Peripheral Arterial Vascular Disease Research Articles

THE “BACK TO THE FUTURE” OF CARDIOTHORACIC SURGERY: HIGH–RISK INTERVENTIONAL PROCEDURE TURNED DOWN TO CONVENTIONAL CARDIAC SURGERY

Abstract Background Structural interventional cardiology has been introduced at the beginning of our century to address high–risk patient suffering from severe aortic stenosis. Since then several technique and technology have been proposed to address an increasing population of patients and mitral valve diseases have been also addressed. While several authors are pushing up the indications for structural interventional procedures, however, we are experiencing some situations were conventional surgery is considered an alternative to high risk interventional procedures. Here we present a peculiar case of “back to the future” in cardiothoracic surgery. Case Description A 76 yo female patient, was referred to our Division from a peripheral Hospital suffering from severe aortic stenosis and coronary artery diseases. Medical history of the patient included persistent AF, COPD, arterial peripheral vascular disease, moderate chronic renal insufficiency and moderate dilatation of ascending aorta. Patient was previously assessed by another Centre and a percutaneous treatment (PTCA+TAVI) was proposed. Due to further admission for cardiac failure–related symptoms, however, patient was urgently referred to our Division. Fig 1 and 2 summarized clinical findings. “Heart team” evaluation, based also on the product specialist evaluation, considered the patient not suitable for interventional procedure due to the high risk of sub–optimal medium–term prognosis. Due to further clinical deterioration an extremely high–risk surgical procedure was mandatory. Results Surgical procedure included a sutureless aortic valve replacement, a MV plasty, a double coronary graft + a cpmbined carotid endoarterectomy. Postoperative course was free from significant complications and the patient was discharged to rehabilitation clinic on 15th postoperative days. Conclusion Despite interventional procedure are continuing to increase either as number of procedure either as complexity of diseases treated, conventional cardiac surgery remains still the only option for treatment in many clinical scenario. As a sort of “back to the future” situation, patient originally referred for interventional procedures are turned down due to the high risk of sub–optimal results. In such condition conventional cardiac surgery, performed with high level of accuracy could represent the last and only treatment option for high risk patients.

Risk factors for cardiovascular disease in primary Sjögren's syndrome (pSS): a 20-year follow-up study.

Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease characterized by a chronic grade of inflammation. Cardiovascular events represent the major causes of morbidity and mortality in patients with inflammatory rheumatic diseases; however, the significance and prevalence of cardiovascular disease in patients with pSS remain unclear. To determine the clinical significance of cardiovascular disease in pSS and analyze the risk of cardiovascular disease according to glandular/extraglandular involvement and positivity to anti-Ro/SSA and/or anti-La/SSB autoantibodies. A retrospective study including patients diagnosed with pSS fulfilling the 2016 ACR/EULAR classification criteria was followed and evaluated in our outpatient clinic between 2000 and 2022. The prevalence of cardiovascular risk factors with pSS was evaluated, and a possible association with clinical and immunological characteristics, the treatments received, and the impact on cardiovascular disease were determined. Univariate and multivariate regression analyses were performed in an attempt to determine potential risk factors associated with cardiovascular involvement. A total of 102 pSS patients were included. Eighty-two percent were female, with a mean age of 65±24 years and a disease duration of 12.5 ±6 years. Thirty-six patients (36%) had at least one cardiovascular risk factor. Arterial hypertension was diagnosed in 60 (59%) patients, dyslipidemia in 28 (27%), diabetes in 15 (15%), obesity in 22 (22%), and hyperuricemia in 19 (18%). History of arrhythmia was found in 25 (25%), conduction defects in 10 (10%), arterial peripheral vascular disease in 7 (7%), venous thrombosis in 10 (10%), coronary artery disease in 24 (24%), and cerebrovascular disease in 22 (22%) of patients. Patients with extraglandular involvement had a higher prevalence of arterial hypertension (p=0.04), dyslipidemia (p=0.003), LDL mean values (p=0.038), hyperuricemia (p=0.03), and coronary artery disease (p=0.01) after adjusting for age, sex, disease duration, and the significant variables in the univariate analysis. Patients with Ro/SSA and La/SSB autoantibodies had a substantially higher risk of hyperuricemia (p=0.01), arrhythmia (p=0.01), coronary artery disease (p=0.02), cerebrovascular disease (p=0.02), and venous thrombosis (p =0.03). In the multivariate logistic regression analysis, higher odds of cardiovascular risk factors were associated with extraglandular involvement (p=0.02), treatment with corticosteroids (p=0.02), ESSDAI>13 (p=0.02), inflammatory markers including ESR levels (p 0.007), and serologic markers such as low C3 levels (p=0.03) and hypergammaglobulinemia (p=0.02). Extraglandular involvement was associated with a higher prevalence of arterial hypertension, dyslipidemia, hyperuricemia, and coronary artery disease. Anti-Ro/SSA and anti-La/SSB seropositivity was associated with a higher prevalence of cardiac rhythm abnormalities, hyperuricemia, venous thrombosis, coronary artery disease, and cerebrovascular disease. Raised inflammatory markers, disease activity measured by ESSDAI, extraglandular involvement, serologic markers including hypergammaglobulinemia and low C3, and treatment with corticosteroids were associated with a higher risk for cardiovascular comorbidities. Key Points • Patients with pSS are vulnerable to cardiovascular risk factors. There is an interconnection between extraglandular involvement, disease activity, inflammatory markers, and cardiovascular risk comorbidities. • Anti-Ro/SSA and anti-La/SSB seropositivity was associated with a higher frequency of cardiac conduction abnormalities, coronary artery disease, venous thrombosis, and stroke. • Hypergammaglobulinemia, elevated ESR, and low C3 are associated with a higher prevalence of cardiovascular comorbidities. • Valid risk stratification tools to help with prevention and consensus on the management of CVDs in pSS patients are warranted.

