Leg Arteries Research Articles

Leech therapy and adjuvant Ayurveda treatment in the management of diabetic foot ulcer with atherosclerosis

Diabetic patients are more prevalent to atherosclerosis (29.1%); however, its pathophysiology is still unclear. Such cases mostly convert into either amputation due to rapid spread or lifelong anticoagulant. Ayurveda is famed to be a tool in prevention and management of such fatal or disabling surgeries by parasurgical procedure, i.e., leech therapy, Agnikarma, etc. This study presents a case of postdiabetic atherosclerosis (male/54 years old) with a complaint of blackening of the great toe of the right lower limb and and other associated symptoms such as intermittent claudication (Garde 4), Burning in sole, occasional numbness in the foot. this case was managed by the Ayurveda para-surgical procedure (Leech therapy). The patient was a known case of DM and taking medication for it for the last 1 year, but his blood sugar level was found to be uncontrolled (HB1Ac: 9.90). The patient had surgical history of coronary artery bypass graft before 8 years. His bilateral lower limb computed tomography angiography was suggestive of diffuse atherosclerotic fibrocalcified wall plaques in abdominal aorta, iliac, femoral, and both leg arteries. Clinical examination revealed black right greater toe with line of demarcation and on palpation, feeble femoral artery and downstream non-palpable arteries. As a part of treatment, leech application along with some rejuvenating oral drugs i.e. Sanjvani vati and pippali churna was given to the patient. On 2nd week of treatment protocol, black gangrenous great- toe was amputed which afterwards become open wound(approx.2cm x 2 cm). Afterward, daily wound dressing was done with Apamarga kshar taila or Thumari taila (As per the status of the wound) after cleaning with Triphala Kwath. After completion of treatment protocol, the patient got 85-90% relief in clinical symptoms and also previously feeble arteries were felt with full volume.

ИЗУЧЕНИЕ СЕРДЕЧНО-СОСУДИСТОЙ СИСТЕМЫ ЧЕЛОВЕКА С ПОМОЩЬЮ УЛЬТРАЗВУКОВЫХ МЕТОДОВ В КОСМИЧЕСКИХ ПОЛЕТАХ: ОСНОВНЫЕ РЕЗУЛЬТАТЫ И ПЕРСПЕКТИВЫ ИССЛЕДОВАНИЙ

Integral ultrasonic investigations of cosmonauts' cardiovascular system (echocardiography, 2D-echography and dopplerography of vessels) at relative rest and studies of the hemodynamic reaction to LBNP (dopplerography of the brain and femoral arteries) were performed with participation of 26 cosmonauts before launch, during missions (8 to 438 days in duration) and after landing. Overall, more than 200 investigations were made at rest and 124 during the LBNP test. It was found that in microgravity the antigravity vascular tone regulation gradually becomes useless. Absence of gravitational stimuli leads to weakening of arterial resistance in all vascular regions below the heart level, blood displacement toward the areas with low vascular resistance, venostasis in the cervicocephalic and abdominal regions, and increase of leg veins capacity and compliance. However, the vital hemodynamic parameters, such as the pump function of the heart, blood supply to the brain, blood pressure and HR remain stable even during a long period in microgravity. Results of USI conducted during the LBNP test imitating the orthostatic blood distribution evidence that the femoral arteries resistance to blood displacement toward the leg arteries degrades progressively as mission continues. Degradation of the vasoconstrictive ability of leg arteries and increase of leg venous capacity and compliance are responsible for the orthostatic instability developing in space. Simultaneous recording of blood flow in the brain and femoral arteries is used to evaluate the reaction of hemodynamics to real and imitated orthostatic effects and to detect initial symptoms of orthostatic instability. The technique can be useful in designing novel methods for preventing orthostatic instability, and controlling their effectiveness.

