicking Large Vessel Arterial Disease.

Straight Sinus Thrombosis with Bilateral Internal Watershed Infarcts Mimicking Large Vessel Arterial Disease.

Revascularization in Diabetic Foot Ulcer and Outcome

Diabetes is a major public health problem regionally and globally. In 2019, the International Diabetes Federation estimated that 465 million (9.3%) people worldwide had diabetes, and by 2045, the number may rise to 700 million (10.9%) [1]. The pooled prevalence of diabetes in the general population of Bangladesh is 7.8% and prevalence of pre-diabetes is 10.1% [2]. Diabetes is a complex disease with many serious potential sequelae, including large vessel arterial disease and microvascular dysfunction. The lifetime risk for foot ulcers in people with diabetes is estimated to be 15% [3]. Development of diabetic foot ulcer is attributed to many interacting factors, the most common ones being peripheral neuropathy and Peripheral Arterial Disease (PAD) [4]. PAD is an important precipitating factor in the outcome of diabetic foot ulcer [4]. Peripheral arterial disease is a common large vessel complication of diabetes, implicated in the development of tissue loss in up to half of patients with diabetic foot ulceration [5]. Diabetic patients with PAD commonly show involvement of the arteries below the knee, especially at the tibial and peroneal arteries, and involvement of the profunda femoris [6]. Diabetic ulcers always require vascular evaluation, and when ischaemia is suspected the diagnostics should be organized rapidly to ensure revascularisation without delay. Foot ulcer in patients with diabetes is associated with an increased risk of lower limb amputation, and thus the primary aim of treatment for ischemic foot ulcer is limb preservation [4]. Invasive revascularization, including open reconstructive surgery and/or endovascular intervention, is the most effective treatment that may improve peripheral circulation and remedy symptoms [4]. The basic aim of any successful revascularization is to achieve pulsatile flow to the foot. The two methods currently available are peripheral bypass surgery and peripheral angioplasty [7]. Current literature shows that percutaneous transluminal angioplasty (PTA) is the first choice of procedures in revascularization of the lower limb [7].

Peripheral arterial disease and revascularization of the diabetic foot.

Diabetes is a complex disease with many serious potential sequelae, including large vessel arterial disease and microvascular dysfunction. Peripheral arterial disease is a common large vessel complication of diabetes, implicated in the development of tissue loss in up to half of patients with diabetic foot ulceration. In addition to peripheral arterial disease, functional changes in the microcirculation also contribute to the development of a diabetic foot ulcer, along with other factors such as infection, oedema and abnormal biomechanical loading. Peripheral arterial disease typically affects the distal vessels, resulting in multi-level occlusions and diffuse disease, which often necessitates challenging distal revascularisation surgery or angioplasty in order to improve blood flow. However, technically successful revascularisation does not always result in wound healing. The confounding effects of microvascular dysfunction must be recognised--treatment of a patient with a diabetic foot ulcer and peripheral arterial disease should address this complex interplay of pathophysiological changes. In the case of non-revascularisable peripheral arterial disease or poor response to conventional treatment, alternative approaches such as cell-based treatment, hyperbaric oxygen therapy and the use of vasodilators may appear attractive, however more robust evidence is required to justify these novel approaches.

Aortic and extracranial large vessel giant cell arteritis: A review of 72 cases with histopathologic documentation

Giant cell arteritis (GCA) is closely identified with the temporal arteritis-polymyalgiarheumatica syndrome of the elderly. It is also a systemic disease that can cripple and kill. Up to 15% of patients with temporal arteritis may have angiographic evidence of extracranial GCA, and aortic insufficiency, ruptured aortic aneurysm, aortic dissection, stroke, or myocardial infarction may be the initial manifestation of systemic GCA. A review of 72 cases of aortic and extracranial GCA, all with histopathologic verification of the disease, revealed that 25% of patients with aortic and extracranial large-vessel GCA had asymptomatic temporal arteritis; the ascending aorta and aortic arch were most frequently involved (39%), followed by the subclavian and axillary arteries (26%), and the femoropopliteal arteries (18%). Nine patients (12.5%) underwent an upper or lower limb amputation. Of the 18 patients whose death was directly attributable to extracranial GCA the causes were ruptured aortic aneurysm (6), aortic dissection (6), stroke (3), and myocardial infarction (3). The findings of these 72 cases caution against attributing all aortic and large-vessel arterial disease in the elderly to atherosclerosis and emphasize that timely surgical intervention may be necessary for life-saving and limb-salvage in patients with aortic and extracranial GCA.

