Peripheral Vascular Complications Research Articles

Peripheral vascular complications after conventional and complex percutaneous coronary interventional procedures

To determine whether complex cardiovascular interventional procedures (including coronary stent implantation, directional atherectomy, aortic valvuloplasty, and the use of an intraaortic balloon pump or cardiopulmonary bypass support) are associated with an increased likelihood of vascular access site complications, 2,400 consecutive cardiac catheterization procedures were prospectively screened over a 12-month study period. Complications occurred in 35 patients after 39 procedures (1.6%) and included the need for vascular surgical repair (17 patients), blood transfusion (28 patients) and systemic antibiotic therapy (7 patients). The incidence of complications after 1,519 diagnostic studies was 0.6%, after 698 conventional coronary balloon angioplasties 2.6%, and after 183 complex interventions 6.0% (p < 0.0001); 43% of the complications occurred after procedures of >2 hours' duration and 14% occurred in patients in whom arterial sheaths remained in situ for >24 hours. Detailed demographic and procedural characteristics were compared between the 35 patients with vascular complications and 150 patients randomly drawn from a computerized database of the uncomplicated procedures performed during the screening period. By univariate analysis with correction for multiple comparisons, variables predicting the likelihood of vascular complications included: periprocedural use of heparin (p < 0.001) or fibrinolytic therapy (p < 0.001), arterial sheath size ≥8Fr (p < 0.001), patient age ≥65 years (p = 0.01), and the presence of peripheral vascular disease (p = 0.03). The results of this study suggest that the overall incidence of access site complications is low but increases with the use of complex cardiovascular interventional procedures. Further refinements in the caliber of the new devices, vigilant monitoring of adjunctive anticoagulant therapy, and careful patient selection may reduce the morbidity and increase the safety of these procedures.

急性大動脈解離時の血清ｃｒｅａｔｉｎｅ ｋｉｎａｓｅ値変動よりみた臓器阻血とその手術的対策

急性大動脈解離時の血清ｃｒｅａｔｉｎｅ ｋｉｎａｓｅ値変動よりみた臓器阻血とその手術的対策

臓器虚血を伴う解離性大動脈りゅうの臨床像と治療成績

臓器虚血を伴う解離性大動脈りゅうの臨床像と治療成績

Treatment of Patients with Aortic Dissection Presenting with Peripheral Vascular Complications

The incidence of peripheral vascular complications in 272 patients with aortic dissection during a 25-year span was determined, as was outcome after a uniform, aggressive surgical approach directed at repair of the thoracic aorta. One hundred twenty-eight patients (47%) presented with acute type A dissection, 70 (26%) with chronic type A, 40 (15%) with acute type B, and 34 (12%) with chronic type B dissections. Eighty-five patients (31%) sustained one or more peripheral vascular complications: Seven (3%) had a stroke, nine (3%) had paraplegia, 66 (24%) sustained loss of a peripheral pulse, 22 (8%) had impaired renal perfusion, and 14 patients (5%) had compromised visceral perfusion. Following repair of the thoracic aorta, local peripheral vascular procedures were unnecessary in 92% of patients who presented with absence of a peripheral pulse. The operative mortality rate for all patients was 25% +/- 3% (68 of 272 patients). For the subsets of individuals with paraplegia, loss of renal perfusion, and compromised visceral perfusion, the operative mortality rates (+/- 70% confidence limits) were high: 44% +/- 17% (4 of 9 patients), 50% +/- 11% (11 of 22 patients), and 43% +/- 14% (6 of 14 patients), respectively. The mortality rates were lower for patients presenting with stroke (14% +/- 14% [1 of 7 patients]) or loss of peripheral pulse (27% +/- 6% [18 of 66 patients]). Multivariate analysis revealed that impaired renal perfusion was the only peripheral vascular complication that was a significant independent predictor of increased operative mortality risk (p = 0.024); earlier surgical referral (replacement of the appropriate section of the thoracic aorta) or more expeditious diagnosis followed by surgical renal artery revascularization after a thoracic procedure may represent the only way to improve outcome in this high-risk patient subset. Early, aggressive thoracic aortic repair (followed by aortic fenestration and/or abdominal exploration with or without direct visceral or renal vascular reconstruction when necessary) can save some patients with compromised visceral perfusion; however, once visceral infarction develops the prognosis is also poor. Increased awareness of these devastating complications of aortic dissection and the availability of better diagnostic tools today may improve the survival rate for these patients in the future. The initial surgical procedure should include repair of the thoracic aorta in most patients.

