Severe Occlusive Disease Research Articles

高齢者頸動脈狭窄症に対する頸動脈ステント留置術

Carotid artery stenting (CAS) is often considered the preferred treatment for severe carotid occlusive disease in patients labelled as “high risk,” including those aged 75 or more. We analyzed 30-day stroke risk and death rates after carotid artery stenting (CAS) for severe symptomatic or asymptomatic carotid stenosis in 55 patients (60 lesions) aged 75 or more and compared the results with those of 119 patients (130 lesions) less than 75 years old. All procedures were performed with protection devices (balloon protection) and were technically successful. Peri-procedural mortality and morbidity of CAS for elderly patients were 1.7% and 6.7%, respectively, but those for younger patients were 0% and 2.3%, respectively. The elderly patients tended to have a high complication rate, although it was not statistically significant. Therefore there was no significant difference in clinical baseline characteristics between the 2 groups. Randomized data that establish the efficacy of CEA versus medical management are not available for elderly patients, especially for individuals aged 80 years or older. Octogenarians should be considered high-risk patients for CAS. Randomized trial data are needed to compare the CAS versus CEA peri-procedural risk of stroke and death by age. Pending results from randomized studies, care should be exercised in selecting octogenarians for CAS.

Loss of Akt1 Leads to Severe Atherosclerosis and Occlusive Coronary Artery Disease

The Akt signaling pathway controls several cellular functions in the cardiovascular system; however, its role in atherogenesis is unknown. Here, we show that the genetic ablation of Akt1 on an apolipoprotein E knockout background (ApoE(-/-)Akt1(-/-)) increases aortic lesion expansion and promotes coronary atherosclerosis. Mechanistically, lesion formation is due to the enhanced expression of proinflammatory genes and endothelial cell and macrophage apoptosis. Bone marrow transfer experiments showing that macrophages from ApoE(-/-)Akt1(-/-) donors were not sufficient to worsen atherogenesis when transferred to ApoE(-/-) recipients suggest that lesion expansion in the ApoE(-/-)Akt1(-/-) strain might be of vascular origin. In the vessel wall, the loss of Akt1 increases inflammatory mediators and reduces eNOS phosphorylation, suggesting that Akt1 exerts vascular protection against atherogenesis. The presence of coronary lesions in ApoE(-/-)Akt1(-/-) mice provides a new model for studying the mechanisms of acute coronary syndrome in humans.

Guidelines for policies on alternatives to allogeneic blood transfusion. 1. Predeposit autologous blood donation and transfusion

SUMMARY This is the first of a series of newly prepared guidelines on alternatives to allogeneic blood transfusion. Further guidelines including the use of cell salvage and of pharmacological approaches to blood conservation will be published in due course. Decades of clinical application demonstrate that it is quite feasible to auto-transfuse blood that has been collected and stored for an interval of up to 6 weeks in standard storage media, and that up to three standard collection volumes (approximately 500 mL) can be collected from normal-sized adults (over 50 kg) during that interval. Furthermore, systems have been developed to reduce risk to participants and to boost haemoglobin (Hb) production during and after the procedure. However, such pre-operative autologous donations (PAD) are not without risk, are of low clinical efficacy and are poorly cost-effective for the vast majority of patients in the UK. These guidelines update those previously issued by the BCSH and do not recommend the practice and use of PAD unless the clinical circumstances are exceptional. They also give an update on the legal regulatory circumstances pertaining to the UK following recent European Directives.

Transplantation of autologous mononuclear bone marrow stem cells in patients with peripheral arterial disease (The TAM-PAD study)

