Peripheral Arterial Obstructive Disease Research Articles

COMPLICAÇÕES CRÔNICAS DO DIABETES MELLITUS TIPO 2

Diabetes mellitus is defined as a chronic non-communicable disease (NCD), being a syndrome characterized by persistent hyperglycemia, resulting from metabolic disorders, which may occur due to the destruction of insulin-producing beta cells or resistance to insulin action. The increase in plasma glucose occurs due to defects in the secretion and/or action of insulin produced by the pancreas, and can be subdivided into three main types: Type 1 Diabetes mellitus (autoimmune), Type 2 Diabetes mellitus (insulin resistant) and Diabetes gestational mellitus. Diabetes is characterized by multiple complications, acute and chronic (divided into microvascular and macrovascular), which constitute an important cause of early mortality. Chronic microvascular complications are associated with specific injuries caused by difficulty in passing blood to the endothelium. This obstruction occurs due to chronic hyperglycemia that triggers endothelial inflammation, resulting in the production of advanced glycolysis products, leading to oxidative stress, inflammation and the appearance of microthrombi, making this passage difficult. Macrovascular complications, in addition to hyperglycemia, are also related to problems such as dyslipidemia, systemic arterial hypertension and smoking. Such factors can lead to stroke, acute myocardial infarction and peripheral arterial obstructive disease. This work proposes a critical review of the existing literature on the chronic complications of Type 2 Diabetes mellitus, highlighting screening, prevention and treatment measures. It is concluded that technical and clinical knowledge about the pathophysiology and alternative interventions is essential for the immediate and comprehensive care of patients with Type 2 Diabetes mellitus, as well as the prevention of its chronic complications.

Conservative management and surgical approaches in the treatment of Peripheral Obstructive Arterial Disease (POAD): An overview

Introduction: Peripheral Obstructive Arterial Disease (PAD) is a condition in which there is a narrowing or blockage of the arteries that supply the lower limbs. The main objective of this systematic review was to identify studies that addressed the pathophysiology, epidemiology and signs and symptoms of PAD, with special emphasis on surgical intervention strategies. Methods:The search was conducted in renowned databases such as PubMed, Scopus, SciELO, Cochrane Library, LILACS, UpToDate and Embase, using controlled descriptors from DeCS. In order to effectively search for studies, descriptors such as "Peripheral Arterial Disease", "Vascular Surgical Procedures", "Myocardial Revascularization", "Angioplasty", "Vascular Grafting", "Thromboendarterectomy" and "Vascular Surgery" were used. These descriptors were combined with Boolean operators "OR" and "AND" to improve the precision of the search. The methodological approach adopted allowed for a thorough and comprehensive search, ensuring the inclusion of relevant studies. Results: The final sample consisted of 28 articles published in indexed scientific journals, addressing different aspects of POAD, such as symptomatology, epidemiology and surgical approach. The articles were available in full for analysis and were written in Portuguese. Analysis of the studies provided a better understanding of the pathophysiology of POAD, identified the main symptoms and examined the different surgical approaches used in treatment.Conclusion: The comprehensive systematic review of the literature on POAD provided valuable information on the disease and its surgical treatment modalities. The results obtained are essential for guiding clinical practice and assisting in decision-making regarding the management of POAD. The methodological approach adopted ensured the inclusion of relevant studies and provided a solid basis for understanding PAOD and providing appropriate care to patients.

Long-term outcomes of percutaneous transluminal renal artery intervention: a retrospective study at a single center

BackgroundThe indications, benefits, and outcomes of percutaneous transluminal renal artery intervention (PTRI) remain controversial. The study purpose was to evaluate the long-term outcomes of PTRI in clinical practice.MethodsA retrospective review of 217 subjects (254 renal arteries; mean age, 59.8 years) who underwent PTRI based on medical database.ResultsThe most common cause of renal artery stenosis was atherosclerosis in 217 (85.4%), followed by Takayasu arteritis (TA) in 23 (9.1%), fibromuscular dysplasia in five (2.0%) and others in nine (3.5%). Mean follow-up duration was 5.7 ± 3.7 years. The first restenosis rate was 7.5% (n = 19; highest in TA: n = 9, 47.4%) and second restenosis occurred in six arteries (five TAs, one fibromuscular dysplasia). Follow-up blood pressure improved from 142.0/83.5 to 122.8/73.5 mmHg (P < 0.001). There was no change within 5 years’ follow-up in estimated glomerular filtration rate (P = 0.44), whereas TA changed from 69.8 ± 20.5 to 84.2 ± 17.9 mL/min/1.73 m² (P = 0.008). Progressive renal dysfunction was related to diabetes mellitus, chronic kidney disease, and peripheral artery obstructive disease on multivariate analysis with hazard ratios (95% confidence intervals) of 2.24 (1.21–4.17), 2.54 (1.33–4.84), and 3.93 (1.97–7.82), respectively.ConclusionsPTRI was associated with a blood pressure reduction. Despite a higher rate of restenosis, patients with TA showed significant improvement in estimated glomerular filtration rate. Diabetes mellitus, chronic kidney disease, and peripheral artery obstructive disease were related with progressive renal dysfunction after PTRI.

