Time and reliability issues associated with automatic vs. manual measurements of Ankle to Brachial pressure Index (ABI) following heavy load exercise

OBJECTIVES

Ankle to brachial index after heavy load exercise is the most accurate way of diagnosing minor arterial lesions in athletes, such as endofibrosis. The reliability and practical aspects of ankle to brachial index measurements after heavy-load exercise have not been studied. The purpose of this study was to analyze the interest of oscillometric automatic vs. manual Doppler measurements, for the calculation of ankle to brachial index, after heavy-load exercise in athletes.

DESIGN

Prospective single-center study.

METHODS

Fifteen healthy trained athletes performed an incremental test twice. Ankle to brachial index measurements were performed at Rest, as soon as possible after exercise (Rec-0), and then started at the 3rd minute of recovery (Rec-3), by two operators using each one of the two ankle to brachial index measurement methods.

RESULTS

Mean times for automatic vs. manual ankle to brachial availability were 99 ± 18 s vs. 113 ± 25 s (p = 0.005) and 44 ± 25 s vs. 53 ± 12 s (p = 0.001) respectively at Rec-0 and Rec-3. Ankle to brachial index values from the two methods were highly correlated (r = 0.89). Mean absolute differences of automatic vs. manual ankle to brachial values from test-retest were 0.04 ± 0.05 vs. 0.08 ± 0.08 (p > 0.05) and 0.07 ± 0.05 vs. 0.09 ± 0.10 (p > 0.05) at Rest and Rec-0.

CONCLUSIONS

Automatic method allows obtaining faster and simultaneously post-exercise ankle to brachial index measurement compare to the manual Doppler. This time issue does not result in a significant change in absolute ankle to brachial index values, nor in the absolute differences of these in test-retest. Nevertheless, the test-retest variability of post-exercise ankle to brachial index results seems smaller with the automatic than the manual method.

Metastatic hepatocellular carcinoma: when surgery and successive palliative treatments lead to remission

Hepatocellular carcinoma (HCC) is the third leading cause of death by cancer worldwide. The prognosis of patients with metastatic HCC remains limited, with an expected median survival lower than 50% at 1 year. Here, we report the case of a 63-year-old man who suffered from a small HCC in the liver and a large unique metastasis in the right adrenal gland. A surgical resection of both lesions was performed. Seven months later, HCC recurred with an isolated right renal metastatic lymphadenopathy and a high alpha-fetoprotein level. HCC was brought under control by sorafenib; the alpha-fetoprotein level was greatly reduced but remained moderately elevated and stable over 2 years after the onset of chemotherapy. Additional external radiotherapy on the metastatic lymphadenopathy led to a normalization of the alpha-fetoprotein level and discontinuation of sorafenib treatment. One year after the end of radiotherapy, a second isolated metastasis occurred in the right lung. This tumor was surgically removed. Twenty-one months after this second surgical procedure, i.e., more than 5.5 years after the initial diagnosis of metastatic HCC, the patient was asymptomatic and tumor free.

Long-term maintenance immunosuppressive regimen with tacrolimus monotherapy

BACKGROUND

The long-term outcome of kidney transplant recipients on monotherapy with calcineurin inhibitors has been poorly analyzed. This study aimed to describe the long-term outcome of patients on Tac monotherapy (mTac) and to compare this regimen to a standard dual therapy with Tac/MMF.

MATERIAL AND METHODS

This retrospective study included 84 consecutive first kidney recipients transplanted between 1998 and 2003 and followed until 2010. Patients were treated with mTac after the 6th month of transplantation. Survival and incidence of adverse events were analyzed and compared to those of patients treated with Tac/MMF as maintenance regimen after the 6th month of transplantation.