Changes in miRNA expression in patients with peripheral arterial vascular disease during moderate- and vigorous-intensity physical activity

BackgroundWalking is the preferred therapy for peripheral arterial disease in early stage. An effect of walking exercise is the increase of blood flow and fluid shear stress, leading, triggered by arteriogenesis, to the formation of collateral blood vessels. Circulating micro-RNA may act as an important information transmitter in this process. We investigated the acute effects of a single bout of 1) aerobic walking with moderate intensity; and 2) anaerobic walking with vigorous intensity on miRNA parameters related to vascular collateral formation.MethodsTen (10) patients with peripheral arterial disease with claudication (age 72 ± 7 years) participated in this two-armed, randomized-balanced cross-over study. The intervention arms were single bouts of supervised walking training at (1) vigorous intensity on a treadmill up to volitional exhaustion and (2) moderate intensity with individual selected speed for a duration of 20 min. One week of washout was maintained between the arms. During each intervention, heart rate was continuously monitored. Acute effects on circulating miRNAs and lactate concentration were determined using pre- and post-intervention measurement comparisons.ResultsVigorous-intensity walking resulted in a higher heart rate (125 ± 21 bpm) than the moderate-intensity intervention (88 ± 9 bpm) (p < 0.05). Lactate concentration was increased after vigorous-intensity walking (p = 0.005; 3.3 ± 1.2 mmol/l), but not after moderate exercising (p > 0.05; 1.7 ± 0.6 mmol/l). The circulating levels of miR-142-5p and miR-424-5p were up-regulated after moderate-intensity (p < 0.05), but not after vigorous-intensity training (p > 0.05).ConclusionModerate-intensity walking seems to be more feasible than vigorous exercises to induce changes of blood flow and endurance training-related miRNAs in patients with peripheral arterial disease. Our data thus indicates that effect mechanisms might follow an optimal rather than a maximal dose response relation. Steady state walking without the necessity to reach exhaustion seems to be better suited as stimulus.