ДИНАМИКА ПОКАЗАТЕЛЕЙ УЛЬТРАЗВУКОВОЙ ДОПЛЕРОГРАФИИ АРТЕРИЙ НИЖНИХ КОНЕЧНОСТЕЙ И ГОЛОВНОГО МОЗГА ВО ВРЕМЯ ВЫПОЛНЕНИЯ СТАТОЭРГОМЕТРИЧЕСКОЙ ПРОБЫ

The paper contains analysis of Doppler ultrasonography data (Doppler US) from the leg and brain arteries of 52 Vietnamese male pilots and 15 Russian male pilots during the static ergometric test (Statoergometre machine). The subjects' age varied between 19 and 27 years. The measured parameters included peak systolic velocity (Vps) and resistive index (RI) of the popliteal (PA) and superficial femoral (SFA) arteries in the right leg, and common carotid artery (CCA) before, during and after testing. Results of the investigation evidenced that static strain in leg muscles during the test causes constriction in a segment distal from the superficial femoral artery confirmed by decreased Vps and increased RI in SFA and increased Vps and stable RI in PA. Under the head-to-pelvis g-loads, the static muscle strain is liable to impede blood pooling in leg muscles. Decreases of CCA Vps and RI due to the static muscle strain in consequence of, probably, vasodilatation in the brain, will be favorable to blood redistribution toward the head at the time of g-load. There was no reliable difference in doppler US data between the Vietnamese and Russian pilots.

Компьютерная томография и ультразвуковое исследование в диагностики некротизирующего фасциита

The purpose — to demonstrate the capabilities of computed tomography and ultrasound in the diagnosis and treatment planning of a patient with a rare case of necrotizing fasciitis. Material and methods. A clinical observation of a 57-year-old patient K. with complaints of pain in the area of the right foot, reddening of the skin on the right foot is presented. T — 37.2 ºC. To determine the nature of the revealed changes, the patient was referred to the Department of Radiation and Functional Diagnostic Methods for soft tissue ultrasound and computed tomography (CT) of the vessels of the lower extremities to assess the lesion and plan surgical treatment. Results. After an ultrasound of the soft tissues of the right leg posterior surface, around the gastrocnemius muscle, an inhomogeneous liquid rim (an echo picture of fasciitis), soft tissue edema was visualized. CT of the lower extremities vessels showed a decrease in blood flow in the lower leg arteries, infiltration and a moderate amount of gas in the soft tissues of n/3 of the lower leg and foot. Discussion. Necrotizing fasciitis (fasciitis necrotisans) is a representative of a large group of surgical infections of soft tissues, the morphological basis of which is progressive necrosis of the superficial fascia (fascia superficialis) and subcutaneous adipose tissue, and the clinical course is particularly severe and is accompanied by high mortality. NF is an emergency surgical situation. Early and accurate diagnosis is critical to provide the necessary aggressive treatment. Conclusion. This clinical observation demonstrates the importance of conducting a study using computed tomography and ultrasound in patients with necrotizing fasciitis for the earliest possible diagnosis and immediate surgical treatment, supported by effective antibiotic therapy.

Clinical benefits of small intestinal submucosa extracellular matrix and review of the evidence.

There is a clear scientific rationale for using cellular, acellular and matrix-like products (CAMPs), such as small intestinal submucosa extracellular matrix (SIS-ECM), in hard-to-heal wounds, such as diabetic foot ulcers (DFUs), venous leg ulcers (VLUs), pressure ulcers and arterial leg ulcers. The clinical evidence supporting the use of SIS-ECM has grown over the past several decades. This evidence base now encompasses a wide range of hard-to-heal wound indications, including DFUs and VLUs, as well as increasingly complex acute wound indications, such as delayed postoperative wounds, traumatic wounds and burns. The aim of this article is to review the steadily amassed body of evidence that describes the clinical outcomes associated with treatment with SIS-ECM and its potential implications for the overall costs of treatment.

Clinical benefits of small intestinal submucosa extracellular matrix and review of the evidence.

There is a clear scientific rationale for using cellular, acellular and matrix-like products (CAMPs), such as small intestinal submucosa extracellular matrix (SIS-ECM), in hard-to-heal wounds, such as diabetic foot ulcers (DFUs), venous leg ulcers (VLUs), pressure ulcers and arterial leg ulcers. The clinical evidence supporting the use of SIS-ECM has grown over the past several decades. This evidence base now encompasses a wide range of hard-to-heal wound indications, including DFUs and VLUs, as well as increasingly complex acute wound indications, such as delayed postoperative wounds, traumatic wounds and burns. The aim of this article is to review the steadily amassed body of evidence that describes the clinical outcomes associated with treatment with SIS-ECM and its potential implications for the overall costs of treatment.

