Significant Peripheral Vascular Disease Research Articles

Ten-Year Experience with a Transapical Approach for Transcatheter Aortic and Mitral Valve Implantation.

The transfemoral approach represents the optimal access for TAVI due to its low invasiveness; however, up to 10-15% of TAVI candidates are considered unsuitable for femoral access because of significant peripheral vascular disease and need alternative access. This is a single-center retrospective observational study including all consecutive adult patients undergoing transcatheter procedures through a TA approach from March 2015 to April 2024. 213 patients underwent transcatheter aortic or mitral valve implantation through a TA approach and were enrolled in this study. The mean age of the patients was 79.5 ± 5.7 years, and 54% of the patients were males. The mean Euroscore II was 7.9 ± 6.4%. One-third of the patients had previous cardiac surgery. The overall mean survival time was 5.3 ± 0.3 years. Nine (4%) patients developed infective endocarditis (IE) during the follow-up. The transapical approach for transcatheter procedures is a safe and effective procedure for patients unsuitable for TF access with low periprocedural mortality and a low rate of post-procedural complications when performed by experienced surgeons and cardiologists.

The Use of Oscillometric Measurement of Ankle–Brachial Pressure Indices as a Screening tool for Peripheral Arterial Disease

Objective: Ankle–brachial pressure indices (ABPIs) are useful in screening for significant peripheral vascular disease (PVD) but require training, expertise, and are operator dependent. The reliability of MESI (MedEarly Healthcare, Nenagh, Tipperary), a novel, operator independent, and affordable device that uses oscillometric analysis to measure ABPI, was compared with ELCAT (Sword Medical, Dublin), the conventional Doppler technique in the vascular laboratory.

Determinants of Bone Material Strength and Cortical Porosity in Patients with Type 2 Diabetes Mellitus.

Reduced bone material strength index (BMSi) and increased cortical porosity (CtPo) have emerged as potentially contributing to fracture risk in type 2 diabetes mellitus (T2DM) patients. To determine whether BMSi or CtPo are related to other diabetic complications. Cross-sectional observational study. Subjects recruited from a random sample of southeast Minnesota residents. A total of 171 T2DM patients (mean age, 68.8 years) and 108 age-matched nondiabetic controls (mean age, 67.3 years). Bone material strength index was measured using microindentation, skin advanced glycation end-products (AGEs) measured using autofluorescence, high-resolution peripheral quantitative computed tomography at the distal radius and tibia, assessment of diabetic microvascular complications including urine microalbuminuria, retinopathy, neuropathy, and vascular disease (ankle brachial index and transcutaneous oxygen tension [TcPO2]). All analyses were adjusted for age, sex, and body mass index. Skin AGEs were negatively correlated with the BMSi in both T2DM (r = -0.30, P < 0.001) and control (r = -0.23, P = 0.020) subjects. In relating diabetic complications to CtPo, we found that T2DM patients with clinically significant peripheral vascular disease (TcPO2 ≤ 40 mm Hg) had higher (+21.0%, P = 0.031) CtPo at the distal tibia as compared to controls; in these subjects, CtPo was negatively correlated with TcPO2 at both the distal tibia (r = -0.39, P = 0.041) and radius (r = -0.41, P = 0.029). Our findings demonstrate that bone material properties are related to AGE accumulation regardless of diabetes status, while CtPo in T2DM patients is linked to TcPO2, a measure of microvascular blood flow.