Efektivitas SNEDDS Kombinasi Fraksi Etil Asetat Daun Cengkodok (Melasthoma malabathricum)-Antibiotik terhadap Bakteri Hasil Isolat dari Pasien Ulkus Diabetik

Diabetic ulcer is a condition where there are neurological abnormalities and peripheral arterial vascular disease that causes infection, ulceration, and/or damage to the deepest skin tissue on the feet of people with diabetes mellitus (DM). The long duration of wound healing is due to the wrong use of antibiotics for a long time, and bacteria tend to become resistant to antibiotics. Antimicrobial compound fraction of cengkodok combined with gentamicin and ciprofloxacin antibiotics for prevention and reduction of antibiotic resistance in the cause of diabetic ulcers. The drug preparation is in the form of self nanoemulsifiying drug delivery system (SNEDDS), which is the optimum combination of cengkodok leaf fraction with gentamicin and ciprofloxacin antibiotics. The use of SNEDDS in this study is because the SNEDDS made from nanoemulsion formulations has small particle size, large surface absorption, and good dispersion, so that it can be evenly dispersed on the skin and penetrates the skin layer. This study aims to determine the effectiveness of the formulation cengkodok leaf fraction with gentamicin and ciprofloxacin antibiotics against B. cereus and S. aureususing the SNEDDS drug delivery system. The test uses the spotless diffusion method without using paper discs. The results showed that the combination of cengkodok leaf fraction with gentamicin and ciprofloxacin antibiotics had better activity against B. cereus and S. aureus than cengkodok leaf fraction, gentamicin and ciprofloxacin only.

Autoantibodies from patients with complex regional pain syndrome induce pro-inflammatory effects and functional disturbances on endothelial cells in vitro.

Complex regional pain syndrome (CRPS) is an inadequate local response after a limb trauma, which leads to severe pain and autonomic and trophic changes of the affected limb. Autoantibodies directed against human β2 adrenergic and muscarinic M2 receptors (hβ2AR and hM2R) have been described in CRPS patients previously. We analyzed sera from CRPS patients for autoantibodies against hβ2AR, hM2R, and endothelial cells and investigated the functional effects of purified IgG, derived from 13 patients with CRPS, on endothelial cells. Eleven healthy controls, 7 radial fracture patients without CRPS, and 10 patients with peripheral arterial vascular disease served as control subjects. The CRPS-IgG, but not control IgG, bound to the surface of endothelial cells ( P < 0.001) and to hβ2AR and hM2R ( P < 0.05), the latter being reversed by adding β2AR and M2R antagonists. The CRPS-IgG led to an increased cytotoxicity and a reduced proliferation rate of endothelial cells, and by adding specific antagonists, the effect was neutralized. Regarding second messenger pathways, CRPS-IgG induced ERK1/2, p38, and STAT1 phosphorylation, whereas AKT phosphorylation was decreased at the protein level. In addition, increased expression of adhesion molecules (ICAM-1 and VCAM-1) on the mRNA level was induced by CRPS-IgG, thus inducing a pro-inflammatory condition of the endothelial cells. Our results show that patients with CRPS not only develop autoantibodies against hβ2AR and hM2R, but these antibodies also interfere with endothelial cells, inducing functional effects on these in vitro, and thus might contribute to the pathophysiology of CRPS.

Adenosine-to-inosine Alu RNA editing controls the stability of the pro-inflammatory long noncoding RNA NEAT1 in atherosclerotic cardiovascular disease

Long non-coding RNAs (lncRNAs) have emerged as critical regulators in human disease including atherosclerosis. However, the mechanisms involved in the post-transcriptional regulation of the expression of disease-associated lncRNAs are not fully understood. Gene expression studies revealed that Nuclear Paraspeckle Assembly Transcript 1 (NEAT1) lncRNA expression was increased by >2-fold in peripheral blood mononuclear cells (PBMCs) derived from patients with coronary artery disease (CAD) or in carotid artery atherosclerotic plaques. We observed a linear association between NEAT1 lncRNA expression and prevalence of CAD which was independent of age, sex, cardiovascular traditional risk factors and renal function. NEAT1 expression was induced by TNF-α, while silencing of NEAT1 profoundly attenuated the TNF-α-induced vascular endothelial cell pro-inflammatory response as defined by the expression of CXCL8, CCL2, VCAM1 and ICAM1. Overexpression of the RNA editing enzyme adenosine deaminase acting on RNA-1 (ADAR1), but not of its editing-deficient mutant, upregulated NEAT1 levels. Conversely, silencing of ADAR1 suppressed the basal levels and the TNF-α-induced increase of NEAT1. NEAT1 lncRNA expression was strongly associated with ADAR1 in CAD and peripheral arterial vascular disease. RNA editing mapping studies revealed the presence of several inosines in close proximity to AU-rich elements within the AluSx3+/AluJo‐ double-stranded RNA complex. Silencing of the stabilizing RNA-binding protein AUF1 reduced NEAT1 levels while silencing of ADAR1 profoundly affected the binding capacity of AUF1 to NEAT1. Together, our findings propose a mechanism by which ADAR1-catalyzed A-to-I RNA editing controls NEAT1 lncRNA stability in ASCVD.

