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Xu K, Lin B, Collado L, Martin MC, Carlson SJ, Raffetto JD, McPhee JT. Predicting wound complications following lower extremity revascularization. J Vasc Surg 2024; 79:642-650.e2. [PMID: 37984755 DOI: 10.1016/j.jvs.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE The aim of this study was to create a simple risk score to identify factors associated with wound complications after infrainguinal revascularization. METHODS The Veterans Affairs Surgical Quality Improvement Program national data set was queried from 2005 to 2021 to identify 22,114 patients undergoing elective open revascularization for peripheral arterial disease (claudication, rest pain, tissue loss) or peripheral aneurysm. Emergency and trauma cases were excluded. The data set was divided into a two-thirds derivation set and one-third validation set to create a risk prediction model. The primary end point was wound complication (wound dehiscence, superficial/deep wound surgical site infection). Eight independent risk factors for wound complications resulted from the model and were assigned whole number integer risk scores. Summary risk scores were collapsed into categories and defined as low (0-3 points), moderate (4-7 points), high (8-11 points), and very high (>12 points). RESULTS The wound complication rate in the derivation data set was 9.7% (n = 1428). Predictors of wound complication included age ≤73 (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.08-1.46), body mass index ≥35 kg/m2 (OR, 1.99; 95% CI, 1.68-2.36), non-Hispanic White (vs others: OR, 1.48; 95% CI, 1.30-1.69), diabetes (OR, 1.23; 95% CI, 1.10-1.37), white blood cell count >9900/mm3 (OR, 1.18; 95% CI, 1.03-1.35), absence of coronary artery disease (OR, 1.27; 95% CI, 1.03-1.35), operative time >6 hours (OR, 1.20; 95% CI, 1.05-1.37), and undergoing a femoral endarterectomy in conjunction with bypass (OR, 1.34; 95% CI, 1.14-1.57). In both the derivation and validation sets, wound complications correlated with risk category. Among the defined categories in the derivation set, wound complication rates were 4.5% for low-risk patients, 8.5% for moderate-risk patients, 13.8% for high-risk patients, and 23.8% for very high-risk patients, with similar results for the internal validation data set. Operative indication did not independently associate with wound complications. Patients with wound complications had higher rates of reoperation and graft failure. CONCLUSIONS This risk prediction model uses easily obtainable clinical metrics that allow for informed discussion of wound complication risk for patients undergoing open infrainguinal revascularization.
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Affiliation(s)
- Ke Xu
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Brenda Lin
- Department of Surgery, Boston Medical Center, Boston, MA
| | | | - Michelle C Martin
- Department of Surgery, VA Boston Healthcare System, West Roxbury, MA; Department of Surgery, Harvard Medical School, Boston, MA
| | - Sarah J Carlson
- Department of Surgery, VA Boston Healthcare System, West Roxbury, MA; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Joseph D Raffetto
- Department of Surgery, VA Boston Healthcare System, West Roxbury, MA; Department of Surgery, Harvard Medical School, Boston, MA
| | - James T McPhee
- Department of Surgery, VA Boston Healthcare System, West Roxbury, MA; Department of Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
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Ozsvath K, Raffetto JD, Lindner E, Murphy EH. Venous compression syndromes in females: A descriptive review. Semin Vasc Surg 2023; 36:550-559. [PMID: 38030329 DOI: 10.1053/j.semvascsurg.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023]
Abstract
Venous compression syndromes have been described, yet the role of sex is poorly understood. Although iliac vein compression has been discussed more often with the advent of newer technologies, research has fallen short on defining epidemiology, best practices for evaluation and treatment, and differences in responses to treatment between men and females. The authors report on iliac vein compression, nonthrombotic renal vein compression, and other venous compression syndromes in females. Literature searches of PubMed were performed using the following keywords: females/females and May Thurner, venous stenting, venous outcomes, deep venous disease, deep venous compression, venous stenting, renal vein compression, renal vein surgery/stent, popliteal vein entrapment, venous thoracic vein entrapment, and popliteal vein entrapment. The articles prompted the authors to research further as the referenced articles were reviewed. Sex representation has not been addressed adequately in the research of venous compression syndromes, making the discussion of best treatment options and long-term outcomes difficult. More specific understanding of epidemiology and response to interventions will only come from research that addresses these issues directly, understanding that some of these syndromes occur rarely.
