Peripheral Vascular Conditions Research Articles

SEX DIFFERENCES IN THE CORONARY SYSTEM OF THE HUMAN HEART

The aim of this study is to investigate sex differences in the coronary system of the heart, considering all relevant consequence, and to compile and analyze the gathered data. Materials and Methods. The authors independently conducted a literature search and selection process using the PubMed database for the review, followed by the generalization of the obtained data. Results. Women exhibit a higher propensity than men for certain cardiovascular diseases, including persistent angina, non-obstructive coronary heart disease, coronary microvascular dysfunction, spontaneous coronary artery dissection, stress cardiomyopathy, and heart failure with preserved ejection fraction (HFpEF). In comparison to men, women typically present with elevated rates of underlying comorbidities, encompassing not only advanced age but also hypertension, diabetes mellitus, obesity, chronic renal failure, peripheral vascular disease, HFpEF, and inflammatory conditions like rheumatoid arthritis. Many of these conditions are linked to diffuse atherosclerosis and microvascular ischemia, with notable parallels between non-obstructive coronary heart disease and coronary microvascular dysfunction. Special attention is paid to patients sharing an increased risk of coronary heart disease events, which is consistent between women and men, except for those with severe coronary flow reserve (CFR) impairment, where women demonstrate an even higher risk. In particular, in cases where CFR impairment is not attributable to obstructive coronary heart disease (precluding revascularization to mitigate cardiovascular risk), there may be justification for a novel therapeutic approach for systemic coronary heart disease management. Cases of severe coronary microvascular dysfunction, often concurrent with non-obstructive coronary heart disease, may indicate a shared mechanism influencing coronary heart disease risk in both genders. This mechanism might involve inflammation, endothelial dysfunction, and heightened cardiomyocyte oxygen demand, culminating in microvascular ischemia, myocardial injury, and compromised cardiac function. Conclusions. Enhanced comprehension of the interplay between coronary vasomotor dysfunction and the concomitance of coronary heart disease with other conditions, such as insulin resistance and heart failure, could foster the advancement of novel systemic treatments aimed at leveraging “complete revascularization” more effectively.

Inhibiting Intracellular α2C-Adrenoceptor Surface Translocation Using Decoy Peptides: Identification of an Essential Role of the C-Terminus in Receptor Trafficking.

The G protein-coupled α2-adrenoceptor subtype C (abbreviated α2C-AR) has been implicated in peripheral vascular conditions and diseases such as cold feet-hands, Raynaud's phenomenon, and scleroderma, contributing to morbidity and mortality. Microvascular α2C-adrenoceptors are expressed in specialized smooth muscle cells and mediate constriction under physiological conditions and the occlusion of blood supply involving vasospastic episodes and tissue damage under pathological conditions. A crucial step for receptor biological activity is the cell surface trafficking of intracellular receptors, triggered by cAMP-Epac-Rap1A GTPase signaling, which involves protein-protein association with the actin-binding protein filamin-2, mediated by critical amino acid residues in the last 14 amino acids of the receptor carboxyl (C)-terminus. This study assessed the role of the C-terminus in Rap1A GTPase coupled receptor trafficking by domain-swapping studies using recombinant tagged receptors in transient co-transfections and compared with wild-type receptors using immunofluorescence microscopy. We further tested the biological relevance of the α2C-AR C-terminus, when introduced as competitor peptides, to selectively inhibit intracellular α2C-AR surface translocation in transfected as well as in microvascular smooth muscle cells expressing endogenous receptors. These studies contribute to establishing proof of principle to target intracellular α2C-adrenoceptors to reduce biological activity, which in clinical conditions can be a target for therapy.

Electronic health record-wide association study for atrial fibrillation in a British cohort.

