Severe Peripheral Vasculopathy Research Articles

Open Conversion Abdominal Aortic Endograft in Thoracic Epidural Anesthesia alone in Patient with Severe COPD: A Case Report of Surgery in awake Patient and Review of the Literature

A 79-year-old male was referred, with open abdomen surgical indication, for an asymptomatic iuxtarenal abdominal aortic aneurysm and type I endoleak with distal migration of an endovascular aortic – bisiliac prosthesis, after an endovascular correction done eight years before. This patient has several comorbidities such severe COPD (Stage IV and oxygen dependent), chronic kidney disease (G4 KDIGO CKD classification), systemic arterial hypertension and severe peripheral vasculopathy. Spirometry gives a picture of severe obstruction: FVC 2,44 L (68%), FEV1 0,68 L (25%), TLC 7.72 L (118%), RV 4,88 L (181%). 3 L/min oxygen arterial blood gas was: pH 7,34, PaO2 74,9 mmHg, PaCO2 51,2 mmHg, HCO3- 24,3 mEq/L, BE – 0,2, SpO2 94,2%. Cardiological consultation did not found any problem (normal ejection fraction, no valvular pathologies, and no pulmonary hypertension). Vascular echography highlighted an aortic aneurysm, confirmed by computed tomography angiography: iuxtarenal abdominal aortic aneurysm of 68 mm × 72 mm extended for 70 mm (Figure 1). According to the European Society of Anesthesiologists guidelines [1,2], general anesthesia is not safe, because of the elevated perioperative risks of severe respiratory complications. After a collegial respiratory risk evaluation, we have decided for an awake surgery with an epidural anesthesia. Operative risks were assessed with the patient who accepted intervention.

Demographic and clinical characteristics of spinal calcinosis in systemic sclerosis: Possible association with peripheral angiopathy.

The objective was to evaluate the demographic and clinical characteristics of systemic sclerosis (SSc) patients with spinal calcinosis. Paraspinal and intraspinal calcinosis was assessed blindly by orthopedic surgeons specializing in spinal diseases using chest high-resolution computed tomography (CT) that was performed for the screening and prospecting of interstitial lung disease in 159 Japanese SSc patients. Among these patients, we identified 27 (17%) with spinal calcinosis, and the most common site was cervical level at 77.8% (21/27). The frequency of spinal calcinosis in the late stage was higher than in the early stage (44.4% vs 29.6%). Multiple calcinosis was identified in 18.5% (5/27). The frequency of paraspinal calcinosis only was 59.3%, intraspinal calcinosis only 18.5%, and both intraspinal and paraspinal calcinosis 22.2%. Among SSc patients, 4.4% (7/159) had CT-based evidence of spinal cord compression. Among cases with spinal cord compression, only one had neurological symptoms, and surgical removal improved the symptoms. The other six SSc patients with spinal calcinosis (3.8% of 159) had no symptoms. Male sex (29.6%) and severe peripheral vasculopathy such as digital ulcers (55.6%) and acro-osteolysis (33.3%) were significantly more frequent in the SSc patients with spinal calcinosis than in the SSc patients without spinal calcinosis (10.6%, 32.6% and 14.4%, respectively). Our results suggest that severe peripheral vasculopathy may be associated with the development of spinal calcinosis. Because SSc patients are prone to spinal calcinosis, when SSc patients claim symptoms such as pain, numbness and movement disorder of the extremities, spinal calcinosis is a complication that should be taken into consideration.

Direct Aortic CoreValve Implantation via Right Anterior Thoracotomy in a Patient with Patent Bilateral Mammary Artery Grafts and Aortic Arch Chronic Dissection

<p>Direct aortic trans-catheter aortic valve implantation is an alternative approach to treat high risk for surgery patients affected by severe aortic stenosis and concomitant peripheral vascular disease.</p><p>We describe a case of direct aortic CoreValve implantation made via a right anterior thoracotomy in a 78-year-old male affected by severe aortic stenosis and severe peripheral vasculopathy, who previously underwent coronary artery bypass grafting, with patent bilateral mammary artery grafts and chronic aortic arch dissection.</p>

Sequential contralateral injection through the same transradial vascular approach in a chronic total occlusion.