For patients with severe, chronic limb ischemia in many cases interventional or surgical treatment is not possible anymore. In the past, both intramuscular and intraarterial transplantation of autologous BMCs had been proved therapeutically beneficial. The TAM-PAD study is the first one to analyze combined intraarterial and intramuscular BMC transplantation in its acute and long-term effects. 13 patients with chronically ischemic limbs due to peripheral arterial disease (Fontaine stage IIb) were recruited and underwent follow-up examinations after 2 and 13 months. Mononuclear cells from bone marrow were injected intramuscular and intraarterial into the ischemic limb. In contrast to the control group, after 2 months the pain-free walking distance of the transplanted patients significantly increased (from 147 +/- 90 to 500 +/- 614 m, p = 0.001). Furthermore the ankle-brachial index was significantly improved (at rest from 0.66+/-0.18 to 0.80+/-0.15, p = 0.003, after stress from 0.64 +/- 0.19 to 0.76 +/- 0.16, p = 0.006). Similar improvement was documented in capillary-venous oxygen-saturation (thigh from 59 +/- 9 to 66 +/- 5, p = 0.005, lower leg from 56 +/- 14 to 63 +/- 5, p = 0.021) and venous occlusion plethysmography (rest from 2.1 +/- 0.7 to 2.5 +/- 0.7, p = 0.009, mean reactive hyperemia from 5.3 +/- 1.8 to 7.2 +/- 1.8, p = 0.003, and peak flow from 7.2 +/- 3.2 to 10.8 +/- 2.8, p = 0.002). After 13 months these positive effects persisted at their improved level. No side effects or complications were monitored. Combined intraarterial and intramuscular transplantation of autologous mononuclear bone marrow stem cells is a clinically feasible and minimally invasive therapeutic option for patients with severe chronic peripheral occlusive arterial disease.

Thromboangiitis Obliterans (Buerger Disease)

A healthy 44-year-old woman presented with a 1month history of diffuse arthralgias followed by skin discoloration of the fingers of both hands that progressed during a 1-week period and was accompanied by resting finger pain exacerbated by exposure to cold. She had a 25-pack-year history of cigarette smoking but no history of illicit drug use. Results of an Allen test were abnormal. Angiography revealed normal vessels interspersed with severe occlusive disease. Work-up with echocardiography and serologic testing for autoimmune antibodies, thrombophilia, and vasculitides, including anticentromere and anti-Scl-70 antibodies, yielded negative results. Thromboangiitis obliterans (Buerger disease) was diagnosed. Thromboangiitis obliterans is a nonatherosclerotic inflammatory disorder of unknown etiology that affects small and medium-sized vessels of the extremities and has a strong association with smoking. Angiographic findings may mimic those of conditions such as scleroderma (CREST syndrome) or prothrombotic disorders. Cessation of cigarette smoking is the only known effective therapy. This patient quit smoking and was treated with aspirin, dalteparin, and daily arterial flow pump therapy, which produced symptomatic improvement.

Preliminary results of subintimal angioplasty for limb salvage in lower extremities with severe chronic ischemia and limb-threatening ischemia

This study examined the hypothesis that superficial femoral artery (SFA) subintimal angioplasty (SI-PTA) can maintain limb salvage with minimal complications in patients with symptomatic occlusive arterial disease. From March 1, 2004, until April 28, 2006, 78 patients with rest pain (62.2%), gangrene (25.6%), or severe progressive claudication (12.2%) were treated consecutively with 82 SFA SI-PTAs (4 bilateral). The mean age was 59 +/- 1.2 years, and 21 (27%) of the patients were female. All patients were treated in the operating room under local anesthesia by using fluoroscopic guidance, and the percentage SFA that was occluded was measured during the diagnostic portion of the procedure. Selective stent placement was performed after successful recanalization of the occluded arterial segments. Patients were treated with chronic aspirin and clopidogrel bisulfate for 3 months and followed up at 30 days and then every 3 months with physical examination and arterial duplex scan. Of the 82 SFA SI-PTA attempts, 76 (92%) were initially successful, with an increase in the ankle-brachial index from 0.46 +/- 0.02 to 0.88 +/- 0.01 (P < .001). Five of the six patients with a failed SFA SI-PTA were female, two of the six had had previous bypass attempts, and one of the six had had a previous SFA SI-PTA attempt by another physician. Forty-nine (64%) of the 76 initially successful SFA SI-PTAs required placement of a stent, and 43 (56.5%) of the successful 76 SFA SI-PTAs required additional PTA of 1 or more arterial segments. The group treated with a successful SFA SI-PTA had 42.5% +/- 3.5% SFA occlusion, compared with 82% +/- 10% (P < .05) in the group with a failed attempt at SFA SI-PTA. Two of the six patients with initial SI-PTA failure underwent leg amputation within 30 days, three were treated with successful leg bypass surgery, and one was lost to follow-up. Of the 76 successful SFA SI-PTAs, 5 (6.5%) failed within 90 days, and the patients were treated successfully with leg bypass surgery. Of the 71 limbs with patent SI-PTAs at 90 days, 68 have remained patent with a mean follow-up 10.4 +/- 0.7 months (range, 2-24 months). Three of the 71 SFA SI-PTAs failed between 4 and 7 months (mean, 5 +/- 0.7 months): 1 patient was treated with successful bypass surgery, 1 patient is currently considering further intervention, and 1 patient was treated with amputation. Ten (14%) of the 71 successful SFA SI-PTAs required limited PTA for asymptomatic restenosis, as identified by the arterial duplex scan (7.4 +/- 1.4 months; range, 2-16 months). There were no perioperative deaths, and three patients have died during follow-up with patent SFA SI-PTAs (9.3 +/- 1.4 months). These data suggest that SFA SI-PTA can be successfully used for limb salvage with minimal morbidity and mortality in a group of patients with severe lower extremity occlusive vascular disease.

