Vascular Episodes Research Articles

Correlation of blood glucose levels and seriousness in patients with acid-ischemic vascular cerebrial episode

Correlation of blood glucose levels and seriousness in patients with acid-ischemic vascular cerebrial episode

Hemodynamics of vascular shunts: trends, challenges, and prospects.

Vascular bypass surgery takes a significant place in the treatment of vascular disease. According to various assessments, this type of surgery is associated with almost 20 % of all vascular surgery episodes (up to 23 % according to the Federal Neurosurgical Center of Novosibirsk). Even though the problem of using of vascular grafts is obvious and natural, many problems associated with them are not still elucidated. From the mechanics' point of view, a vascular bypass is a converging or diverging tee, and the functioning of such structures still does not have strict mathematical formulations and proofs in the general case, which forces many researchers to solve specific engineering problems associated with shunting. Mathematical modeling, which is the gold standard for virtual simulations of industrial and medical problems, faces great difficulties and limitations in solving problems for vascular bypasses. Complications in the treatment of the vascular disease may follow the difficulties in mathematical modeling, and the price can be a cardiac arrest or a stroke. This work is devoted to the main aspects of the medical application of vascular bypasses and their functioning as a mechanical system, as well the mathematical aspects of their possible setup.

#4742 SURVIVAL AND PREDICTORS OF MORTALITY IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Mortality in hemodialysis patients significantly exceeds the one observed in general population. Identifying and early management of risk factors is essential for improving survival of these patients. Aim of the study is to assess survival and evaluate factors related to mortality in hemodialysis population. Method We retrospectively studied 237 patients [99 ♀, median age 76 (69-84) years] undergoing hemodialysis in a single Dialysis Center for a 10-years period of time (from 1/2/2010 to 31/1/2021). Demographics, comorbidities and laboratory parameters were recorded and analyzed. Median survival, mortality rate and factors that may affect them were evaluated. Results The mortality rate was 9.28% in the first year and 36.29% in five years after starting dialysis, respectively (Figure 1. Kaplan-Meier survival curves for the study population). Elderly patients (>65 years) had a lower median survival compared to younger ones (63 versus 103 months, p = 0.031). Survival of diabetics undergoing on-line hemodiafiltration was twice versus those undergoing hemodialysis (87 versus 42 months, p<0.001). Most common causes of death were cardiovascular diseases (32.38%), infections (20.95%) and cancer (18.1%) (p<0.001). Multivariate analysis identified as important predictors of mortality, the existence of: diabetes mellitus [hazard ratio (HR) = 2.387, 95% confidence interval (CI) 1.278-4.46, p = 0.006], peripheral arterial disease (HR = 1.875, 95% CI 1.12-3.139, p = 0.017) and central venous catheter (HR = 2.421, 95% CI 1.297-4.518, p = 0.005). In contrast, absence of vascular access thrombotic episode (HR = 0.289, 95% CI 0.158-0.527, p<0.001) and body mass index >20 kg/m2 (HR = 0.517, 95% CI 0.294-0.909, p = 0.022) had a favorable effect on survival. Conclusion Mortality rate in our cohort was measured 9.28% in first year and 36.29% in five years after starting hemodialysis. Survival was lower at elderly and diabetic patients undergoing hemodialysis. Our study identified some mortality factors potentially modifiable, such as body weight, type of vascular access and method of dialysis treatment.

The Relationship Between Periodontal Disease (PD) and Recurrent Vascular Events in Ischemic Stroke/Transient Ischemic Attack (TIA) Patients: A Hospital-Based Cohort Study