EFFECTS OF ASSISTIVE TENNIS SHOES ON GROUND REACTION FORCE FOR PATIENTS WITH PERIPHERAL ARTERY DISEASE DURING WALKING

Abstract Peripheral artery disease (PAD) is caused due to buildup of atherosclerotic plaques, typically in the leg arteries, preventing adequate blood circulation and ultimately claudication. A previous study showed that the vertical ground reaction force (VGRF) curve is significantly flatter in claudicating patients, resulting in a lower and less fluctuant center of mass when ambulating. Patients with PAD also demonstrate significantly decreased propulsion forces in the anterior– posterior direction. Assistive tennis shoes (carbon fiber: CF, and spring-loaded: SL) can potentially assist push-off by substituting for muscle forces using energy stored in a carbon fiber plate or metal spring within the shoe. This study aims to examine how the CF and SL shoes impact walking performance in patients with PAD. A total of ten patients with PAD performed a progressive treadmill test using a pressure-instrumented treadmill for each shoe type: i) standard shoes, ii) CF shoes, and iii) SL shoes. We calculated the peak VGRF for three subjects to date as an average of ten stance phases for the beginning of the walking condition (pain free condition). Preliminary results from three subjects showed that patients with PAD generated a greater peak VGRF wearing CF and SL shoes compared to normal shoes during the heel contact (normal: 0.97±0.10BW, CF: 1.03±0.08BW, and SL: 1.09±0.10BW) and push-off (normal: 0.97±0.06BW, CF: 0.99±0.04BW, and SL: 1.03±0.05BW). In future, we will calculate the VGRF for the remaining patients in pain free and pain conditions and conduct statistical analysis to identify significant differences among shoe types.

“Trench Foot” on the Banks of Lake Geneva: A Severe Case of Nonfreezing Cold Injury

Formerly known as “trench foot” or “immersion foot,” nonfreezing cold injury (NFCI) is a rare condition mainly seen among vulnerable groups. We report the case of a homeless male diagnosed with NFCI after having spent 2 days in rainy, cold weather. He presented with white, wrinkled feet and sensorimotor loss. Imaging revealed thrombosis of the leg arteries. No revascularization procedure was possible, and the patient developed soft tissue necrosis requiring bilateral transtibial amputation. Our case highlights the high morbidity linked with NFCI and the need for early recognition and treatment by medical health professionals along with the implementation of preventive measures.

Arterial calcification over time in pseudoxanthoma elasticum: a repeated measurements study

Abstract Background Pseudoxanthoma elasticum (PXE) is a rare genetic disorder, characterized by progressive systemic arterial calcification and an elevated cardiovascular disease risk. Although arterial calcification is an established risk factor of cardiovascular morbidity and mortality, insights into its artery-specific changes over time in PXE remain lacking. Objectives To assess artery-specific changes in arterial calcification over time in PXE and to investigate the associations of cardiovascular risk factors with these changes. Methods We prospectively included 311 PXE patients (mean age 53.1 years, 185 [59.5%] females). During a median follow-up of 3.7 (25th–75th percentiles 1.3–4.2) years patients underwent 472 full-body, non-contrast computed tomography (CT) scans (maximum of 6 CTs per patient) to quantify the volume (μL) of intracranial carotid artery calcification (ICAC), extracranial carotid artery calcification (ECAC), coronary artery calcification (CAC), aortic calcification (AoC), iliac artery calcification (IAC), and leg artery calcification (LAC) and total body calcification (sum of all arteries). We calculated absolute yearly change (follow-up volume × baseline volume / time difference) and relative yearly change (absolute change divided by baseline volume × 100%) in calcification. The correlations amongst arteries in absolute and relative calcification change were assessed using Spearman's correlation coefficients. Risk factors for change in arterial calcification were assessed using linear mixed models (including age as time variable and with all risk factors entered simultaneously into models). Results Calcification volume change ranged from 3% to 12% increase per year, with a total body calcification progression of 11% per year. The correlations amongst arteries in absolute and relative yearly progression of calcification were only weak to moderate (correlation coefficients ranged from 0.23 between CAC and ECAC to 0.38 between CAC and LAC). Hypertension was markedly associated with increased AoC (multiplicative change in calcification per 5 years of age 1.46 [95% CI 1.13–1.89]). Moreover, the strongest predictor of ICAC change was ever smoking (1.23 [95% CI 1.03–1.46]) and of ECAC change was hypercholesterolemia (1.21 [95% CI 1.02–1.43]). Conclusions Arterial calcification volume progressed with 11% per year in PXE, with considerable variation between and only moderate correlation amongst arteries. Moreover, we found several modifiable, artery-specific risk factors for the progression of calcification. Although both PXE and risk factor presence are considered systemic in nature, our findings highlight that considerable differences exist between arteries in susceptibility to calcification. As such, our results provide important insights into the mechanisms underlying arterial calcification in PXE, which might be used for more targeted treatment and prevention. Funding Acknowledgement Type of funding sources: None.