RESULTS

Mean follow-up of the mTac cohort was 8.7 ± 2.2 years. Overall patient and graft survival of the mTac cohort was 91.3% and 86.6%, respectively, at year 8 posttransplant. Tac monotherapy was started in 93.3% of patients at month 6 posttransplant and maintained in 50% of the cohort at the end of the follow-up period. Incidence of acute rejection (AR) and chronic allograft nephropathy (CAN) were 11.9% and 16.6%, respectively. Kaplan-Meyer analysis did not show any difference in patient and graft survival between mTac patients and patients under Tac/MMF. At year 6, compared to Tac/MMF patients, mTac patients had a significantly lower incidence of AR after the 6th month posttransplant and no difference in CAN, cancer, NODAT, and cardiovascular events incidence.

CONCLUSIONS

This work suggests that long-term maintenance immunosuppression with mTac is safe in low-immunological risk patients and should be considered for use especially in patients with MMF intolerance.

[Exercise-induced renal ischemia after kidney transplantation: report of two cases]

INTRODUCTION

Renal transplant patients are high cardiovascular risk patients. Regular ultrasound surveillance of the renal transplant artery and the iliac artery upstream from the anastomosis is required to detect potential arterial stenosis. The purpose of this article was to illustrate the hemodynamic impact of exercise in such patients and the screening efficiency of Doppler ultrasound stress testing.

METHODS

Two renal transplant patients were hospitalized in our center for impaired renal function, worsening hypertension, and intermittent claudication. This association of peripheral vascular disease and renal dysfunction led us to perform a Doppler ultrasound stress test to search for vascular stenosis upstream from the graft. Hemodynamic fluctuations in the ipsilateral leg were recorded during flexion-extension exercises.

RESULTS

Iliac artery lesions were found in both patients: the Doppler examination showed decreased systolic velocity in the graft artery during exercise, compatible with iliac steal syndrome. Surgical treatment was performed in both patients. After surgery, the control Doppler ultrasound stress test showed that systolic flow did not decline in the graft vessels during exercise. Renal function stabilized in one patient and improved in the other; claudication disappeared after surgery.

CONCLUSION

Doppler ultrasound stress testing can be a valuable tool for detecting exercise-induced renal graft ischemia in transplant patients. Its screening performance should be determined in a larger population before routine use.

Long-term results of stenting of the aortic bifurcation

BACKGROUND

To evaluate the long-term results in a multicentric continuous series of narrowing lesions of the aortic bifurcation treated with a kissing stent.

METHODS

From January, 1st 1999 to the December, 31st 2001, all of the patients (n = 80) presenting with stenosis of the aortic bifurcation (n = 15) and/or the 2 common iliac arteries (n = 65), treated with a kissing stent, in 8 teaching hospitals were collected retrospectively. The risk factors were smoking (91%), dyslipidemia (60%), arterial hypertension (42%) and diabetes (27%). In 84% of cases, the indication for treatment was claudication. The lesions were stenotic < 70% (n = 76) and/or thrombotic (n = 18). The associated lesions were external iliac stenoses (n = 21), common femoral stenoses (n = 19), femoro-popliteal stenoses (n = 42), arteriopathy in the leg (n = 35). Follow-up was clinical examination and Doppler US scan.

RESULTS

The success rate of the technique was 89%. There were 4 cases (5.3%) of residual stenosis and 4 cases (5.3%) of dissection. The length of the lesions treated in the aorta and the iliac arteries was respectively 17.1 ± 7 and 17.3 ± 9 mm. The stents were all placed as kissing stents, and had a mean diameter and a mean length of 13.75 mm and 56 mm in the aorta and 9 mm and 48 mm in the iliac arteries, respectively. At 5 years, 19 patients had required repeat angioplasty in the treated area, and 13 had undergone open surgery. Primary and assisted primary patency at 5 years were 64.5% and 81.8%, respectively.

CONCLUSION

Long-term follow-up of endovascular treatment with kissing stents for stenosis of the aortic bifurcation shows that this technique gives good results, though it does not justify doing away with classical revascularisation surgery, in a population with major cardiovascular risk factors.

Exercise treadmill testing in patients with claudication, with and without diabetes

AIM

To compare symptoms and walking capacities of patients with and without diabetes reporting vascular-type claudication.