Background In this cohort study, the association between periodontal disease (PD) andrecurrent vascular events was determined among the subjectswithischemic stroke/transient ischemic attack (TIA), and the extent and severity of periodontal disease were estimated among these subjects. Methods This prospective, longitudinal, hospital-based cohort study included 153 individuals who had a stroke or TIA. They were divided into two groups: high periodontal disease (HPD) (N=55, mean age: 59.40±12.21) and low periodontal disease (LPD) (N=98, mean age: 53.03±12.82). Clinical attachment loss (CAL) and probing pocket depth (PPD) were used to measure the severity of the periodontal disease. TOAST criteria were used to determine the ischemic stroke etiology, and the NIH Stroke Scale (NIHSS) was used to determine theischemic stroke severity. A follow-up survey found that vascular incidents recurred. Results HPD individualsexhibited a higher median NIHSS (eight) than LPD patients (seven) in a subset of stroke population (N=23). Thirty-eight cardiovascular events occurred in the first three months after enrollment, including 23 strokes and seven TIAs, and five myocardial infarctions(MIs). There were three deaths from vascular causes. There was a non-significant association between PD and composite vascular events (HR 1.06, 95% CI, 1.03 to 1.09, p=0.71). Compound vascular events were not related to severe HPD (HR 1.31, 95 % CI 0.54 to 3.16, p=0.07). Conclusion In stroke/TIA patients, there is no link between high periodontal disease and recurrent vascular episodes. The proportions of stroke subtypes were not substantially differentbetween HPDand LPD.

Experience of the use of dipyridamole for secondary prevention of ischemic stroke

Acute cerebrovascular accident (ACV) is an important medical and social problem, which is associated with high morbidity, mortality and frequent disability. The current system for providing specialized medical care to patients with stroke has shown its effectiveness, as evidenced by a decrease in hospital mortality and an increase in the number of patients returning to work. However, the incidence of stroke remains high, which is also associated with the COVID-19 pandemic. Every third patient with COVID-19 had neurological symptoms, and a pathomorphological study of the brain of the deceased showed signs of hypoxic encephalopathy in every fifth. Due to the fact that with COVID-19 there is a high probability of developing ischemic stroke (IS), it is necessary to promptly identify and correct the following factors that contribute to the occurrence of stroke with COVID-19: cardiovascular diseases, diabetes mellitus, arterial hypertension, atherosclerosis. Direct exposure to the virus results in systemic inflammatory hyperactivity with a prothrombotic state secondary to protein C and S deficiency. An important problem is both the prevention of the first and recurrent stroke, regardless of the etiology. The basis of secondary prevention is the correction of risk factors, as well as the development of an individual program with antihypertensive, lipid-lowering therapy. The leading line of secondary prevention of IS is antiplatelet therapy, which reduces the risk of developing acute vascular episodes by 25%. For the purpose of secondary prevention of ischemic stroke, acetylsalicylic acid, dipyridamole, clopidogrel are used. In the discussed clinical observation, a patient developed repeated episodes of transient ischemic attack against the background of a stenosing process in the common carotid artery, hypertension, and a previous coronavirus infection. Given that the greatest risk of recurrent stroke is associated with atherosclerosis, which can be complicated by thrombus formation, chimes and acetylsalicylic acid were chosen for secondary prevention. Follow-up observation showed the correctness of the chosen tactics.