Antibacterial microspheres with a bionic red-blood-cell like hollow structure and superior swelling recovery capacity for efficient traumatic hemostasis

Broad interest in developing new commercial hemostatic agents has been widely aroused for massive blood loss in terms of hospital surgery and on the battlefield. In this study, we report biomimetic red-blood-cell like (RBC-like) hydrogel microspheres with controllable surface morphology by adjusting the proportion of carboxylated chitosan (CM) and gelatin (G) using Fe3+ as crosslinking agent. It is worth noting that the microspheres are similar to RBCs in the dry state, with a microporous structure on the surface and a hollow structure inside, and enable restoration to the microsphere shape after absorbing water. The CMG1 microspheres show the best hemostatic effect, as indicated by whole blood coagulation in vitro and rat liver and leg artery damage models in vivo. The microspheres exhibit antibacterial properties against Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus). In addition, the microspheres have satisfactory degradation performance, hemocompatibility, biocompatibility and histocompatibility. This study indicates that these RBC-like microsphere-based hemostatic powders facilitate a physical barrier in wounds by forming aggregations. In addition, the micropores on the surface of the microspheres make it swell rapidly by absorbing blood, aggregating coagulation factors, activating platelets and ultimately accelerating the coagulation cascade to facilitate hemostasis. In conclusion, CMG1 hydrogel microspheres present potential application in the field of emergency hemostasis.

PET Imaging of Leg Arteries for Determining the Input Function in PET/MRI Brain Studies Using a Compact, MRI-compatible PET System.

In this study, we used a compact, high-resolution, and MRI-compatible PET camera (VersaPET) to assess the feasibility of measuring the image-derived input function (IDIF) from arteries in the leg with the ultimate goal of enabling fully quantitative PET brain imaging without blood sampling. We used this approach in five 18F-FDG PET/MRI brain studies in which the input function was also acquired using the gold standard of serial arterial blood sampling. After accounting for partial volume, dispersion, and calibration effects, we compared the metabolic rates of glucose (MRglu) quantified from VersaPET IDIFs in 80 brain regions to those using the gold standard and achieved a bias and variability of <5% which is within the range of reported test-retest values for this type of study. We also achieved a strong linear relationship (R2 >0.97) against the gold standard across regions. The results of this preliminary study are promising and support further studies to optimize methods, validate in a larger cohort, and extend to the modeling of other radiotracers.

Radiography and Computed Tomography Detection of Intimal and Medial Calcifications in Leg Arteries in Comparison to Histology.

Calcifications are common in the tunica intima and tunica media of leg arteries. There is growing interest in medial arterial calcifications, as they may be modifiable with treatment. We aimed to investigate radiography and computed tomography (CT) for the detection and characterization of both types of arterial calcification in leg arteries in relation to histology. In a postmortem study we therefore investigated 24 popliteal and 24 tibial arteries. The reference standard was presence of arterial calcification and the dominance of intimal or medial calcification on histology. Radiographs and CT scans were scored for presence of calcification and for dominant intimal or medial pattern based on prespecified criteria (annularity, thickness, continuity). Both radiography and CT detected 87% of histologically proven calcifications but missed mild calcifications in 13%. When only the arteries with detected calcifications were included, a moderate agreement was observed on intimal/medial location of calcifications between histology and radiography (correct in 19/24 arteries (79%); Kappa 0.58) or CT (correct in 33/46 arterial segments (72%); Kappa 0.48). With both modalities there was a slight tendency to classify intimal calcifications as being located in the media and to miss media calcification. Our study demonstrates the potential and limitations of both radiography and CT to detect and classify arterial calcifications in leg arteries.