Autologous Mononuclear Stem Cell Transplantation in Patients With Peripheral Occlusive Arterial Disease

Patients with chronic peripheral occlusive arterial disease often are not candidates for conventional revascularization procedures. Preclinical trials have shown that the transplantation of autologous bone marrow cells induces and increases the collateral vessel formation. We analyzed the clinical benefit of combined intraarterial and intramuscular transplantation of adult autologous mononuclear bone marrow stem cells in patients with lower-limb peripheral occlusive arterial disease. Patients with severe peripheral occlusive arterial disease and a reduced walking distance (Fontaine stage II or III) were included. Bone marrow was harvested from the hip under local anesthesia and mononuclear cells were transplanted intramuscularly and intraarterially into the ischemic limb after isolation under good manufacturing practice conditions. After 2 months, pain-free walking distance increased 3.7-fold. Furthermore, the ankle-brachial index was significantly improved at rest and after exercise. Similar improvements could be documented by capillary-venous oxygen saturation and venous occlusion plethysmography. No side effects or complications were detected during transplantation and during time of follow-up. Combined intraarterial and intramuscular transplantation of autologous mononuclear bone marrow stem cells is a clinically feasible and minimally invasive therapeutic option for patients with severe, chronic peripheral occlusive arterial disease.

High-grade symptomatic and asymptomatic carotid stenosis in the very elderly. A challenge for proponents of carotid angioplasty and stenting

BackgroundCarotid angioplasty and stenting (CAS) is often considered as the preferred treatment for severe carotid occlusive disease in patients labelled as "high risk", including those aged 80 or more. We analyzed 30-day stroke risk and death rates after carotid endarterectomy (CEA) for severe symptomatic or asymptomatic carotid disease in patients aged 80 or more, by comparison with the outcome of CAS reported in the recently- published literature.MethodsA retrospective review was conducted on a prospectively compiled computerized database of all primary CEAs performed by a single surgeon at our institution from 1990 to 2003. Descriptive demographic data, risk factors, surgical details, perioperative strokes and deaths, and other complications were recorded.ResultsIn all, 1260 CEAs were performed in 1099 patients; 1145 were performed in 987 patients less than 80 years old, and 115 were performed in 112 patients aged 80 or more. There were 11 perioperative strokes in the 1145 procedures in the younger group, for a stroke rate of 0.8%, and no strokes in the 115 procedures in the older group. The death rates were 0% for the octogenarians and 0.3% for the younger group.ConclusionThe conviction that older age means higher risk needs to be revised. Patients aged 80 or more can undergo CEA with no more perioperative risks than younger patients. Proponents of CAS should bear this in mind before recommending CAS as the best therapeutic option for such patients.