SARS-COV-2 Pandemic for Patients with Chronic Obstructive Peripheral Arterial Disease: Impact of Interruption to Access According to Gender in a Single Center Experience

This retrospective study aims to evaluate the impact of interrupted services for peripheral arterial disease (PAD) patients and especially women in a single north-eastern Italian center over a period of 3months prior to the pandemic, during the first (2020) and the second (2021) wave of contagion in northern Italy. Patients with PAD at Rutherford stages 3 to 6 that required revascularization between March 2019 and March 2021 were classified into 3 groups, according to the period of treatment: the prepandemic period, the pandemic-20 period, and the pandemic-21 period. Twenty-eight patients were treated in the prepandemic period, 21 in the pandemic-20 period, and 39 in the pandemic-21 period. It was observed that in the both pandemic periods patients presented with more severe stages of limb ischemia, Rutherford 5 and 6 stages. During pandemic-20, patients underwent mostly open surgery, followed by hybrid procedures. No differences were observed between the 3 groups in major amputations, length of hospital stay, type of discharge, limb salvage and mortality. During long-term follow-up, limb salvage appeared to be significantly better in the pandemic-21 group. The gender analysis revealed a significantly reduced female proportion of overall treated patients in 2020 and 2021 compared to the prepandemic period. In the pandemic-20 this difference appears even more evident since treatments on females represented 19% of the total while in the same period of the previous year the male/female percentage was comparable (54% vs. 46%). The women admitted presented higher stages of disease and tended to have a longer hospital stay than men. At 12-month follow-up, limb salvage was similar between the 2 genders but was slightly worse in women. An efficient reorganization of the vascular surgery services during the pandemic period guaranteed the quality and standard of treatment offered in the preceding periods. Among patients suffering from PAD the impact of the pandemic was greater for the female gender. It is therefore important that in addition to a reorganization of hospital services to provide adequate care for patients with ACOP in the pandemic period, greater information and awareness of women.

Infrared thermography imaging as a diagnostic tool in the case of acute lower limb ischemia

Atherosclerosis is the major cause of cardiovascular diseases (CVD) in the world. It is a multifocal disease that leads to plaque formation and subsequent ischemia in the arteries of the body. Atherosclerotic obstructive peripheral artery disease causes disturbance of blood delivery to the tissues, which can be translated as temperature decrease on the skin surface, making surface temperature an important indicator of vascular health. Even though there are many classical diagnostic tools for assessing patients with peripheral vascular dysfunction, they have many limitations. On the other hand, infrared thermography imaging presents a noninvasive, relatively cheap, quick and reliable method that does not require direct doctor-to-patient contact. It provides a real time screening information of the tissue perfusion, based on the skin surface temperature. In this article, we present a case of a patient with type B aortic dissection, treated with an endovascular approach. A postprocedural closure device complication led to an acute left lower limb ischemia during the night, which was promptly diagnosed with the help of an onsite high-resolution infrared thermography optimized by specialized AI based software performed by the physician on duty followed by remote evaluation by the operator. The obstruction was treated immediately with successful endovascular recanalization and flow restoration and again evaluated with the thermographic camera confirming excellent tissue vascular result. Infrared thermography imaging can be a time-saving method for physicians, while being a very convenient method for the patient and that is why we advocate on the usage of specialized software supported high resolution thermography imaging as a supplementary diagnostic modality for patients with peripheral artery disease.

Major bleedings in mechanical prosthetic heart valves patients on Vitamin K antagonist treatment. Data from the PLECTRUM Study

Patients with mechanical prosthetic heart valves (MHV) need vitamin K antagonist (VKA) treatment, due to the high thrombotic risk. The need to evaluate the bleeding risk of these patients is of great clinical relevance. This is an observational retrospective multicenter study among Centers affiliated to the Italian Federation of Anticoagulation Clinics on MHV patients, with the aim to evaluate the risk of major bleeding (MB) and associated risk factors. 2357 patients with MHV were included in the study, patients were followed for 24.081 pt-years; 246 patients had MB (rate 1.0 ×100 pt-yrs), 54 were intracranial hemorrhage (rate 0.22 ×100 pt-yrs). Patients with MB were significantly older, more affected by peripheral obstructive arterial disease (POAD) and atrial fibrillation (AF), and presented a history of previous MB, with respect to patients who did not bleed. Patients with MB showed a trend for lower time in therapeutic range (TTR), and a significant number of patients had a TTR in the lower quartile. Patients with MB had a higher mortality rate with respect to patients who did not bleed (p=0.001). The history of previous bleeding, the presence of POAD or of AF, and a TTR in the lowest quartile, were significantly associated with MB. MHV patients treated with VKAs followed by Anticoagulation Clinics, showed a low bleeding risk. Risk factors associated with major bleeding are older age, the presence of POAD or AF, the history of previous bleeding, and poor quality of anticoagulation. Patients who experienced MB during anticoagulation are at high risk of death.

