[Examination for deep vein thrombosis in the Iwate Sanriku coastal area stricken by the Great East Japan Earthquake Disaster in 2011--measurement of D-dimer using POCT apparatus]

After the Great East Japan Earthquake Disaster in 2011, examinations for below the-knee deep vein thrombosis (BK-DVT) were carried out to prevent victims from secondary health damage by Iwate Prophylactic Examination Organization from economy-class syndrome. In this examination, D-dimer was measured using cobas h 232, a point-of-care testing (POCT) apparatus, in addition to medical interview, blood pressure measurement, and lower limb vein sonography. In the BK-DVT examination carried out in Tanohata in October and in Miyako in November 2012, the BK-DVT-positive number(percentage) in lower limb vein sonography was six (13.3%) in Tanohata and four (4.1%) in Miyako among 136 subjects (average age of 69.0 +/- 11.9, male:female sex ratio of 28:108). D-dimer in BK-DVT-positive subjects was 1.31 +/- 1.27 microg/mL, significantly higher than that in BK-DVT-negative subjects without cardiac diseases (0.46 +/- 0.50 microg/mL, p < 0.05). Eight subjects (5.6%) with higher D-dimer values were immediately referred to the nearest hospital. It was shown that the POCT apparatus was very useful when lifelines were not available and when the examination was performed in refuges since they are small, light and simple to operate, and the medical technologists played important roles in various examinations because of their high skill and abilities.

The role of hybrid procedures in the treatment of critical limb ischemia

Patients affected by critical limb ischemia (CLI) represent a complex and high risk clinical problem, and a multidisciplinary approach is often demanded. The amputation rate in patients affected by CLI is still high. Introduction of endovascular procedure shook up the CLI concept of treatment. The increasing experience of Vascular Surgeons in endovascular technique forced these specialist to match classic surgical skills and endovascular tools in order to achieve the best treatment for each patients. The combination of the two techniques identifies the hybrid procedure. Aim of this paper is to define indication, necessity and results of the hybrid procedure in patients suffering from CLI.

Meta-analysis of the prevalence, incidence and natural history of critical limb ischemia

AIM

Critical limb ischemia (CLI) is a significant morbid condition among the elderly. The epidemiology and natural history of this condition are poorly defined.

METHODS

Systematic review and meta-analysis of studies evaluating the prevalence, incidence and natural history of CLI were performed.

RESULTS

Six studies reported on the prevalence of severe lower limb ischemia (ABI <0.60, ankle pressure <70 mmHg or Fontaine III-IV) in 82,923 subjects and its pooled prevalence was 800/100,000 population (95%CI 300-1400). The Oxford Vascular Study assessed the incidence of vascular events in the general population and estimated an incidence of CLI of 22/100,000 population per year (95%CI 17-28). Two studies reported an incidence of CLI in subjects >65 years old of 113 and 200/100,000 population per year, respectively. Nine studies reported on the treatment strategy in 2144 legs with CLI: the pooled rate of any revascularization procedure was 70.4%, of primary amputation 8.4%, and of conservative treatment 20.3%. After conservative treatment for CLI, one-year pooled leg salvage rate was 57.4% (95%CI 45.1-69.7%, ten studies reporting on 734 legs included), survival 75.4% (95%CI 59.2-91.6%, four studies included) and amputation-free survival 51.4% (95%CI 32.7-71.2%, five studies included).

CONCLUSION

The incidence of CLI in the elderly is rather high. Series reporting on treatment strategies in these patients showed that a revascularization is attempted in 70% of cases. Conservative treatment in patients with unreconstructable CLI, high operative risk and/or refusing any revascularization procedure is associated with acceptable one year leg salvage.

Delayed complete limb ischemia following a closed tibial shaft fracture

We present a 19-year-old collegiate athlete who sustained a low-energy closed tibial shaft fracture. Following closed reduction, the dorsalis pedis and posterior tibial pulses were symmetric to the contralateral limb on physical examination. Angiography later confirmed triple vessel arterial disruption complicated by delayed ischemia requiring limb revascularization. Lower extremity triple vessel occlusion from a low-energy injury is rare, and delayed presentation requiring limb salvage is even more unusual. We review the literature, describe the diagnosis and treatment, and propose a strategy for post-fracture reduction management of vascular status.