AB040. 69. The use of oscillometric measurement of ankle-brachial pressure indices as a screening tool for peripheral arterial disease

: Ankle brachial pressure indices (ABPIs) are useful in community and primary care settings in screening for significant peripheral vascular disease (PVD) but require training, expertise and are operator dependent. We compared the reliability of a novel automated (operator independent) affordable device that uses oscillometric analysis to measure ABPI with conventional Doppler measurement in a vascular laboratory environment. ABPIs were measured on a series of patients referred for assessment with no known history of vascular disease using a standard Doppler technique (ELCAT, Sword Medical, Dublin) and a novel oscillometric device (MESI, MedEarly Healthcare, Nenagh, Co.Tipperary). The ABPI readings were recorded and patients were categorised as having “Normal” (ABPI >0.9) or “Abnormal” (ABPI <0.9 or incompressible using MELCAT versus “Error” or “no normal value obtained” using MESI) based on lowest values in either leg. A total of 12 patients were studied included. Among the 6 patients with normal ABPI (MELCAT), all had normal readings on MESI. 5/5 of those with ABPI <0.9 using MELCAT also had abnormal results using MESI (mainly error results). One patient categorised as having incompressible vessels (MELCAT) had normal results using MESI and had normal (0.6) toe pressure indices. MESI identifies patients with abnormal ABPI with a specificity of 100% and sensitivity of 83.3%. The positive and negative predictive values of MESI were 100% and 87.5% respectively. Despite small numbers in this pilot study we have identified the potential use of the MESI device as a screening tool in a community/primary care setting with potential for reducing demand for vascular lab and vascular OPD. Further evaluation is indicated required in a clinically appropriate setting.

Acute aortoiliac occlusive disease during percutaneous transluminal angioplasty in the setting of ST-elevation myocardial infarction: a case report

BackgroundAortoiliac occlusive disease, which is also referred to as Leriche syndrome, is a chronic atherosclerotic occlusive disease that occurs at the level of the aortic bifurcation. It is often thought to present with a triad of clinical symptoms: (1) intermittent lower extremity vascular claudication, (2) impotence, and (3) weak/absent femoral pulses.Case presentationWe report a case of a 47-year-old Caucasian woman who presented with an acute inferior ST-elevation myocardial infarction. During percutaneous transluminal angioplasty, our patient suddenly developed severe bilateral lower extremity pain, absent femoral pulses, and cool extremities. Distal aortogram revealed 95% stenosis with an apple core-like lesion in the mid-abdominal aorta. Stent placement resulted in improved blood flow to the distal aortic segment and resolution of symptoms.ConclusionsThe presence of significant peripheral vascular disease, significant cardiac risk factors, and/or difficulty accessing the femoral artery should caution a transfemoral approach during percutaneous transluminal angiography. This approach may precipitate aortoiliac occlusion and/or thromboembolism to the lower extremities. We encourage interventional cardiologists to (1) take extra caution when manipulating the wire and catheter and (2) strongly consider using a transradial approach in such patients.

Comparison of negative pressure wound therapy with moist wound therapy in the treatment of diabetic foot ulcers with non-revascularisable peripheral vascular disease

Background: Diabetic foot problems are the commonest reason for hospitalization of diabetic patients (about 30% of admissions) and absorb some 20% of the total health-care costs of the disease more than all other diabetic complication. The numbers of patients with chronic wounds and wound complications continues to increase. Wound management is a challenge in diabetic wound. Chronic wounds require significant medical, nursing and financial input with poor long-term results. One-third of all diabetic patients have significant peripheral neuropathy and/or peripheral vascular disease (PVD). In India prevalence of foot ulcers in diabetic patients in clinic population is 3%. Over the past several years negative pressure wound therapy (NPWT) using vacuum- assisted closure has emerged as the treatment of complex wounds of the diabetic foot. Many reports on the use of Vacuum Assisted Closure (VAC) therapy after failed revascularization have found increased chances of success. Clinicians should consider negative pressure wound therapy as an adjunct to other modalities in an effort to avoid complications.Methods: Total of 51 patients were included in this prospective study. They were randomly divided into two groups, negative pressure wound therapy (NPWT) group (25 patients) and control group (26 patients) who were treated with regular dressings. All the patients included had peripheral vascular disease which was declared non-revascularisable after vascular workup. Initial mean surface area was measured in each patient. Transcutaneous oxygen pressure was recorded in all the patients and each patient followed up based on their granulation tissue development and need for amputation in each group.Results: After wound management, mean surface area of the diabetic wounds was 39.08cm2 in the NPWT group (P=0.019), and 38.63cm2 in the control group (P=0.327). The use of NPWT may be an effective initial wound therapy to achieve faster wound bed granulation showing signs of healing in 19 among 25 patients (76%) compared to control group 7 showed granulation among 26 patients (26%) (P=0.001). The incidence of secondary higher amputation in NPWT group is 6/25 (24%), the control group 17/26 (65%) (P=0.003), suggesting reduced incidence of secondary higher amputations in NPWT group. After treatment, the experimental group significantly improved in measures of foot ulcer surface area compared with the control group. Further studies are needed to clarify the effects and indications and to modify the technique of this alternative treatment for use on non healing wounds.Conclusions: NPWT-treated patients reached a successful wound treatment endpoint more rapidly, and the benefit was apparent in all wound sizes. NPWT appears to be a safer and efficacious method, than moist wound therapy for the treatment of diabetic foot ulcers.