Atrial fibrillation (AF) confers a major healthcare burden from hospitalisations and AF-related complications, such as stroke and heart failure. We performed an electronic health records-wide association study to identify the most frequent reasons for healthcare utilization, pre and post new-onset AF. Prospective cohort study with the linked electronic health records of 5.6 million patients in the United Kingdom Clinical Practice Research Datalink (1998-2016). A cohort study with AF patients and their age-and sex matched controls was implemented to compare the top 100 reasons of frequent hospitalisation and primary consultation. Of the 199,433 patients who developed AF, we found the most frequent healthcare interactions to be cardiac, cerebrovascular and peripheral-vascular conditions, both prior to AF diagnosis (41/100 conditions in secondary care, such as cerebral infarction and valve diseases; and 33/100 conditions in primary care), and subsequently (47/100 conditions hospital care and 48 conditions in primary care). There was a high representation of repeated visits for cancer and infection affecting multiple organ systems. We identified 10 novel conditions which have not yet been associated with AF: folic acid deficiency, pancytopenia, idiopathic thrombocytopenic purpura, seborrheic dermatitis, lymphoedema, angioedema, laryngopharyngeal reflux, rib fracture, haemorrhagic gastritis, inflammatory polyneuropathies. Our nationwide data provide knowledge and better understanding of the clinical needs of AF patients suggesting: (i) groups at higher risk of AF, where screening may be more cost-effective, and (ii) potential complications developing following new-onset AF that can be prevented through implementation of comprehensive integrated care management and more personalised, tailored treatment. NCT04786366.

Muscleblind-like (MBNL) protein family overexpression lead to pro-synthetic phenotype modulation of arterial human vascular smooth muscle cells in diabetes mellitus

Background and Aims : Diabetes Mellitus (DM) is a metabolic disorder affecting ten percent of the worldwide population. The morbidity of DM patients is strongly correlated to cardiovascular diseases (CVD), including cerebrovascular disease, peripheral vascular conditions, and ischemic heart disease. Previous studies have shown that vascular smooth muscle cells (VSMC) from DM patients are often functionally impaired with increased expressions of inflammatory and pro-fibrotic genes. Given its importance in arteriopathy, we aim to understand better the molecular pathway leading to VSMC phenotype modulation in DM.

Single institutional experience of peripheral applications of a liquid embolic agent: Ethylene Vinyl Alcohol Copolymer

ObjectiveTo evaluate the safety and efficacy of ethylene vinyl alcohol (EVOH) copolymer for the treatment of a variety of peripheral vascular pathologies.ResultsBetween October 2010 and October 2017, 43 patients who underwent total 54 EVOH embolization procedures for the treatment of peripheral vascular pathologies were included. The cases which involved the use of EVOH for the treatment of nonvascular, neurologic, ophthalmologic, otolaryngologic or head-neck pathologies were excluded. The demographic data, technical and clinical success rates, and procedure-related details and complications were obtained. The most common indications for EVOH embolization were type II endoleaks (n = 18) and peripheral arteriovenous malformations (n = 14). The majority of cases (62.5%) used EVOH without any adjunct embolic material. The results of this study showed 100% technical success rates and 89% clinical success rates. No events of nontarget embolization or other procedure-related complications were noted. The mortality & morbidity rates were 0%. The loss to follow up rate was 16% (9 /54). The mean follow-up period was 134 days (range, 30 to 522 days).ConclusionThe single institutional experience supports the safety and efficacy of EVOH embolization in the treatment of various peripheral vascular conditions.

P1334PREOPERATIVE VOLUME STATUS IN VASCULAR ACCESS CREATION, A DESPISED INFLUENCE?