Techniques for large sheath insertion during endovascular thoracic aortic aneurysm repair

Despite improvements in operative technique and perioperative management, conventional open repair of descending thoracic aortic aneurysms (DTAs) continues to be associated with significant morbidity and a perioperative mortality between 4.8% and 20%, which may be even more pronounced in the acute setting. Since the first description of the endovascular repair of a thoracic aortic aneurysm by Dake et al, several studies have shown the safety of this approach, as well as possible decreases in perioperative mortality and complications, most notably paraplegia. Because of the less invasive nature and likely improved perioperative outcomes of endovascular repair of DTA, this is rapidly becoming the favored approach for management in these patients. Many patients, however, continue to be ineligible because of suboptimal vascular access, aortic arch angulation, and landing zone inadequacies. Although industry has been working to solve the last two issues, vascular access continues to be of major concern because delivery systems remain excessively large. In the United States, the currently available endografts for thoracic aorta aneurysms require delivery sheaths ranging from 20F to 25F, depending on the size of the graft and the manufacturer (Table). Despite these challenges, with the recent approval by the US Food and Drug Administration of the Gore Thoracic Aortic Graft endoprosthesis (W.L. Gore and Associates, Inc, Flagstaff, Ariz) and the ongoing evaluation of the Talent (Medtronic, Santa Rosa, Calif) and Zenith TX1 and TX2 (Cook Inc, Bloomington, Ind) endografts, it is clear that this technology is moving forward. With more widespread use and continued innovation, industry should be able to overcome the difficulties currently encountered with vascular access for the introduction of thoracic aortic endografts. Until that time, however, one should be knowledgeable of and comfortable with the implementation of several adjunctive maneuvers that may allow graft placement in otherwise ineligible patients. Furthermore, a thorough knowl-

Phenol lumbar sympathectomy for severe arterial occlusive disease in the elderly.

Phenol chemical lumbar sympathectomy is an additional aid in the management of ischaemic rest pain and incipient gangrene. This technique was used in 132 elderly patients in Bath between September 1972 and March 1975 and the results are presented here. The patients were unfit for reconstructive arterial surgery. In this series an image intensifier was used in order to make the procedure safer. One hundred and twenty-six patients were available for review, their average age being 71.5 years. The average period of follow-up was 16.3 months. Of the 126 patients, 111 were not diabetic, and of these 45 (41 per cent) had satisfactory results while 17 (15.4 per cent) had persistent symptoms but had avoided amputation. Thirty (27 per cent) patients required amputation and 12 of these died as a direct result of this procedure. A further 19 patients in the non-diabetic group died during the period of follow-up. However, of the 15 diabetic patients, only 3 (20 per cent) improved whilst one patient with persistent symptoms avoided amputation. The remainder either died (8) or had an amputation (5) during the period of follow-up. Two died after amputation.

Die „Beckenkammspan-Interpositionsarthrodese“ des oberen Sprunggelenks

Bony fusion of the ankle in a functionally favorable position for restitution of a painless weight bearing while avoiding a leg length discrepancy.Disabling, painful osteoarthritis of the ankle with extensive bone defect secondary to trauma, infection, or serious deformities such as congenital malformations or diabetic osteoarthropathies.Acute joint infection. Severe arterial occlusive disease of the involved limb.Lateral approach to the distal fibula. Fibular osteotomy 7 cm proximal to the tip of the lateral malleolus and posterior flipping of the distal fibula. Exposure of the ankle. Removal of all articular cartilage and debridement of the bone defect. Determination of the size of the defect and harvesting of a corresponding tricortical bone graft from the iliac crest. Also harvesting of autogenous cancellous bone either from the iliac crest or from the lateral part of the proximal tibia. Insertion of the tricortical bone graft and filling of the remaining defect with cancellous bone. Fixation with three 6.5-mm titanium lag screws. Depending on the extent of the defect additional stabilization of the bone graft with a titanium plate. Fixation of the lateral fibula on talus and tibia with two 3.5-mm titanium screws for additional support. Wound closure in layers. Split below-knee cast with the ankle in neutral position.Between January 2002 and January 2004 this technique was used in five patients with extensive bone defects (four women, one man, average age 57 years [42-77 years]). No intra- or early postoperative complications. The AOFAS (American Orthopedic Foot and Ankle Society) Score was improved from 23 points preoperatively to 76 points postoperatively (average follow-up time of 25 months). Two patients developed a nonunion and underwent a revision with an ankle arthrodesis nail. A valgus malposition after arthrodesis in one patient was corrected with a supramalleolar osteotomy.