Palmar petechiae in a patient with diabetes mellitus

A 64-year-old man with a history of celiac disease (CD), congestive heart failure, and diabetes mellitus complicated by end-stage renal disease and peripheral neuropathy, was admitted to the hospital for non-healing ulcerations of his hands with osteomyelitis from his peripheral arterial vascular disease. He reported that his CD was under good control with a strict gluten-free diet prior to admission. Physical exam revealed prominent petechiae on his bilateral palms and fingers (Fig 1). A biopsy was performed and demonstrated collections of neutrophils in the papillary dermis (Fig 2).

Predicting risk factors that lead to free flap failure and vascular compromise: A single unit experience with 565 free tissue transfers

Even though the benefit of free tissue transfer is uncontested in complex reconstructive cases, vascular compromise and/or flap failure remain a challenge for the surgeon and identification of possible risk factors can aid in the preoperative planning. The aim of this study was to identify the individual risk factors leading to flap failure and/or vascular compromise in free tissue transfers in a single institution over a period of 10 years and to create an index predicting these problems, as well as finding predictors of other postoperative complications. Data from all the patients undergoing free tissue transfers between 2009 and 2018 were retrospectively analyzed (demographics, comorbidities, flap failure, vascular compromise, and other complications). The results from the univariate and multivariate analyses were used to create an index. A predictability index with three classes (low, moderate, and high risk) was calculated for each patient, based on defect etiology and the presence of coronary heart disease, diabetes, smoking, peripheral arterial vascular disease, and arterial hypertension. A patient with moderate-risk index had 9.3 times higher chances of developing vascular compromise than those in the low-risk group, while a high-risk index had 18.6 higher odds (p=0.001). American Society of Anesthesiologists (ASA) classification was found to be a predictor of complications in free tissue transfer (p=0.001). If patients at a high risk of vascular compromise could be identified preoperatively through this predictability index, patient counseling could be improved and the surgeon might adapt the reconstructive plan and choose an alternative reconstructive strategy.

Carbon dioxide (Co2) Angiography in Diabetic Patients with Peripheral Arterial Disease and Chronic Renal Insufficiency as a Standard Procedure