Abstract Background and Aims The most common causes of early primary failures of a vascular access (VA) is related to small caliber vessels. Weight gain between dialyses expands both extracellular and blood volume, which may lead to rises in intravascular filling and vessels caliber. If patients presented after weekend, their weight and probably volemia would be higher. Dry weight concept has evolved over time and nowadays incorporates objective measures of volume status like body bioimpedance spectroscopy (BIA) and lung ultrasound. We hypothesized that preoperative volume status may influence vascular filling and vessels diameter with a significant impact on VA outcomes. Method A clinical, prospective, randomized, open-label, single-center crossover trial. Inclusion criteria: age 18-80ys, under regular hemodialysis (3/week), no heart failure (CHF) and no acute pulmonar edema (APE) on the previous year. Exclusion criteria: >3 sessions/week, CHF or APE. Before the last-week session, patient’s clinical parameters were recorded. BIA and ultrasound vascular mapping were performed. After this first evaluation, dry weight was increased 0,5 Kg, and after weekend, the same protocol was conducted. Primary end point was to compare vein diameters. Results 126 vessels were evaluated (84 veins and 42 arteries) from 21 patients. Mean age was 69±10y and 52% female. Primary end point was achieved (Table 1). Other than humeral arterial blood flow, every parameters evaluated through ultrasound mapping significantly increased (p<0,05) after dry weight adjustment (>0,5 Kg) plus weekend weight gain. After cross over, weight, overhydration (OH), extracellular water (ECW) and OH/ECW significantly increased (p<0,05), however, most patients had a mild-moderate OH (86-90%). Blood pressure and total body water haven’t changed significantly. No complications were reported. Conclusion Some additional degree of OH comparing to midweek weight gain may be effective and safe in improving peripheral vascular conditions that are predictors of VA success. The currently lack of evidence of vascular mapping may be due to the lack of evaluation of cofactors such as volemia. Therefore, BIA and lung ultrasound may be future tools that combined to vascular ultrasound could be a safe and effective way to optimize and evaluate preoperative conditions to improve VA outcomes. Larger and multicentric studies are needed.

Germany: Lifocolor – plastics masterbatch

Left main artery coronary disease represents the highest risk lesion of ischemic heart disease. Revascularization can be accomplished by surgery or percutaneous interventions. This study highlights the case of a patient with severe multiple peripheral vascular conditions and complex coronary anatomy treated with percutaneous coronary intervention using mechanical circulatory support. (Level of Difficulty: Intermediate.)

Preface: The First International Symposium on Biomechanics and Mechanobiology in Cardiovascular System

Preface: The First International Symposium on Biomechanics and Mechanobiology in Cardiovascular System

A surgeon's guide to anticoagulant and antiplatelet medications part one: warfarin and new direct oral anticoagulant medications.

An increasing number of potent antiplatelet and anticoagulant medications are being used for the long-term management of cardiac, cerebrovascular, and peripheral vascular conditions. Management of these medications in the perioperative and peri-injury settings can be challenging for surgeons, mandating an understanding of these agents and the risks and benefits of various management strategies. In this two-part review, agents commonly encounter by surgeons in the perioperative and peri-injury settings are discussed and management strategies for patients on long-term antiplatelet and anticoagulant therapy reviewed. In part I, we review warfarin and the new direct oral anticoagulants. In part II, we review antiplatelet agents and assessment of platelet function and the perioperative management of long-term anticoagulant and antiplatelet therapy.

Surgeon's guide to anticoagulant and antiplatelet medications part two: antiplatelet agents and perioperative management of long-term anticoagulation.

An increasing number of potent antiplatelet and anticoagulant medications are being used for the long-term management of cardiac, cerebrovascular, and peripheral vascular conditions. Management of these medications in the perioperative and peri-injury settings can be challenging for surgeons, mandating an understanding of these agents and the risks and benefits of various management strategies. In this two part review, agents commonly encountered by surgeons in the perioperative and peri-injury settings are discussed and management strategies for patients on long-term antiplatelet and anticoagulant therapy reviewed. In part one, we review warfarin and the new direct oral anticoagulants. In part two, we review antiplatelet agents and assessment of platelet function and the perioperative management of long-term anticoagulation and antiplatelet therapy.

Improving Knowledge of Vascular Interventions: An Educational Program for the Adult Learner

Purpose:According to Billings and Halstead, ‘‘adults make a commitment to learning when the learning goals are perceived as immediately useful and realistic and as important and relevant to their personal, professional, and career needs’’. This knowledge of the adult learner, coupled with a focused learning assessment of past participants, provided focus and direction to the vascular nursing staff of a large academic medical center when developing an educational exhibit for nursing staff, clinicians, students and visitors. Description: A small group of vascular nurses organized an educational exhibit during Vascular Nursing Week for nursing staff, clinicians, students and visitors. The themes of the exhibit were endovascular and peripheral vascular interventions. Incorporating multiple adult learning methods, displays included simulator demonstrations of endovascular and peripheral vascular interventions, videos on peripheral interventional procedures, ‘‘touch and feel’’ of stents, poster presentations, educational pamphlets and discussion. Evaluation/Outcomes: A five-item questionnaire was developed to evaluate the overall understanding of risk factors for peripheral vascular conditions and treatments. Participants were encouraged to provide feedback and suggestions for future educational opportunities. The response rate (n=59) demonstrated greater than 80% of participants strongly agreed that the demonstrations and education provided improved their knowledge and understanding of vascular disease and interventions. Intended to be an educational opportunity, the success of the event was also measured by improved collaboration, communication and camaraderie amongst nursing staff and vascular surgeons. Poster 11