Endovascular treatment of lower extremity ischemia in chronic renal failure patients on dialysis: early and intermediate term results

BACKGROUND

Peripheral arterial occlusive disease is common in patients with chronic renal failure requiring dialysis. Despite the increasing use of endovascular revascularization for lower extremity ischemia, the success rates of treating lower extremity ischemia in this challenging population remain obscure.

OBJECTIVES

To assess the results of endovascular revascularization for lower extremity ischemia in dialysis patients.

METHODS

We conducted a retrospective review of all dialysis patients who underwent endovascular treatment for critical limb ischemia (CLI) in our institution between 2007 and 2011. Data collected included comorbidities, clinical presentation, anatomic distribution of vascular lesions, amputation and survival rates.

RESULTS

We identified 50 limbs (41 patients). Indications included gangrene in 22%, non-healing wounds in 45%, rest pain in 31%, and debilitating claudication in 4%. Mean follow-up was 12 months (1-51 months). Nineteen patients required amputations. Freedom from amputation at 5 years was 40%. Factors associated with amputation included non-healing wounds or gangrene (68% and 36% respectively) and diabetes (P < 0.05). The survival rate was 80% after 5 years.

CONCLUSIONS

Despite improvement in endovascular techniques for lower extremity revascularization, the incidence of limb salvage among dialysis patients remains poor, resulting in a high rate of major amputations.

Working conditions at hospital food service and the development of venous disease of lower limbs

The present study assesses some factors that may influence the development of lower limb venous disease in workers of a hospital food service unit. An Ergonomic analysis of work was carried out at a hospital located in the south of Brazil. As for data collection, the following were used: interviews and body mass index assessment; specific clinical examination to diagnose venous disease, water displacement volumetry of the lower limbs. The activities performed at the workplace were followed by direct observation with image registration, use of pedometers, stopwatches, decibel meter, and digital thermo-hygrometer. It was observed different degrees of venous disease in 78% of the cases investigated. The volumetric variation of the lower limbs was 5.13%, showing the presence of edema. Working in hospital food service is associated with circulatory disorders of lower limbs, such as edema and venous disease. The following risk factors were identified: standing activities at work during a long period of time, high temperature, and humidity and carrying heavy weights.

Endovascular first as "preliminary approach" for critical limb ischemia and diabetic foot

The treatment of the critical limb ischemia (CLI) and diabetic foot (DB) is still object of discussion and the gold standard for revascularization has not yet been identified. In these two decades the introduction of endovascular procedures had a large impact on the surgical revascularization and were added to the practice of vascular surgeons in patients who cannot be candidates for a bypass. This may be due to significant comorbidities, a reduced life expectancy, infection or gangrene in the possible sites of distal anastomoses, the unavailability of suitable veins, or the absence of an adequate "landing zone" for the distal part of the bypass. Various studies have evaluated the role of PTA in DF and CLI that resulted favourable in terms of feasibility, technical efficacy, the reduced number of complications, and limb salvage rates. Anyway, long-term patency is better after bypass surgery than after angioplasty, which is burdened by a high restenosis rate. In our experience we tried to practice endovascular approach as a first choice. If the procedure cannot be concluded safely, we continue the intervention surgically or use a hybrid approach. The endovascular-first strategy seems to be the future regardless of comorbidity of the patient and the degree of pathology. The vascular surgeon remains the only specialist that can decide the correct intervention without pressure or been forced and, last but not least, the only one who can independently perform hybrid interventions.

Determination of lower extremity peripheral artery disease: the role for automated Oscillometric measurement of ankle brachial index in Nigerians

AIMS AND OBJECTIVES

To determine the prevalence of LEAD and compare the accuracy of ABI obtained by automated oscillometric method with Doppler ultrasonography.

PATIENTS AND METHODS

This study compared the accuracy of ABI obtained by automated oscillometric method versus that by Doppler among 153 hypertensive patients aged 18 years and above, attending the hypertension clinic of the University of Benin Teaching Hospital, Benin-City.