Introduction - The objective of this study is to evaluate the diagnostic and therapeutic carbon dioxide (CO2) angiography in patients with diabetes mellitus, peripheral arterial vascular disease (PAD) and chronic renal insufficiency (CRI) to determine whether to use of carbon dioxide angiography in this type of patients should be a standard. Methods - Lower limb angiographic procedures with CO2 (diagnostic and diagnostic-interventional) were collected from the database of our clinic of 205 consecutive patients between 2012 and 2017 and retrospectively reviewed. Of the 205 patients with PAD undergoing CO2 angiography 196 had a admitting diagnose of CRI≥ stage III(GFR<45, moderate to severe Kidney function loss) and 9 patients had a iodinated contrast medium hypersensitivity Results - Of the 205 patients undergoing CO2 angiography, 122 (60%) had diabetes mellitus. 18% Had PAD Fontaine stage II, 20% stage III and 62% stage IV. Of the patients without known diabetes mellitus at the begin of medical hospitalization, 29 (35%) had a glycated haemoglobin levels above 6.1%. Of the diabetic patients 116 (95%), had CRI≥ stage III (stage III 47%, stage IV 45% and stage V with residual excretion 8%). However of the 116 diabetics with CRI≥ stage III, the CRI was only known at 74%. Of the remainder of the 24% (30 patients) with unknown CRI, 20 had CRI stage III and 10 had stage IV. Lower limb angiographic procedures with CO2 in diabetics, were performed diagnostically at 30% and diagnostically-interventional at 70%. Balloon dilatation was performed in 81% of diagnostic interventional angiographies (30% crural) and in 19% was placed a stent. Postinterventionall, 95% of patients didn’t have any deterioration of the renal parameters. Conclusion - CO2-guided angiographies are technically safe; reduce the need of a iodinated contrast medium(ICM) application, prevent deterioration of renal function in patients with pre-existing renal insufficiency. This study shows diabetic patients with PAD as an increased risk patient for CNI. As shown, 95% of patients with diabetes who also had PAD, had CRI ≥stage.III at the same time. These patients require quickly and low-risk (kidney-safe) lower limb imaging to help preserve the leg. A ICM examination is contraindicated in these patients and CO2 angiography should be used as the standard, so that no comparison group could be produced to compare the results. Despite the CO2 angiography, 30% of the patients were able to undergo a crural balloon dilatation. The study shows the high rate of diabetic patients with PAD with a not necessarily known CRI, in which CO2 angiography should be used as a standard.

Infrapopliteal Carbon Dioxide (CO2) Angiography in Diabetic Patients with Critical Limb Ischemia. Limb Rescue and Prevent Kidney Failure

Introduction: The objective of this study is to evaluate the diagnostic and therapeutic carbon dioxide (CO2) angiography below the knee in patients with diabetes mellitus and peripheral arterial vascular disease (PAD). To determine efficacy and diagnostic accuracy of carbon dioxide angiography below the knee Methods: Lower limb angiography below the knee with CO2 (diagnostic and diagnostic-interventional) were collected from the database of our clinic of 129 consecutive patients between 2012 and 2018 and retrospectively reviewed. Of the 129 patients with PAD undergoing CO2 angiography 128 had a admitting diagnose of CRI≥ stage III(GFR< 45, moderate tosevere Kidney function loss) and PAD stage IV. Results: Of the 128 patients undergoing CO2 angiography and CLI, 122 (95%) had diabetes mellitus. Of the patients without known diabetes mellitus at the begin of medical hospitalization, 6 (5%) had a glycated haemoglobin levels above 6.4%. The admitting renal insufficiency was: stage III 62%, stage IV 29% and stage V 9%( with residual excretion). All of them had a necrosis or ulceration in the foot area. Lower limb angiographic procedures with CO2 in diabetics, were performed diagnostically at 9 patients(7%) and diagnostically-interventional at 119 (93%). From the 128 angiography in 36 patients(28%) we did under CO2 at least one crural artery revascularization. Balloon dilatation of 2 crural vessels in the same intervention was performed in 24%. The anterior tibial artery was dilated 63 times, posterior 33 and fibular 49. Postinterventionall, 95% of patients didn't have any deterioration of the renal Parameters. Conclusion: CO2-guided angiographies are technically safe; reduce the need of a iodinated contrast medium(ICM) application. Early and late limb salvage can be achieved based on CO2 endovascular revascularisation of infrapopliteal arteries. This method can be an important treatment option in diabetic patients to prevent deterioration of renal function in patients with pre-existing renal insufficiency. These patients require quickly and low-risk (kidney-safe) lower limb imaging to help preserve the leg Disclosure: No conflict interset

Multisystem vascular disease with successful multisystem percutaneous transcatheter revascularization: Total body stenting

Patients with diabetes mellitus along other risk factors are vulnerable to develop micro and macro vascular disease including coronary artery, carotid, upper and lower extremities peripheral vascular disease. Physicians dealing with patients with coronary artery disease should at least suspect a disease(s) within other vascular territory or system and vies a versa for this at risk patients. We report a case of 74 year old male patient with history of heavy smoking, chronic obstructive pulmonary disease (COPD), hypertension, diabetes, dyslipidemia, old stroke, chronic renal impairment and chronic anemia. He was referred from another hospital, with history of recurrent, transient ischemic attacks (TIAs), right upper limb and bilateral lower limb claudication, chest pain and three episodes of Non ST elevation Myocardial infarction within the last 2 months. Cardiac catheterization showed multivessel Coronary Artery Disease (CAD), severe occlusive peripheral arterial vascular disease (PAD), in addition to occluded right subclavian and critical bilateral internal carotid artery subtotal stenosis were found and managed successfully with multisystem Percutaneous Transcatheter intervention with near total body stenting.