Prevalence of hypertension and physical activity among Brazilian adults and elderly: A national analysis

The demographic, nutritional and epidemiological transitions happened very rapidly in Brazil. As a consequence, non-communicable diseases (NCDs) are responsible for most deaths in the country. Hypertension is responsible for cardiovascular, brain, coronary, renal and peripheral vascular conditions. Hypertension is highly prevalent and tends to increase at older ages. Studies indicate that physically inactive adults have a 30% increased risk of developing hypertension as compared with their active peers. Obesity is also an important risk factor for hypertension. These findings indicate the need for preventive programs to reduce the incidence of chronic diseases, through the incorporation of behavioral changes such as healthy eating and regular physical activity. A cross-sectional study was conducted with a sample of 12,324 adults and 6,580 elderly individuals aged 60 years or more in the urban area of 100 municipalities in 23 Brazilian states (AQUARES-UFPPEL). These subjects answered questions about the reported diagnosis of hypertension and participation in physical activity during leisure time (IPAQ). The prevalence of reported diagnosis of hypertension was 16.3% (95% CI 15.6 to 16.9) among adults and 51.8% (95% CI 50.6 to 53.0) among the elderly. Among adults, the prevalence of hypertension was 14.4% in males and 17.8% in women (p < 0.001). Inactive adults were more likely to present hypertension as compared to their active peers (p = 0.01). Regarding the elderly, the prevalence of hypertension was 44.6% in men and 56.9%in women (p < 0.001). Inactive elderly subjects were more likely to present hypertension than their active peers(p = 0.002). The results show that the prevalence of physical inactivity among adults and elderly hypertensive patients is high and that policies to promote physical activity are urgently needed.

A Log-linearized Peripheral Arterial Viscoelastic Index and Its Application to Endoscopic Thoracic Sympathectomy

This paper proposes a novel technique to monitor peripheral vascular conditions by using biological signals, such as electrocardiogram, arterial pressure, and pulse oximetric plethysmogram. A second-order log-linearized model (called the log-linearized peripheral arterial viscoelastic model) is used to describe the nonlinear viscoelastic relationship between the blood pressure waveform and the transillumination plethysmographic waveform. The proposed index is able to estimate the changes of stiffness of peripheral arterial wall induced by sympathetic nervous activity, and the validity of the proposed method is then discussed by monitoring peripheral vascular conditions during arm position tests and during endoscopic thoracic sympathectomies (ETSs). As results of the arm position tests, the stiffness was arm position-independent (Up: 4.0 [%], Down: 5.5 [%]). Then, as results of the ETSs, the variation of the stiffness was significantly changed between before and during the ETS procedure (p < 0.01), and between during and after the ETS procedure (p < 0.01). The above experimental results clearly show that the proposed method can assess changes in the sympathetic nervous activity during ETSs.