METHODS

We recorded self-reported maximal walking distance, maximal walking distance on treadmill test (3.2 km h(-1) , 10% slope), exercise transcutaneous oxygen pressure DROP index [limb transcutaneous oxygen pressure (TcpO2) changes from rest minus chest TcpO2 changes from rest] and symptoms on treadmill in 230 patients with diabetes and 982 patients without diabetes. Exercise-induced proximal and distal symptoms were analysed in the perspective of underlying proximal and distal ischaemia (DROP value < negative 15 mmHg).

RESULTS

Self-reported maximal walking distance did not differ between groups, whereas maximal walking distance on treadmill test was lower in patients with diabetes vs. patients without diabetes (261 ± 257 and 339 ± 326 m, respectively; P < 0.05 when adjusted for potential confounders). In patients with ischaemia, the number of ischaemic areas (proximal and/or distal on right and/or left) was comparable between the two groups. Patients with diabetes had more distal ischaemia than patients without diabetes (38 vs. 29%, respectively; P < 0.01), whereas proximal ischaemia was similar between groups. The prevalence of lower-limb exercise-related symptoms without ischaemia was comparable between groups. There were more symptoms other than lower-limb pain in patients with diabetes than patients without diabetes (29.6 vs. 18.3%, respectively; P < 0.01).

CONCLUSIONS

Patients with diabetes show more severe limitation on the treadmill and more non-limb symptoms than patients without diabetes, although self-reported walking capacity is comparable between the two groups. Using TcpO2, we confirm that patients with diabetes reporting claudication show more distal ischaemia than patients without diabetes, with no difference at the buttock level. Treadmill testing is of interest in patients with peripheral artery disease and diabetes.

Functional outcome of hypogastric revascularisation for prevention of buttock claudication in patients with peripheral artery occlusive disease

We have defined proximal lower limb ischaemia as a decrease in Exercise-transcutaneous oxygen pressure (TcPO(2)) lower than minus 15mmHg at the buttock level in patients with peripheral artery occlusive disease. The purpose of this study was to objectively evaluate the benefits of direct versus indirect revascularisation of internal iliac arteries (IIAs) for prevention of buttock claudication in this population. We retrospectively reviewed the charts of proximal ischaemia patients who underwent revascularisation and both preoperative and postoperative stress TcPO(2) testing. Revascularisation procedures were classified as either direct revascularisation, including percutaneous transluminal angioplasty and internal iliac artery bypass, resulting in a direct inflow in a patent IIA (group 1) or indirect revascularisation, including aortobifemoral bypass and recanalisation of the femoral junction on the ischaemic side, resulting in indirect inflow from collateral arteries in the hypogastric territory (group 2). Patency was checked 3 months after revascularisation in all cases. Treadmill exercise stress tests were performed before and after revascularisation using the same protocol designed to assess pain, determine maximum walking distance (MWD) and measure TcPO(2) during exercise. In addition, ankle-brachial indices (ABIs) were calculated. Between May 2001 and March 2008, a total of 93 patients with objectively documented proximal ischaemia underwent 145 proximal revascularisation procedures using conventional open techniques in 109 cases and endovascular techniques in 36. Direct revascularisation was performed on 50 limbs (35%) (group 1) and indirect revascularisation on 95 limbs (65%) (group 2). The mean interval between revascularisation and stress testing was 60+/-74 days preoperatively and 149+/-142 days postoperatively. No postoperative thrombosis was observed. Buttock claudication following revascularisation was more common in group 2 (p<0.001). No difference was observed between the two groups with regard to improvement in MWD (365 / 294 m) and ABI (0.20/0.22). Disappearance of proximal ischaemia was more common after direct revascularisation (p<0.01). The extent of lesions graded according to the TASC II classification appeared not to be predictive of improvement in assessment criteria following revascularisation. Conversely, patency of the superficial femoral artery was correlated with improvement (p<0.01). This study indicates that direct revascularisation, if feasible, provides the best functional outcome for prevention of buttock claudication.

