[Peculiarities of arterial access in endovascular surgery in elderly patients]

In elderly patients, when performing endovascular cathlabs manipulation the radial and cubital accesses is preferable. We propose a new arterial access on the back surface of the hand in the anatomical snuffbox. Artery catheterization of the hand in the anatomical snuffbox preserves intact the radial artery in the forearm for subsequent potential surgical interventions.

Effect of remote ischaemic conditioning on contrast-induced nephropathy in patients undergoing elective coronary angiography (ERICCIN): rationale and study design of a randomised single-centre, double-blind placebo-controlled trial

Background

Contrast-induced nephropathy (CIN), an acute kidney injury resulting from the administration of intravascular iodinated contrast media, is an important cause of morbidity/mortality following coronary angiographic procedures in high-risk patients. Despite preventative measures intended to mitigate the risk of CIN, there remains a need for an effective intervention. Remote ischaemic conditioning (RIC), where non-injurious ischaemia is applied to an arm prior to the administration of contrast, has shown promise in attenuating CIN but its effectiveness in preserving long-term renal function is unknown, which will be studied as part of the effect of remote ischaemic conditioning against contrast-induced nephropathy (ERICCIN) trial. (http://Controlled-trials.com Identifier: ISRCTN49645414.)

Methods

The ERICCIN trial is a single-centre, randomised double-blinded placebo-controlled trial which plans to recruit 362 patients who are at risk of CIN, defined by pre-existent renal impairment (estimated glomerular filtration rate <60 ml/min/1.73 m²), over a period of 2 years. Patients will be randomised to either control or RIC consisting of 4, 5 min 200 mmHg balloon-cuff inflation/deflations, to the upper arm. The primary endpoint will be the development of CIN (>25 % of eGFR, or rise of creatinine of >44 μmol/l) at 48 h. A key secondary endpoint will be whether RIC impacts upon persistent renal impairment over the 3-month follow-up period. Additional secondary endpoints include the measurement of serum neutrophil gelatinase-associated lipocalin and urinary albumin at 6, 48 h and 3 months following administration of contrast.

Implications

Findings from ERICCIN trial will potentially demonstrate that RIC attenuates contrast-induced acute and chronic kidney injury and influence future clinical practice guidelines in at-risk patients undergoing coronary angiographic procedures.

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.

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.

Comparison of one- and two-stage basilic vein transposition for arterio-venous fistula formation in haemodialysis patients: preliminary results

OBJECTIVE

This study aimed to compare the results of one-and two-stage basilic vein transposition (BVT) in haemodialysis patients.

METHODS

This was a non-randomised, retrospective study between January 2007 and January 2012 on 96 patients who were diagnosed with end-stage renal failure (ESRF) (54 males, 42 females; mean age 43.6 ± 14 years) and underwent one- or two-stage BVT in our clinic. All patients who were not eligible for a native radio-cephalic or brachio-cephalic arterio-venous fistula (AVF) were scheduled for one- or two-stage BVT after arterial (brachial, radial and ulnar) and venous (basilic and cephalic) Doppler ultrasonography. Patients were retrospectively divided into two groups: group 1, basilic vein diameter > 3 mm and patients who underwent one-stage BVT; and group 2, basilic vein diameter < 3 mm and patients who underwent two-stage BVT. In group 1, the basilic vein with a single incision was anastomosed to the brachial artery, followed by superficialisation. In group 2, the basilic vein was anastomosed to the brachial artery and they underwent the superficialisation procedure one month postoperatively. Fistula maturation and postoperative complications were assessed.

RESULTS

The mean diameter of the basilic vein was statistically significantly higher in group 1 (3.46 ± 0.2 mm) than in group 2 (2.79 ± 0.1 mm) (p < 0.05). In terms of postoperative complications, thrombosis, haemorrhage and haematoma were significantly higher in group 1 (34, 36 and 17%, respectively) than in group 2 (23, 14 and 6%, respectively) (p < 0.05). The rate of fistula maturation was significantly lower in group 1 (66%), compared to group 2 (77%) (p < 0.05).Time to fistula maturation was significantly shorter in group 1 (mean 41 ± 14 days), compared to group 2 (mean 64 ± 28 days) (p < 0.05).

CONCLUSION

Two-stage BVT was superior to one-stage BVT due to its lower rate of postoperative complications and higher fistula maturation, despite its disadvantage of late fistula use. Although the diameter of the basilic vein was larger in patients who underwent one-stage BVT, we observed that one-stage BVT was disadvantageous in terms of postoperative complications and fistula maturation.