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Affiliation(s)
- Kathleen Ozsvath
- St Peters Health Partners, Vascular Associates, Albany, NY; Samaritan Hospital, 2 New Hampshire, Troy, NY, 12211.
| | - Joseph D Raffetto
- Harvard Medical School, Boston, MA; Uniformed Services University of the Health Sciences, Bethesda, MD; Veterans Affairs Boston Healthcare System, Boston, MA; Brigham and Females's Hospital, Boston, MA
| | | | - Erin H Murphy
- Venous and Lymphatic Center, Sanger Heart and Vascular, Atrium Health, Charlotte, NC
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Eid MA, Barry MJ, Tang GL, Henke PK, Johanning JM, Tzeng E, Scali ST, Stone DH, Suckow BD, Lee ES, Arya S, Brooke BS, Nelson PR, Spangler EL, Murebee L, Dosluoglu HH, Raffetto JD, Kougais P, Brewster LP, Alabi O, Dardik A, Halpern VJ, O’Connell JB, Ihnat DM, Zhou W, Sirovich BE, Metha K, Moore KO, Voorhees A, Goodney PP. Effect of a Decision Aid on Agreement Between Patient Preferences and Repair Type for Abdominal Aortic Aneurysm: A Randomized Clinical Trial. JAMA Surg 2022; 157:e222935. [PMID: 35947375 PMCID: PMC9366657 DOI: 10.1001/jamasurg.2022.2935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/04/2022] [Indexed: 12/19/2022]
Abstract
Importance Patients with abdominal aortic aneurysm (AAA) can choose open repair or endovascular repair (EVAR). While EVAR is less invasive, it requires lifelong surveillance and more frequent aneurysm-related reinterventions than open repair. A decision aid may help patients receive their preferred type of AAA repair. Objective To determine the effect of a decision aid on agreement between patient preference for AAA repair type and the repair type they receive. Design, Setting, and Participants In this cluster randomized trial, 235 patients were randomized at 22 VA vascular surgery clinics. All patients had AAAs greater than 5.0 cm in diameter and were candidates for both open repair and EVAR. Data were collected from August 2017 to December 2020, and data were analyzed from December 2020 to June 2021. Interventions Presurgical consultation using a decision aid vs usual care. Main Outcomes and Measures The primary outcome was the proportion of patients who had agreement between their preference and their repair type, measured using χ2 analyses, κ statistics, and adjusted odds ratios. Results Of 235 included patients, 234 (99.6%) were male, and the mean (SD) age was 73 (5.9) years. A total of 126 patients were enrolled in the decision aid group, and 109 were enrolled in the control group. Within 2 years after enrollment, 192 (81.7%) underwent repair. Patients were similar between the decision aid and control groups by age, sex, aneurysm size, iliac artery involvement, and Charlson Comorbidity Index score. Patients preferred EVAR over open repair in both groups (96 of 122 [79%] in the decision aid group; 81 of 106 [76%] in the control group; P = .60). Patients in the decision aid group were more likely to receive their preferred repair type than patients in the control group (95% agreement [93 of 98] vs 86% agreement [81 of 94]; P = .03), and κ statistics were higher in the decision aid group (κ = 0.78; 95% CI, 0.60-0.95) compared with the control group (κ = 0.53; 95% CI, 0.32-0.74). Adjusted models confirmed this association (odds ratio of agreement in the decision aid group relative to control group, 2.93; 95% CI, 1.10-7.70). Conclusions and Relevance Patients exposed to a decision aid were more likely to receive their preferred AAA repair type, suggesting that decision aids can help better align patient preferences and treatments in major cardiovascular procedures. Trial Registration ClinicalTrials.gov Identifier: NCT03115346.
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Affiliation(s)
- Mark A. Eid
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Michael J. Barry
- Massachusetts General Hospital Center for Shared Decision Making, Boston
| | | | | | | | - Edith Tzeng
- Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania
| | | | - David H. Stone
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Bjoern D. Suckow
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | - Shipra Arya
- Palo Alto VA Medical Center, Palo Alto, California
| | | | | | | | | | | | | | | | | | | | - Alan Dardik
- West Haven VA Medical Center, West Haven, Connecticut
| | | | | | | | - Wei Zhou
- Tucson VA Medical Center, Tucson, Arizona
| | - Brenda E. Sirovich
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Kunal Metha
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Kayla O. Moore
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | - Amy Voorhees
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
| | - Philip P. Goodney
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Lurie F, Malgor RD, Carman T, Dean SM, Iafrati MD, Khilnani NM, Labropoulos N, Maldonado TS, Mortimer P, O'Donnell TF, Raffetto JD, Rockson SG, Gasparis AP. The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment. Phlebology 2022; 37:252-266. [PMID: 35258350 PMCID: PMC9069652 DOI: 10.1177/02683555211053532] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts' opinions on the available literature on lymphedema while following the Delphi methodology. METHODS In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever >70% agreement was achieved. RESULTS The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3-C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment. CONCLUSION This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.