Vascular Complications of the Patient Undergoing Sntra-aortic Balloon Pumping

Despite advances in intra-aortic balloon catheters and consoles, the vascular complication rate of IABP has not decreased. Predisposing complication factors identified through research include gender, diabetes, peripheral vascular disease, catheter size, prolonged pumping, ankle-arm index less than 1.0, and insertion method. Signs and symptoms of leg ischemia due to thromboembolus or compartment syndrome may occur in as high as 40 per cent of patients. Assessment, documentation, and teaching remain important aspects of the nurse's role in the prevention and detection of vascular complications.

Peripheral Vascular Complications from Percutaneous Transluminal Coronary Angioplasty: A Comparison with Transfemoral Cardiac Catheterization

The peripheral vascular complications associated with percutaneous transfemoral coronary angioplasty were compared with those that occurred during conventional transfemoral cardiac catheterization. Among 644 patients undergoing percutaneous transluminal coronary angioplasty (PTCA), 6 patients (0.9%) suffered peripheral vascular complications, whereas 35 of 2904 patients having cardiac catheterizations (1.2%) had a peripheral vascular complication. The types of complications associated with both procedures were similar and included groin hematomas, false aneurysms, arterial dissection, arterial perforation, and neurological deficits. The frequency of surgical repair of these complications also was similar in the two groups (50% required repair for a PTCA complication, 34% were repaired after a catheterization complication). The PTCA-associated complications included one myocardial infarction and one death, whereas neither of these occurred in association with a catheterization-induced vascular complication. The surgical management of five of the six PTCA complications was difficult, largely because of the size of the sheath-related puncture site and the presence of active bleeding from the associated systemic anticoagulation. PTCA carries the same risk of development of a peripheral vascular complication as found in transfemoral cardiac catheterization. Care must be taken to prevent sheath-related injury to the aorta-iliac-femoral system and hemorrhagic complications at the puncture site are of particular concern and require urgent surgical attention.

Cessation of smoking in patients with intermittent claudication. Effects on the risk of peripheral vascular complications, myocardial infarction and mortality: Jonason T, Bergstrom R. Acta Med Scand 1987;221:253–260

The effects of smoking cessation were studied in 343 patients who were initially evaluated because of intermittent claudication between 1974 and 1982. Two hundred sixty-six men and 77 women with a mean age of 62 years were included. Specific exclusion criteria included abstinence from smoking, diabetes mellitus, rest pain or gangrene, previous lower extremity vascular surgery, and requirement of vascular surgery or primary amputation within 1 month of the initial evaluation. After the first examination, half of the patients participated in a supervised educational and physical training program for a period lasting up to 10 months. Follow-up assessment was performed in 1985. Within one year of the initial evaluation, 11% of patients had discontinued the use of cigarettes and were classified as nonsmokers for the purposes of the study; the others were defined as smokers. Clinical outcome in these two groups was compared. Baseline characteristics of the two groups were statistically similar. Rest pain did not develop in any nonsmoker. In smokers, the cumulative proportion with rest pain was 16% at 7 years (p < 0.05). The cumulative proportion of smokers and nonsmokers having peripheral arterial reconstruction was 31% and 8%, respectively. There was no difference in the proportion of the two groups having arterial reconstruction because of disabling claudication. The duration of claudication before initial evaluation did not affect the risk of rest pain or the need for reconstructive surgery. Participation in the short-term training program had no impact on the risk of development of rest pain or need for surgical intervention. The cumulative proportions with myocardial infarctions after 10 years were 11% and 53% for nonsmokers and smokers, respectively; the cumulative rates of cardiac-related deaths were 6% and 43%, respectively; and the 10-year survival rate was 82% and 46%, respectively. Continued smoking was significantly associated with myocardial infarction (p <0.05), cardiac-related death (p <0.05), and overall mortality (p <0.05) when subjected to multivariate analysis. The findings of this study emphasize the importance of discontinuation of smoking in patients with intermittent claudication. Benefits in both the peripheral arterial system and the coronary circulation were noted in those who stopped smoking.