Hospitalizations before and after initiation of chronic hemodialysis

Hospitalization rate is high in patients on chronic hemodialysis (HD). We investigated whether initiation of HD changes the rate and length of hospitalization. We analyzed hospitalizations in HD patients in one hospital over 15 years. We compared annual rate and length of hospitalizations, both presented as mean (95% confidence interval [CI]) between the pre-HD and HD period. Three hundred ninety-two patients, 98% men, 59% diabetic, and 66.3 ± 11.2 years old at the onset of HD, had 1016 hospitalizations in the pre-HD period (60.0 ± 42.9 months) and 1627 hospitalizations in the HD period (32.5 ± 25.9 months). Higher values were found in the HD than the pre-HD period for rate, (pre-HD 0.557 [95% CI 0.473-0.611], HD 2.198 [95% CI 1.997-2.399] admissions/[patient-year], P<0.001) and length (pre-HD 4.63 [95% CI 3.71-5.55], HD 28.07 [95% CI 23.55-32.59] days/patient-year], P<0.001) of hospitalizations for all causes, cardiac disease, infections, vascular access, peripheral vascular disease, metabolic disturbances, gastrointestinal diseases, and miscellaneous conditions, mainly respiratory illness and malignancy. Similar differences were found when we compared the year before and the year after the start of HD. Diabetics had higher all cause rate and length of hospitalizations than non-diabetics in the pre-HD and HD periods. The rate and length of hospitalizations was higher in the HD than the pre-HD period for both HD-specific conditions and conditions encountered in both HD and general populations. Study of factors specific to HD that may affect these conditions should constitute the first step toward improving the morbidity of patients on HD.

Diannexin Treatment Decreases Ischemia-Reperfusion Injury at the Endothelial Cell Level of the Microvascular Bed in Muscle Flaps

Ischemia-reperfusion injury (IRI) is a common and serious complication of reperfusion following vascular occlusion. We present a novel interpretation of the pathogenesis of IRI. According to this hypothesis, anoxia resulting from ischemia allows translocation of phosphatidylserine to the surface of endothelial cells (ECs), providing an attachment site for leukocytes and platelets. This attachment impedes blood flow through the microvasculature. During IRI mediators of increased vascular permeability are produced, resulting in edema. We have developed a recombinant homodimer of human Annexin V, Diannexin, to attenuate IRI. Annexin V (36 kDa) rapidly passes from the circulation into the urine. In Diannexin 2 annexin V molecules are joined by a short peptide linker to produce a 73 kDa protein, which exceeds the renal filtration threshold. Diannexin has a half-life of about 2.5 hours in the human circulation. Diannexin also has a higher affinity for phosphatidylserine on cell surfaces than the monomer has. Such binding inhibits leukocyte attachment to ECs, and inflammatory mediator formation, during IRI. The aim of the study now reported was to ascertain the effects of Diannexin on IRI in the rat cremaster muscle flap, as revealed by intravital microscopy. During IRI there was increased attachment of leukocytes to ECs, reduced blood flow and augmented vascular permeability. Administration of Diannexin before or just after ischemia prevented these effects. Diannexin inhibited transmigration of leukocytes during IRI. Edema complicates peripheral vascular surgery, stroke, and other clinical conditions. Diannexin has proven to be safe when administered to patients after major surgical operations, and it may be useful to prevent IRI associated with peripheral vascular surgery.

Drug evaluation of clopidogrel in patients with ischemic stroke

Clopidogrel is an effective antiplatelet medication used for the secondary prevention of ischemic events in patients with various cardiovascular, cerebrovascular and peripheral vascular disease conditions. The objective of this paper is to discuss the role of clopidogrel in ischemic stroke patients and to review the existing data from randomized trials supplemented by pilot and mechanistic studies that supports these indications for its use. An analysis of the mechanism of action and pharmacology of clopidogrel is provided. After Phase III trials, such as the CAPRIE (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events) and MATCH (Management of Atherothrombosis with Clopidogrel in High-risk patients) trials, the role of clopidogrel in secondary prevention is well defined. The role of clopidogrel in acute ischemic stroke and neurointerventional procedures is evolving based on new pilot trials. At present, there is insufficient data to recommend the use of clopidogrel in acute ischemic stroke. Clopidogrel may be a valuable alternative to aspirin. However, more studies are required to assess the role of clopidogrel in selected patient groups with respect to acute ischemic stroke.

Spinal neuromodulation: a novel approach in the management of peripheral vascular disease

Since the original report about the use of spinal cord stimulation (SCS) in patients with peripheral vascular disease (PVD) over 30 years ago, its clinical effectiveness remains controversial. Animal studies have confirmed the peripheral vasodilatory effect of SCS, at least partially mediated by antidromic afferent nerve stimulation with subsequent release of vasoactive substances. Although initial studies established the therapeutic benefits of this SCS in patients with poor peripheral circulation, two recent randomized, controlled studies have failed to demonstrate any beneficial effects, raising scepticism regarding the usefulness of SCS in treating PVD. The reason for such dissimilar results is unknown, but may be the result of inappropriate or differential patient selection, or relatively small sample populations in the randomized studies. Therefore, further investigation is required to address the efficacy and indications of SCS in the treatment of peripheral ischemic vascular conditions.