Surgical resection and vascularized bone reconstruction in advanced stage medication-related osteonecrosis of the jaw

A retrospective review of all patients with stage 3 medication-related osteonecrosis of the jaw (MRONJ), treated by surgical resection and immediate vascularized bone reconstruction at a tertiary care medical center, was performed. Eleven patients were included, seven female and four male; their mean age was 65.8 years (range 56–73 years). Mean follow-up was 25 months. Ten patients had received intravenous bisphosphonates. The most common pathology was breast cancer (4/11). Pain (n=8) and pathological fracture (n=7) were the most common presenting symptoms. Microvascular free flaps consisted of seven fibula osteocutaneous flaps and four scapula osteocutaneous free flaps. All patients reported resolution of symptoms, with complete bone union identified radiographically (100%). Complications occurred in three patients (27%). One patient required removal of hardware at 8 months postoperative. Dental implant rehabilitation was completed in two patients. Ten patients are tolerating an oral diet. Ten patients are alive without evidence of MRONJ at any of the surgical sites. One patient died 28 months after surgery from progression of metastatic disease. Advanced MRONJ can be successfully treated in patients using vascularized tissue transfer, including those patients with significant peripheral vascular disease. Dental rehabilitation is a viable option for advanced MRONJ patients treated by vascularized flap reconstruction.

Transcaval Transcatheter Aortic Valve Replacement With the ACURATE-neo Aortic Bioprosthesis: First North AmericanExperience.

A 77-year-old man presented with severe symptomatic aortic stenosis. He had multiple comorbidities, including significant chronic obstructive pulmonary disease and severe peripheral vascular disease. Doppler echocardiography demonstrated a heavily calcified and severely stenotic aortic valve, with a

PP.39.09

Objective: Completely different activation patterns were recently demonstrated for the renin-angiotensin-aldosteron system (RAAS) depending on whether renal artery stenosis (RAS) is unilateral or bilateral. Based on these premises, the present trial aimed to compare the prevalence of risk factors and the extension of atherosclerotic (ATS) disease in consecutive patients with significant (> 60%) uni- vs. bilateral RAS. Design and method: We prospectively enrolled 52 patients referred to renal angiography for suspected RAS and diagnosed with significant (> 60%) uni- or bilateral stenosis, subsequently resulting in 2 groups (27-unilateral RAS and 25-bilateral RAS). Before catheterization, he following parameters were assessed: demographics, cardiac history, known duration of hypertension, cardiovascular risk factors, features of extracoronary vascular disease, related comorbidities and associated cardiovascular drug therapy. In all patients, coronary artery disease (CAD) was confirmed during cardiac catheterization and an echocardiographic evaluation was performed in all patients. Results: No significant differences were established between the 2 groups regarding age, gender, body surface area, creatinine clearance, serum cholesterol, blood pressure, medication and left ventricle ejection fraction. The prevalence of conventional cardiovascular risk factors was similar in the 2 series: smoking, obesity, dyslipidemia, hypertension and diabetes. Moreover, similar outcomes were determined in the 2 study arms concerning the prevalence of coronary artery disease, as well as its severity (significant stenosis in single-vessel – 16% vs. 8%, two-vessel – 15% vs.16 % and three-vessel– 21% vs. 25%). However, the prevalence of significant ATS in extracardiac vessels was higher in the bilateral RAS group: carotid arteries and lower limb arteries (p < 0.01). Conclusions: The prevalence of conventional ATS risk factors and the CAD severity were similar in patients with either unilateral or bilateral RAS. However, a higher prevalence of significant carotid or peripheral vascular disease was found in bilateral RAS cases. As conventional cardiovascular risk factors were similarly distributed between groups, the present data may reflect a larger total body plaque burden in patients with bilateral RAS, thus possibly emphasizing a causal relationship between the specific RAAS activation pattern and an advanced generalized ATS. This paper is supported by the Sectional Operational Programme Human Resources Development (SOP HRD), finance from the European Social Fund and by the Romanian Government under the contract number POSDRU/159/1.5/5/137390.

