Clinical Outcomes after Isolated Infrapopliteal Revascularization in Hemodialysis Patients with Critical Limb Ischemia: Endovascular Therapy versus Bypass Surgery

A Novel Graft Route by Passage under the Achilles Tendon in Paramalleolar Distal Bypass Using the Small Saphenous Vein

A 77-year-old man with diabetes presented to our hospital because of left toe gangrene, requiring infrapopliteal revascularization. The patient was on hemodialysis for renal dysfunction. The great saphenous veins had been used for a previous coronary artery bypass. Hence, the small saphenous vein was applied in a popliteal-to-distal posterior tibial artery bypass. The vein graft was passed under the Achilles tendon to reduce graft length, preventing external compression around the ankle. We performed minor amputation and provided negative pressure wound therapy to promote ulcer healing. The wounds healed entirely after two months.

[Advantages of profundoplasty in patients with lower limb critical ischaemia in redo operations]

Our study was aimed at determining advantages of profundoplasty in patients with critical ischaemia of lower limbs in repeat arterial reconstructions. It included a total of 56 patients subjected to redo operations for thrombosis of a femoropopliteal bypass graft. Of these, 29 underwent profundoplasty (group I) and 27 repeat femoropopliteal bypass grafting (group II). Critical ischaemia was relieved in the early postoperative period in 28 (97%) and 24 (89%) patients of group I and II, respectively. The 3-year patency rate after profundoplasty amounted to 100% and after femoropopliteal bypass grafting to 47% (p<0.05). The lower-limb amputation rates over the 3-year period of follow up amounted to 3 (10%) and 11 (41%), p<0.05, respectively. Over the 3-year period of follow up, there was no statistically significant difference in the values of the ankle-brachial index (p>0.05).

[Significance of the deep femoral ertery in repeat reconstructions]

Atherosclerosis obliterans is managed by various reconstructions of lower-limb arteries, but despite this, in the immediate and remote postoperative period there appears the necessity to carry out repeat reconstructions, which might be caused by shunt thrombosis, progression of atherosclerosis, etc. One of the methods of solving this problem is revascularization of lower-limb arteries through the deep femoral vein with plasty thereof. In occlusive lesions of the superficial femoral artery, the deep femoral artery plays the key role in blood supply of the entire extremity. The article deals with the principles of repeat surgical treatment of lower-limb arteries with the use of the deep femoral artery, also discussing the problems concerning the frequency of occurrence of thromboses in various positions, and the role of the deep femoral artery in blood supply of the lower extremity. The problem of efficacy of redo operations on lower-limb arteries using the deep femoral artery is still important. Despite the possibility of revascularization of lower extremities through the deep femoral vein, a high percentage of amputations remains. The terms of patency of the reconstructed deep femoral artery has proved to be several times longer than those of femoropopliteal and femorotibial shunts in the remote postoperative period. Besides, there are no clear-cut criteria for prognosis of efficacy of reconstructive interventions on the deep femoral artery in patients with multi-segment lesions of arteries of lower extremities after primary interventions, therefore, no common surgical policy exists. The use of the deep femoral artery in patients with ischaemia of lower extremities is explained by the minimally traumatic nature and confirmed efficacy after a series of previously performed multilevel operations, severe lesions of the distal bed, as well as in patients with severe concomitant diseases.

Impact of Multivascular Disease on Cardiovascular Mortality and Morbidity in Patients Receiving Hemodialysis: Ten-Year Outcomes of the Q-Cohort Study

AIM

Multivascular disease, indicating concurrent arteriosclerotic lesions in a number of different vascular beds, is an independent risk factor for recurrent ischemic events in the general population. However, the impact of multivascular disease on the risk of developing cardiovascular disease has not been fully evaluated in patients receiving hemodialysis.

METHODS

A total of 3,504 hemodialysis patients were prospectively followed for 10 years. In this study, multivascular disease was defined as the coexistence of coronary artery disease and stroke. We examined the relationship between multivascular disease and the occurrence of composite cardiovascular endpoint, consisting of cardiovascular death, nonfatal coronary artery disease, nonfatal stroke, and peripheral artery disease.

RESULTS

The proportion of participants with multivascular disease was 5.7% (n=200) at baseline. During follow-up (median, 106.6 months; interquartile range, 50.1-121.8 months), 1,311 patients experienced the composite endpoint, which was defined as at least one of the following: cardiovascular death (n=620), nonfatal coronary artery disease (n=318), nonfatal stroke (n=340), and peripheral artery disease (n=257). Compared with the group with no history of cardiovascular disease, the risk of experiencing the composite endpoint increased significantly with higher numbers of injured vascular beds in patients with single vascular disease (hazard ratio, 1.68; 95% confidence interval, 1.49-1.89) and in those with multivascular disease (hazard ratio, 2.11; 95% confidence interval, 1.71-2.60). In a multivariable analysis, multivascular disease was an independent predictor of cardiovascular events, in addition to diabetes, aging, and hypertension.

CONCLUSIONS

This study clearly demonstrated that multivascular disease was a powerful predictor for cardiovascular mortality and morbidity in patients receiving hemodialysis.

Preventive effects of fraxin on ischemia/reperfusion-induced acute kidney injury in rats

AIM

Kidney ischemia reperfusion (IR) injury is an important health problem resulting in acute kidney failure. The oxidative stress and inflammatory process are the underlying mechanisms of IR injury. It has been purposed in this study to research the possible protective effects of fraxin on kidney injury induced by IR.

MATERIAL AND METHODS

32 Sprague Dawley male rats were divided into 4 groups. The groups were organized as follows; sham, IR, IR + fraxin 10 mg/kg, and IR + 50 mg/kg fraxin groups. Some oxidant, antioxidant and inflammatory parameters were evaluated in kidney tissues removed at the end of our experimental study.