Tobacco Education: Reduced Risk for Peripheral Artery Disease

Peripheral arterial (vascular) disease (PAD/PVD) in its association with significant mortality and morbidity rates has become a significant public health concern. One of the most influential risk factors for PAD is tobacco use, which carries a 3-4-fold increase d risk for PAD often presenting as severe disease. The diagnosis of PAD is usually made a decade earlier in smokers than nonsmokers. The amputation rates in patients with PAD who smoke is twice higher than those that have never smoked. Smoking elevates the risk for PAD several folds and approximately 90% of persons with PAD have a history of smoking. Although the precise mechanism by which chronic smoking induces vascular disease is not entirely understood, growing evidence shows that impairment of endothelial morphology and function plays a crucial role in the pathogenesis of vascular disease. Oxidants, delivered by cigarette and deposited in pulmonary vessels through the systemic vasculature, activate superoxide producing enzymes within the vascular wall via oxidative stress and might be the cause of endothelial dysfunction and dysregulation of endothelial barrier. The World Health Organization (WHO) estimates that there are currently 1.1 billion tobacco smokers’ worldwide ages 15 years and older. Recently, smoking-related death have been said to account for 4.9 million persons per year worldwide. Tobacco use is considered the most important preventable vascular risk factor for PAD in men and women. The association between smoking and PAD is even stronger than that between smoking and coronary disease. The connection between smoking and PAD was identified in 1911 when Erb reported that intermittent claudication was three times more common in smokers and six times more common in heavy smokers in comparison with nonsmokers.

Is It Better to Give or to Receive?

Is It Better to Give or to Receive?

The Diagnosis and Treatment of Peripheral Arterial Vascular Disease.

In peripheral arterial occlusive disease (PAOD), arterial stenosis or occlusion impairs perfusion in the territory of the distal portion of the aorta and the iliac and leg arteries. In Germany, the prevalence of PAOD rises with age, reaching 20% among persons over age 70. This guideline was prepared by a collaboration of 22 medical specialty societies and two patient self-help organizations on the basis of pertinent publications that were retrieved by a systematic search in PubMed for articles that appeared from 2008 to April 2014, with a subsequent update to May 2015. 294 articles were assessed, including 34 systematic reviews and 98 randomized controlled trials (RCTs). The diagnostic assessment of PAOD is based on physical examination, blood pressure at the ankles, and color-coded duplex ultrasonography (grade A recommendation). Other tomographic imaging methods can be used for suitable indications. The main elements of the treatment of PAOD are the control of cardiovascular risk factors and structured vascular exercise (grade A recommendation). Acetylsalicylic acid and statins are the main drugs for symptomatic PAOD (grade A recommendation). Patients with claudication and correlated structural findings can undergo an endo - vascular or open surgical procedure. Critical ischemia is an indication for arterial revascularization as soon as possible (grade A recommendation); this may be performed either by open surgery or by an endovascular procedure of one of the types that are now undergoing rapid development, or one of the crural treatment options. There is inadequate evidence concerning the optimal drug regimen after revascularization procedures. The diagnostic assessment of PAOD is based on physical examination, measurement of the ankle-brachial index (ABI), and duplex ultrasonography. Acetylsalicylic acid and statins are indicated for patients with symptomatic PAOD. Endovascular procedures should be used if indicated. Randomized studies are needed to provide better evidence on many open questions in the treatment of PAOD.

Prevention and treatment of atherosclerosis with flaxseed-derived compound secoisolariciresinol diglucoside.