Lipoprotein(a) concentration and the blood content of INFγ-producing T-helpers 17 (Th17/1) in males with premature coronary artery disease

Aim. To analyze the relationship of blood lipid profile parameters, including the level of lipoprotein(a) (Lp(a)), and the content of circulating CD4+ T-lymphocytes with premature coronary artery disease (CAD).Material and methods. This retrospective cross-sectional study included 76 men aged 40 to 79 years. Patients were divided into following groups: main group — patients with CAD (58 [54;64] years, n=56) onset before the age of 55; control group — patients (62 [57;66] years, n=20) without CAD and obstructive CAD and peripheral arterial disease. Statins were taken by 51 (91%) and 9 (45%) patients in the main and control groups, respectively. In serum and plasma samples, lipid spectrum parameters and Lp(a) concentration were determined. Cellular phenotyping was performed by direct immunofluorescence in a culture of mononuclear leukocytes isolated from blood. To determine cytokines, cells were in vitro activated with inhibitor of intracellular transport of secretory proteins. Cell fluorescence was determined using flow cytometry.Results. Patients of both groups were comparable in age, body mass index, prevalence of hypertension and diabetes. Blood Lp(a) concentrations were higher in the CAD group than in the control group (49 [10;102] mg/dL vs 12 [4,3;32] mg/ dL, p&lt;0,05). The content of INFγ-producing T-helpers 17 (Th17/1) was also higher in the CAD group (19 [15;24] vs 13 [11;22], % of Th17, p=0,05). Logistic regression revealed that elevated Lp(a) levels (≥30 mg/dL) and relative amounts of Th17/1 (&gt;14% of Th17) independently of each other, atherogenic lipoprotein cholesterol levels, classical risk factors, and statin use were associated with premature CAD in the general group of patients with odds ratio (OR) of 4,6 (95% confidence interval (CI), 1,1-20,2) and 10,9 (2,1-56,7), p&lt;0,05, respectively. The combination of Lp(a) &gt;30 mg/dl and Th17/1 over 14% significantly increased the risk of premature CAD (OR, 28,0, 95% CI, 4,31-181,75, p=0,0005).Conclusion. We have shown for the first time that an increased Lp(a) concentration with an increased Th17/1 content is associated with the premature CAD in men.

Reduction of Occupational Radiation Exposure During Endovascular Treatment of Peripheral Artery Disease Using Radiation Absorbing Drapes

A chronic exposure to low dose radiation, as encountered in endovascular procedures, may impact the health of surgeons and radiologists over a timespan of several months to a lifetime. This study evaluates the feasibility and efficacy of a radiation absorbing sterile drape (RADPAD) to reduce operator exposure during the endovascular treatment of obstructive peripheral artery disease (PAD). Between February 2016 and September 2017, patients with PAD who received percutaneous transluminal angioplasty, stent placement, remote endarterectomy, or a combination thereof were included in this nonrandomized study. Patients were equally divided over a study cohort (with RADPAD) and a control cohort (without RADPAD). The unshielded body dose (E) of the staff was measured via electronic dosimeters placed at a chest height of the first operator (FO), second operator (SO), and sterile nurse (SN). A virtual maximum operator (MO) dose was constructed, yielding the highest dose per fluoroscopy run for either of the operators. Simultaneously, the dose area product (DAP) and C-arm settings for each fluoroscopy run were extracted. Staff exposures of the study cohort and control cohort were compared in terms of relative exposure (E/DAP). A secondary analysis involved an analysis of the individual fluoroscopy runs using a multivariate generalized linear mixed effect model. In total, 49 patients were included in this study. The use of RADPAD was technically feasible. Significant reductions of relative exposure were observed when comparing the study cohort with the control cohort. The relative exposure of the FO was reduced with 66.5% (1.82 vs. 0.61μSv/Gycm2, P<0.001), the relative exposure of the SO with 68.3% (0.55 vs. 0.17μSv/Gycm2, P=0.02), and the relative exposure of the MO with 65.8% (2.06 vs. 0.71μSv/Gycm2, P<0.001). Dose levels of SN were too low to draw conclusions under the current sample size. The multivariate generalized linear mixed effect model showed a significant correlation between absolute exposure of the MO and the use of the RADPAD (odds: 0.51, P<0.001). Usage of a radiation absorbing drape (RADPAD) during endovascular treatment of PAD results in statistically significant reduction in a relative operator dose while presenting no drawbacks. The use of these drapes is advised in future peripheral endovascular procedures.