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Affiliation(s)
- Fedor Lurie
- 92661Jobst Vascular Institute of Promedica, Toledo, OH, USA.,University of Michigan at Ann Arbor, Ann Arbor, MI, USA
| | | | - Teresa Carman
- 5718Vanderbilt University Medical Center, Nashville, TN, USA
| | - Steven M Dean
- 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mark D Iafrati
- 1867Tufts University School of Medicine, Boston, MA, USA
| | - Neil M Khilnani
- 12295Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA
| | | | | | | | | | - Joseph D Raffetto
- VA Boston Healthcare System, Boston, USA.,Harvard Medical School, Boston, USA.,Brigham and Women's Hospital, Boston, USA
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Reslan OM, McPhee JT, Brener BJ, Row HT, Eberhardt RT, Raffetto JD. Peri-Procedural Management of Hemodynamic Instability in Patients Undergoing Carotid Revascularization. Ann Vasc Surg 2022; 85:406-417. [PMID: 35395375 DOI: 10.1016/j.avsg.2022.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/14/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
Acute perioperative changes in arterial pressure occur frequently, particularly in patients with cardiovascular disease or those receiving vasoactive medications, or in relation to certain cardiovascular surgical procedures. Hemodynamic Instability (HI) are common in patients undergoing carotid revascularization because of unique patho-physiological and surgical factors. The operation, by necessity, disrupts the afferent pathway of the baroreflex, which can lead to postendarterectomy HI. Poor arterial pressure control is associated with increased morbidity and mortality after carotid revascularization, but good control of arterial pressure is often difficult to achieve in practice. The incidence, implications, and etiology of HI associated with carotid surgery are reviewed, and some recommendations made for its management. Close monitoring and titration of therapy are probably the most important considerations rather than specific choice of agents.
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Affiliation(s)
- Ossama M Reslan
- VA Fargo HCS, Fargo ND, Division of Vascular Surgery, Department of Surgery; University of North Dakota School of Medicine & Health Sciences, Department of Surgery.
| | - James T McPhee
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Boston University School of Medicine, Boston Medical Center
| | - Bruce J Brener
- Newark Beth Israel Medical Center, Division of Vascular Surgery, Department of Surgery
| | - Hunter T Row
- University of North Dakota School of Medicine & Health Sciences, Department of Surgery
| | - Robert T Eberhardt
- Boston University School of Medicine, Boston Medical Center; Division of Cardiovascular Medicine, Department of Medicine
| | - Joseph D Raffetto
- VA Boston HCS, West Roxbury MA, Division of Vascular Surgery, Department of Surgery; Harvard Medical School, Brigham and Women's Hospital
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Raffetto JD. The novel and exciting research of E-selectin inhibition for deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2021; 10:221. [PMID: 34920847 DOI: 10.1016/j.jvsv.2021.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 01/29/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Joseph D Raffetto
- Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston Veterans Affairs Healthcare Systems, West Roxbury, Mass.
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Raffetto JD, Khalil RA. Mechanisms of Lower Extremity Vein Dysfunction in Chronic Venous Disease and Implications in Management of Varicose Veins. Vessel Plus 2021; 5. [PMID: 34250453 DOI: 10.20517/2574-1209.2021.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Chronic venous disease (CVD) is a common venous disorder of the lower extremities. CVD can be manifested as varicose veins (VVs), with dilated and tortuous veins, dysfunctional valves and venous reflux. If not adequately treated, VVs could progress to chronic venous insufficiency (CVI) and lead to venous leg ulcer (VLU). Predisposing familial and genetic factors have been implicated in CVD. Additional environmental, behavioral and dietary factors including sedentary lifestyle and obesity may also contribute to CVD. Alterations in the mRNA expression, protein levels and proteolytic activity of matrix metalloproteinases (MMPs) have been detected in VVs and VLU. MMP expression/activity can be modulated by venous hydrostatic pressure, hypoxia, tissue metabolites, and inflammation. MMPs in turn increase proteolysis of different protein substrates in the extracellular matrix particularly collagen and elastin, leading to weakening of the vein wall. MMPs could also promote venous dilation by increasing the release of endothelium-derived vasodilators and activating potassium channels, leading to smooth muscle hyperpolarization and relaxation. Depending on VVs severity, management usually includes compression stockings, sclerotherapy and surgical removal. Venotonics have also been promoted to decrease the progression of VVs. Sulodexide has also shown benefits in VLU and CVI, and recent data suggest that it could improve venous smooth muscle contraction. Other lines of treatment including induction of endogenous tissue inhibitors of metalloproteinases (TIMPs) and administration of exogenous synthetic inhibitors of MMPs are being explored, and could provide alternative strategies in the treatment of CVD.