O22 Pregnancy planning in non-criteria antiphospholipid syndrome

Case report - IntroductionAntiphospholipid Syndrome (APS) is an autoimmune condition manifested by vascular thrombosis with or without pregnancy related morbidities. APS classification criteria require detection of persistent antibodies: Anti-Cardiolipin Antibody (aCL), Anti-Beta Glycoprotein I (ab2GPI) and circulating Lupus Anticoagulant (LAC).Criteria for the diagnosis of obstetric antiphospholipid syndrome allow for optimal treatment planning in pregnancy and reduction of foetal and maternal morbidity. There are, however, several “non-criteria” features of APS, including late pre-eclampsia, which may also infer adverse obstetric outcomes.We highlight a treatment dilemma in a young female with lupus and APS with history of previous pregnancy that was complicated by pre-eclampsia.Case report - Case descriptionWe describe a case of a 26-year-old female with systemic lupus erythematosus (SLE), “triple positive” APS markers (aPL) and non-criteria APS obstetric morbidity.During her first pregnancy she presented at 22 weeks with severe and frequent migraine episodes. She had no other active clinical manifestations of SLE. There was no prior history of pregnancy and therefore no previous obstetric morbidity nor had she had any vascular thrombotic episodes. She had been commenced on low-dose aspirin (LDA) at the start of her pregnancy and was already taking hydroxychloroquine (HCQ). The dose of HCQ was increased to 400mg daily leading to improvement in the headaches. She had persistent strong ACL antibodies, positive LAC and ab2GPI antibodies. ANA was positive with hypocomplementemia and neutropenia but normal range double-stranded DNA antibodies.After discussion with a tertiary centre, it was recommended to continue HCQ and LDA. Low molecular weight heparin (LMWH) was not proposed as she did not fulfil criteria for obstetric APS. Her pregnancy was subsequently complicated by pre-eclampsia and post-partum sepsis.Two years later she sought advice to plan her second pregnancy, raising important questions as to whether the same treatment strategy should be followed or if alternative approaches should be considered, given the history of pre-eclampsia and its association with APS. Again, she did not meet the international consensus (revised Sapporo) criteria for diagnosis of obstetric APS.After further discussion with the tertiary centre, she commenced high-dose aspirin 150mg/day alone. Uterine artery dopplers were recommended and LMWH proposed if bilateral notching was noted. Dopplers were normal.Her blood pressure (BP) fluctuates between 130-145mmHg systolic. She has occasional crops of mouth ulcers but no other SLE features. Migraines continue every 2—3 weeks although severe attacks are infrequent. C4 is persistently low with normal Ds DNA and urine protein/creatinine ratio.Case report - DiscussionOur case raises questions on how pregnancy should be safely managed in patients without a prior history of APS-related pregnancy complications but who nevertheless have risk factors, in the form of APS antibody positivity and non-criteria obstetric manifestations of APS. Her previous pregnancy was treated with LDA and HCQ which had proved insufficient in avoiding the outcome of pre-eclampsia.The objective of prophylactic treatments is to prevent adverse outcomes such as miscarriage, which carry significant maternal morbidity including psychological manifestations such as depression and anxiety. In first pregnancies, mothers have no existing obstetric history, such that current treatment guidance provides few recommendations for preventative interventions, even where other risk factors are apparent. Furthermore, non-criteria manifestations of obstetric APS are now well recognised, which may further highlight potential risk for obstetric morbidity but fail to trigger interventions as they are not included within the current international criteria. These manifestations include late pre-eclampsia, placental abruption and late pregnancy loss, unexplained in vitro fertilisation failures, two unexplained miscarriages and three non-consecutive miscarriages. Low positive antibody titres and intermittent aPL are also included.Studies suggest that women with non-criteria APS may benefit from standard treatment for obstetric APS which includes LMWH in addition to aspirin, with good pregnancy outcomes.HCQ has a dose-dependent effect in preventing thrombosis through inhibition of platelet aggregation and aPL Ab-related thrombosis. However, pregnancy itself is a prothrombotic condition and in the presence of persistent triple positive aPL is a risk factor for adverse pregnancy outcomes.Further studies are needed to define the risk of non-criteria APS on pregnancy outcomes and define optimal treatment strategies.Case report - Key learning pointsObstetric APS carries significant risk for maternal foetal morbidity including miscarriage and pre-term birth.Significant maternal psychological effects are recognised even following a single miscarriage.The international consensus (revised Sapporo) criteria for diagnosis of obstetric antiphospholipid syndrome exclude certain non-criteria clinical and laboratory manifestations that may confer adverse pregnancy outcomes.First pregnancies are challenging to risk stratify in patients with identified aPL as there will be no prior pregnancy history to reference.Ultrasound doppler velocimetry is a useful non-invasive tool to diagnose poor placental perfusion, a predictor of obstetric complications, hence identifying high-risk pregnancies.Further research is required to establish the diagnostic validity, predictive value, and treatment implications of non-criteria manifestations of obstetric APS.

Discovery of Anti-SS-A Antibodies during Stroke Investigations in Young Adults: What Impact?