Does carotid endarterectomy improve cognitive functioning?

Carotid endarterectomy (CEA) might improve cognitive functioning, but studies thus far have produced mixed results. The aim of the present study was to examine the effect of CEA on cognitive functions in a methodologically more strict design, first by testing the presumption of preoperative cognitive impairment and second through a better control for the possible influence of the nonspecific effects of practice and surgery. Preoperative performance on a neuropsychologic test battery of 56 patients with severe occlusive disease of the carotid artery but without history of major stroke was compared with the performance of 46 healthy control subjects and 23 patients before endarterectomy of the superficial femoral artery (remote endarterectomy). The degree of cognitive change in the 2 patient groups was compared at 3 and 12 months postoperatively. We assessed mood to control for possible momentary affective influences on cognition. Before CEA, patients showed reduced functioning compared with that seen in healthy control subjects in terms of attention, verbal and visual memory, planning of motor behavior, psychomotor skills, and executive function. Performance of patients before remote endarterectomy was reduced as well. Improvements in several cognitive functions were observed after both types of surgical interventions and were attributed to psychologic relief from uncomplicated surgery and to practice. No specific restorative effect of CEA on cognitive functioning was observed. The preoperative impairment in several cognitive domains might be caused by factors that patients with various types of vascular disease might have in common, such as small-vessel disease or other undetected abnormalities within the brain.

Value of absence of a transient myocardial perfusion defect during stress myocardial perfusion study in patients undergoing major vascular surgery

Pre-operative cardiac assessment is important in the evaluation of patients undergoing major vascular surgery. Our study aims to evaluate the value of absence of a transient myocardial perfusion defect during radionuclide myocardial perfusion study for prediction of cardiac events (myocardial infarction, sudden cardiac death, unstable angina, coronary artery revascularization and congestive heart failure) in patients undergoing major vascular surgery. We studied 63 consecutive patients (ages 35-83 [avg. 64], male 39, female 24) with radiographically proven, abdominal aortic aneurysm or severe aortofemoral occlusive disease who underwent major vascular surgery (abdominal aortic aneurysm repair [38] or aortofemoral bypass [25]). The subjects all had multiple coronary artery risk factors (hypertension 48, diabetes 10, hyperlipidemia 23, tobacco use 39, family history of coronary artery disease 10), but a negative pre-operative stress myocardial perfusion study for myocardial ischemia. Of these 63 patients, 17 patients were able to exercise and achieve their adequate 85% maximal predicted heart rate. Thirty-eight patients received adenosine infusion of 140 microg/kg/min for 6 min. Six patients received dipyridamole infusion of 0.56 mg/kg over 4 min. Two patients received dobutamine infusion at 5, 10, 20, 30, and 40 mg/kg/min. Of the 63 patients, 60 received 3-4 mCi of thallium-201 ((201)Tl) and 3 patients received 8-9 mCi of technetium-99m (99mTc) at rest and 25-30 mCi 99mTc during stress. The subjects all underwent major vascular surgery and were followed up to one year for any cardiac events. Of the 63, who underwent pre-operative cardiac assessment with myocardial perfusion testing, 25 had a fixed myocardial perfusion defect (scar) and none had evidence of transient myocardial perfusion defect (ischemia). One subject had coronary artery bypass grafting 11 months after aortofemoral bypass surgery. One died from a stroke one month after aortofemoral bypass surgery. Of the remaining 61 patients, none had any cardiac events up to one year after major vascular surgery.