Digoxin vs. beta-blocker therapy in atrial fibrillation: analysis from the ESC-EHRA EORP Atrial Fibrillation General Long-Term (AFGen LT) Registry

Abstract Background There is a long-standing and unresolved controversy over the effects of digoxin on mortality. Furthermore, there is scarce evidence comparing the use of digoxin to beta-blocker in the general population with atrial fibrillation (AF). In this study, we aimed to evaluate the effects of digoxin over beta-blocker therapy among patients with AF. Methods Patients from the EORP-AF General Long-Term Registry with AF who were treated with either digoxin or beta-blocker were included. All patients were over 18 years old and had documented evidence of AF within 12 months prior to enrolment. The outcomes of interest were all-cause mortality, cardiovascular (CV) mortality, non-CV mortality and number of patients with unplanned hospitalisation (total and AF-related). These were recorded until the last known follow-up available. Results Of 6377 patients, 549 (8.6%) and 5828 (91.4%) were treated with digoxin and beta-blockers, respectively. Patients in the digoxin group were older (73 vs. 71 years, p&amp;lt;0.001) with reduced renal function (eGFR 65.4 vs. 68.7 mL/min/1.73m2, p=0.002), and had (in general) greater burden of comorbidities in terms of chronic kidney disease, chronic obstructive pulmonary disease, heart failure, hypertension and peripheral artery disease. Nonetheless, the use of anticoagulation therapy was comparable between both groups (p=0.112). Over 24 months follow-up, there were 550 (8.6%) all-cause mortality and 1304 (23.6%) patients with unplanned emergency hospitalisation. Digoxin use was associated with increased all-cause mortality (hazard ratio [HR] 1.90 [95% CI, 1.48–2.44]), both from CV and non-CV causes (CV: HR 2.21 [95% CI, 1.49–3.26]); non-CV: HR 1.70 [95% CI, 1.04–2.79]). There was no statistical difference in terms of unplanned emergency hospitalisation (HR 0.99 [95% CI, 0.80–1.21]) and AF-related hospitalisation (HR 0.78 [95% CI, 0.58–1.06]) between both groups. Using multivariable cox regression analysis, digoxin compared to beta-blocker therapy was independently linked to increased all-cause mortality (HR 1.52 [95% CI, 1.11–2.09]) and CV mortality (HR 1.82 [95% CI, 1.11–2.97]), but was not related to non-CV mortality (HR 1.31 [95% CI, 0.71–2.41]), emergency hospitalisation (HR 0.91 [95% CI, 0.71–1.16]) or AF-related hospitalisation (HR 0.88 [95% CI, 0.62–1.24]), after adjustment for known risk factors. Conclusion We demonstrated that the use of digoxin was independently associated with excess all-cause mortality, driven by CV death, but was non-inferior to beta-blocker in terms of preventing unplanned emergency or AF-related hospitalisation, after accounting for important risk factors. Funding Acknowledgement Type of funding sources: None.

Arterial Thrombotic Events in CML Patients Treated with First-Line Nilotinib: Incidence, Management and Impact on the Long Term Outcome — a Gimema CML WP Analysis