ObjectivesFrench national guidelines recommend searching for anti-SS-A antibodies during the second-line assessment of stroke in adults < 55 years of age in the absence of an identified etiology. We aimed to assess the impact of finding anti-SS-A antibodies during the etiological investigations of stroke in young adults. MethodsMedical files from all patients ≤ 55 years of age admitted to a single stroke unit during a five-year period and for whom anti-SS-A antibodies were positive were retrospectively analyzed. ResultsTwelve patients were included (9 women; median age 48.5 years), with a rate of anti-SS-A antibody positivity of 1.6% (95% confidence interval [0.71–2.55] %; 12/735 admissions). The etiologies of the 12 ischemic events based on the TOAST classification were large-artery atherosclerosis (n = 1), cardioembolism (n = 1), small-vessel disease (n = 1), other determined etiology (n = 3), multiple etiology (n = 1), and no determined etiology (n = 5). A connective tissue disease (CTD) was discovered in 8/12 patients (1 primary Sjögren's Syndrome, 1 mixed CTD, 1 systemic sclerosis, 2 antiphospholipid syndromes, 1 undetermined CTD, 2 lupus). Anti-SSA antibodies were not directly responsible for the stroke in any of the 12 cases. A link between the autoimmune disease and the neurological vascular episode could be hypothesized for four patients, but it never influenced the therapeutic decision. ConclusionsFinding anti-SS-A antibodies during the etiological assessment of a stroke of young adults is rare. However, it may be worthwhile to refer the patient to a rheumatologist/an internist because CTD may be discovered and may require specific follow-up.

A device for surveillance of vascular access sites for bleeding: results from a clinical evaluation trial

Post-procedural wound haemorrhage is a potentially life-threatening complication. For haemodialysis patients, bleeding is often encountered after vascular access procedures and fatal episodes have been reported. Visual monitoring for bleeding is manpower intensive and bleeding episodes may still be missed between inspections. A device, Blood WArning Technology with Continuous Haemoglobin sensor (BWATCH), was developed to detect bleeding from wounds. This a prospective, observational clinical trial on patients who have had a dialysis catheter inserted or removed. The battery-powered, disc-shaped device (43 mm diameter, 12 mm height) was placed over the dressing for at least six hours. The device detects reflected light with characteristics specific for haemoglobin and an alarm would be triggered if bleeding occurs. There were 250 participants (177 post-insertion, 73 post-removal) and 36 episodes of bleeding occurred. The device alarm was triggered in all instances but there were also 9 false alarms. Specificity was 95.8%, false positive rate was 4.2% and positive predictive value was 80.0%. Sensitivity and negative predictive value were 100% but detection failure may still occur due to improper application or device maintenance. The use of technological aids for monitoring improves patient safety and may reduce demand on manpower.

Vascular surgery and an occurrence of stroke

Introduction. The brain responds to metabolic disorders with a limited array of symptoms and signs. The brain has enormous needs in terms of substrate and blood flow. Aim. This paper presents a case report reporting episode of stroke. Description of the case. The incidence of cerebral vascular episodes in the form of strokes, transient episodes of cerebral ischemia is reported. Conclusion. The chemical constituency of the brain are generally quite different from those of other tissues. Stroke is a clinical syndrome characterized by sudden focal or generalized brain dysfunction.

Exploring the Viability of NARNIA with Cognitive-Communication Difficulties: A Pilot Study.

Everyday discourse is a common context for the difficulties experienced by people with acquired neurogenic communication disorders. While evidence is present for effective manualized interventions that directly improve the discourse skills in aphasia, this remains limited for people with cognitive-communication disorders. This proof of concept study used an in-depth case series approach to trial the NARNIA discourse intervention used successfully in aphasia to explore transferability of the protocol and effectiveness in people with cognitive-communication impairments. Four female participants with mild to moderate cognitive-communication difficulties (mean age: 52.8 years)-two following traumatic brain injury and two following vascular episodes-were recruited. Modifications were made to the protocol to accommodate the participant group. Cognitive-linguistic abilities, self-perceptions of communicative behavior and psychosocial recovery, and repeated discourse measures were assessed pre-, immediately post, and at 4 weeks following intervention, to measure treatment effectiveness. Significant gains were observed in quantity of output, informativeness, and efficiency of information across both everyday and narrative discourse genres for all participants. However, in contrast to previous studies, minimal change was observed in discourse macrostructure elements. Significant improvements were also observed in memory or working memory for two participants. This study provides preliminary evidence for the effectiveness of using an adapted protocol with people with cognitive-communication disorders, highlighting how adaptations may address the cognitive needs of this diverse clinical group.