Cellulosmicrobium cellulans isolated from a patient with acute renal failure

Introduction: Cellulosimicrobium cellulans is a rare human pathogen that is associated with chronic immunosuppression, such as human immunodeficiency virus infection, post‐transplantation or end‐stage renal disease. Case presentation: A 59‐year old man with a past medical history of significant cardiovascular, cerebrovascular and peripheral vascular disease was admitted to the intensive care unit (ICU) with intractable seizures. Physical examination, radiographic imaging and culture results suggested the patient had developed metabolic encephalopathy due to pneumonia caused by Staphylococcus aureus and Moraxella catarrhalis. The patient recovered neurologically with the use of broad‐spectrum antibiotics but developed acute renal failure during his stay. Seven days later, he relapsed into seizure activity and two separate blood cultures grew Cellulosimicrobium cellulans. Despite maximal antibiotic therapy, the patient continued to deteriorate. After 16 days, the patient’s family withdrew care and he subsequently died. Conclusion: We report the isolation of Cellulosimicrobium cellulans from a patient who developed acute renal failure following a prolonged stay in the ICU for sepsis encephalopathy.

OP160: The effect of peripheral vascular disease on the blood supply of the anterolateral thigh free flap: A radiographic study

Purpose The anterolateral thigh (ALT) flap has gained popularity over the last few decades for the reconstruction of various surgical defects given its distinct advantages including great versatility and low donor site morbidity. The anatomy of the main perforating vessel of the ALT flap, the descending branch of the lateral circumflex femoral artery (dbLCFA), has been well described in the literature, however only one study has investigated its patency in patients with significant co-morbidities. The aim of this study is to assess the degree of vascular stenosis of the dbLCFA in patients with multiple co-morbidities as compared to medically-fit controls. Material and methods 128 sets of angiographic data were collected from 93 patients retrospectively over a 12 month period. The percentage stenosis of superficial femoral artery (SFA), LCFA and dbLCFA was measured and converted into an established scoring system. Statistical analyses were performed using Chi-square tests. Results Mean stenosis of dbLCFA was 12.5%. Interestingly, 24.0% of patients without peripheral vascular disease (PVD) showed some degree of stenotic changes in dbLCFA, whereas only 10.7% of those with PVD had some degree of stenosis. There was no correlation between dbLCFA stenosis and patient co-morbidity. The SFA was significantly affected by smoking, hypercholesterolaemia (p Conclusions This study shows that the dbLCFA is not affected by patient co-morbidity including peripheral vascular disease when compared to medically-fit controls. Even in individuals with severe vascular stenosis of the superficial system (including complete obstruction); there is often complete sparing of the deep vascular system. Surgical reconstruction using the ALT flap is a relatively safe procedure for patients even with multiple co-morbidities including significant peripheral vascular disease and no additional pre-operative investigations are required.