Keeping up-to-date on lipid-lowering drugs.

Geriatric Nursing Volume 25 Number 4 Since publication of the last drug consult column on lipid-lowering drugs 3 years ago,1 2 new drugs are being used for dyslipidemia, and the evidence supporting the use of drugs for dyslipidemia is mounting. Of particular interest for nurses working with older adults is information from recent clinical trials with large numbers of older adults to address questions about upper age limits for the benefits of lipid-lowering drugs. A recent review of such clinical trials concluded that “the notion that drug interventions are of no value in older patients should be abandoned.”2 Thus, gerontologic nurses need to keep up to date on the latest evidence-based recommendations for treatment of dyslipidemia and on information about lipidlowering drugs for older adults. Dyslipidemia, defined as abnormal serum lipoprotein levels, is a risk factor for cardiovascular disease when lowdensity lipoprotein (LDL) cholesterol levels are high or high-density lipoprotein (HDL) cholesterol levels are low. In 2001, the National Cholesterol Education Program published the Adult Treatment Panel (ATP III) guidelines for identifying and treating dyslipidemia,3 and these recommendations have been widely used for 3 years. The ATP III paid particular attention to people aged 50 years and older and encouraged health care providers to consider a number of risk factors for people of any age when evaluating the need for interventions. In contrast to previous reports that determined risk based partially on the ratio between LDL and HDL cholesterol, the updated report recognizes that HDL cholesterol should be maintained above 60 mg/dL, and LDL cholesterol should be low regardless of any ratio. For example, the LDL goal for healthy people with no risk factors is <160 mg/dL, but the LDL goal for someone with multiple risks is <100 mg/dL. The ATP III identifies the following conditions as risk factors: • Cardiovascular disease (e.g., angina, angioplasty, bypass surgery) • Cerebrovascular conditions (e.g., ischemic stroke, transient ischemic attacks, symptomatic carotid artery stenosis) • Peripheral vascular conditions • Diabetes mellitus The report categorizes 3 levels of risk and recommends acceptable lipoprotein ranges according to the person’s Keeping Up-to-Date on Lipid-Lowering Drugs

Experience with permanent by-pass grafts in treatment of occlusive arterial disease.

Of all the peripheral vascular conditions in which the surgeon has employed some form of vascular graft or prosthesis, arteriosclerotic occlusive disease has proved to be the most difficult to conquer. In some patients with this condition the serious involvement of all the vessels of a limb, including the smaller distal arteries, makes the use of a graft impractical, since its continued function or benefit is very unlikely in such a compromised arterial tree. In other patients with intermittent small areas of complete or partial occlusion, success with grafts has been transient at times because the surgeon has not completely excluded potential areas of subsequent occlusion in a major peripheral artery. However, added to these failures must be those relating to surgical technique. Imperfect anastomoses, a poorly executed associated thrombendarterectomy, and unsuitable graft material have contributed to the list of failures in at least the early cases of most hospitals.

Lumbar sympathectomy in peripheral vascular disease.

THE AMOUNT of arterial obstruction which results from any peripheral vascular disease is the sum of the anatomic obstruction in the diseased blood vessel plus the constriction resulting from vasomotor impulses. These impulses may be thought of as those which are normally present producing normal vascular tone and those which are present because of abnormal reflexes. Such reflexes may arise in the area of disease in the blood vessels and, after passing through efferent and afferent loops contained within the sympathetic nervous system, return to the same vascular bed to produce abnormal vasoconstriction. Sympathectomy was early used in those forms of peripheral vascular disease in which there is a large vasospastic element. The first indication for such surgical treatment was considered to be Raynaud's disease and scleroderma. More recently the operative procedure has been used with greater acceptance in peripheral vascular conditions in which the amount of vasomotor tone, depending