THE CONTRIBUTION OF CARRIER THE ALLELIC VARIANT G1691A OF THE GENE V OF COAGULATION FACTOR TO THE DEVELOPMENT OF THROMBOTIC COMPLICATIONS DEPENDING ON THE PRESENCE OF CARDIOVASCULAR RISK FACTORS IN INDIVIDUALS WITH SECONDARY LEUKOCYTOSIS, THROMBOCYTOSIS A

Introduction. In addition to the "Classical" Risk Factors (RF) for Arterial and Venous Thrombosis, some authors, as triggers for the development of the latter, refer to reactive changes in Peripheral Blood (PB) counts and markers of Hereditary Thrombophilia. The results of most studies indicate that the "Classical" Risk Factors (RF) for Vascular Thrombotic Episodes are strong triggers of their development, the presence of which eliminates the Pro-thrombogenic potential of carrier of the Hereditary Thrombophilia and reactive changes in Peripheral Blood (PB) (RChPB). However, to date, there is no data regarding the assessment of contribution of the Leiden Mutation in the cohort with both reactive changes in Peripheral Blood (PB) and Risk Factors (RF) for Thrombotic Complications (ThC).&#x0D; Results. In patients with reactive changes in the Peripheral Blood (PB), the Leiden Mutation occurs in 5,92% of cases (9 carriers). In individuals with Thrombotic Complications (ThC), the Allele G1691A of the Proaccelerin Gene is determined more often than in a cohort without them (5 out of 31 vs 4 out of 121; p=0,030). In the general cohort of individuals with reactive changes in Peripheral Blood (PB), carriage of the Leiden Mutation increased the risk of Thrombotic Complications (ThC) by 3,05 times (Relative Risk (RR) = 3,05; 95% Confidence Interval (CI) = 1,54-6,03). In patients without Risk Factors (RF) and people under 60 years of age, Thrombosis occurred more often with the Nucleotide Variant of Allele G1691A of the Gene V of Coagulation Factor than with the Allele of wild-type (3 out of 6 vs 4 out of 75; p=0,007 and 4 out of 6 vs 8 out of 107; p=0,010, respectively). The probability of developing of Thrombosis with carriage the Allele G1691A of the Proaccelerin Gene in patients with Thrombotic Complications (ThC) without Risk Factors (RF) and in younger patients was 10,57 (95% Confidence Interval (CI) = 2,60-42,87) and 16,83 times (95% Confidence Interval =3,43-82,41), respectively. The risk of Thrombotic events in people without Risk Factors (RF) younger than 60 years is 16,75 times (Relative Risk (RR) = 16,75; 95% Confidence Interval (CI) = 3,44-81,50). However, the frequency and risk of Thrombosis did not increase in individuals with Risk Factors (RF), in patients over 60 years of age or in a cohort with Risk Factors over 60 years of age.&#x0D; Conclusion. Carriage the Allele G1691A of the Gene V of Coagulation Factor in patients with reactive Thrombocytosis, Leukocytosis and Secondary Polycythemia increases the risk of Thrombosis primarily due to patients without Risk Factors (RF) younger than 60 years.