A novel ultrasound-assisted laser technique to remove atherosclerotic plaques

Atherosclerosis is a medical condition in which arteries hardens and narrows due to the buildup of fat, cholesterol, calcium, and other substance. It can affect arteries of heart, brain, arms, legs, pelvis, and kidney, resulting in ischemic heart disease, carotid artery disease, peripheral artery disease, and chronic kidney disease. Laser based treatment techniques like laser angioplasty and carotid artery laser endarterectomy can be used to treat most common atherosclerosis disease like ischemic heart disease and carotid artery disease. Excimer laser coronary angioplasty (ELCA) is a clinical technique to remove the arterial plaque. However, the use of ELCA remains low due to higher risk of complication and its low efficacy in removing plaques as compared with balloon angioplasty. In this study, we developed a novel technology that uses ultrasound along with laser to assist the removal of atherosclerotic plaque. Spatio-temporally synchronized pulsed laser and ultrasound was used. The preliminary experiments were performed on pig belly fat sample to find the optimal ultrasound and laser parameters. The final experiment was performed on the plaque samples collected from patient during carotid endarterectomy procedure. Our results show that the addition of ultrasound can effectively reduce the needed laser power, which could result in improved treatment safety and efficiency.

Aortic-tibial transiliac wing extra-anatomic bypass with distal fistula for treatment of an infected deep femoral pseudoaneurysm.

Transiliac wing bypass has been reported to be a viable extra-anatomic alternative technique for patients presenting with a history of groin infection or irradiation.1Enzmann F.K. Nierlich P. Eder S.K. Aspalter M. Dabernig W. Aschacher T. et al.Trans-iliac bypass grafting for vascular groin complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Of the 32 reported cases, only two patients had undergone transiliac aortic–tibial or iliotibial bypass.2Sekanina G. Lemminger F. Bruecher D. Iliaco-crural bypass through a borehole in the iliac fossa as extra-anatomic vascular bypass in infected inguinal canal and posterior aspect of the knee.Chirurg. 1995; 66: 142-145PubMed Google Scholar,3Heldenberg E. Lorber J. Cheyn D. Bass A. Transiliac wing alternate route bypass for infected groin vascular graft.J Vasc Surg. 2014; 60: 504-505Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We report the case of a 72-year-old man with a complex history of multiple lower limb revascularizations, who had been admitted for a deep femoral infected anastomotic pseudoaneurysm (A) and left chronic limb threatening ischemia. Computed tomography showed chronic occlusions at the femoropopliteal level, with a previous thrombosed obturator canal bypass. The only patent lower leg artery was the posterior tibial artery (PTA) from its mid-third to the foot.A transiliac wing aortic–tibial prosthetic bypass was performed through a pararectal retroperitoneal approach (B/Cover). The infrarenal aorta and common iliac arteries were cross-clamped before implanting an 8-mm expanded polytetrafluoroethylene graft soaked in rifampicin at the terminal aorta level. It was tunneled into the retroperitoneal space, over the psoas muscle. A U-shape osteotomy was performed at the anterior left iliac wing border through a second lateral incision to guide the bypass. Another incision was made at the lateral side of the thigh to guide the graft route between the femoral condyles. It was associated with a distal arteriovenous bypass between the PTA and a fibular vein (C), before the distal anastomosis of the aortic–tibial bypass, to partially deviate the aortic blood flow from the PTA into the venous circulation.The second part of the procedure consisted of deep femoral pseudoaneurysm repair. It was developed at the distal anastomosis level of the thrombosed obturator canal bypass, which was removed to the obturator canal during the same procedure. The deep femoral artery was then ligated with 5-0 polypropylene suture. Transiliac wing bypass has been reported to be a viable extra-anatomic alternative technique for patients presenting with a history of groin infection or irradiation.1Enzmann F.K. Nierlich P. Eder S.K. Aspalter M. Dabernig W. Aschacher T. et al.Trans-iliac bypass grafting for vascular groin complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Of the 32 reported cases, only two patients had undergone transiliac aortic–tibial or iliotibial bypass.2Sekanina G. Lemminger F. Bruecher D. Iliaco-crural bypass through a borehole in the iliac fossa as extra-anatomic vascular bypass in infected inguinal canal and posterior aspect of the knee.Chirurg. 1995; 66: 142-145PubMed Google Scholar,3Heldenberg E. Lorber J. Cheyn D. Bass A. Transiliac wing alternate route bypass for infected groin vascular graft.J Vasc Surg. 2014; 60: 504-505Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar We report the case of a 72-year-old man with a complex history of multiple lower limb revascularizations, who had been admitted for a deep femoral infected anastomotic pseudoaneurysm (A) and left chronic limb threatening ischemia. Computed tomography showed chronic occlusions at the femoropopliteal level, with a previous thrombosed obturator canal bypass. The only patent lower leg artery was the posterior tibial artery (PTA) from its mid-third to the foot. A transiliac wing aortic–tibial prosthetic bypass was performed through a pararectal retroperitoneal approach (B/Cover). The infrarenal aorta and common iliac arteries were cross-clamped before implanting an 8-mm expanded polytetrafluoroethylene graft soaked in rifampicin at the terminal aorta level. It was tunneled into the retroperitoneal space, over the psoas muscle. A U-shape osteotomy was performed at the anterior left iliac wing border through a second lateral incision to guide the bypass. Another incision was made at the lateral side of the thigh to guide the graft route between the femoral condyles. It was associated with a distal arteriovenous bypass between the PTA and a fibular vein (C), before the distal anastomosis of the aortic–tibial bypass, to partially deviate the aortic blood flow from the PTA into the venous circulation. The second part of the procedure consisted of deep femoral pseudoaneurysm repair. It was developed at the distal anastomosis level of the thrombosed obturator canal bypass, which was removed to the obturator canal during the same procedure. The deep femoral artery was then ligated with 5-0 polypropylene suture. Appendix