RESULTS

Of the 153 patients studied, 64 (41.8%) and 48 (31.4%) had ABI <0.9 using hand held Doppler ultrasound and automated oscillometric method respectively, while 39 (25.5%) had LEAD detected by both methods. Assuming the gold standard for diagnosis of LEAD was by Doppler ABI < 0.9, ABI obtained by automated oscillometric method had a sensitivity, specificity, positive and negative likelihood ratios of 60.9%, 89.9%, 6.03 and 0.43 respectively while the area under the receiver operating characteristic curve was 0.787. There was good and positive correlation between ABI obtained by automated oscillometric method and Doppler ultrasound with a Pearson's correlation coefficient of 0.73 and 0.74 for left and right lower limbs respectively (p<0.001) CONCLUSION: ABI obtained using automated oscillometric method is a good alternative to Doppler ultrasonography when screening for LEAD.

[Ultrasonic monitoring foam sclerotherapy for serious varicosis of lower extremity]

OBJECTIVE

To evaluate the efficacy and safety of foam sclerotherapy for lower extremity varicosis in C4 to C6 patients.

METHODS

A total of 32 patients (32 limbs) with serious lower extremity varicosis classified as C4 to C6 were enrolled. Ultrasonic monitoring of foam sclerotherapy was performed after subfascial endoscopic perforator suture and saphenous vein ligation. They were followed up monthly at outpatient department. Duplex Doppler scan was performed during each interview.

RESULTS

All patients were treated successfully. An average of 3.2 perforators were ligated per leg (1-5 perforators). The average volume of foam sclerosing agent was 27.5 ml per leg. Mild chest tightness was observed in one patient but computed tomography (CT) scan excluded pulmonary embolism. Obvious local inflammatory reaction was observed in 4 patients. Residual vein mass without blood signal was seen in 3 patients. No such serious complication as cerebral ischemia was observed. The average follow-up period was 4.8 (1-10) months. Obvious varicose veins and clinical symptoms disappeared at 1 month. And venous ulcers in patients classified as C5 healed within 3 months.

CONCLUSION

Ultrasonic monitoring of foam sclerotherapy, incorporation with saphenous vein ligation and subfascial endoscopic perforator suture, is both safe and effective in the treatment of serious lower extremity varicosis classified as C4 to C6.

Twelve-months follow-up of supervised exercise after percutaneous transluminal angioplasty for intermittent claudication: a randomised clinical trial

The aim of this study was to explore the effects during 12 months follow-up of 12 weeks of supervised exercise therapy (SET) after percutaneous transluminal angioplasty (PTA) compared to PTA alone on physical function, limb hemodynamics and health-related quality of life (HRQoL) in patients with intermittent claudication. Fifty patients were randomised to an intervention or a control group. Both groups received usual post-operative care and follow-up measurements at three, six and 12 months after PTA. The intervention group performed 12 weeks of SET after PTA. The control group did not receive any additional follow-up regarding exercise. During the 12 months' follow-up, the members of the intervention group had significantly better walking distance than the control group. The intervention group had a significantly higher HRQoL score in the physical component score of the SF-36, and the domains of physical function, bodily pain and vitality. For limb hemodynamics, there was a non-significant trend towards better results in the intervention group compared to the control group.

CONCLUSION

SET after PTA yielded statistically significantly better results for walking distance and HRQoL in the intervention group than the control group during the 12 months of follow-up.

[Heparin-induced thrombocytopenia in a patient with acute thrombosis, acute aortic dissection and acute lower limb ischaemia]

This case report presents the course of illness, as well as the diagnosis and therapy, of acute thrombosis and abdominal aortic dissection after Fogarty thrombectomy with the symptoms of acute limb ischaemia in a 42-year-old female patient suffering from heparin-induced thrombocytopenia. HIT is a severe iatrogenic complication emerging after unfractionated or low molecular weight heparin administration, with rather easy diagnosis; however, it is often neglected due to the rarity of its occurrence.

[Hybrid procedures for multilevel femoral and popliteal artery occlusive disease]

OBJECTIVE

To evaluate the immediate and mid-term effectiveness of hybrid procedures (combined open surgery and endovascular therapy) for multilerel femoral and popliteal artery occlusive disease.

METHODS

Between June 2009 and June 2012, 22 cases of severe femoral and popliteal artery occlusive disease were treated by hybrid surgery. There were 15 men and 7 women with an age range of 52-78 years (mean, 66.2 years) and with a disease duration of 6 months to 5 years (mean, 1.5 years). Of 22 patients, 13 had a history of smoking; 8 were classified as Fontaine III and 14 as Fontaine IV. The complications included diabetes (8 patients), hypertension (16 patients), hyperlipemia (10 patients), coronary heart disease (11 patients), and chronic kidney failure (1 patient). Patency analyses were performed using Kaplan-Meier life tables and log-rank test.