The Role and Clinical Significance of High-Sensitivity C-Reactive Protein in Cardiovascular Disease

The Role and Clinical Significance of High-Sensitivity C-Reactive Protein in Cardiovascular Disease

The D&amp;T Report

The D&amp;T Report

Invited Commentary

Invited Commentary

Three-Year Outcomes of Multivessel Revascularization in Very Elderly Acute Coronary Syndrome Patients

Comparative effectiveness of interventional treatment strategies for the very elderly with acute coronary syndrome remains poorly defined due to study exclusions. Interventions include percutaneous coronary intervention (PCI), usually with stents, or coronary artery bypass grafting (CABG). The elderly are frequently directed to PCI because of provider perceptions that PCI is at therapeutic equipoise with CABG and that CABG incurs increased risk. We evaluated long-term outcomes of CABG versus PCI in a cohort of very elderly Medicare beneficiaries presenting with acute coronary syndrome. Using Medicare claims data, we analyzed outcomes of multivessel PCI or CABG treatment for a cohort of 10,141 beneficiaries age 85 and older diagnosed with acute coronary syndrome in 2003 and 2004. The cohort was followed for survival and composite outcomes (death, repeat revascularization, stroke, acute myocardial infarction) for three years. Logistic regressions controlled for patient demographics and comorbidities with propensity score adjustment for procedure selection. Percutaneous coronary intervention showed early benefits of lesser morbidity and mortality, but CABG outcomes improved relative to PCI outcomes by three years (p < 0.01). At 36 months post-initial revascularization, 66.0% of CABG recipients survived (versus 62.7% of PCI recipients, p < 0.05) and 46.1% of CABG recipients were free from composite outcome (versus 38.7% of PCI recipients, p < 0.01). In very elderly patients with ACS and multivessel CAD, CABG appears to offer an advantage over PCI of survival and freedom from composite endpoint at three years. Optimizing the benefit of CABG in very elderly patients requires absence of significant congestive heart failure, lung disease, and peripheral vascular disease.

AS-248: Association of Significant Peripheral Vascular Disease and Coronary Artery Disease in an Asian Population

Peripheral vascular disease (PVD) is a known risk factor of significant coronary artery disease (CAD). The aim of this study was to analyze the association of PVD and CAD when a patient (pt) presents with significant PVD.

Clinical Profile, Treatment Assignment and Clinical Outcome of Patients With Severe Aortic Stenosis Not Eligible to Participate in a Clinical Trial of Percutaneous Aortic Valve Replacement

Patients with severe aortic stenosis and considered at high surgical risk or inoperable, and not eligible for a randomized clinical trial evaluating percutaneous aortic valve replacement (PAVR), were studied. Many of the patients referred to the study did not meet the inclusion criteria and/or had conditions listed in the exclusion criteria. These patients were then deferred to other treatment modalities. The study cohort consisted of 285 patients with severe aortic stenosis referred to participate in a clinical trial of PAVR. Patients were screened for eligibility on the basis of the protocol inclusion and exclusion criteria and deferred to other treatment modalities if they did not meet the enrollment criteria. Those patients were followed clinically by telephone contact or office visits. Of the 285 patients referred for PAVR, 216 (75.8%) were not included. The leading reasons for lack of eligibility were significant peripheral vascular disease in 50 (23.1%), Society of Thoracic Surgeons score <10% in 48 (22.9%), aortic valve area >0.8 cm(2) in 30 (13.9%), significant coronary artery disease in 25 (11.6%), and renal failure in 22 (10.2%). Sixty-nine of these patients (31.9%) were treated medically, 102 (47.2%) with balloon aortic valvuloplasty, and 45 (20.9%) with surgical aortic valve replacement. Major baseline characteristics were similar. Society of Thoracic Surgeons scores were lower in the surgical group compared with the medical and balloon aortic valvuloplasty groups (10.2 +/- 2.5 vs 12.8 +/- 3.3 vs 13.7 +/- 3.3, respectively, p <0.001). During a median follow-up period of 175.5 days (range 55.7 to 344.75), the mortality rate was higher in the balloon aortic valvuloplasty group compared with the medical and surgical aortic valve replacement groups (46 [45.1%] vs 22 [31.9%] vs 10 [22.2%], respectively, p = 0.01). In conclusion, high-risk patients with severe aortic stenosis who are deferred from PAVR often do poorly and incur high mortality rates, especially when treated with balloon valvuloplasty or medical therapy, while a loss of quality of life is apparent in those treated surgically.