KEY FINDINGS

It was detected that the oxidant and proinflammatory markers increased and antioxidant parameters decreased in IR group but the results significantly reversed in treatment groups compared to IR group. And also, 8-OHdG, NF-κB, HAVCR1 immunopositivities were at severe levels and these results attenuated in IR fraxin + 10 mg/kg, and IR + fraxin 50 mg/kg groups.

SIGNIFICANCE

These presented results have shown that fraxin performed protective effects against kidney injury induced by IR.

Propolis and Its Combination with Boric Acid Protect Against Ischemia/Reperfusion-Induced Acute Kidney Injury by Inhibiting Oxidative Stress, Inflammation, DNA Damage, and Apoptosis in Rats

Ischemia reperfusion (I/R) injury which causes kidney dysfunction is one of the most studied diseases directly linked to oxidative stress. In this regard, it is important to protect cells against damage by inducing antioxidant response. Herein, we aimed to evaluate the therapeutic roles and possible mechanisms of propolis and boric acid in kidney I/R injury based on relevant basic research and clinical studies. Sprague-Dawley rats were subjected to 50 min of ischemia followed by 3 h of reperfusion. Animals were randomly divided into a control group (the abdominal wall was just opened and closed), an I/R injury group, the propolis intervention group (200 mg/kg, intragastric administration, 1 h before ischemia), boric acid intervention group (14 mg/kg, intragastric administration 1 h before ischemia), and the propolis + boric acid intervention group (intragastric administration 1 h before ischemia). Kidney function, the antioxidant defensive system, and renal damage were assessed. In addition, the oxidative stress and inflammatory status were estimated in renal tissue. Furthermore, DNA damageand apoptosis were detected by immunohistochemistry. When compared with I/R group, propolis alone and especially propolis + boric acid groups significantly improved functional parameters. While the antioxidant response was increased, renal injury size and apoptosis were significantly decreased in both groups. Also, the MDA and TNF-α levels besides the 8-OHdG formation were downregulated. According to these outcomes, it can be said that especially propolis together with boric acid ameliorates kidney injury caused by I/R through acting as an antioxidant, anti-inflammatory, and antiapoptotic agent. In conclusion, propolis alone and its combination with boric acid could be developed as therapeutic agents against serious renal I/R injuries.

The Incidence and Associated Factors of Sudden Death in Patients on Hemodialysis: 10-Year Outcome of the Q-Cohort Study

Aim: The incidence of sudden death and its risk factors in patients on hemodialysis remain unclear. This study aimed to clarify the incidence of sudden death and its risk factors in Japanese patients on hemodialysis.

Methods: A total of 3505 patients on hemodialysis aged ≥ 18 years were followed for 10 years. Multivariate-adjusted hazard ratio (HR) with 95% confidence interval (95% CI) of each risk factor of sudden death were calculated using a Cox proportional hazards model.

Results: During the 10-year follow-up, 1735 patients died, including 227 (13%) sudden deaths. The incidence rate of sudden death was 9.13 per 1000 person-years. In multivariable-adjusted Cox analysis, male sex (HR 1.67; 95% CI 1.20–2.33), age (HR 1.44; 95% CI 1.26–1.65 per 10-year higher), the presence of diabetes (HR 2.45; 95% CI 1.82–3.29), history of cardiovascular disease (HR 1.85; 95% CI 1.38–2.46), cardiothoracic ratio (HR 1.21; 95% CI 1.07–1.39 per 5% higher), serum C-reactive protein (HR 1.11; 95% CI 1.03–1.20 per 1-mg/dL higher), and serum phosphate (HR 1.15; 95% CI 1.03–1.30 per 1-mg/dL higher) were independent predictors of sudden death. A subgroup analysis stratified by sex or age showed that lower serum corrected calcium levels, not using vitamin D receptor activators in women, and a shorter dialysis session length in men or older people (≥ 65 years) increased the risk for sudden death.

Conclusions: This study clarified the incidence of sudden death and its specific predictors in Japanese patients on hemodialysis.

Clinical Effects of Planned Endovascular Therapy for Critical Limb Ischemia Patients with Tissue Loss

Aim: The aim of this study was to investigate the clinical effect of planned endovascular therapy (EVT) for critical limb ischemia (CLI) patients with tissue loss. Although several rounds of EVT for CLI patients are required for complete wound healing, time required for complete wound healing depends on the wound severity. We hypothesized that planned EVT might reduce the time to wound healing.

Methods: A total of 89 limbs of 76 CLI patients with tissue loss, who had undergone more than at least two EVTs were included in this study. From January 2013 through December 2015 (Conventional-EVT-group, 52 limbs), indication of target lesion revascularization (TLR) was decided based on decreased skin perfusion pressure (SPP) values or delayed wound healing. From January 2016 through October 2016 (Planned-EVT-group, 37 limbs), TLR were done every two months regardless of the SPP values until complete wound healing was obtained. Time to wound healing and complete wound healing rates were compared between the two groups.

Results: No significant differences existed in baseline patients and lesion characteristics between the two groups. There was no significant difference in total EVT numbers between the two groups (2.0; interquartile range, 2.0–3.0 versus 2.0; interquartile range, 2.0–3.0; P = 0.9). Although complete wound healing rate was similar in both groups (71.2% versus 73.0%, p = 1.0), time to wound healing was significantly shorter (95 days versus 143 days, p = 0.025) in the Planned-EVT-group than in the Conventional-EVT-group.

Conclusions: Planned-EVT is a useful strategy to shorten the time to wound healing for CLI patients with tissue loss.