PS1580 PREVALENCE AND RISK FACTORS FOR THROMBOSIS IN ADULT ITP PATIENTS TREATED WITH TPO‐RA

Background:Thrombopoietin‐receptor‐agonists (TPO‐RA) are effective treatments of immune thrombocytopenia (ITP). Previous long‐term TPO‐RA clinical trials have shown that thrombotic events occurred in 6% of TPO‐RA‐treated ITP patients, with thrombotic events appearing to be more frequent in patients of older age and having at least 1 general risk factor for thrombosis.Aims:To evaluate the prevalence of venous and arterial thrombosis in patients with primary ITP during treatment with TPO‐RA.Methods:Multicenter retrospective study that included 121 adult primary ITP patients from 19 secondary and tertiary Spanish hospitals who had initiated treatment with Romiplostim (ROM) or Eltrombopag (ELT) as long‐term therapy between January 2012 and December 2014. Information on patient characteristics was collected from medical records to assess and compare risk factors of ITP patients with and without vascular events (VE).Results:A total of 121 patients (median age 63 years, range 19–96 years; 68% chronic phase), initiated TPO‐RA (ROM 54; EPG 67). During a 329.3 patient‐year time under treatment (exposure to ROM and ELT of 161.03 and 168.27 patient‐year, respectively) 15 patients experienced 17 vascular episodes (9 arterial, 8 venous). One patient presented antiphospholipid antibodies, five had been diagnosed with neoplasia, one with vascular peripheral disease, two with hypothyroidism –one of whom also had renal disease‐. Seven events occurred with ROM, and 10 with ELT. The annualized risk was 4.2 and 5.9 VE/100 patient‐years in ROM and ELT treated patients, respectively (median 5.2). Most VE occurred in the first year of TPO‐RA therapy (median 276 days; 5–1183), with a trend toward earlier events under ROM than ELT (127 days vs 360 days, respectively; p = 0.070). In the case of ischemic events the median time to arterial events was 165 vs. 606 days in ROM and ELT treated patients; P = 0.029. There were no significant differences in the 15 patients vs. the 106 patients that did not suffer from vascular events in terms of gender, age, diabetes, hypertension, previous vascular events, nor time on prednisone as 1st line therapy. In patients experiencing VE on TPO‐RA, a significant association with previous splenectomy (53.3% vs. 25.5%, P = 0.026), and chronic phase of the disease (93.3% vs. 64.1%, P = 0.024) compared with those not having such characteristic was detected. Surprisingly previous malignancy significantly associated with VE under TPO‐RA treatment (33% vs. 2.8%, P = 0.000009). All patients were reported to have sustained complete remission of previous neoplasias (1 colon carcinoma; 1 Burkitt lymphoma; 1 bladder cancer; 1 breast cancer; 1 patient with history of thyroid, breast and ovarian tumors) and were not receiving antineoplastic therapies. In multivariate analysis with logistic regression only previous malignancy predicted significantly higher odds of VE (Table 1).Summary/Conclusion:In this study, we describe an annualized risk of 5.2 vascular events/100 patient‐years in TPO‐RA treated patients. Venous and arterial thromboembolism are not frequent complications in ITP patients under TPO‐RA, except in particular settings, such as in splenectomized and chronic patients. Our data revealed a novel association of history of previous neoplasia with thrombotic events in patients with TPO‐RA. These results suggest that a history of prior cancer should be systematically screened before TPO‐RA initiation, and if so, alternative therapy should be considered; however, due to the limited sample size, further research is warranted.image

Recomendaciones sobre el tratamiento de la hipertensión arterial en la prevención secundaria del ictus isquémico

Stroke continues to be one of the leading causes of death and disability in the world. One of the main problems with a patient who has survived from a stroke is the possibility of developing a new vascular episode again. Hypertension is the modifiable vascular risk factor with the greatest impact for both primary prevention and stroke recurrence. The Group for the study of Hypertension and Brain (GEHYC) from the Spanish Society of Hypertension aims to spread the importance of strict control of blood pressure in order to prevent cerebrovascular diseases. In this article, this multidisciplinary Group reviews the latest evidence regarding antihypertensive treatment and secondary prevention of ischemic stroke.