A normal penile pressure cannot rule out the presence of lesions on the arteries supplying the hypogastric circulation in patients with arterial claudication

Abstract

Proximal claudication remains a difficult diagnosis. The ankle to brachial index may be insensitive in the case of isolated hypogastric lesions. Penile pressure represents an alternative method for proximal arteries. Surprisingly, the accuracy of penile pressure measurement in detecting lesions on the arteries supplying pelvic circulation in patients suffering claudication has rarely been studied. We aimed to evaluate the diagnostic accuracy of the penile brachial index < 0.60 (penile over brachial systolic pressure ratio) to non-invasively investigate arteriographic lesions on arteries supplying the hypogastric circulation in 88 male patients referred for Fontaine stage II. The receiver operating characteristic (ROC) curve was used to define the diagnostic performance of the penile brachial index and search for a specific cut-off point in this population. Accuracy was 69.3% (95% confidence interval: 58.6–78.7) for the detection of an arterial stenosis or occlusion on at least one side. The penile brachial index ≤ 0.45 was 74% sensitive and 68% specific to discriminate the 19 patients with bilateral arterial occlusion from the other 66 patients. In conclusion, the penile brachial index is relatively insensitive for the detection of proximal abnormal blood flow impairment except in the case of bilateral occlusion of arteries supplying the hypogastric circulation in patients with claudication. A normal penile pressure is probably not efficient enough to rule out the presence of lesions on the arteries towards the hypogastric circulation in patients with arterial claudication.

[Surgical-site infections following varicose vein surgery according to a continuous series of 408 interventions in a teaching hospital]

OBJECTIVE

To determine the incidence of surgical-site infections (SSI) following varicose vein surgery in the vascular surgery ward of a French teaching hospital.

PATIENTS AND METHODS

A prospective surveillance of SSI was conducted during one year, with a 30-day postoperative follow-up. SSI cases were identified by using the definitions of the Centers for Disease Control (CDC, USA). Data acquisition and analysis were performed with the Epi-Info 6.04 software (CDC).

RESULTS

Three quarters of the 408 included interventions were characterized by a NNIS score equal to 0. All patients underwent a hair removing practice before intervention. Hair removing methods were very heterogeneous and often not in accordance with national recommendations (e.g. mechanic shaving for 44.6% of patients). The incidence of SSI was 1.2% (95% confidence interval=[0.2-2.2]). All infections were identified after hospital discharge. Four infected patients out of five presented obesity or excess weight, and two patients had diabetes mellitus. The mean age of infected patients was significantly higher than non-infected ones (70.4 years versus 52.0; p<0.01). All SSI had consequences like rehospitalization, reintervention, or antimicrobial therapy.

CONCLUSION

According to our results, SSI following varicose vein surgery are scarce and mainly concerned high-risk patients. However, in an aim of prevention, it seems necessary to homogenize hair removing methods in this ward.

Surgical reconstruction of the superior vena cava system: indications and results

BACKGROUND

Obstruction of the superior vena cava (SVC) secondary to malignant or benign diseases is rarely treated by surgical reconstruction. The purpose of this retrospective study is to report our experience and compare our results with previous data in the literature.

METHODS

From 1993 to 2006, 24 patients underwent operative reconstruction of the SVC. Mean patient age was 58 years. The underlying disease was primary bronchopulmonary malignant neoplasm in 50%, mediastinal malignant neoplasm in 21%, and symptomatic benign disease in 29%. Forty-six percent of patients presented clinical signs of superior vena cava compression (SVCC). Our indications were based on two criterions: clinical symptoms of superior vena caval compression or histological examination of the superior vena caval lesion that indicates potential for complete surgical excision.

RESULTS

Median duration of postoperative intensive care was two days. Mortality at 30 days was 12% for malignant diseases. All patients presenting clinical signs of SVCC improved. Mean follow-up was 28 months (range, 1-129). No thrombosis was observed during follow-up. Overall survival was 53% at 1 year and 35% at 5 years. For patients with malignant bronchopulmonary disease, survival was 50% at 1 year and 25% at 5 years. Mortality was 0% for patients with benign disease.