Characterization of the receptors for insulin and the insulin-like growth factors on micro- and macrovascular tissues.

Insulin and insulin-like growth factors (IGFs) have been implicated in the pathogenesis of diabetic retinopathy and peripheral vascular complications. Previously, we have shown that retinal capillary endothelial cells responded to insulin and IGFs for metabolic and growth effects, whereas aortic endothelial cells were not responsive. In contrast, vascular supporting cells from both retinal capillaries (i.e. pericytes) and aorta (i.e. smooth muscle cells) responded equally to insulin, IGF-I, and IGF-II. The structure and ligand specificities of the receptor for these peptides were studied by covalently cross-linking 125I-labeled peptide hormones to their respective receptors using disuccinimidyl suberate, followed by polyacrylamide gel electrophoresis and autoradiography. The binding subunit of the insulin receptor, alpha-subunit, for all cell types was found to have a mol wt 145,000 under reduced conditions. Labeling of this band was inhibited by 10(-9) M insulin, antiinsulin receptor antibodies, and 10(-8) M IGF-I, but not by multiplication-stimulating activity (IGF-II). The beta-subunit of the insulin receptor in endothelial cells was identified by its ability to be autophosphorylated when stimulated by insulin and was found to have a mol wt of 99,000. Covalent cross-linking of IGF-I to its receptor revealed a mol wt of 145,000, similar to that of insulin receptor, except that IGF-I was 100-fold more potent than insulin in competing with [125I]IGF-I for binding. [125I]IGF-II in all cells was cross-linked to receptor with mol wt of 260,000 and 230,000 under reduced and nonreduced conditions, respectively. IGF-I competed weakly with [125I]IGF-II, whereas insulin was ineffective. [125I]IGF-II also bound to the band with alpha mol wt of 135,000, which was inhibited by insulin, IGF-I, and IGF-II. In summary, receptors for insulin, IGF-I, and IGF-II on cells from micro- and macrovessels are biochemically similar to those in other cells. Interestingly, the finding of large numbers of IGF-I and IGF-II receptors on endothelial cells suggests that these growth factors play a physiological role and are involved in vascular complications associated with diabetes.

Diabetes mellitus and intermittent claudication. Relation between peripheral vascular complications and location of the occlusive atherosclerosis in the legs.

Forty-seven diabetic patients with intermittent claudication without rest pain or gangrene at the initial examination were followed up over a six-year period. They were compared with 224 non-diabetic patients with intermittent claudication. The cumulative proportions of patients with gangrene were 31% in the diabetic group and 5% in the control group (p less than 0.001). The corresponding figures for rest pain and/or gangrene were 40 and 18%, respectively (p less than 0.001). The frequency of aorto-iliac and multiple stenoses was higher among diabetic patients who developed peripheral vascular complications (rest pain, gangrene) than in the control group. The frequency of multiple stenoses was also higher in the former subgroup than in diabetics without such complications. In conclusion, the degree of involvement of the large vessels in occlusive arterial disease influences the risk of development of peripheral vascular complications in diabetic patients with intermittent claudication.

The new beta-adrenergic antagonists.