Invited commentary

This report represents a thorough analysis of the search for associations between plasma renin or aldosterone levels and excised carotid artery plaque characteristics and composition and includes evaluation of many important intraplaque inflammatory mediators. Because activation of the renin-angiotensin system has been previously described to be associated with an increase in coronary and cerebrovascular events, it seemed logical to assume that these levels should correlate with the atherosclerotic plaque. Failure to find such a relationship was unexpected, which implies that the mechanism for the clinical outcomes is unrelated to acceleration of plaque lesion growth or plaque destabilization. Interestingly, a higher incidence of the composite of subsequent major clinical cardiovascular events was noted to be associated with higher levels of renin and aldosterone, although a history of prior cardiac disease at baseline was also higher among these patients. Nonetheless, the association of subsequent cardiovascular events did reflect greater numbers of adverse cerebrovascular and peripheral vascular episodes in addition to cardiac events. In attempting to understand the findings presented, it must be noted that plasma samples were obtained at only one point during the lifetime of the atherosclerotic process. Were the mature plaques derived from arteries that may have long since become activated by the renin-angiotensin system and no longer were dependent on it for continued activity, with the effect of renin and aldosterone most critical in the early stages of lesion development? Alternatively, although exclusion of patients using angiotensin-converting enzyme inhibitors in this real-life population would have severely limited the sample set size available for analysis, such inhibition may still compromise the ability to interpret these results, even if use of this drug class did not appear to affect the results of preliminary Cox regression analysis. Certainly, use of these inhibitors has been associated with reductions in cardiovascular events.1Yusuf S. Sleight P. Pogue J. Bosch J. Davies R. Dagenais G. Heart Outcomes Prevention Evaluation Study InvestigatorsEffects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients.N Engl J Med. 2000; 342: 145-153Crossref PubMed Scopus (8167) Google Scholar Could it be that elevated renin and aldosterone levels have, in fact, no causal role, but rather serve merely as markers of an as yet undiscovered mechanism of plaque destabilization? Whatever the case, atherosclerosis remains a complex process, resistant to complete explanation despite the laudable efforts of committed researchers such as Dr Hillaert and her colleagues. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Renin and aldosterone are not associated with vulnerable plaque characteristics in patients with carotid artery diseaseJournal of Vascular SurgeryVol. 68Issue 1PreviewThe renin-angiotensin-aldosterone system is increasingly being recognized to play an important role in the development and clinical course of cardiovascular diseases. Renin-angiotensin-aldosterone system activation is associated with clinical outcome in various populations of cardiovascular patients, such as patients with coronary artery, peripheral artery, and cerebrovascular disease. In this study, we investigated the associations between plasma renin and aldosterone concentrations and atherosclerotic plaque characteristics and secondary vascular events in patients undergoing carotid endarterectomy. Full-Text PDF Open Archive

Successfully Managing Impending Skin Necrosis following Hyaluronic Acid Filler Injection, using High-Dose Pulsed Hyaluronidase

Summary:Facial fillers are becoming increasingly popular as aesthetic procedures to temporarily reduce the depth of wrinkles or to contour faces. However, even in the hands of very experienced injectors, there is always a small possibility of vascular complications like intra-arterial injection of filler substance. We present a case report of a patient who developed features of vascular obstruction in right infraorbital artery and tell-tale signs of impending skin necrosis, after hyaluronic acid filler injection by an experienced injector. The diagnosis of a vascular complication was made quickly with the help of clinical features like blanching, livedo reticularis, and poor capillary refill. Patient was treated promptly with “high-dose pulsed hyaluronidase protocol” comprising three 1,000-unit pulses of hyaluronidase, administered hourly. There was no further increase in size of the involved area after the first dose of hyaluronidase. All of the involved area, along with 1 cm overlapping in uninvolved skin area, was injected during each injection pulse, using a combination of cannula and needle. Complete reperfusion and good capillary filling were achieved after completion of 3 pulses, and these were taken as the end-point of high-dose pulsed hyaluronidase treatment. Immediate skin changes after filler injections, as well as after hyaluronidase injections and during the 3-week recovery period, were documented with photographs and clinical notes. Involved skin was found to have been fully recovered from this vascular episode, thus indicating that complete recovery of the ischemic skin changes secondary to possible intra-arterial injection could be achieved using high-dose pulsed hyaluronidase protocol.

Orthopaedic Manifestations of Sickle Cell Disease.

Sickle cell disease (SCD) is an autosomal recessive disorder that results in hemolytic anemia related to abnormal hemoglobin and erythrocyte levels. SCD is characterized by vascular occlusive episodes, visceral sequestration, and aplastic or hemolytic crises. These crises most commonly occur in bone. The orthopaedic manifestations of SCD comprise much of the morbidity associated with this disorder. Osteonecrosis and osteomyelitis are among the most disabling and serious musculoskeletal complications in patients with SCD. Effective management of the bone and joint sequelae requires an accurate diagnosis, an understanding of the pathophysiology of the disease, and knowledge of available medical and surgical treatment alternatives. The major orthopaedic manifestations of SCD are osteonecrosis, osteomyelitis, septic arthritis, and bone infarction. Patients with SCD require close monitoring in the perioperative period because of the risk for vasoocclusive crisis.