Diagnosis and treatment of limb fractures associated with acute peripheral ischemia

Acute Peripheral Ischemia (API) is the most severe acute complication after both open and closed fractures, as ischemia compromises not only the vitality of the affected limb, but also the patient's life, because metabolic anaerobic changes following ischemia have serious local and general consequences. These explain why early diagnosis of API is very important for the prognosis of the traumatized limb.The authors analyse cases when API was not diagnosed immediately after trauma, but some time after the first examination, due to either low systolic BP or to late onset of API. The patients were analysed concerning the type of the fracture, the reason for delayed diagnosis of API, the moment of API diagnosis and the arterial injury. In all those cases, surgery was performed immediately after API diagnosis, in order to identify and treat the complex injuries(bone and vascular).

Report on the Hemodialysis Reliable Outflow (HeRO) experience in dialysis patients with central venous occlusions

OBJECTIVE

The Hemodialysis Reliable Outflow (HeRO) graft (Hemosphere/CryoLife Inc, Eden Prairie, Minn) has provided an innovative means to obtain hemodialysis access for patients with severe central venous occlusive disease. The outcomes of this novel treatment modality in a difficult population have yet to be clearly established.

METHODS

A retrospective review of HeRO graft placement from June 2010 to January 2012 was performed. Patient hemodialysis access history, clinical complexity, complications, and outcomes were analyzed. Categoric data were described with counts and proportions, and continuous data with means, ranges and, when appropriate, standard deviations. Patency rates were analyzed using life-table analysis, and patency rate comparisons were made with a two-group proportion comparison calculator.

RESULTS

HeRO graft placement was attempted 21 times in 19 patients (52% women), with 18 of 21 (86%) placed successfully. All but one was placed in the upper extremity. Mean follow-up after successful placement has been 7 months (range, 0-23 months). The primary indication for all HeRO graft placements except one was central vein occlusion(s) and need for arteriovenous access. Patients averaged 2.0 previous (failed) accesses and multiple catheters. Four HeRO grafts (24%), all in women, required ligation and removal for severe steal symptoms in the immediate postoperative period (P < .01 vs men). Three HeROs were placed above fistulas for rescue. All thrombosed <4 months, although the fistulas remained open. An infection rate of 0.5 bacteremic events per 1000 HeRO-days was observed. At a mean follow-up of 7 months, primary patency was 28% and secondary patency was 44%. The observed 12-month primary and secondary patency rates were 11% and 32%, respectively. Secondary patency was maintained in four patients for a mean duration of 10 months (range, 6-18 months), with an average of 4.0 ± 2.2 thrombectomies per catheter.

CONCLUSIONS

HeRO graft placement, when used as a last-resort measure, has been able to provide upper extremity access in patients who otherwise would not have this option. There is a high complication rate, however, including a very high incidence of steal in women. HeRO grafts should continue to be used as a last resort.

Male breast cancer manifesting as cephalic vein thrombosis

Male breast cancer is an uncommon disease with a low annual prevalence in Western countries. Venous thromboembolism may be associated during malignancy of the breast. We report a 70-year-old man who presented with superficial vein thrombosis of right upper limb that predicted the diagnosis of breast invasive ductal carcinoma. Key issues surrounding the diagnosis, treatment, and relationship between breast cancer and venous disorders are discussed. Breast cancer and venous thromboembolism are 2 conditions that are often correlated more than expected, and attention to the combination of these clinical presentations is required.

The clinicopathological determinants of native arteriovenous fistula failure in patients on maintenance hemodialysis

BACKGROUND

Progressive narrowing of the venous part of dialysis fistulae is caused by hemodynamic and inflammatory factors.

OBJECTIVES

The pathogenic and clinical determinants of deterioration of the functioning of arteriovenous fistulae in chronically hemodialyzed patients were evaluated.

MATERIAL AND METHODS

The hemodynamic parameters and the activity of inflammatory growth factors in the vessel wall of newly implanted fistulae were assessed and correlated with the clinical course of 34 hemodialyzed patients. Measurements taken at the time of implanting the fistulae included blood flow in the venous part of the anastomosis and its widest diameter by ultrasound Power Doppler, a histopathologic examination of fistula wall samples and measurements of mRNA expression for growth factors PDGFβ1 and TGFβ in the fistula wall. The results were correlated with clinical data from 36 months' observation: duration of fistula maturation, adequacy of dialysis treatment (eKt/V), the patient's survival, morbidity linked with vascular access problems and general cardiovascular morbidity.