RESULTS

All patients underwent successfully procedures. The time of operation was 70-160 minutes (mean, 137 minutes). Acute myocardial infarction, hematoma of incision, fracture of stent, and stent thrombosis occurred in 1 case, respectively. At 6 months after surgery, the ankle brachial index (ABI), the transcutaneous oxygen pressure (TcpO2), and the average intermittent claudication distance were significantly increased when compared with preoperative ones [0.79 +/- 0.33 versus 0.32 +/- 0.18, (42.7 +/- 15.7) kPa versus (17.6 +/- 11.6) kPa, and (420 +/- 80) m versus (160 +/- 54) m, P < 0.05]. The patients were followed up 6-24 months (mean, 14.5 months). The primary patency rate, primary assisted patency rate, and second patency rate were 77.3% (17/22), 90.9% (20/22), and 95.5% (21/22) respectively, showing no significant difference among them (P > 0.05). No significant difference was found in various-stage patency rates between patients at Fontaine III and IV (P > 0.05).

CONCLUSION

Hybrid procedures provide an effective treatment of multilevel femoral artery and popliteal artery disease while there is good outflow.

Differences in skin microcirculation on the upper and lower extremities in patients with diabetes mellitus: relationship of diabetic neuropathy and skin microcirculation

INTRODUCTION

During recent years, the role of microcirculation has received increasing attention especially for its potential pathogenic role in the development of diabetes complications, particularly diabetic foot syndrome. The aim of this study was to evaluate the differences in the skin microcirculatory reactivity on the upper and lower extremities (UE and LE, respectively) in the patient with type 2 diabetes mellitus (T2DM). We also evaluated the changes in the skin microcirculation independently of the individual test for peripheral diabetic neuropathy (DN) diagnosis (Semmes-Weinstein monofilaments, Bio-Thesiometer [Bio-Medical Instrument Co., Newbury, OH], and Neuropad(®) [TRIGOcare International GmbH, Wiehl, Germany]).

PATIENTS AND METHODS

Fifty-two patients with T2DM were enrolled. Microvascular reactivity was measured by laser Doppler iontophoresis, using 1% acetylcholine chloride (ACH) and 1% sodium nitroprusside.

RESULTS

Significant reduction of perfusion was found in LE compared with UE when using ACH. In patients with DN skin microvascular reactivity on LE and UE was reduced, compared with patients without DN. Impaired skin microvascular reactivity to ACH (dominant on LE) was demonstrated in all patients who were positive in at least one of the tests for the presence of DN.

CONCLUSIONS

Reactivity of the skin microcirculation is worse on the foot than on the hand. This study confirmed a close relationship of DN and impaired skin microcirculation. It seems that autonomous neuropathy (assessed using the Neuropad) precedes the manifestation of somatosensory neuropathy.

Computerized venous strain-gauge plethysmography is a reliable method for measuring venous function

OBJECTIVES

To achieve reference values for computerized strain-gauge plethysmography (SGP), to assess reproducibility, and to evaluate the influence of different factors such as age, gender, body mass index, and symptomatic post-thrombotic disease on commonly used variables.

METHODS

Sixty-three healthy controls and 56 patients with previous deep venous thrombosis (DVT) were included. All participants underwent computerized SGP with evaluation of outflow capacity, as well as evaluation of venous reflux and muscle pump function.

RESULTS

All variables were significantly reduced in DVT limbs, both compared with contralateral limbs and with healthy controls. Only two patients had all values within normal ranges (=mean ± 2 SD in controls). Measures of outflow capacity had a coefficient of variation (CV) of 5-6% and exercise-induced volume changes a CV of 10-15%. In symptomatic post-thrombotic limbs half-refilling time was significantly related to presence of edema (R = -0.28, p < .05) and to chronic skin changes (R = -0.58, p < .001).

CONCLUSIONS

We suggest that our values in healthy controls can be used as new reference values for computerized venous strain-gauge plethysmography. The computerized design ensures high reproducibility and the results indicate that this is a very useful and sensitive test for functional quantitative assessment of patients with venous disease.