In therapeutics, new drugs do not necessarily have advantages over the parent compounds. This is not true with the new beta-adrenergic antagonists -cardio-selective agents are less likely to cause bronchospasm in patients suffering from asthma or chronic obstructive pulmonary disease; agents with partial agonist activities are safer in patients who have ventricular dysfunction, atrioventricular conduction delay, bronchial asthma, and peripheral vascular complications; and poor lipid-solubility together with elimination via the renal route have improved the duration of action. However, protection against these complications is not complete; dependence on renal excretion has made adjustment of the dose in patients with renal dysfunction mandatory; and propranolol is still the only agent available for intravenous administration. These agents are not entirely free of the side-effects attributed to propranolol. Surgical patients treated with the newly introduced beta-adrenergic antagonists deserve the same anaesthetic care as that delineated for patients treated with propranolol.

Percutaneous transluminal coronary angioplasty in patients with prior coronary bypass surgery

To improve symptomatic status and avoid reoperation, 122 initial and 7 repeat percutaneous transluminal coronary angioplasty procedures were performed in 116 patients with disabling angina pectoris at a mean of 26.8 months (range 2 to 132) after coronary bypass surgery. Marked angiographic improvement (greater than 30% reduction in diameter stenosis) was obtained in 107 (88%) of the 122 initial procedures and in all 7 repetitions. Mean stenosis was reduced from 78 +/- 13% (mean +/- standard deviation) to 25 +/- 13% (p less than 0.0001) and mean pressure gradient from 49 +/- 15 to 11 +/- 8 mm Hg (p less than 0.0001). Complications were: emergency surgery (three patients), Q wave infarction (one patient), myocardial infarction by enzyme criteria only (four patients) and non-occluding coronary dissection (one patient). There were no neurologic or peripheral vascular complications and no early deaths. One late death occurred 14 months after an unsuccessful but uncomplicated angioplasty procedure. At a mean follow-up of 8.3 months, 88 patients (76%) were free of angina or in improved condition. In patients followed up for at least 6 months, evidence of restenosis occurred in 9 (53%) of 17 saphenous veins, 1 (50%) of 2 proximal graft anastomoses, 4 (18%) of 22 distal graft anastomoses and 5 (14%) of 37 native coronary arteries. When coronary anatomy is suitable, percutaneous transluminal angioplasty is an attractive alternative to reoperation in symptomatic patients with prior coronary bypass surgery.

Infectivity of tuberculosis.

<b>Objective:</b> To assess the determinants of poor mid-term health related quality of life (HRQoL) at one year after primary isolated coronary artery bypass grafting (CABG). <b>Methods:</b> 463 patients who underwent primary isolated CABG for multivessel disease and came for their annual follow up at the outpatient clinic during one year at Harefield Hospital, Middlesex, were approached to participate in the present study. Prospective clinical data were collected as part of the clinical care of the patients and were retrospectively analysed when the patients consented to participate in the study at their outpatient visit. After their consent they were given three HRQoL assessment questionnaires. Scores, together with clinical data, were analysed by both univariate and multivariate analyses with regard to poor HRQoL outcome. <b>Results:</b> 437 (94.4%) patients consented to participate in the study and filled in the HRQoL questionnaires. Ten variables were identified in the univariate analysis as potential predictors of poor scores of the physical element of HRQoL; however, only three variables—gastrointestinal problems, congestive heart failure, and type D personality trait—predicted poor physical scores independently. Eleven variables were identified in the univariate analysis as potential predictors of poor scores of the mental element of HRQoL; however, only three variables—peripheral vascular disease, infective complications, and type D personality trait—predicted poor physical scores independently. <b>Conclusion:</b> Preoperative gastrointestinal problems, preoperative congestive heart failure, and type D personality trait were independent predictors of the poor physical component of HRQoL. Peripheral vascular disease, infective complications, and type D personality trait were independent predictors of the poor mental component of HRQoL. Interestingly, patients with type D personality were more than twice as likely to have poor physical HRQoL and more than five times as likely to have poor mental HRQoL.