Endovascular interventions in patients with glass iii infrainguinal arterial disease: 2-year results

To evaluate the results of endovascular surgery in patients with chronic limb-threatening ischemia (CLTI) with infrainguinal arterial disease GLASS III. Treatment outcomes were analyzed for the period 2017-2018. Inclusion criteria were age over 18 years, CLTI, extended (>20 cm) stenosis de novo and occlusion of femoropopliteal segment (FPS) combined with occlusive lesion of tibial arteries. We analyzed 147 patients divided into 2 groups depending on stenting strategy. FPS-1-TA included 53 patients who underwent angioplasty (± stenting) of femoropopliteal arteries and lower leg arteries resulted at least one patent tibial artery. FPS-2-TA enrolled 94 patients who underwent angioplasty of femoropopliteal arteries and lower leg arteries resulted ≥2 patent tibial arteries. Mean age was 71.0±9.8 years. There were 75 men. Demographics and clinical characteristics of patients were similar. Technical success rate was 100%. Mean length of stenting was 203 ± 99 mm. Occlusion of all 3 leg arteries correlated with high incidence of femoropopliteal stenting. In the FPS-1-TA group, stents were implanted in 39 patients, in the FPS-2-TA group - in 71 patients (73.6% and 75.5%, respectively, p=0.8). Braided nitinol stents were used for stenting of the lower third of superficial femoral artery and p1-p3 segments. Mean follow-up period was 22.6±1.1 months. Two-year results were not age-specific in our study. Kaplan-Meier overall survival, freedom from amputation and amputation-free survival for the entire sample were 79.6%, 81.0%, and 66.7%, respectively. We compared these values in both groups using Mantel-Cox log-rank test and obtained significant differences (67.9% vs 86.2%, p=0.004; 64.2% vs 90%, p<0.0001; 47.2% vs 77.7%, p<0.0001, respectively). Our results are comparable with literature data regarding freedom from amputation and amputation-free survival. We obtained significant differences in overall survival and freedom from amputation depending on endovascular strategy for tibial arteries. Correction of distal vessels with recanalization of at least two tibial arteries is advisable for endovascular treatment of diffuse complex lesions.