Management of chronic venous leg ulcers: A literature-guided approach

Venous leg ulcers are a chronic recurrent problem. This disorder has been described in rural, urban, developed, and underdeveloped parts of the world. About 1% of the population will be afflicted with a poorly healing lower extremity wound during their lifetime.1 Estimates of the prevalence of lower extremity wounds in Sweden2 and England3,4 are 0.12 and 0.19%, respectively. Approximately, 40 to 70% of these wounds are believed to have a venous component.2,4,5 Most of these patients were older than 50 and female.4,5 Chronic venous insufficiency with ulceration may occur in up to 3.6% of the population over the age of 15 in Brazil.6 In the 2-year period from 1990 to 1992 there were more than 1.3 million outpatient visits in the United States for venous ulcers.7 As many as 22% of the patients with venous ulcers also have concomitant large vessel arterial disease.4 Because of the chronic and recurrent nature of venous ulcers, these figures may grossly underestimate the prevalence of this disease. The actual costs attributed to this illness are therefore difficult to assess. In Scandinavia treatment was estimated to cost 25 million U.S. dollars in 1985.8 This does not include the loss of productivity and personal suffering that occurs because of this chronic affliction. On the basis of population demographics, estimated costs in the United States would probably be at least an order of magnitude greater.There has been a recent surge in interest in the treatment of these wounds. This has been supported by the advent of new treatments and technologies and a growing interest in gerontology. In 1992 alone more than 100 publications were concerned with venous ulcers. Although several excellent reviews on the treatment and etiology of venous wounds have been published in the past several years,9–16 no consensus exists on the treatment of these wounds. Furthermore, it is difficult to develop a standard care for the treatment of these wounds based on the conventional wisdom of these publications. A consensus standard care or best care would greatly facilitate the health care provided to these patients and would make it possible to have a benchmark against which to compare new treatment modalities. The purpose of this article is to review the recent English literature to develop a consensus standard treatment protocol based on data from published controlled trials.The information used in this article was obtained by a Medline-based search of the literature since 1966. A recent study evaluated this approach for medical problem solving.17 Key search terms were venous, ulcer, leg ulcer, chronic wound, treatment, debridement, compression, topical, and dressing. More than 1200 studies were identified. Literature was reviewed if it was in the English language, the patients studied had venous ulcers, and the trials described were conducted in a randomized controlled fashion. Articles were excluded if it was impossible to determine if the study was controlled and if it was not possible to determine which patients had venous ulcers in a study with more than one wound type. Categories for the protocol were based on typical recommendations for the treatment of patients with chronic wounds. These categories were removal of etiologic cause, wound debridement and infection control, wound cleansing, wound dressings, adjuvant agents (topical, device, or systemic), miscellaneous treatments, and surgical closure. The method section of the controlled trials was tabulated in an effort to determine what was deemed appropriate, standard care.

Middle cerebral artery occlusion as a cause of isolated subcortical infarction.

We report two patients with large subcortical hemispheric infarctions, located in areas prone to the development of lacunes, who had occlusion of the middle cerebral artery demonstrated by arteriography. The cortical vessels were perfused by leptomeningeal collaterals. We suggest that large vessel arterial disease should be considered as a possible etiology of large subcortical infarctions and propose that the term lacune should not be used in cases in which neither the size nor the pathophysiologic mechanism of the lesion conform to C.M. Fisher's description.