Der modifizierte erweiterte distal gestielte sapheno-fasziokutane Suralislappen: Klinische Ergebnisse

Summary An anatomical study was performed to develop a modified technique for an extended saphenofasciocutaneous sural flap for coverage of large combined soft tissue lesions at the lower leg and foot. Then a prospective clinical study was performed to investigate the clinical applicability of the new technique. From August 1999 to August 2002, 7 patients with 10 large combined soft tissue lesions with exposed tendon, bone and joint or compound infected wounds, with loss of bone and osteitis, were prospectively examined after an operative treatment using the extended saphenofasciocutaneous sural flap. All patients had a variety of additional risk factors or severe co-morbidity (traumatic ipsilateral vascular lesion of the major nutrient artery of the lower leg, ipsilateral deep vein thrombosis, diabetic polyneuro-pathy with arteriosclerotic vessels and severe occlusive vascular disease). The size of defect of the ten combined soft tissue lesions ranged from 80 to 180 cm2. The defects were located in the mid and hind foot and also the lower leg. A complete coverage of all defects was achieved in a single-stage procedure with a distally based modified saphenofasciocutaneous sural flap from the proximal lower leg. All flaps survived completely withhot any partial necrosis of the flap. The flap donor site was directly closed in 7 cases and a simultaneous skin graft was applied in 3 cases. All patients were repeatedly clinical examined and the mean duration of followup was 22 months. All flaps had complete success. Any secondary donor site morbidity was not registered. We did not observe formations of neuromas of the sural nerve. There was no need for secondary de-bulking. Venous congestion nor long lasting edema were not seen. All patients were satisfied with the functional and aesthetic results. The new flap provides many advantages. The flap is reliable for covering large defects even in a selection of patients with sub-stancial risk factors by preservation of the major arteries of the lower leg. The technique represents safe surgery, which can be performed at a single stage without microsurgery with an easy and quick dissection and with minimal morbidity of donor site.

Aortic Arch and Descending Thoracic Aortic Aneurysms: Experience with Stent Grafting for Second-Stage “Elephant Trunk” Repair

Reconstruction of aortic arch and descending thoracic aortic aneurysms (TAAs) is technically challenging and associated with significant morbidity and mortality. We report our experience with extensive TAAs using a two-stage "elephant trunk" repair, with the second stage completed using an endovascular stent graft (ESG). Over 6 years, 111 patients underwent ESG treatment of TAAs at Mount Sinai Medical Center. Twelve of these patients were referred for ESG placement for the second stage of elephant trunk reconstruction because comorbidities placed them at high risk of open surgical repair. Our database was analyzed for technical and clinical success and perioperative complications. The mean follow-up was 11.8 months (range 1-64 months). Twelve patients (five women and seven men) with a mean age of 69 +/- 10 years underwent repair of their distal aortic arch and descending TAAs. These aneurysms included nine atherosclerotic aneurysms, one pseudoaneurysm, and two penetrating atherosclerotic ulcers. Three patients were symptomatic. Stent graft repair was technically successful in 91.7% or 11 of 12 patients. Excessive aortic arch tortuosity resulted in failure to deploy a stent graft in one patient. An antegrade approach through the open elephant trunk was used in two patients with severe iliac occlusive disease. Endoleaks (type 2) were identified in two patients with no aneurysm expansion; however, a 14 mm expansion over 1 year occurred in a patient with no identifiable endoleak. One early mortality occurred in a patient with a ruptured 6 cm infrarenal AAA after successful exclusion of the 8 cm TAA. Second-stage elephant trunk reconstruction of an extensive TAA using an ESG is effective in the short term. Its long-term durability remains to be determined.

New England Medical Center Posterior Circulation Stroke Registry II. Vascular Lesions

Among 407 New England Medical Center Posterior Circulation Registry (NEMC-PCR) patients, the extracranial (ECVA) and intracranial vertebral arteries (ICVA) were the commonest sites of severe occlusive disease followed by the basilar artery (BA). Severe occlusive lesions were found in >1 large artery in 148 patients; 134 had unilateral or bilateral severe disease at one arterial location. Single arterial site occlusive disease occurred most often in the ECVA (52 patients, 15 bilateral) followed by the ICVA (40 patients, 12 bilateral) and the BA (46 patients). Involvement of the ICVAs and the BA was very common and some patients also had ECVA lesions. Hypertension, smoking, and coronary and peripheral vascular disease were most prevalent in patients with extracranial disease while diabetes and hyperlipidemia were more common when occlusive lesions were only intracranial. Intra-arterial embolism was the most common mechanism of brain infarction in patients with ECVA and ICVA occlusive disease. ICVA occlusive lesions infrequently caused infarction limited to the proximal territory (medulla and posterior inferior cerebellum). BA lesions most often caused infarcts limited to the middle posterior circulation territory (pons and anterior inferior cerebellum). Posterior cerebral artery occlusive lesions were predominantly embolic. Penetrating artery disease caused mostly pontine and thalamic infarcts. Prognosis was poorest in patients with BA disease. The best prognosis surprisingly was in patients who had multiple arterial occlusive lesions; they often had position-sensitive transient ischemic attacks during months or years.