Steady state vascular imaging with extracellular gadobutrol: evaluation of the additional diagnostic benefit in patients who have undergone a peripheral magnetic resonance angiography protocol

BACKGROUND

To evaluate the feasibility and additional diagnostic benefit of a high-resolution steady state 3D-volume interpolated breath-hold exam (VIBE) sequence between a continuous table movement (CTM) MR angiography of the entire runoff vasculature and a time-resolved (TWIST) MRA of the calves.

METHODS

In this retrospective IRB approved study 224 patients (72 women, 152 men, mean age 67.29 ± 13.9) were included who had undergone a low-dose MR angiographic protocol at 3T (Siemens TimTrio) after injection of 0.1 mmol/kg gadobutrol including a CTM MRA, a time-resolved MRA of the calf station and a steady state 3D VIBE sequence prior to the time-resolved MRA. One board-certified radiologist rated the image quality of the steady state VIBE sequences on an ordinal three point scale (excellent, good, poor) and analyzed the images for additional diagnostic findings of and beyond the vascular system in comparison to the CTM MRA and the time-resolved MRA. Descriptive statistics and demographic patient data were used for further evaluation.

RESULTS

The image quality of the steady state imaging of the pelvis, upper and lower leg was excellent in up to 88%, 84% and 47%, respectively, while poor image quality was only detected in the upper (2%) and lower leg (6%). An additional diagnostic benefit was found in 44% of the patients overall. The most common relevant pathologies included inflammatory processes of the soft tissues (26%), thrombi (14%), abscesses (13%) and tumors (11%). In subgroups of patients above the age of 60, 65, 70, 75 and 80 years an additional pathology was found in 50% 33%, 44%, 65% and 58%, respectively. There was no significant difference in terms of additional findings between men and women (46% and 39%, p > 0.05) and inpatients and outpatients (42% and 45%, p > 0.05).

CONCLUSION

Steady state imaging is also feasible with extracellular contrast agents with good image quality yielding additional diagnostic findings in up to 44% and above in patients older than 60 years of age irrespective of gender or patient status. Given the short acquisition time of 4 minutes this sequence could be added to all peripheral MRA exams.

Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis

BACKGROUND

Lower extremity peripheral artery disease is the third leading cause of atherosclerotic cardiovascular morbidity, following coronary artery disease and stroke. This study provides the first comparison of the prevalence of peripheral artery disease between high-income countries (HIC) and low-income or middle-income countries (LMIC), establishes the primary risk factors for peripheral artery disease in these settings, and estimates the number of people living with peripheral artery disease regionally and globally.

METHODS

We did a systematic review of the literature on the prevalence of peripheral artery disease in which we searched for community-based studies since 1997 that defined peripheral artery disease as an ankle brachial index (ABI) lower than or equal to 0·90. We used epidemiological modelling to define age-specific and sex-specific prevalence rates in HIC and in LMIC and combined them with UN population numbers for 2000 and 2010 to estimate the global prevalence of peripheral artery disease. Within a subset of studies, we did meta-analyses of odds ratios (ORs) associated with 15 putative risk factors for peripheral artery disease to estimate their effect size in HIC and LMIC. We then used the risk factors to predict peripheral artery disease numbers in eight WHO regions (three HIC and five LMIC).

FINDINGS

34 studies satisfied the inclusion criteria, 22 from HIC and 12 from LMIC, including 112,027 participants, of which 9347 had peripheral artery disease. Sex-specific prevalence rates increased with age and were broadly similar in HIC and LMIC and in men and women. The prevalence in HIC at age 45-49 years was 5·28% (95% CI 3·38-8·17%) in women and 5·41% (3·41-8·49%) in men, and at age 85-89 years, it was 18·38% (11·16-28·76%) in women and 18·83% (12·03-28·25%) in men. Prevalence in men was lower in LMIC than in HIC (2·89% [2·04-4·07%] at 45-49 years and 14·94% [9·58-22·56%] at 85-89 years). In LMIC, rates were higher in women than in men, especially at younger ages (6·31% [4·86-8·15%] of women aged 45-49 years). Smoking was an important risk factor in both HIC and LMIC, with meta-OR for current smoking of 2·72 (95% CI 2·39-3·09) in HIC and 1·42 (1·25-1·62) in LMIC, followed by diabetes (1·88 [1·66-2·14] vs 1·47 [1·29-1·68]), hypertension (1·55 [1·42-1·71] vs 1·36 [1·24-1·50]), and hypercholesterolaemia (1·19 [1·07-1·33] vs 1·14 [1·03-1·25]). Globally, 202 million people were living with peripheral artery disease in 2010, 69·7% of them in LMIC, including 54·8 million in southeast Asia and 45·9 million in the western Pacific Region. During the preceding decade the number of individuals with peripheral artery disease increased by 28·7% in LMIC and 13·1% in HIC.