Background: Nilotinib has better efficacy compared to imatinib, with higher chances of achieving treatment-free remission. However, nilotinib is associated to a higher incidence of arterial thrombotic events (ATEs), limiting its use in selected patients.Aims: To investigate the characteristics of ATEs and their impact on the long-term outcome of CML patients treated with nilotinib first-line.Methods: We retrospectively analyzed 345 patients ≥ 18 years of age (18-49 years, 147 patients; 50-64 years, 109 patients; > 64 years, 89 patients) with CP CML enrolled in multicenter prospective clinical trials of the GIMEMA CML WP investigating nilotinib as first-line treatment (Clinical.Trials.gov: NCT00481052; NCT00769327; NCT01535391). The median age at CML diagnosis was 53 (18 - 86) years. The median follow-up was 58 (22-82) months; total nilotinib exposure: 1043 patient-years. We analyzed the rate, type, management, and outcome of ATEs; moreover, we compared the molecular response rates and the long-term outcome of patients with or without ATEs.Definitions: ATEs: peripheral arterial obstructive disease (PAOD), ischemic heart disease (IHD), significant carotid stenosis and ischemic stroke, or other significant ischemic events; major molecular response (MMR): BCR-ABL≤ 0.1% (IS), with > 10.000 ABL copies; MR4: BCR-ABL≤0.01% (IS), with > 10.000 ABL copies.Results: Incidence and characteristics of ATEs: 30/345 (8.7%) patients had ATEs during treatment with nilotinib. Most common ATEs were IHD (4.1%), PAOD (2.3%), and (asymptomatic) carotid stenosis (1.1%). The median age at CML diagnosis of these patients was 64 (43-85) years, and the median age at ATEs was 67 (47 - 89) years. In patients of 18-49, 50-64, and > 64 years of age the rate of ATEs was 2%, 11%, and 15.7%, respectively; ATEs / 100 patient-years: 0.53, 2.7, and 3.6, respectively (relative risk in patients > 64 years vs. patients of 18-49 years: 6.7). The median duration of nilotinib treatment at ATE was 25 (1- 78) months: 87% and 60% of patients had achieved a MMR and MR4, respectively. These rates were comparable to those observed in patients without ATEs (MMR: 83%; MR4: 64%).Management of ATEs: 50% of patients received medical treatment only, while the remaining required invasive interventions, including coronary angioplasty with stent positioning (30%), lower limbs amputations (10%), and peripheral vascular by-passes (7%). Overall, 70% of patients were hospitalized; 80% of patients (7% of the whole cohort) permanently discontinued nilotinib because of ATEs. Nilotinib dose reduction was performed in most of the remaining patients.Outcome of ATEs: the median follow-up after ATE was 15 (1 - 58) months (total patient-years after ATEs: 52). No patient died for ATEs. The 5-year progression-free survival and overall survival were similar in patients with or without ATEs (PFS: 96% vs. 92%, p=0.55; OS: 96% vs. 93%, p=0.79)Summary: After a median follow-up of almost 5 years, 8.7% of patients treated in first-line with nilotinib had ATEs. In patients > 64 years the relative risk of ATEs was 6.7 times higher compared to patients < 50 years of age. For the management of ATEs, half of the patients received medical treatment only; the remaining patients required invasive procedures, including major surgeries in 20% of cases. Importantly, no patient died for ATEs, and ATEs did not significantly affect response rates and long-term outcome of CML patients treated with nilotinib first-line. DisclosuresGugliotta:Incyte: Consultancy, Honoraria; Bristol Myers Squibb: Consultancy, Honoraria; Novartis: Consultancy, Honoraria. Castagnetti:Novartis: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Incyte: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria. Breccia:TEVA: Speakers Bureau. Tiribelli:Bristol Myers Squibb: Consultancy, Honoraria; Incyte: Consultancy, Honoraria; Novartis: Consultancy, Honoraria. Fava:Incyte: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Novartis: Consultancy, Honoraria. Soverini:Bristol-Myers Squibb: Consultancy; Novartis: Consultancy; Incyte Biosciences: Consultancy. Martinelli:Pfizer: Consultancy; Celgene: Consultancy; Johnson&Johnson: Consultancy; Roche: Consultancy; Ariad/Incyte: Consultancy; Amgen: Consultancy. Pane:Novartis: Honoraria, Speakers Bureau. Saglio:Roche: Consultancy, Honoraria; BMS: Consultancy, Honoraria; Incyte: Consultancy, Honoraria; Ariad: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Ariad: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Incyte: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Roche: Consultancy, Honoraria. Baccarani:Novartis: Consultancy, Honoraria; Incyte: Consultancy, Honoraria; BMS: Consultancy, Honoraria. Rosti:Incyte: Research Funding, Speakers Bureau; Bristol Myers Squibb: Research Funding, Speakers Bureau; Pfizer: Research Funding, Speakers Bureau; Novartis: Research Funding, Speakers Bureau.

A predictive score for 30-day survival for patients undergoing major lower limb amputation for peripheral arterial obstructive disease

To analyze outcomes following major lower extremity amputations (mLEAs) for peripheral arterial obstructive disease, gangrene, infected non-healing wound and to create a risk prediction scoring system for 30-day mortality. In this single-center, retrospective, observational cohort study. All patients treated with above-the-knee amputation (AKA) or below-the-knee amputation (BKA) between January 1st, 2010 and June 30th, 2018 were identified. The primary outcome of interest was early (≤ 30 days) mortality. Secondary outcomes were postoperative complications and freedom from amputation stump revision/failure. We identified 310 (77.7%) mLEAs performed on 286 patients. There were 188 (65.7%) men and 98 (34.3%) women with a median age of 79 years (IQR, 69–83 years). We performed 257 (82.9%) AKA and 53 (17.1%) BKA. There were 49 (15.8%) early deaths, which did not differ among the age quartiles of this cohort (15.4% vs. 14.3% vs. 15.4% vs. 19.5%, P = 0.826). Binary logistic regression analysis identified age > 80 years (OR 2.24, 95% CI 1.17–4.31; P = 0.015), chronic obstructive pulmonary disease (OR 2.12, 95% CI 1.11–4.06; P = 0.023), and hemodialysis (OR 2.52, 95% CI 1.15–5.52; P = 0.021) to be associated with early mortality. The final score (range 0–10) identified two subgroups with different mortality at 30 days: lower-risk (score < 4, 10.8%), and higher-risk (score ≥ 4: 28.7%; OR 3.2, 95% CI 1.63–6.32; P < 0.001). In our experience, mLEAs still have a 14% mortality rate over the years. Our lower-risk group (score < 4) is characterized by a lower rate of perioperative death and longer survival.Graphic abstract