Contralateral injection has been described as a useful tool in the treatment of chronic total occlusions (CTOs) to evaluate the distal segments of the occluded artery [1, 2]. This case shows that contralateral injections are feasible through just one puncture using a 6 Fr sheath, a long guidewire of 0.014” and a 5 Fr diagnosis catheter in parallel. We present a 64-year-old man with severe peripheral vasculopathy. Coronary angiography showed a chronic total occlusion at the left circumflex artery and severe stenosis in the right coronary artery; circulation to the marginal branch was supplied from a posterolateral branch of the right coronary artery. Percutaneous coronaty intervention (PCI) was performed through a 6 Fr sheath placed in the right radial artery. We began the procedure treating the left circumflex artery occlusion with an EBU 3.5 6 Fr guiding catheter and an Asahi Sion “J” guidewire which crossed the occlusion easily. However, after dilatations with a 2.5 × 15 mm balloon, no distal filling was observed (Figure 1A). Figure 1 A – Left main (LM) is engaged with the EBU guiding catheter. *Guidewire (0.014” 300 cm BMW Universal). B – Right coronary artery (RCA) is engaged in the ostium (RCA) with the JR 5 Fr diagnosis catheter while the angioplasty guidewire ... We changed the first angioplasty guidewire for a 0.014” 300 cm length BMW guidewire. We passed in parallel a regular wire (0.035” 260 cm J) inside the guide catheter until it reached the aortic root. Then, using the same sheath, we changed to a JR 5 Fr diagnosis catheter to perform a contralateral injection. The injection from the right coronary artery showed that the guidewire was placed successfully in the marginal branch (Figure 1B). After that we advanced the previous guiding catheter using again the regular guide in the aortic root while still maintaining the 0.014” BMW 300 cm in the marginal branch. Needing buddy-wire technique, a 2.5 × 33 mm everolimus drug-eluting stent was successfully deployed in the middle segment of the circumflex artery towards the marginal branch, and another similar 2.25 × 18 mm stent distally to the previous one (Figure 1C). Thereafter the collateral circulation to the marginal branch disappeared. This case shows that contralateral injections are feasible through a unique puncture site using a 6 Fr sheath, a long guidewire of 0.014” placed in the endpoint branch and a 5 Fr diagnosis catheter in parallel. The 0.035” 260 cm J regular wire placed in the aortic root helps to change catheters, improving the softness of the angioplasty guidewire (and avoiding its prolapse in the coronary artery). Recently there have been published reports of two different ways to perform bilateral angiography in a single radial access once the wires had crossed the CTO but it was uncertain whether the wires were in the true lumen. The first one, called BASIRALA (bilateral angiography in a single radial access) [3], uses a microcatheter to inject selectively in the donor branches connected with CTOs. The second one [4] involves injecting with the same multipurpose guiding catheter in which the operator creates a loop of the wire in the coronary sinus and ascending aorta. This looped wire allows the catheter to be turned towards the contralateral artery without disengagement of the wire. None of these three techniques can offer a real simultaneous contralateral injection. It is possible, simple and safe to perform contralateral injections using a parallel long angioplasty 0.014” guidewire and a diagnosis catheter one French smaller than the sheath. The use of one 0.035” 260 cm regular wire helps during catheter exchanges.