INTERPRETATION

In the 21st century, peripheral artery disease has become a global problem. Governments, non-governmental organisations, and the private sector in LMIC need to address the social and economic consequences, and assess the best strategies for optimum treatment and prevention of this disease.

FUNDING

Peripheral Arterial Disease Research Coalition (Europe).

Vein graft failure

After the creation of an autogenous lower extremity bypass graft, the vein must undergo a series of dynamic structural changes to stabilize the arterial hemodynamic forces. These changes, which are commonly referred to as remodeling, include an inflammatory response, the development of a neointima, matrix turnover, and cellular proliferation and apoptosis. The sum total of these processes results in dramatic alterations in the physical and biomechanical attributes of the arterialized vein. The most clinically obvious and easily measured of these is lumen remodeling of the graft. However, although somewhat less precise, wall thickness, matrix composition, and endothelial changes can be measured in vivo within the healing vein graft. Recent translational work has demonstrated the clinical relevance of remodeling as it relates to vein graft patency and the systemic factors influencing it. By correlating histologic and molecular changes in the vein, insights into potential therapeutic strategies to prevent bypass failure and areas for future investigation are explored.

Successful revascularization of chronic total occlusion of lower extremity arteries: a wire only and bail out use of re-entry device approach

AIM

The management of progressive peripheral artery disease experienced a vast change in paradigms over the last decades for the benefit of minimal invasive therapy as a first-line strategy. With the constant development of new devices, materials and dedicated access strategies, more complex lesions can be managed but the limitations to successfully treat chronic total occlusions are still the challenge to re-enter the true lumen. The aim of this retrospective study was to investigate, if a "wire only" strategy leads to an acceptable success rate in a mixed cohort of CTO lesions and to what extend re-entry devices are used.

METHODS

We retrospectively analyzed patients treated at the Vascular Center Berlin between 2011 and 2013 with chronic total occlusion out of a prospective conducted database (Endovascular MILestones - EMIL) for demographics, risk factors, co-morbidities, technical success rates, lesion characteristics and use of guidewires as well as re-entry systems. A total of 128 patients with 146 lesions, which represent a subgroup of all the cases performed in our center, following a predefined treatment algorithm for chronic total occlusions (CTOs), have been analyzed.

RESULTS

We achieved a technical success in 133 (91.1%) of all cases following a "wire only" strategy. Out of 13 (8.9%) CTOs with technical failure in 7 (53.9%) CTOs a re-entry device (Off-Road®) with a 100% technical success has been used. In 91.1% of chronic total occlusion lesions the use of 2 wires only (88.7%) led to a successful recanalization. A "wire only" strategy followed by the use of a re-entry device as a bail out strategy, led to a total of 140 (96%) lesions to be successfully recanalized.

CONCLUSION

In more than 90% of all cases with chronic total occlusion of peripheral lower extremity arteries, endovascular intervention has been successful following a "wire only" strategy. When deciding to use a re-entry device, in case of a failure of a proper wire re-entry at the reconstitution point, a technical success rate of 100% was achieved. Therefore following a strict wire algorithm and considering the use of a re-entry system as a bail out strategy will lead to a successful minimal invasive management of chronic total occlusion in nearly 100% of the cases with TASC II A - D lesions.

[Impact of saturation of the mixed capillary blood on the subjective estimation of the postoperative pain intensity]

The impact of prolonged perineural blocade of n. femoralis on a subjective estimation of the postoperative pain intensity and its connection with the mixed capillary blood saturation was investigated.