Frailty impairs the endothelial function of elderly with chronic heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Background Frailty has a high prevalence of heart failure (HF). It is believed that existing circulatory disturbance increase oxidative stress and chronic inflammation, predisposing to anabolic-catabolic imbalance. Thus, there is impairment of the efficient use of oxygen by skeletal muscles, limiting the physical-functional performance in these individuals. However, little is known about the influence of frailty on endothelial function in the elderly. Purpose To analyze the influence of frailty on endothelial function in the elderly with and without HF. Methods This was a descriptive cross-sectional study, which included individuals aged ≥60 years, with or without HF, who did not have diabetes, anemia, peripheral obstructive arterial disease and/or congenital heart disease. The Cardiovascular Health Study (CHS) frailty scale criteria were used to assess frailty (phenotype). Endothelial function at rest was evaluated by near-infrared spectroscopy ([NIRS]; slope 1, lowest tissue oxygen saturation [StO2], area under the curve [AUC] of StO2, slope 2, StO2 peak, overshoot, ΔStO2nadir_peak and Δtime nadir_peak) during arterial occlusion maneuver on the forearm. Results were grouped according to the frailty phenotype: robust, pre-frail and frail. Shapiro-Wilk test was used to assess the normality of data. Quantitative data were compared using a two-way analysis of variance plus Bonferroni post hoc test to determine the influence of the frailty or HF on endothelial function variables. A p-value &amp;lt;0.05 was considered statistically significant. Results Fifty-two elderly people (61% women) participated in the study, with a mean age of 70.3 ± 7.1 years. Of these, 52% (n = 27) had a diagnosis of HF. Among the sample, 35% (n = 18) were robust, 45% (n = 23) pre-frail, and 20% (n = 11) frail. Endothelial function analysis identified that there was an influence of frailty on reperfusion rate (slope 2 and ΔStO2 nadir-peak; p &amp;lt; 0.05) and desaturation during arterial occlusion (AUC StO2; p &amp;lt; 0.05) only in the HF group. Conclusion The coexistence of frailty and HF seems to impair endothelial function since frail elderly with HF had lower reperfusion rate and higher desaturation during the arterial occlusion test. Abstract Figure. Endothelial function assessment by NIRS

Effect of preoperative pneumococcal immunization on the incidence of respiratory infection in the postoperative period of cardiac surgery

Objective: To analyze whether the incidence of respiratory infections in the postoperative period of cardiac surgery is lower in patients immunized with the 13-valent pneumococcal conjugate vaccine. To study the main risk factors related to the development of infections in patients undergoing cardiac surgery. Methodology: 40 patients were included in the study, randomized 1: 1 to receive pneumococcal vaccine or placebo, 14 days before undergoing elective cardiac surgery. The incidence of infections in the 30 postoperative days was compared between groups. Results: There were 6 respiratory infections in the vaccine group and 2 in the placebo group (p=0.2024) and one death in the placebo group and none in the vaccine group (p=0.3173). Chronic obstructive pulmonary disease (p=0.003), diabetes mellitus (p=0.047) and peripheral arterial disease (p=0.0001) were listed as risk factors for the development of infections, which generated an increase in hospital stay (95% CI : 1.33- 7.13; p =0.0147) and ICU stay in the postoperative period (95% CI: 1.87- 33.45; p=0.0025). Conclusion: The application of pneumococcal vaccine 13v did not influence the development of postoperative pulmonary infections. Chronic obstructive pulmonary disease, diabetes mellitus and peripheral arterial disease were identified as risk factors for the development of infections, increasing the length of total hospital stay and time in the ICU.

INFLAMMATORY BIOMARKERS AND OBESITY IN RESISTANT HYPERTENSION

Objective: To evaluate the relationship between inflammatory biomarkers and obesity in a large cohort of patients with resistant hypertension (RHT). Design and method: This cross-sectional study evaluated 423 subjects with RHT (30.5% male; 63.9 ± 10.8 years old), 215 (50,8%) of whom are obese. In all subjects the inflammatory biomarkers, TNF-alfa, MCP-1, E-Selectin and PAI-1, were dosed. Socio-demographic characteristics, anthropometric measurements and cardiovascular risk factors were recorded. Variance analysis compared the serum levels of 4 biomarkers inflammatory and the bivariate analysis compared resistant hypertensives with and without obesity. Results: Obese subjects are younger, with a higher prevalence of peripheral obstructive arterial disease. No difference was found concerning to the blood pressure, neither to subclinical lesions. The values of PAI-1 (123 [107–164] vs 113 [89–138] and E-Selectin (53.2 [34.2–68.6] vs 44.6 [20.8–62.0] were significantly higher in patients with obesity. The other biomarkers evaluated did not evidence association with obesity. Conclusions: Among the inflammatory biomarkers evaluated, which was most strongly correlated with obesity was PAI-1 and E-Selectin. According to literature PAI-1 is tightly linked to metabolic disorders, such as insulin resistance and central obesity, while E-Selectin has an important role on atherosclerosis's development.