RESULTS

The mean duration of fistula maturation was 44.9 days (N = 43, SD = 38.6), whereas the average duration of fistula usage as dialysis access was 795.9 ± 480.6 days. Fistula blood flow at the time of implantation, averaged 1782.2 ± 1735.3 ml/min. The mean number of hospitalization days due to vascular access morbidity was 9.9 ± 15.6 days and it correlated positively with the fistula blood flow (R = 0.596, P = 0.004). There was a negative correlation between the expression of PDGFβ1 mRNA and fistula blood flow (R = -0.673, P = 0.011), as well as between TGFβ expression and patient survival (R = -0.722, P = 0.002).

CONCLUSIONS

Inflammatory activity of the vessel wall growth factors PDGFβ1 and TGFβ implies impairment of fistula function and the patient's cardiovascular morbidity.

Update on aneurysm disease: current insights and controversies: peripheral aneurysms: when to intervene - is rupture really a danger?

Peripheral artery aneurysms are rarer than abdominal aortic aneurysms (AAA), although the true prevalence is not well known. They often coexist with aortic and other peripheral artery aneurysms. In contrast to AAA, where the principal risk is that of rupture, thromboembolism is more common, contributing a bigger risk in the more common lesions. Although rupture does occur, with incidence related to anatomical site, aneurysm diameter cannot be used to guide management with the same confidence as in AAA. In addition, the rarity of these lesions results in a paucity of evidence with which to guide intervention. Consequently they are difficult lesions to manage, and numerous aneurysm and patient factors must be considered to provide treatment individualised for each case. We discuss popliteal, femoral, carotid, subclavian, upper limb, visceral and false aneurysms, focussing on the risk of rupture and thromboembolism, and current thresholds for intervention, based on the available published literature.

A computational approach to generate concurrent arterial networks in vascular territories

In this work, a computational procedure is proposed to vascularize anatomical regions supplied by many inflow sites. The proposed methodology creates a partition of the territory to be vascularized into nonoverlapping subdomains that are independently supplied by the so-called perforator arteries (inflow sites). Then, in each subdomain, the constrained constructive optimization method is used to generate a network of vessels. The identification of subdomains in a certain vascular territory perfused by many perforator arteries turns out to be a fundamental problem towards understanding the morphological conformation of peripheral beds in the cardiovascular system. The methodology is assessed through two academic examples showing the main structural features of the so-defined vascular territory partition and the corresponding arterial networks. In addition, the vascularization of a three-dimensional sheet-like tissue is presented with potential application in flap planning and design.

Remote ischemic preconditioning in hemodialysis: a pilot study

Hemodialysis (HD)-induced myocardial ischemia is associated with an elevated cardiac troponin T, and is common in asymptomatic patients undergoing conventional HD. Remote ischemic preconditioning (RIPC) has a protective effect against myocardial ischemia-reperfusion injury. We hypothesized that RIPC also has a protective effect on HD-induced myocardial injury. Chronic HD patients were randomized to the control group or the RIPC group. RIPC was induced by transient occlusion of blood flow to the arm with a blood-pressure cuff for 5 min, followed by 5 min of deflation. Three cycles of inflation and deflation were undertaken before every HD session for 1 month (total 12 times). The primary outcome was the change in cardiac troponin T (cTnT) level at day 28 from baseline. Demographic and baseline laboratory values were not different between the control (n = 17) and the RIPC groups (n = 17). cTnT levels tended to decrease from day 2 in the RIPC group through to 28 days, in contrast to no change in the control group. There were significant differences in the change of cTnT level at day 28 from baseline [Control, median; -0.002 ng/ml (interquartile range -0.008 to 0.018) versus RIPC, median; -0.015 ng/ml (interquartile range -0.055 to 0.004), P = 0.012]. RIPC reduced cTnT release in chronic conventional HD patients, suggesting that this simple, cheap, safe, and well-tolerated procedure has a protective effect against HD-induced ischemia.