Prophylactic Use of Intra-aortic Balloon Pump in Aortocoronary Bypass for Patients with Left Main Coronary Artery Disease

Aortocoronary bypass surgery in patients with left main coronary artery disease is reported to have an operative mortality of between 1.4 and 39%. It is generally accepted that the operative mortality in this group of patients is considerably greater than in routine bypass candidates, presumably due to the large amount of myocardium threatened by a single lesion. In an effort to preserve threatened left ventricular myocardium, intra-aortic balloon pumping was instituted prophylactically prior to sternotomy in 20 consecutive patients with left main coronary artery disease (luminal narrowing greater than 50%). Sixty per cent of these patients had New York Heart Association Class IV angina, 25% had Class III, and 15% Class II. Fifty per cent of the patients in this group presented with unstable angina. Operative patients requiring left ventricular aneurysmectomy and/or valve replacement, were excluded. No operative deaths have been encountered in 20 consecutive patients managed in this manner. One patient displayed signs of myocardial infarction in the postoperative period. Correctable peripheral vascular ischemic complications of pump insertion were encountered in three patients. Preliminary results from this ongoing study support the hypothesis that prophylactic intra-aortic balloon pumping is a low risk procedure that should be utilized routinely in aortocoronary bypass surgery for left main coronary artery disease.

Assessment of Peripheral Vascular Disease in Patients With Diabetes: Two Case Studies

This report proposes that perfusion scanning in combination with arteriography be included in the diagnostic work-up of the diabetic patient who, because of peripheral vascular complications, is a candidate for surgery. Two cases are reported which illustrate the extremes of the findings: abnormal arteriogram-normal scan indicating large-vessel disease without significant small-vessel involvement. It is suggested that these patients are candidates for vascular reconstruction. The other extreme is the normal arteriogram-abnormal scan indicating small-vessels disease without significant large-vessel involvement. It is apparent that these patients are not candidates for vascular reconstruction.

Complications of selective coronary arteriography by the Judkins technique and their prevention

Complications encountered during 351 selective coronary artery and coronary artery bypass examinations performed by the Judkins technique are reviewed. The over-all incidence of cardiac and peripheral vascular complications was 3.13 per cent. The cardiac complications included four ventricular fibrillations and one acute myocardial infarction. Peripheral vascular complications included three femoral artery thromboses, two peripheral emboli, and one probable cerebral embolus. There was one death. The incidence of cardiac complications was not significantly different from that reported in the literature with the Sones technique and local arterial complications were significantly lower than those reported with the Sones technique. The causes of individual complications are analyzed and measures to minimize these complications are described. The Judkins technique is a simple, reliable, qyick, and safe method of selective coronary arteriography. The incidence of complications can be kept at an acceptably low level by stringent observation of every minor detail of the technique.

Red cell 2, 3-diphosphoglycerate levels among diabetic patents with and without vascular complications.

There have been differences of opinion among authors concening in the levels of red cell 2,3-diphosphoglycerate (2,3-DPG) and nucleotides in nonacidotic diabetic patients. Our data suggest that abnormal levels of 2, 3-DPG in diabetic patients are related to the presence of vascular complications and not to the duration of the disease per sec. 2,3-DPG levels are normal in diabetic patients with no evidence of vascular complications (group A). In ambulatory patients with vascular complications (group B), significantly higher levels of 2,3-DPG are found than in normal subjects and patients in group A. In hospitalized diabetic patients with active peripheral vascular complications (group C), levels of 2,3-DPG are likewise significantly increased over those of normal subjects and patients of group A. 2,3-DPG was found to be significantly elevated in patients of group C as compared with group B. 2,3-DPG levels in venous blood from infected legs as compared with those of the peripheral venous blood were not significantly different, thereby ruling out local factors. There were no differences in the blood lactate levels in any of the group studied. The elevation of the 2,3-DPG levels may be a reflection of attempted red blood cell compensation for tissue hypoxia in the diabetic with vascular disease.