Stenting of superior mesenteric and celiac arteries

A 72-year-old woman with a complex medical history, which included abdominal pain in both lower quadrants for many years, presented to the emergency room with increased complaint of abdominal pain. She was evaluated for this complaint and a 30-pound weight loss. She had been seen the previous day for evaluation in the department of vascular surgery. A duplex ultrasound was performed, which demonstrated high-grade stenosis in the superior mesenteric artery (SMA) and celiac artery. An angiogram was scheduled to evaluate with possible intervention. That evening her abdominal pain increased, and she was instructed to go to the emergency room for evaluation. Because her lactate levels had increased to 2.6 mmol/L and she demonstrated the progressive symptoms of postprandial abdominal pain, it was decided to urgently perform a mesenteric angiogram. Arterial access was obtained in an antegrade manner through a left brachial approach by using micropuncture techniques. A 0.035-inch floppy glide wire was advanced from the brachial into the axillary and subclavian arteries and then to the descending thoracic aorta, and the sheath was up-sized to 6 French. A pigtail catheter was placed over the wire; the wire was removed, and an aortogram was performed. This demonstrated severe three-vessel mesenteric occlusive disease (Fig 1). Lateral aortograms and selective views of the SMA were performed. This demonstrated a lesion in the SMA, which was treated with balloon angioplasty and stented with a 6 24 Genesis Stent (Cordis, Johnson & Johnson Company, Warren, NJ). There was a residual lesion that was dilated with a 7 2 Opta-Pro balloon (Cordis, Johnson & Johnson Company). Next, selective views of the celiac artery were performed. This demonstrated a lesion that was treated with balloon angioplasty and stented with a 7 14 Genesis stent (Cordis, Johnson & Johnson Company). An 8 20 Opta-Pro balloon (Cordis, Johnson & Johnson Company) was used to post-dilate the residual lesion. Post-angiograms were taken of the aorta, demonstrating brisk flow through both vessels (Fig 2). The

Finger pricking

A 59-year-old man with diabetes mellitus and end-stage renal disease requiring peritoneal dialysis was admitted for amputation of the right lower leg because of severe arterial occlusive disease. During his recovery, he started glucose self-monitoring and a few days later, complained of pain and purple discolouration of the fourth finger of his left hand. Examination showed multiple small, well circumscribed areas of skin necrosis around recent finger pricking sites. Despite treatment with iloprost infusions, the lesions progressed to necrosis of the distal phalange.