CONCLUSION

Review of the literature indicates that replacement of the SVC is an uncommon procedure. Our experience suggests that the need for SVC reconstruction should not, however, be considered as a contraindication for resection of a bronchopulmonary or mediastinal neoplasm in an otherwise potentially curable patient, provided it can be achieved in a single block with clear margins. Replacement of the SVC can also be performed with low mortality and morbidity for effective treatment of SVCC secondary to benign disease that fails to respond to medical therapy.

First report of an ilio-popliteal bypass through the greater sciatic foramen. Case report

A 47 year-old man, who had a history of pelvic radiotherapy for the treatment of testicular tumour 30 years ago, was referred with minor tissue loss of the right lower extremity, grade III, category 5 of the Rutherford classification. His groin region presented with severe radiation damage. Arteriography demonstrated the occlusion of external iliac and femoral arteries. Revascula-risation was performed in the lateral decubitus position, with a ringed polytetrafluoroethylene (PTFE) graft bypass between normal common iliac and popliteal arteries through the greater sciatic foramen. Quick healing was observed. Patient is well 6 months postoperatively. Immediate and 6 month postoperative imaging demonstrated the good patency of the graft. A duplex ultrasound performed 6 month postoperatively showed no significant compression while the patient was in the sitting position.

Vascular microanatomy of the pontomedullary junction, posterior inferior cerebellar arteries, and the lateral spinal arteries

SUMMARY

This study of 25 brains at the pontomedullary junction defined the different possible origins of the perforating arteries and lateral spinal arteries in relation to the posterior inferior cerebellar arteries (PICAs). - If the PICA emerges from the common trunk of the AICA-PICA coming from the basilar artery, it never gives perforating arteries or a lateral spinal artery on the lateral surface of the brain stem but supplies blood to a part of the ipsilateral cerebellar hemisphere. - If the PICA arises extradurally at C1, it never gives perforating arteries for the lateral surface of the brain stem, but it gives pial branches for the posterior surface of the medulla oblongata and is always the origin of the lateral spinal artery. - If the PICA emerges in the intradural vertebral artery, it is the source of the perforating arteries for the lateral surface of the brain stem and of the blood supply of the ipsilateral cerebellum.

Pseudo-anévrisme aortique sous-rénal à Coxiella burnetii

Peripheral vascular expressions of Coxiella burnetti Q fever are not well known. Endocarditis with negative blood culture is the most frequent clinical presentation of chronic Q fever. To date, very few cases of aneurisms or vascular grafts infections have been described. We report the case of a 54-year-old man who presented an infrarenal abdominal aorta infection, leading to a giant pseudo aneurismal formation. Blood serology and polymerase chain reaction amplification identified C. burnetti from the aortic thrombus after pseudo aneurism surgery. The treatment associated infrarenal abdominal aorta repair using a cryopreserved aorta allograft, and long-term antibiotic therapy.

Surgery of the pretransversal vertebral artery: indications and results

AIM

The aim of this study was to evaluate our results with elective vertebral arteries surgery, to emphasize the indications of such revascularization and to compare it with previous larger studies.

METHODS

The medical records of all patients who underwent a pretransversal vertebral artery (VA) revascularization between 1990 and 2004 at our University Hospital were retrospectively reviewed.

RESULTS

Forty patients, with a mean age of 60.5 years, met the criteria for VA surgery and accounted for 4.2% of the vascular surgeries involving the brain. Seventeen (42.5%) patients presented with vertebrobasilar insufficiency of hemodynamic origin, 16 (40%) with embolism, and 7 (17.5%) had no neurological symptoms. Direct vertebrocarotid reimplantation was the main procedure performed. No death or stroke occurred preoperatively or during the perioperative period. Mean follow-up was 31 months. Overall survival was 86.9% at 3 years and the primary patency rate was 97.5% at 3 years.

CONCLUSION

Our study confirms the good results achieved by the pretransversal conventional VA surgery. This surgery remains few in number despite the fact that about 25% of ischemic strokes occur in the vertebrobasilar region. Vertebrobasilar signs should be better recognized to avoid performing this type of procedure merely based on imaging criteria.