Selective Intraarterial Vasopressin in the Treatment of Upper Gastrointestinal Hemorrhage

Recent reports of selective intraarterial vasopressin or epinephrine therapy in upper gastrointestinal hemorrhage, primarily variceal, have suggested that this technique is extremely effective and free of hazard. During the past 2 years we have used intraarterial vasopressin in 35 patients, one-third of whom were bleeding from esophageal varices and two-thirds from a variety of upper gastrointestinal sites. Hemorrhage from esophageal varices was controlled in 79% by the administration of vasopressin into the superior mesenteric artery. Vasopressin infusion into the celiac axis or superselectively into its branches was effective in 82% of the episodes of nonvariceal bleeding. Simultaneous celiac and superior mesenteric arterial infusions were sometimes required to control bleeding. Infectious, cardiorespiratory, or vascular complications were observed in more than one-third of the patients. Spontaneous peritonitis and catheter-associated bacteremia were infectious complications which can probably be prevented by vasopressin infusions of shorter duration. Cardiac arrest, arrythmias, and other signs of systemic vasopressin effect are presumably preventable by slower rates of infusion. Extensive small bowel necrosis was encountered in 1 patient. Minor peripheral vascular complications were occasionally observed. Although these studies suggest that vasopressin is effective therapy, prospective controlled clinical trials are needed to establish the efficacy and safety of this new therapeutic tool in stopping hemorrhage and in improving survival.

TREATMENT OF DIABETIC NEUROPATHY WITH CLOFIBRATE

AbstractSince angiopathy is an important factor in the pathogenesis of diabetic peripheral neuropathy, any drug which modifies lipid deposition in the peripheral vessels is of value in therapy. Therefore a double‐blind study was made of the lipid‐lowering agent, clofibrate (ethyl chlorophenoxyisobutyrate). Clofibrate (2 gm daily) was given to 9 patients with diabetie neuropathy, and a placebo to 6 such patients, during a 12‐month period. The diagnosis of neuropathy was confirmed by electromyography.Seven of the 9 clofibrate patients improved clinically during the medication period, as judged by the disappearance of pain, paresthesia and numbness, by an increase in muscle strength, and by a return of deep tendon reflexes. Only 1 of the 6 placebo patients showed clinical improvement. Moreover, in 3 of the placebo group, peripheral vascular complications developed which resulted in gangrene and leg amputation. In none of the clofibrate patients did vascular complications develop during the same period. No untoward side effects were noted.The concentration of serum lipids (cholesterol, total lipids, phospholipids and triglycerides) did not change significantly in either group. Changes of conduction velocity in the motor and sensory nerves were not significant in the clofibrate group, whereas there was a tendency toward deterioration in the placebo group.The clinical improvement observed and the lack of major side effects with the dosage used warrant further study of clofibrate in the management of diabetic neuropathy.

Chronic ulcers of the leg associated with blood dyscrasias.

BLOOD dyscrasias, particularly the congenital hemolytic anemias, 1 are of primary importance in a consideration of the possible causes of chronic recurrent ulcers of the leg. An association of leg ulcers with sickle cell anemia is generally better appreciated than the relationship of this symptom to other forms of congenital hemolytic anemia, e. g., congenital hemolytic icterus (familial acholuric jaundice, spherocytic anemia) and Mediterranean disease (Cooley's anemia, thalassemia). In a review of the subject of indolent ulcers of the leg in diseases of the blood, in addition to the conditions already mentioned, Gendel 2 lists the following: Banti's syndrome, thrombocytopenic purpura, Gaucher's disease, pernicious anemia, and chronic hemolytic polycythemia. The latter was presented before the Royal Society of Medicine by Rau, Pulvertaft and Humble. 3 Gendel 2 did not include polycythemia vera (erythremia, Osler-Vaquez disease). However, ulcerations of the lower extremities 4 and peripheral vascular complications have

Peripheral vascular complications in prostatic surgery: Strasberg, Alex: Canad. M. A. J. 41: 377, 1939

Peripheral vascular complications in prostatic surgery: Strasberg, Alex: Canad. M. A. J. 41: 377, 1939