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Affiliation(s)
- Joseph D Raffetto
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Raouf A Khalil
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
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8
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Gonzalez-Ochoa AJ, Raffetto JD, Hernández AG, Zavala N, Gutiérrez O, Vargas A, Loustaunau J. Sulodexide in the Treatment of Patients with Early Stages of COVID-19: A Randomized Controlled Trial. Thromb Haemost 2021; 121:944-954. [PMID: 33677827 DOI: 10.1055/a-1414-5216] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may induce several vascular endothelial-dependent systemic complications, and sulodexide has pleiotropic actions on the vascular endothelium, which may prove beneficial. We aimed to assess the effect of sulodexide when used within 3 days of coronavirus disease 2019 (COVID-19) clinical onset. We conducted a randomized placebo-controlled outpatient trial. To be included, patients must have been at high risk for severe clinical progression. Participants received sulodexide (oral 1,000 LRU/d) or placebo for 21 days. The primary endpoint was the need for hospital care. Also assessed were patients' need for supplemental oxygen as well as D-dimer and C-reactive protein (CRP) levels, thromboembolic events, major bleeding, and mortality. A total of 243 patients were included in the per-protocol analysis from June 5 to August 30, 2020. Of these, 124 received sulodexide and 119 received a placebo. Only 17.7% of the patients in the sulodexide group required hospitalization, compared with 29.4% in the placebo group (p = 0.03). This benefit persisted in the intention-to-treat analysis (15% in sulodexide group vs. 24% with placebo [p = 0.04]). With sulodexide, fewer patients required supplemental oxygen (30 vs. 42% [p = 0.05]). After 2 weeks, fewer patients had D-dimer levels >500 ng/dL (22 vs. 47% [p < 0.01]), and patients also had lower mean CRP levels (12.5 vs. 17.8 mg/dL [p < 0.01]). There were no between-group differences in thromboembolic events, major bleeding, or mortality. Treatment of COVID-19 patients with sulodexide, when provided within 3 days of clinical onset, improved their clinical outcomes. Although the results should be confirmed, sulodexide could be valuable in an outpatient setting.
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Affiliation(s)
- Alejandro J Gonzalez-Ochoa
- Department of Vascular-Endovascular Surgery, CLINEDEM, Colonia Comercial, San Luis Rio Colorado, Sonora, México.,Division of Vascular Surgery, Department of Surgery, Hospital General de Zona No12 Instituto Mexicano Seguro Social, San Luis Rio Colorado, Sonora, México
| | - Joseph D Raffetto
- Department of Surgery, Brigham and Women's Hospital, VA Boston Healthcare System, Harvard University, Boston, Massachusetts, United States
| | - Ana G Hernández
- Department of Otorhinolaryngology, CLINEDEM, Colonia Comercial, San Luis Rio Colorado, Sonora, México
| | - Nestor Zavala
- Hospital General de Zona No12 Instituto Mexicano Seguro Social, San Luis Rio Colorado, Sonora, México
| | - Obed Gutiérrez
- Department of Emergency Medicine, Hospital General de Zona No12 Instituto Mexicano Seguro Social, San Luis Rio Colorado, Sonora, México.,Department of Emergency, Hospital General, San Luis Rio Colorado, Sonora, México
| | - Arturo Vargas
- Urban Outpatient Care Center, Secretaria de Salud, San Luis Rio Colorado, Sonora, México
| | - Jorge Loustaunau
- Department of Emergency, Hospital General de Zona No12 Instituto Mexicano Seguro Social, San Luis Rio Colorado, Sonora, México
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Carlson SJ, Forsyth AM, Alfson DB, Martin MC, Raffetto JD, McPhee JT. Safety and Feasibility of Radial Arterial Access for Lower Extremity, Mesenteric, and Aneurysm-Adjunctive Interventions. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2020.12.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Raffetto JD, Ligi D, Maniscalco R, Khalil RA, Mannello F. Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment. J Clin Med 2020; 10:jcm10010029. [PMID: 33374372 PMCID: PMC7795034 DOI: 10.3390/jcm10010029] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022] Open