Exertional Leg Pain in a Runner

1699 HISTORY: A 35 year old African American male presents with progressive 2 year history of exertional posterior calf pain. Patient describes no pain at rest, but the pain becomes severe after ¼ to ½ mile of running. The pain is a crampy, sharp pain in the posterior calf without radiation, relieved with discontinuation of exercise. Past medical history was significant for hypertension well controlled on ramipril. Remote history, four years previous, of left leg deep venous thrombosis (DVT) following a prolonged airplane flight. No tobacco, alcohol, cocaine, or other drug use, and family history was negative for clotting disorders. The patient had been started on conservative therapy for 2 months without improvement. PHYSICAL EXAMINATION: African American male with normal neutral walking gait without limp. Lower extremity alignment was neutral without any asymmetry or obvious deformities. Tenderness to deep palpation in the posterior calves bilaterally, but no compartment tenderness at rest or with exertion. The patient had no bony tenderness or tenderness to percussion over the tibia or fibula. Ankle, knee, and hip had full passive and active range of motion. Strength was normal and symmetric throughout the lower extremity. Sensation to light touch and pin prick were intact with normal deep tendon reflexes. Distal pulses were diminished (1+) bilaterally but were symmetric with no change while in plantarflexion. The skin over the dorsum of his foot was slightly cool to the touch without pallor. DIFFERENTIAL DIAGNOSIS: Medial Tibial Stress Syndrome Chronic Exertional Compartment Syndrome Sural Nerve Entrapment Popliteal Artery Entrapment Arterial Occlusive Disease TEST AND RESULTS: Radiographs bilateral tibia/fibula −negative for fracture. Bilater duplex ultrasounds −negative for DVT Nerve Conducton Studies −negative Ankle Brachial Index −0.83 right side, 0.78 left side Arteriogram −severe femoral artery occlusive disease bilaterally from the groin to the tibial vessels Hypercoagulable work-up – + Lupus anticoagulant, + Anti-cardiolipin antibody (+ Antiphospholipid antibody syndrome) Rheumatologic panel −negative Echocardiogram (with bubble study) – negative for intracardiac thrombus or patent foramen ovale FINAL WORKING DIAGNOSIS: Extensive arterial occlusive disease in femoral arteries bilaterally. TREATMENT AND OUTCOMES: Unsuccessful attempt at thrombolysis Reduction of activity from running to walking as tolerated. Chronic anticoagulation with warfarin. Cilastazol for symptomatic treatment of intermittent claudication. Modification of cardiac risk factors. Unable to return to activity at previous level.

Exertional Leg Pain in a Runner

1699 HISTORY: A 35 year old African American male presents with progressive 2 year history of exertional posterior calf pain. Patient describes no pain at rest, but the pain becomes severe after ¼ to ½ mile of running. The pain is a crampy, sharp pain in the posterior calf without radiation, relieved with discontinuation of exercise. Past medical history was significant for hypertension well controlled on ramipril. Remote history, four years previous, of left leg deep venous thrombosis (DVT) following a prolonged airplane flight. No tobacco, alcohol, cocaine, or other drug use, and family history was negative for clotting disorders. The patient had been started on conservative therapy for 2 months without improvement. PHYSICAL EXAMINATION: African American male with normal neutral walking gait without limp. Lower extremity alignment was neutral without any asymmetry or obvious deformities. Tenderness to deep palpation in the posterior calves bilaterally, but no compartment tenderness at rest or with exertion. The patient had no bony tenderness or tenderness to percussion over the tibia or fibula. Ankle, knee, and hip had full passive and active range of motion. Strength was normal and symmetric throughout the lower extremity. Sensation to light touch and pin prick were intact with normal deep tendon reflexes. Distal pulses were diminished (1+) bilaterally but were symmetric with no change while in plantarflexion. The skin over the dorsum of his foot was slightly cool to the touch without pallor. DIFFERENTIAL DIAGNOSIS: Medial Tibial Stress Syndrome Chronic Exertional Compartment Syndrome Sural Nerve Entrapment Popliteal Artery Entrapment Arterial Occlusive Disease TEST AND RESULTS: Radiographs bilateral tibia/fibula −negative for fracture. Bilater duplex ultrasounds −negative for DVT Nerve Conducton Studies −negative Ankle Brachial Index −0.83 right side, 0.78 left side Arteriogram −severe femoral artery occlusive disease bilaterally from the groin to the tibial vessels Hypercoagulable work-up – + Lupus anticoagulant, + Anti-cardiolipin antibody (+ Antiphospholipid antibody syndrome) Rheumatologic panel −negative Echocardiogram (with bubble study) – negative for intracardiac thrombus or patent foramen ovale FINAL WORKING DIAGNOSIS: Extensive arterial occlusive disease in femoral arteries bilaterally. TREATMENT AND OUTCOMES: Unsuccessful attempt at thrombolysis Reduction of activity from running to walking as tolerated. Chronic anticoagulation with warfarin. Cilastazol for symptomatic treatment of intermittent claudication. Modification of cardiac risk factors. Unable to return to activity at previous level.