Atherosclerosis is the primary cause of coronary artery disease, heart attack, strokes, and peripheral vascular disease. Alternative/complimentary medicines, although are unacceptable by medical community, may be of great help in suppression, slowing of progression and regression of atherosclerosis. Numerous natural products are in use for therapy in spite of lack of evidence. This paper discusses the basic mechanism of atherosclerosis, risk factors for atherosclerosis, and prevention, slowing of progression and regression of atherosclerosis with flaxseed-derived secoisolariciresinol diglucoside (SDG). SDG content of flaxseed varies from 6mg/g to 18 mg/g. Flaxseed is the richest source of SDG. SDG possesses antioxidant, antihypertensive, antidiabetic, hypolipidemic, anti-inflammatory and antiatherogenic activities. SDG content of some commonly used food has been described. SDG in very low dose (15 mg/ kg) suppressed the development of hypercholesterolemic atherosclerosis by 73 % and this effect was associated with reduction in serum total cholesterol, LDL-C, and oxidative stress, and an increase in the levels HDL-C. A summary of the effects of flaxseed and its components on hypercholesterolemic atherosclerosis has been provided. Reduction in hypercholesterolemic atherosclerosis by flaxseed, CDC-flaxseed, flaxseed oil, flax lignan complex and SDG are 46 %, 69 %, 0 %, 34 % and 73 % respectively in dietary cholesterol -induced rabbit model of atherosclerosis. SDG slows the progression of atherosclerosis in animal model. Long-term use of SDG regresses hypercholesterolemic atherosclerosis. It is interesting that regular diet following high cholesterol diet accelerates in this animal model of atherosclerosis. In conclusion SDG suppresses, slow the progression and regresses the atherosclerosis. It could serve as an alternative medicine for the prevention, slowing of progression and regression of atherosclerosis and hence for the treatment of coronary artery disease, stroke and peripheral arterial vascular diseases.

Chapter 15 - Pseudoxanthoma elasticum

Pseudoxanthoma elasticum (PXE) is characterized by elastic tissue fragmentation and calcification. The deterioration of elastic fibers leads to characteristic yellowish papules and plaques (pseudoxanthomas) and retinal angioid streaks. Although these findings may begin in childhood, the diagnosis is typically not made until the second or third decade after the skin and retinal findings become more prominent. Cerebrovascular complications include brain infarction due to narrowing and occlusion of cerebral arteries and aneurysm formation. Intracranial hemorrhage can occur in the absence of aneurysm, and gastrointestinal hemorrhage is common. Peripheral arterial vascular disease can lead to intermittent leg claudication. A skin biopsy often demonstrates calcified elastic fibers, even in a mildly affected area of skin. The inheritance is autosomal recessive, although heterozygotes may exhibit some features of the disease. PXE is due to mutation of the ABCC6 gene on chromosome 16. There is no treatment, but certain lifestyle modifications may limit the complications. The potential for retinal hemorrhage has led to recommendations for limitations of contact sports or other activities that might facilitate eye trauma. Other recommendations include maintaining a normal lipid profile, avoidance of aspirin and nonsteroidal anti-inflammatory agents, and limiting dietary calcium intake.

Full steam ahead with remote ischemic conditioning for stroke.

Full steam ahead with remote ischemic conditioning for stroke.

Effect of gender differences on 1-year mortality after transcatheter aortic valve implantation for severe aortic stenosis: results from a multicenter real-world registry

The aim of this analysis is to examine the influence of gender differences on the outcome after transcatheter aortic valve implantation (TAVI) from a multicenter real-world registry in Germany (TAVI registry). The impact of gender differences on the clinical outcome after TAVI was examined in small studies with conflicting results. Consecutive patients (n = 1,432) undergoing TAVI in the period between January 2009 and June 2010 in Germany were evaluated. Differences in all-cause mortality were examined with Kaplan-Meier estimates and proportional hazards models. Women comprised 57.8 % of the cohort. The Edwards Sapien valve (18.5 %) and CoreValve (81.5 %) were used through the transfemoral (87.7 %), subclavian (3.0 %), transapical (8.6 %), or transaortic approach (0.7 %). At baseline, women had higher aortic gradients and were older. Men had more comorbidities: prior myocardial infarction, prior revascularization, prior coronary artery bypass surgery, peripheral arterial vascular disease and chronic obstructive pulmonary disease. Women had more periprocedural vascular complications in comparison to men (25.2 vs. 17.2 %, p < 0.001). There was no significant difference in mortality at 30-day follow-up (7.6 % for women vs. 8.6 % for men, p = 0.55). The adjusted HR for 1-year all-cause mortality favored women, HR 0.75 (95 % CI 0.57-0.98, p = 0.0346) with a mortality rate of 17.3 vs. 23.6 % for men. Female gender is associated with better 1-year survival after TAVI. These results suggest that TAVI could be the best treatment modality for elderly women with symptomatic severe aortic stenosis.