Abstract
Venous leg ulcers (VLUs) are one of the most common ulcers of the lower extremity. VLU affects many individuals worldwide, could pose a significant socioeconomic burden to the healthcare system, and has major psychological and physical impacts on the affected individual. VLU often occurs in association with post-thrombotic syndrome, advanced chronic venous disease, varicose veins, and venous hypertension. Several demographic, genetic, and environmental factors could trigger chronic venous disease with venous dilation, incompetent valves, venous reflux, and venous hypertension. Endothelial cell injury and changes in the glycocalyx, venous shear-stress, and adhesion molecules could be initiating events in VLU. Increased endothelial cell permeability and leukocyte infiltration, and increases in inflammatory cytokines, matrix metalloproteinases (MMPs), reactive oxygen and nitrogen species, iron deposition, and tissue metabolites also contribute to the pathogenesis of VLU. Treatment of VLU includes compression therapy and endovenous ablation to occlude the axial reflux. Other interventional approaches such as subfascial endoscopic perforator surgery and iliac venous stent have shown mixed results. With good wound care and compression therapy, VLU usually heals within 6 months. VLU healing involves orchestrated processes including hemostasis, inflammation, proliferation, and remodeling and the contribution of different cells including leukocytes, platelets, fibroblasts, vascular smooth muscle cells, endothelial cells, and keratinocytes as well as the release of various biomolecules including transforming growth factor-β, cytokines, chemokines, MMPs, tissue inhibitors of MMPs (TIMPs), elastase, urokinase plasminogen activator, fibrin, collagen, and albumin. Alterations in any of these physiological wound closure processes could delay VLU healing. Also, these histological and soluble biomarkers can be used for VLU diagnosis and assessment of its progression, responsiveness to healing, and prognosis. If not treated adequately, VLU could progress to non-healed or granulating VLU, causing physical immobility, reduced quality of life, cellulitis, severe infections, osteomyelitis, and neoplastic transformation. Recalcitrant VLU shows prolonged healing time with advanced age, obesity, nutritional deficiencies, colder temperature, preexisting venous disease, deep venous thrombosis, and larger wound area. VLU also has a high, 50-70% recurrence rate, likely due to noncompliance with compression therapy, failure of surgical procedures, incorrect ulcer diagnosis, progression of venous disease, and poorly understood pathophysiology. Understanding the molecular pathways underlying VLU has led to new lines of therapy with significant promise including biologics such as bilayer living skin construct, fibroblast derivatives, and extracellular matrices and non-biologic products such as poly-N-acetyl glucosamine, human placental membranes amnion/chorion allografts, ACT1 peptide inhibitor of connexin 43, sulodexide, growth factors, silver dressings, MMP inhibitors, and modulators of reactive oxygen and nitrogen species, the immune response and tissue metabolites. Preventive measures including compression therapy and venotonics could also reduce the risk of progression to chronic venous insufficiency and VLU in susceptible individuals.
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Affiliation(s)
- Joseph D. Raffetto
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Correspondence: (J.D.R.); (F.M.)
| | - Daniela Ligi
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
| | - Rosanna Maniscalco
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
| | - Raouf A. Khalil
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Ferdinando Mannello
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
- Correspondence: (J.D.R.); (F.M.)