Framework Utilizing Machine Learning to Facilitate Gait Analysis as an Indicator of Vascular Dementia

Vascular dementia (VD), the second most common type of dementia, effects approximately 13.9 per cent of people over the age of 71 in the United States alone. 26% of individuals develop VD after being diagnosed with congestive heart failure. Memory and cognition are increasingly affected as dementia progresses. However, these are not the first symptoms to appear in some types of dementia. Alterations in gait and executive functioning have been associated Vascular Cognitive Impairment (VCI). Research findings suggest that gait may be one of the earliest affected systems during onset of VCI, immediately following a vascular episode. The diagnosis tools currently utilized for VD are focused on memory impairment, which is only observed in later stages of VD. Hence we are proposing a framework that isolates gait and executive functioning analysis by applying machine learning to predict VD before cognition is affected, so pharmacological treatments can be used to postpone the onset of cognitive impairment. Over a period of time, we hope to be able to develop prediction algorithms that will not only identify but also predict vascular dementia.

Venous thromboembolism and vascular access thrombosis in patients with end-stage renal disease on maintenance hemodialysis: Cross-sectional results of the Vienna InVestigation of AtriaL fibrillation and thromboembolism in patients on hemoDIalysis (VIVALDI)

BackgroundPatients with end-stage renal disease (ESRD) on maintenance hemodialysis (HD) are at risk for occurrence of vascular access thrombosis and venous thromboembolism (VTE). Understanding the extent of these complications and identifying risk factors can help improve management strategies. MethodsAdult HD patients were cross-sectionally recruited into the Vienna InVestigation of AtriaL fibrillation and thromboembolism in patients on hemoDIalysis (VIVALDI). In this investigation, retrospective data on the incidence and risk of VTE and vascular access thrombosis was analyzed using logistic regression and negative binomial regression for counts of vascular access thrombosis episodes. ResultsThe analysis includes 626 patients on HD, which constitutes 73% of the total HD population in Vienna, Austria. One-hundred-seventy-eight patients (28.4%) had 275 vascular access thrombosis events during 2463.1 patient-years on HD, corresponding to an incidence rate (IR) of 111.6 events per 1000 patient-years on HD. In the multivariable negative binomial regression model, we found that patients suffered from vascular access thrombosis 2.5 times more often (IR ratio 2.63, 95% confidence interval [CI] 1.48–4.68, p=0.001) if toxic nephropathy was their cause of ESRD (n=28, 4.5%) compared to patients with other causes of ESRD. Sixty-one patients (9.7%) had a history of VTE and the IR of VTE events during the time on HD was 10.9 per 1000 patient-years on HD (women: IR 15.1, men IR 8.6). Female sex (odds ratio [OR] 1.90, 95%CI 1.07–3.36, p=0.029) and atrial fibrillation (OR 2.00, 95%CI 1.10–3.64, p=0.023) were independently associated with VTE. ConclusionsThromboembolic events including vascular access thrombosis and VTE are frequent complications in patients on HD. Risk evaluation for thromboembolism, including sex and clinical parameters, may identify high-risk patients and improve their clinical management.

Slurred Speech Spells Trouble…

An 86-year-old lady was referred to the TIA clinic with recurrent episodes of slurred speech, disorientation and flashing lights in her vision. She was known to have difficult to control hypertension and atrial fibrillation, but had been stable on warfarin for many years with no previous vascular events or bleeding episodes. MRI imaging showed a large number of cerebral microbleeds in a lobar distribution, and also 2 small acute subcortical infarcts in the right frontal lobe. The appearances overall were suggestive of cerebral amyloid angiopathy. Her recurrent and stereotyped symptoms were felt to be more in keeping with transient focal neurological events (TFNE) related to cerebral amyloid angiopathy rather than TIAs. However, this left us with a dilemma as to whether to stop or continue warfarin treatment in the light of her acute infarcts and established atrial fibrillation.

The Self-Analysis of a Clinical Neurological Case

Being a professor of psychiatry I submit my own vascular stroke episode, the evolution of the symptoms and the treatment to recovery.