Trans-catheter aortic valve implantation through the ascending aorta in a patient with previous right pneumonectomy

Methods A 74 year old male with severe aortic stenosis was referred for consideration of aortic valve replacement. He was highly symptomatic with both angina and dyspnea (NYHA class III). The echocardiogram confirmed moderate depression of LVEF. Coronary angiography demonstrated severe stenosis of the left-descending and right coronary arteries. His comorbidities included diabetes mellitus, peripheral vascular disease and left pneumonectomy, with residual poor lung function. His logistic EuroSCORE was 16.6%. Two drug eluting stents were implanted. Trans-femoral route was not feasible because of a small-caliber femoral arteries and severe peripheral vasculopathy, including subclavian severe stenosis. Trans-apical approach was also not desirable because the ventricular apex was shifted to the right and would have posed technical. Upper partial thoracotomy 5 cm far from the right border of the sternum at the second intercostal space and partial resection of the rib was performed and the ascending aorta was exposed. An 18-Fr sheath was introduced through a small puncture 6 cm over the aortic plane. Valvulotomy was performed with a 25-mm balloon and a 29-mm device was then implanted. Results A good result was obtained with minimal paravalvular leak. He did not developed heart failure or auriculo-ventricular block, but sub-acute right-sided limb ischemia appeared 72 hours from the procedure, which required percutaneous revascularization. Within one year of follow-up he remains asymptomatic from a cardiovascular point of view.

Direct aortic transcatheter aortic valve implantation, a promising new approach

The transcatheter aortic valve implantation (TAVI) is an established therapy option for high risk patients with severe aortic valve stenosis. The peripheral arterial (Femoral or Subclavien) and the minimal invasive surgical access via Apex are the standard access routes. Out come and prognosis of TAVI is determined by the peripheral vessel complications, strokes, paravalvular leak and apical cardiac infarction. The direct aortic (DA) approaches is a new alternative for the minimal invasive surgical TAVI access. We report our experience and discuss the different aspects this technique. Between September 2011 and August 2012 we performed in 50 patients DA-TAVI via partial upper sternotomy with the self expanding Medtronic CorValve bioprothesis. From the tenth patient DA was the primary access route for TAVI. The Procedure is done in general anesthesia and performed by an interventional heart team in the operating room (OR). The fast-track anesthesia with immediate extubation after the procedure in the OR was established after the tenth patient. The mean patients age was 78 ± 5,2 years and 52% were male. The mean logistic EuroSCORE were 20,3 ± 10,8. Coronary artery disease were documented in 30 (60%) patients, including eight re-do procedures. In 15 (30%) cases were severe peripheral vasculopathy the main indication for DA access. Procedural success was 100%. Mean aortic gradient dropped immediately under 5 mm Hg, end diastolic left ventricle pressure improved on average by 30% in all patients and there was no vascular complications. Stroke occurred in one patient. 5 patients had, during the first days after the procedure, a psycho-organic syndrome, where a stroke was excluded. The post-operative echocardiogram demonstrated in 45 (90%) patients non to trace, in 4 (8%) patients mild and in 1(2%) patient moderate aortic regurgitation. Direct aortic access for TAVI is a surgical simple, flexible and safe approach to treat high risk patients with symptomatic aortic stenosis and might enrich the surgical TAVI access with a new promising approach.

Direct Aortic Access for Transcatheter Self-Expanding Aortic Bioprosthetic Valves Implantation

Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis at high risk for operation; however, these patients are also often affected by severe iliac-femoral arteriopathy that prohibits the transfemoral approach. From May 2008 to January 2012, 400 patients were evaluated for TAVI at our center; of these, 141 patients (64 men; mean age 81.3±8 years) with severe symptomatic aortic stenosis and no reasonable surgical option due to excessive risk were eligible for CoreValve (137 patients; Medtronic Inc, MN) or Sapien (Edwards Lifesciences, CA) implantation. Twenty-five patients (all affected by severe peripheral vasculopathy, including five re-do procedures), with a mean The Society of Thoracic Surgeons mortality score 11%±6%, underwent CoreValve implantation directly from the ascending aorta through a right anterior minithoracotomy. This case series was reviewed to evaluate the clinical outcomes of these patients. A combined team of cardiologists, cardiac surgeons with expertise in hybrid procedures, and anesthetists performed all the procedures. In all patients after valve deployment, the mean aortic gradient immediately dropped to 5 mm Hg or less, and the angiographic grade aortic insufficiency was 1 or less in 22 patients. One patient was converted to the transfemoral approach due to an extremely fragile aortic wall, but the patient died of abdominal aorta aneurysm rupture on postoperative day 1. Procedural success was obtained in the remaining 24 patients. A left ventricle tear in 1 patient was successfully surgically treated. Four patients required a permanent pacemaker implantation. Thirty-day mortality was 8% (2 patients). All discharged patients improved their New York Heart Association functional class and functional capacity, and echocardiograms demonstrated good valve performance up to 2 years (mean valve gradient, 9 mm Hg). During follow-up, 1 patient died of cachexia and another of bone marrow aplasia. TAVI with the direct aortic approach is safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, including those requiring a re-do procedure, and has emerged as a valuable alternative route to transapical access.