Assessment of the PPG up-stroke time to predict peripheral lower limb arterial occlusive disease (PAOD): Application to the pOpmetre ®

Screening for peripheral lower limb arterial occlusive disease (PAOD) is a major challenge for the prevention, management and treatment of patients with arteriosclerosis. The Ankle Brachial Index (ABI) is the reference method, it requires expertise and time which are limiting factors for systematic screening. The analysis of a photoplethysmographic (PPG) wave form in the lower limb can be an interesting alternative. In a retrospective pilot study we analyzed the possibility of detecting PAOD by measuring the up-stroke time wave form (UTP) at the toe by PPG method. The ABI (minimum of 2 leg arteries) and the UTP (pOpmeter® - Axelife - France) were collected in 54 patients during a vascular assessment and presenting different stages of PAOD. Of the 108 lower limbs registered, 25 were excluded for technical difficulties (very severe PAOD, mediacalcosis, toe amputation). 83 lower limbs were analyzed. Mean age was 69 ± 12; 75% men, 28% diabetics, 47% hypertensive. 17% without PAOD (stage 0); 44% stage 1; 23% stage 2; and 2% Stage 3. The 200 milliseconds UTP threshold identifies PAOD from stage 1 with: sensitivity 77%, specificity 94%, a positive predictive value 96% and negative predictive value 68% (Yule Q = 0.96). UTP makes it possible to identify an PAOD in 100% of patients with mediacalcosis (ABPI > 1.4, n = 3, diabetic = 2). The UTP measured by PPG at the toe is a simple and rapid method (< 2 min) detects the PAOD stages 1 to 3 with 94% specificity, 77% sensitivity that must be improved by using other thresholds to optimize the test. These results have to be confirmed with a prospective study.

Long-term results of proximal and distal reconstructions in patients with lower limb arteries diffuse lesions and diabetes mellitus

Relevance . Treatment of diffuse lesions of the arteries of the lower extremities is often reduced to primary amputation at the hip level, since the healing of trophic ulcers is not guaranteed during arterial reconstruction. Profundoplasty without distal bypass surgery can be considered an alternative method. The aim of this study is to compare the long-term results of distal shunting and isolated profundoplasty in patients with diffuse lesions of the lower limb arteries and trophic ischemic ulcers. Materials and Methods . The study included 86 patients with diffuse lesions of the lower limb arteries. There were 52 (60.4%) men and 34 (39.6%) women. The average age was 67.3 16.8 years. All patients had diffuse lesions of the arteries below the pupar ligament, the state of the lower leg arteries was 5-8.5 points on the Rutherford scale, in all cases there were trophic ulcers. Group 1 included 48 patients who underwent reconstruction of the leg arteries. Group 2 consisted of 38 individuals who had limited intervention with endarcteriotomy from common femoral and deep femoral arteries. Results and Discussion . Amputations at the hip level were performed within a year in 11 (23.4%) patients of group 1 and in 3 (6.3%) patients within 30 days after surgery. Thus, 14 (29.7%) patients lost their limbs. A comparative analysis revealed that the group of patients with amputations had a more severe form of diabetes (p = 0.003), an outflow score on the Rutherford scale (p 0.001), and lower transcutaneous oxygen tension values before and after surgery. Within 12 months after the bypass surgery, the primary patency of the shunts was 65.9% (thrombosis occurred in 16 patients). Conclusion . The preservation of the limb in patients in our study by the end of 1 year after reconstruction is similar regardless of the reconstruction method. Given the minimal invasion during profundoplasty, this operation may be the method of choice for diffuse lesions of the arteries of the lower extremities.

Computed tomography-based calcium scoring in cadaver leg arteries: Influence of dose, reader, and reconstruction algorithm