Carotid axillary artery bypass: an option following failed open and percutaneous procedures

Percutaneous transluminal angioplasty and stenting is being employed with increasing frequency for stenosis involving the brachiocephalic circulation. However, the efficacy of these procedures is limited by intimal hyperplasia and subsequent re-stenosis. Long-term results for treating lesions of the subclavian or innominate artery have shown significant re-stenotic rate. Accordingly, carotid-subclavian bypass remains as an important procedure. Alternative methods may still be required, particularly after failure of open re-vascularization and percutaneous techniques. This report describes an underused technique that enables upper extremity revascularization following prior attempts at endovascular and standard open techniques.

The benefit of non contrast-enhanced magnetic resonance angiography for predicting vascular access surgery outcome: a computer model perspective

INTRODUCTION

Vascular access (VA) surgery, a prerequisite for hemodialysis treatment of end-stage renal-disease (ESRD) patients, is hampered by complication rates, which are frequently related to flow enhancement. To assist in VA surgery planning, a patient-specific computer model for postoperative flow enhancement was developed. The purpose of this study is to assess the benefit of non contrast-enhanced magnetic resonance angiography (NCE-MRA) data as patient-specific geometrical input for the model-based prediction of surgery outcome.

METHODS

25 ESRD patients were included in this study. All patients received a NCE-MRA examination of the upper extremity blood vessels in addition to routine ultrasound (US). Local arterial radii were assessed from NCE-MRA and converted to model input using a linear fit per artery. Venous radii were determined with US. The effect of radius measurement uncertainty on model predictions was accounted for by performing Monte-Carlo simulations. The resulting flow prediction interval of the computer model was compared with the postoperative flow obtained from US. Patients with no overlap between model-based prediction and postoperative measurement were further analyzed to determine whether an increase in geometrical detail improved computer model prediction.

RESULTS

Overlap between postoperative flows and model-based predictions was obtained for 71% of patients. Detailed inspection of non-overlapping cases revealed that the geometrical details that could be assessed from NCE-MRA explained most of the differences, and moreover, upon addition of these details in the computer model the flow predictions improved.

CONCLUSIONS

The results demonstrate clearly that NCE-MRA does provide valuable geometrical information for VA surgery planning. Therefore, it is recommended to use this modality, at least for patients at risk for local or global narrowing of the blood vessels as well as for patients for whom an US-based model prediction would not overlap with surgical choice, as the geometrical details are crucial for obtaining accurate flow predictions.

[Upper thoracic sympathectomy in treatment of upper limb ischaemia in distal lesions of the arterial bed]

Analysed herein was efficacy of 76 videothoracoscopic upper chest sympathectomies performed for upper limb ischaemia in a total of 61 patients. Of these, 15 patients were found to suffer bilateral lesions. The findings of clinical follow up and instrumental examinations (laser Doppler flowmetry, rheovasography, measuring transcranial oxygen tension in tissues) made it possible to draw a conclusion on efficacy of upper chest sympathectomy in distal lesions of the vascular bed of the upper extremities.

[Antegrade catheterization of the brachial artery during treatment of arteriovenous angiodysplasia of the forearm and hand]

The authors share herein their experience with an antegrade brachial access for treatment of patients presenting with arteriovenous angiodysplasia localizing on the distal portions of the upper limbs, also describing the choice of the site for puncture and the technique of antegrade catheterization of the brachial artery. This is followed by reporting the results of successful use of this access in a total of 27 patients. The access is simple to create, making it possible to easily perform the intervention using instruments of standard length. It is also safe, requires no bed rest in the postoperative period, and is well tolerated by the patients.

[Phenomenon of ischemic steal syndrome in patients with different arteriovenous fistulas for hemodialysis and its surgical correction]

Patients with arteriovenous fistulas (648 cases) were examined for hemodialysis. The ischemic steal syndrome was detected in 47 patients and it was associated with vascular access for hemodialysis. A frequency of given complication was studied with correlation of the type of vascular access. The data of clinical and instrumental examination were described. It was revealed, that the development of steal syndrome was influenced by the blood circulation volume velocity on fistulas. Different reconstructive operations were performed on 42 patients in order to save the access for hemodialysis and eliminate the ischemia. The ligation of fistula was carried out for 5 patients. The survival of arteriovenous fistulas after reconstructive operations was till 46 months during the period of follow-up study.

[2011 ESC guidelines on the diagnosis and treatment of peripheral artery diseases]

In this article, we present the 2011 guidelines on the diagnosis and treatment of peripheral artery diseases. The document covers the diagnostic modalities and therapeutic strategies for the atherosclerotic disease of the extra-cranial carotid, mesenteric, renal, upper and lower extremity arteries indicating the class and level of evidence of the recommendations.