Oxidative stress in diabetic foot ulcer

Summary Background Hyperglycemia causes tissue injury leading to vascular damage through generation of free radicals and their effect on endothelium in diabetics. The present study has been designed to evaluate the oxidant stress by measuring malondialdehyde, antioxidant status and nitric oxide synthase activity in diabetic foot ulcer. Materials and methods Thirty-two diabetic patients with peripheral vascular disease [PVD] and foot ulcer, fifteen diabetic patients without evidence of significant diabetic neuropathy or peripheral vascular disease and fifteen healthy control subjects were included in this study. Blood samples were taken for estimation of malondialdehyde, Vitamin E and superoxide dismutase [SOD] enzyme. Immunocytochemical staining of full thickness skin biopsies for NADPH diaphorase was carried out which is colocalised with nitric oxide synthase. Results Serum malondialdehyde level was significantly higher in the patients with PVD as compared with the diabetic controls [1.164 ± 0.371 vs. 0.710 ± 0.277 nmol/mL] and non-diabetic controls. Superoxide dismutase and tocopherol [Vitamin E] levels were significantly lower in patients with PVD than in diabetics without PVD. Immunocytochemical study The tissue section obtained from 10 diabetic wound stained for NADPH diaphorase activity show intense staining while the control sections of the skin biopsy from diabetic patients without PVD did not show staining of the tissue. Conclusion Diabetic wounds have high level of NO synthase activity favoring heightened NO production. Increased free radicals generation [evidenced by increased malondialdehyde and superoxide dismutase level] and reduced level of antioxidants [Vitamin E] or endothelial resistance to NO might be contributory to ineffectiveness of NO on microcirculation. No such study has been done earlier to show a complex abnormality of oxidative stress in diabetic foot lesions.

Magnetic Resonance Angiography for Free Fibula Flap Transfer

Recent refinements of magnetic resonance angiography (MRA) allow imaging vessels as small as the septocutaneous perforators (< or = 1 to 2 mm diameter), but a Medline review reveals no report of septocutaneous vessel imaging for free flap surgery. Challenges in fibula free flap preparation include knowledge of: (1) tibioperoneal anatomy, (2) the positions of the perforator vessels on the peroneal artery and their course in the posterolateral intermuscular septum, and (3) the cutaneous distribution of the perforators. Questioning whether high-resolution MRA could image these, we studied the lower extremities of nine healthy volunteers. MRA demonstrated tibioperoneal anatomy in sufficient detail to exclude anatomic variants and significant peripheral vascular disease and showed septocutaneous perforators arising from the peroneal artery and coursing in the posterolateral intermuscular septum to the skin. High-resolution MRA provided anatomic and clinical information that conventionally has been impossible to obtain preoperatively or has required multiple tests, often of an invasive nature.

Acute Esophageal Necrosis and Low-Flow State

Acute esophageal necrosis (AEN), also called black esophagus, is quite exceptional. Endoscopic findings show circumferential black discolouration of the esophagus with or without exudates. The etiology of AEN is presently unknown and is assumed to be multifactorial. Distal esophageal involvement with proximal extension ending sharply at the gastroesophageal junction is the most common presentation. The present case report describes the clinical and endoscopic evolution of black esophagus observed in a patient with significant peripheral vascular disease, who was presented to the intensive care unit at the Hopital Saint-Francois d'Assise (Quebec City, Quebec). Through an extensive review of the literature, common underlying clinical conditions of patients diagnosed with AEN have been identified.