Fate of the asymptomatic contralateral limb after initial intervention for ipsilateral critical limb ischemia

AIM

In Trans-Atlantic Inter-Society Concensus (TASC) II, patients at risk for critical limb ischemia (CLI) without symptoms are termed "chronic subclinical ische mia," but research are still lacking. The objective was to find out whether clinically asymptomatic contralateral limbs at the time of treatment for ipsilateral CLI could be regarded as "chronic subclinical ischemia".

METHODS

Ninety-six patients with CLI who had no symptoms in the contralateral limb were retrospectively reviewed. The symptoms of the contralateral limb after initial intervention for the ipsilateral limb were surveyed. Risk factors for developing CLI and tissue loss were then analyzed.

RESULTS

Five patients (5.2%) became claudicants, 37 patients (38.5%) had symptoms of CLI, and 14 (14.6%) experienced tissue loss during the follow-up period. The overall CLI-free rates at 12, 36, and 60 months were 79.2%, 55.2%, and 45.8%, respectively, while the tissue loss-free rates at 12, 36, and 60 months were 91.3%, 78.8%, and 78.8%, respectively. Risk factor for developing CLI on the contralateral limb was having skin perfusion pressure (SPP) <40 mmHg at the surgery for ipsilateral limb. The presence of SPP <40 mmHg and end stage renal failure with hemodialysis resulted in a significantly high probability of tissue loss.

CONCLUSION

Patients with CLI with an asymptomatic contralateral limb with an SPP value <40 mmHg are at a high risk of developing CLI and tissue loss during the follow-up period. Information on the contralateral limb at initial surgery may help to speculate the fate of the asymptomatic contralateral limb.

Acute limb ischemia in nonagenarians

AIM

Acute limb ischemia (ALI) is not infrequently associated with limb loss (10-30%) or death of the affected patient (15-30%). These results can be even worse in elderly population. The aim of this study is to quantify safety and efficacy of early revascularization in over 90 years old patients with acute limb ischemia.

METHODS

This is a prospective registry lasting from January 2012 to January 2013. We include all consecutive over 90 years patients treated for ALI (N.=15). A careful preoperative Duplex scan (DS) were performed in each patient. All patients underwent surgery by Fogarty's embolectomy, and endovascular completion procedure if needed (N.=3).

RESULTS

We performed 18 revascularizations (15 lower limbs, 3 upper limbs) in 15 patients (2 staged bilateral femoral, 1 simultaneous bilateral femoral). The mean follow-up was 124 days (4-365). Technical success was obtained in 16 cases (88.9%). At disharge mortality was 5.9% (1 case), and amputation rate was 6.2% (1 pt). The Kaplan-Meier curves at 1 year revealed an estimated freedom from death, amputation and re-occlusion of 76.5%, 88.2%, and 71.3%, respectively.

CONCLUSION

The over 90 years old patient represent a challenging case for vascular surgeon. Vascular procedures involve high mortality rate but emergent revascularization by Fogarty Embolectomy in ALI is safe and effective even in older patient.

[PRP-therapy and regular physical load in complex treatment of patients with distal form of arterial occlusion]

In a structure of the cardio-vascular system diseases in Ukraine the part of chronical ischemia of the lower extremities tissues constitutes more than 20%. Due to diffuse affection of the distal parts of arterial bed it is impossible to succeed in performance of a direct" revascularization in 40% of patients. In 60-87% of such patients a severe ischemia of the lower extremities tissues occurs, causing the necessity of their high amputation performance on the hip level. The results of surgical treatment of 36 patients, suffering inoperable types of the peripheral arteries occlusion were analyzed. In 18 patients the algorithm of intraoperative ultrasound duplex scanning was applied, surgical interventions were performed using optimized procedures. As a second stage the PRP-therapy was conducted, since the second post-operative day all the patients have had performed the elaborated complex of physical exercises, directed on the shin and hip muscles strengthening. Optimization of the lower extremities indirect revascularization methods have permitted to increase the rate of the treatment positive results from 55.6 to 88.9%, to reduce the unsatisfactory results rate--from 44.4 to 11.1%. The PRP-therapy and complex of regular physical exercises conduction have promoted the VEGF content enhancement in the blood serum by 15.6%. malleolar-brachial index--by 28.9% in the patients, suffering occlusion of femoro-popliteo-tibial segment. PRP-concentrate constitutes a potent cell biological activator of the VEGF, improves metabolism and microcirculation in muscles and cells of the skin.