Paraparesis due to ischemic lumbosacral Radiculoplexopathy

Background: Lumbosacral radiculoplexopathy (LSRP) is a rare entity, with several etiologies described in the literature. Vascular lesions to the lower part of the aorta and the common iliac artery can cause LSRP of ischemic etiology. Clinical Presentation: A 66-year-old man with a previous history of peripheral obstructive arterial disease (POAD) requiring aortobifemoral and femoropopliteal procedures had a prolonged hospital stay due to various complications: stent infection and occlusion, aortoenteric fistula causing hemorrhagic shock, transmetatarsal amputation of the right foot. In this context, he underwent multiple endovascular procedures. At discharge, the patient presented flaccid paraparesis, distal bilateral hypoesthesia, saddle anesthesia and urinary and anal incontinence. Spinal cord infarction was excluded. An electromyographic study confirmed the diagnosis of bilateral LSRP of ischemic etiology. Conclusion: This case highlights the importance of including ischemic etiology as a differential diagnosis of peripheral nerve injuries, namely in patients with POAD.

Continuous peripheral nerve block for in-patients with lower limb ischemic pain

OBJECTIVES:Demonstrate that continuous peripheral nerve block (CPNB) may be an alternative with adequate analgesia and a lower incidence of side effects for ischemic pain due peripheral obstructive arterial disease (POAD).METHODS:Retrospective cohort study with 21 patients with POAD, Fontaine IV graded, with foot pain. Patients were submitted to continuous sciatic nerve block (CSNB), through a perineural catheter. Primary outcomes were pain intensity (by numerical rating scale) and opioid consumption (in oral morphine equivalents).RESULTS:During CSNB, pain scores markedly decreased in comparison to the pre-block period.CONCLUSIONS:CPNB may be a good option for ischemic pain treatment in in-patients, as it provides effective pain control with fewer adverse effects.

Co-Registration of Peripheral Atherosclerotic Plaques Assessed by Conventional CT Angiography, MicroCT and Histology in Patients with Chronic Limb Threatening Ischaemia

To co-register conventional computed tomography angiography (CTA), with exvivo micro-computed tomography (microCT) and histology of popliteal atherosclerotic plaques. Improving the non-invasive imaging capabilities may be valuable to advance patient care with peripheral arterial obstructive disease towards lesion and individual based treatment. In this prospective observational study, 12 popliteal arteries from 11 symptomatic patients who had undergone transfemoral amputations for chronic limb threatening ischaemia and who had pre-operative CTA, were analysed exvivo by microCT and histology. A total of 353 histological cross sections were co-registered with microCT and CTA, and classified as: lipid rich (LP, n=26), fibrous (FP, n=80), or calcific (CP, n=247) plaques. CTA and microCT plaque density was calculated in 791 regions of interest as Hounsfield units (HU). CTA and microCT could identify plaque components that were confirmed by histology such as fibrous tissue (FP), lipid pool/core (LP), and calcification (CP). MicroCT densities were 77.8 HU for FP (IQR 52.8, 129.5 HU),-28.4 HU for LP (IQR-87.1, 13.2 HU), and 3826.0 HU for CP (IQR 2989.0, 4501.0 HU). CTA densities of the three components of the plaque were: 78.0 HU for FP (IQR 59.5, 119.8 HU), 32.5 HU for LP (IQR 15.0, 42 HU), and 641.5 HU for CP (IQR 425.8, 1135 HU). The differences were statistically significant between the HU densitometric characteristics among the three groups (p<.0001) for both imaging modalities. Overall, microCT performed better diagnostically than conventional CTA for the three types of plaques: areas under the receiving operator characteristics curve were greater for microCT than CTA for FP (0.97 vs. 0.90), for LP (0.88 vs. 0.67), and for CP (0.97 vs. 0.90). CTA and microCT can be used to identify histological atherosclerotic plaque components, with better diagnostic performance for microCT. This study demonstrates the feasibility of using microCT to assess plaque morphology lesions in a manner that approaches histology thus becoming a useful tool for exvivo assessment of atherosclerosis and towards lesion based treatment.