Expanding the Eligibility for Transcatheter Aortic Valve Implantation: The Trans-Subclavian Retrograde Approach Using the III Generation CoreValve Revalving System

Our aim was to assess the safety and feasibility of the retrograde trans-subclavian approach to transcatheter aortic valve implantation (TAVI) in selected high-risk patients with aortic stenosis (AS) and severe peripheral vasculopathy. TAVI is an emerging therapeutic option to treat inoperable/high-risk patients affected by symptomatic AS. However, these patients are also often affected by severe iliac-femoral arteriopathy, rendering the transfemoral approach unemployable for percutaneous revalving procedure. From among those patients in our department between May 2007 and December 2008, who were refused surgical aortic valve replacement because of high surgical risk and were ineligible for transfemoral percutaneous aortic valve replacement, we scheduled 3 for TAVI by the subclavian approach. Procedures were performed by a combined team of cardiologists, cardiac surgeons, and anesthetists in the catheterization laboratory. The III generation CoreValve Revalving System (CoreValve Inc., Irvine, California) with an 18-F delivery system was introduced in all cases by the left subclavian artery. Prosthetic valves were successfully implanted in all 3 cases, leading to a fall in transvalvular gradient without significant paravalvular regurgitation. No intraprocedural or periprocedural complications occurred. Two patients developed an atrioventricular block requiring the implantation of a permanent pacemaker. All patients were discharged in asymptomatic status, with good prosthesis performance. No adverse events occurred within the 3-month follow-up. TAVI by subclavian retrograde approach seems safe and feasible in inoperable/high-risk patients with AS and peripheral vasculopathy, who are neither eligible for surgical valve replacement nor transfemoral percutaneous aortic valve implantation. Further studies are needed to evaluate the long-term efficacy of this new therapy.

Prevalence of osteomyelitis in non-healing diabetic foot ulcers: usefulness of radiologic and scintigraphic findings

The study was conducted in order to assess the prevalence of osteomyelitis and the predictive value of radiographic (xR) and combined Tc 99-bone and leukocyte scanning (CS) findings in diabetic foot ulcers that met criteria for hospital admission (FUH). Out of 150 episodes of ulceration managed in an outpatient basis, 33 (in 28 NIDDM patients) requiring admission were evaluated. In all cases plain xR and CS were carried out. Seventeen episodes (51.5%) had a good outcome (healed or improving, at the time of the last follow up). Osteomyelitis was found in 21 episodes and 14 (66.6%) of them required an amputation. In 13 cases where xR showed characteristic radiologic changes of osteomyelitis (11 of them had a positive CS) 11 (84.6%) underwent an amputation. However, when osteomyelitis was diagnosed only by a positive CS, only 3/8 (37.5%) required a toe amputation. Severe peripheral vasculopathy was present in 44% of cases who required amputation and only in 17.6% of those who did not. We conclude that in FU underlying osteomyelitis is frequent and associated to a higher amputation rate than when no bone infection is identified (66.6 vs 17%), even when corrected for vascular status (OR 11, CI 95% 1.65–74.2), with a worse outcome when xR changes are already present.