PurposeComputed tomography (CT) might be a good diagnostic test to accurately quantify calcium in vascular beds but there are multiple factors influencing the quantification. The aim of this study was to investigate the influence of different computed tomography protocol settings in the quantification of calcium in the lower extremities using modified Agatston and volume scores. MethodsFresh-frozen human legs were scanned at different tube current protocols and reconstructed at different slice thickness. Two different iterative reconstruction protocols for conventional CT images were compared. Calcium was manually scored using modified Agatston and volume scores. Outcomes were statistically analyzed using Wilcoxon signed-rank tests and mean absolute and relative differences were plotted in Bland-Altman plots. ResultsOf the 20 legs, 16 had CT detectable calcifications. Differences between thick and thin slice reconstruction protocols were 129 Agatston units and 125% for Agatston and 78.4 mm3 and 57.8% for volume (all p ≤ 0.001). No significant differences were found between low and high tube current protocols. Differences between iDose4 and IMR reconstruction protocols for modified Agatston were 34.2 Agatston units and 17.7% and the volume score 33.5 mm3 and 21.2% (all p ≤ 0.001). ConclusionsSlice thickness reconstruction and reconstruction method protocols influenced the modified Agatston and volume scores in leg arteries, but tube current and different observers did not have an effect. This data emphasizes the need for standardized quantification of leg artery calcifications. Possible implications are in the development of a more universal quantification method, independent of the type of scan and vasculature.

C28. Chronic Limb Threatening Ischemia in Patient With Aortoiliac Occlusive Disease (Leriche Syndrome) and Pulmonary Hypertension

Abstract Background Chronic limb-threatening ischemia (CLTI) is a manifestation of peripheral arterial disease (PAD) which is characterized by stenosis or occlusion of peripheral arteries causing impaired perfusion to the extremities, especially during rest and chronic progresses, which are associated with decreased quality of life and increased morbidity and mortality. Case Description A 51-year-old man complained of wound on both legs and pain during light activity. Risk factor is smoking for 30 years. History of primary pulmonary hypertension since 30 years. Physical examination revealed decreased pulsation from femoral artery to dorsalis pedis arteries in both leg. Echocardiography with RA and RV dilatation, D-shaped LV during systolic, mild TR and normal LV systolic function. Dupplex ultrasound and MSCT scan pulmonary-abdominal angiography shows thrombus in the abdominal aorta causing occlusion of blood flow distally. There is a comorbid pulmonary hypertension which causes right heart failure with symptoms of dyspnea. This patient is at high risk of undergoing revascularization surgery, so that in severe comorbid conditions an extraanatomical bypass with axillobifemoral bypass graft is considered. Discussion Atherosclerosis that occurs in the abdominal aorta, iliac artery, and femoropopliteal artery is called aortoiliac occlusive disease (AIOD). This condition when symptomatic is known as Leriche syndrome with a triad of symptoms of claudication, impotence, and reduced or no palpable pulsation of the femoral artery. Medical management include antiplatelet, statin, analgetic, and therapy according to risk factors. The main purpose is revascularization by surgery or endovascular which aims to improve blood flow to the distal artery.

C28. Chronic Limb Threatening Ischemia in Patient With Aortoiliac Occlusive Disease (Leriche Syndrome) and Pulmonary Hypertension

Abstract Background Chronic limb-threatening ischemia (CLTI) is a manifestation of peripheral arterial disease (PAD) which is characterized by stenosis or occlusion of peripheral arteries causing impaired perfusion to the extremities, especially during rest and chronic progresses, which are associated with decreased quality of life and increased morbidity and mortality. Case Description A 51-year-old man complained of wound on both legs and pain during light activity. Risk factor is smoking for 30 years. History of primary pulmonary hypertension since 30 years. Physical examination revealed decreased pulsation from femoral artery to dorsalis pedis arteries in both leg. Echocardiography with RA and RV dilatation, D-shaped LV during systolic, mild TR and normal LV systolic function. Dupplex ultrasound and MSCT scan pulmonary-abdominal angiography shows thrombus in the abdominal aorta causing occlusion of blood flow distally. There is a comorbid pulmonary hypertension which causes right heart failure with symptoms of dyspnea. This patient is at high risk of undergoing revascularization surgery, so that in severe comorbid conditions an extraanatomical bypass with axillobifemoral bypass graft is considered. Discussion Atherosclerosis that occurs in the abdominal aorta, iliac artery, and femoropopliteal artery is called aortoiliac occlusive disease (AIOD). This condition when symptomatic is known as Leriche syndrome with a triad of symptoms of claudication, impotence, and reduced or no palpable pulsation of the femoral artery. Medical management include antiplatelet, statin, analgetic, and therapy according to risk factors. The main purpose is revascularization by surgery or endovascular which aims to improve blood flow to the distal artery.