Kissing Stent Technique for TASC C-D Lesions of Common Iliac Arteries: Clinical and Anatomical Predictors of Outcome

The endovascular treatment of peripheral artery obstructive disease in Trans-Atlantic Inter-Society (TASC) C and D lesions involving the aortic bifurcation is a matter of debate. The aim of this study is to evaluate the technical and clinical success of kissing stenting in this context and to analyze predictors of outcome. All patients treated for aortoiliac TASC C and D lesions with kissing stenting (from 2012 to 2017) in a 6-year period were retrospectively analyzed. Preoperative anatomical features were evaluated by reviewing computed tomography angiography images to identify severe iliac calcifications (SICs) versus not SIC (NSICs). Primary end points were as follows: technical success (TS), procedural success, primary patency (PP), and clinical success (CS). Secondary end points were as follows: secondary patency, assisted patency, survival, mid-term procedure-related complications, and risk factors that affected TS and mid-term results. In a 6-year period, 51 patients fulfilled the inclusion criteria. TS was achieved in 49 (96.1%) cases. Thirty-one patients (60.8%) received a dual antiplatelet therapy (DAPT) for at least 1month after the procedure. 30-day CS was 94.1%. Median follow-up was 45.7months (IQR: 24.5, 8-86 range). The CS was 92.6% at 3years, with a PP of 86.8% and a secondary patency of 93.2% at 3years. Six (13.2%) iliac axis occluded during the first follow-up year. NSIC was statistically and independently associated with a lower PP (73% vs. 96%, P=0.03); DAPT was statistically and independently associated with higher PP than single antiplatelet therapy (96% vs. 75%, P=0.03); these results were confirmed by Cox regression analysis (HR: 0.14, 95%, IC: 0.01-0.89, P=0.05 for DAPT analysis; HR: 6.8, 95%, IC: 1.21-59, P=0.05 for NSIC analysis). Endovascular treatment for TASC C-D is an effective technique. Postoperative stent occlusion is higher in patients with no DAPT and it usually occurs during the first postoperative year. Preoperative NSIC lesions are associated with reduced PP at 3years of follow-up.

Prevalence and Predictors of Atherosclerotic Peripheral Arterial Obstructive Disease in Severe Heart Valve Diseases.

Despite witnessing an upsurge in heart valve diseases (HVDs), the correlation between HVDs and atherosclerotic peripheral arterial obstructive disease (PAOD) remains unclear. This study aims to investigate the prevalence and predictors of PAOD in HVDs.In this study, a total of 245 consecutive patients were examined: 153 with severe aortic valve stenosis (AS), 66 with severe primary mitral valve regurgitation (MR), and 26 with severe pure native aortic valve regurgitation (AR). All patients underwent ultrasound scan of the carotid artery to ascertain the presence of internal carotid artery stenosis (ICAS). ICAS was defined as a peak systolic velocity ≥ 125 cm/second and/or ≥ 50% reduction in diameter. In addition, we measured the ankle-brachial index in each leg using a volume plethysmograph. A result of ≤ 0.9 was considered lower extremity artery disease (LEAD).The presence of ICAS was statistically more frequent in patients with severe AS than in patients with severe MR and AR (11.1% versus 1.5% versus 3.8%; P = 0.038). LEAD was present in patients with severe AS (17.6%) and MR (10.6%) but not in patients with severe AR (P = 0.037). The multivariate analysis revealed that the presence of severe AS (OR, 5.6 [1.3-24.9]; P = 0.023) was an independent predictor for ICAS, while history of coronary artery disease (OR, 4.8 [2.2-10.5]; P < 0.001) was an independent predictor for LEAD.The prevalence of PAOD varies depending on each valvular disease. Individual screening should be considered on the basis of atherosclerotic risk factors, especially for patients with severe AS.

Atherosclerotic Extension of Carotid Arteries: An Insertion in Clinical Practice.

Introduction Atherosclerotic disease is a diffuse disease that is strongly associated with age, risk factors, and variable progression. The anatomical prevalence of atheromas does not always follow, a sequence by sectors, and in many cases are concomitant. Objectives This study is aimed at studying atherosclerosis in the arterial territories of the carotid and lower limbs, in order to correlate their extension as a form of primary prevention. Methods Participating patients with the main risk factors for atherosclerotic disease were composed of two groups: one with chronic peripheral obstructive arterial disease (PAD) and another without PAD. After performing carotid ultrasound Doppler (USD) of all patients, the occasional prevalence of the disease was evaluated. We performed by statistical tests the correlation between the findings in these patients and the risk factors. Obtaining n from 226 patients, in which 116 patients are from the PAD group and 110 patients are from the group without PAD. Results Our findings add up to 8.8% for lesions over 50% in patients with PAD, with 6.2% over 70% meeting the few published scientific findings. In this study, the correlation was evaluated between carotid stenosis and PAD, in which we observed a positive association. We observed in the studies that the prevalence of moderate and severe carotid stenosis was similar to patients with coronary artery disease (CAD). There are a number of nonclassical risk factors that we do not evaluate, but even studying the traditional ones, we find that they are less than 27% dependent. Conclusion Therefore, our study proposes an improvement in the clinical approach of patients with PAD for both the carotid and coronary territory, not using only 2 factors traditional risk factors, for the extension study and to consider the PAD that has 10% dependence alone, as effect and projection of the carotid atherosclerotic plaque.