Peripheral vascular disease as remote ischemic preconditioning, for acute stroke

ObjectivesRemote ischemic preconditioning (RIPC) is a powerful endogenous mechanism whereby a brief period of ischemia is capable of protecting remote tissues from subsequent ischemic insult. While this phenomenon has been extensively studied in the heart and brain in animal models, little work has been done to explore the effects of RIPC in human patients with acute cerebral ischemia. This study investigates whether chronic peripheral hypoperfusion, in the form of pre-existing arterial peripheral vascular disease (PVD) that has not been surgically treated, is capable of inducing neuroprotective effects for acute ischemic stroke. MethodsIndividuals with PVD who had not undergone prior surgical treatment were identified from a registry of stroke patients. A control group within the same database was identified by matching patient's demographics and risk factors. The two groups were compared in terms of outcome by NIH Stroke Scale (NIHSS), modified Rankin scale (mRS), mortality, and volume of infarcted tissue at presentation and at discharge. ResultsThe matching algorithm identified 26 pairs of PVD-control patients (9 pairs were female and 17 pairs were male). Age range was 20–93 years (mean 73). The PVD group was found to have significantly lower NIHSS scores at admission (NIHSS≤4: PVD 47.1%, control 4.35%, p<0.003), significantly more favorable outcomes at discharge (mRS≤2: PVD 30.8%, control 3.84%, p<0.012), and a significantly lower mortality rate (PVD 26.9%, control 57.7%, p=0.024). Mean acute stroke volume at admission and at discharge were significantly lower for the PVD group (admission: PVD 39.6mL, control 148.3mL, p<0.005 and discharge: PVD 111.7mL, control 275mL, p<0.001). ConclusionChronic limb hypoperfusion induced by PVD can potentially produce a neuroprotective effect in acute ischemic stroke. This effect resembles the neuroprotection induced by RIPC in preclinical models.

Venn diagrams in cardiovascular disease: the Heart Team concept

Venn diagrams are illustrations composed of overlapping circles that demonstrate the relations between finite collections of things1 and are most useful in defining areas of commonality among different aggregations. Originally described by John Venn in the 1880s to teach elementary set theory, these diagrams are most often used to illustrate set relationships in such fields as probability, statistics and computer science. Venn diagrams can also be useful for understanding the roles of various stakeholders in the management of cardiovascular disease from its diagnosis through its treatment. As the field progresses, the area of overlap of the cardiovascular disease Venn diagram continues to expand. This is evident in many aspects of cardiovascular disease management, including individual diagnosticians and treatment specialists, diseases, technologies, institutions, payers and regulators. Despite a movement towards convergence in areas of disease management, however, professional societies remain in their individual silos. This article explores whether Venn diagrams of professional societies, which traditionally had little overlap or mutual engagement, should continue to converge until they merge into one. The well-recognized concept of atherosclerosis as a disease that affects all vascular beds has focused therapeutic strategies on the coexistence, for example, of coronary artery disease and peripheral arterial disease in the same patient. Whereas in the past there was a tendency to treat an acute coronary syndrome as an isolated event in a patient, attention now focuses on the fact that other manifestations of the disease, such as peripheral arterial disease and cerebral vascular disease, are likely to be present in this patient as well, and the involvement of these other vascular beds may affect treatment strategies. Thus, the evolution of the understanding about atherosclerosis has stimulated physicians and surgeons who focus on these different vascular beds to strategize together about the treatment of this patient. Another example of …