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Gianesini S, Raffetto JD, Mosti G, Maietti E, Sibilla MG, Zamboni P, Menegatti E. Volume control of the lower limb with graduated compression during different muscle pump activation conditions and the relation to limb circumference variation. J Vasc Surg Venous Lymphat Disord 2020; 8:814-820. [DOI: 10.1016/j.jvsv.2019.12.073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/11/2019] [Indexed: 11/28/2022]
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Columbo JA, Kang R, Spangler EL, Newhall K, Brooke BS, Dosluoglu H, Lee ES, Raffetto JD, Henke PK, Tang GS, Mureebe L, Kougias P, Johanning J, Arya S, Scali ST, Stone DH, Suckow BD, Orion K, Halpern V, O'Connell J, Inhat D, Nelson P, Tzeng E, Zhou W, Barry M, Sirovich B, Goodney PP. Design of the PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) Trial. Ann Vasc Surg 2020; 65:247-253. [PMID: 31075459 PMCID: PMC10740366 DOI: 10.1016/j.avsg.2019.02.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/25/2019] [Accepted: 02/21/2019] [Indexed: 10/26/2022]
Abstract
For patients with abdominal aortic aneurysm (AAA), randomized trials have found endovascular AAA repair (EVAR) is associated with lower perioperative morbidity and mortality than open surgical repair (OSR). However, OSR has fewer long-term aneurysm-related complications, such as endoleak or late rupture. Patients treated with EVAR and OSR have similar survival rates within two years after surgery, and OSR does not require intensive surveillance. Few have examined if patient preferences are aligned with the type of treatment they receive for their AAA. Although many assume that patients may universally prefer the less-invasive nature of EVAR, our preliminary work suggests that patients who value the lower risk of late complications may prefer OSR. In this study, called The PReferences for Open Versus Endovascular Repair of Abdominal Aortic Aneurysm (PROVE-AAA) trial, we describe a cluster-randomized trial to test if a decision aid can better align patients' preferences and their treatment type for AAA. Patients enrolled in the study are candidates for either endovascular or open repair and are followed up at VA hospitals by vascular surgery teams who regularly perform both types of repair. In Aim 1, we will determine patients' preferences for endovascular or open repair and identify domains associated with each repair type. In Aim 2, we will assess alignment between patients' preferences and the repair type elected and then compare the impact of a decision aid on this alignment between the intervention and control groups. This study will help us to accomplish two goals. First, we will better understand the factors that affect patient preference when choosing between EVAR and OSR. Second, we will better understand if a decision aid can help patients be more likely to receive the treatment strategy they prefer for their AAA. Study enrollment began on June 1, 2017. Between June 1, 2017 and November 1, 2018, we have enrolled 178 of a total goal of 240 veterans from 20 VA medical centers and their vascular surgery teams across the country. We anticipate completing enrollment in PROVE-AAA in June 2019, and study analyses will be performed thereafter.
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Affiliation(s)
- Jesse A Columbo
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Ravinder Kang
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Emily L Spangler
- Department of Vascular Surgery, Birmingham VA Medical Center, Birmingham, AL
| | - Karina Newhall
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Benjamin S Brooke
- Department of Vascular Surgery, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT
| | - Hasan Dosluoglu
- Department of Vascular Surgery, Buffalo VA Medical Center, Buffalo, NY
| | - Eugene S Lee
- Department of Vascular Surgery, Sacramento VA Medical Center, Mather, CA
| | - Joseph D Raffetto
- Department of Vascular Surgery, West Roxbury VA Medical Center, West Roxbury, MA
| | - Peter K Henke
- Department of Vascular Surgery, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Gale S Tang
- Department of Vascular Surgery, VA Puget Sound Health Care System, Seattle, WA
| | - Leila Mureebe
- Department of Vascular Surgery, Durham VA Health Care System, Durham, NC
| | - Panagoitis Kougias
- Department of Vascular Surgery, Michael E. DeBakey VA Medical Center, Houston, TX
| | - Jason Johanning
- Department of Vascular Surgery, Omaha VA Medical Center-VA Nebraska-Western Iowa HCS, Omaha, NE
| | - Shipra Arya
- Department of Vascular Surgery, Atlanta VA Medical Center, Decatur, GA
| | - Salvatore T Scali
- Department of Vascular Surgery, Malcom Randall VA Medical Center, Gainesville, FL
| | - David H Stone
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Bjoern D Suckow
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Kristine Orion
- Department of Vascular Surgery, West Haven VA Medical Center, West Haven, CT
| | - Vivienne Halpern
- Department of Vascular Surgery, Phoenix VA Health Care System, Phoenix, AZ
| | - Jessica O'Connell
- Department of Vascular Surgery, West Los Angeles Medical Center, Los Angeles, CA
| | - Daniel Inhat
- Department of Vascular Surgery, Minneapolis VA Health Care System, Minneapolis, MN
| | - Peter Nelson
- Department of Vascular Surgery, James A. Haley Veterans' Hospital, Tampa, FL
| | - Edith Tzeng
- Department of Vascular Surgery, VA Pittsburg Healthcare System, Pittsburg, PA
| | - Wei Zhou
- Department of Vascular Surgery, Southern Arizona VA Health Care System, Tucson, AZ
| | - Michael Barry
- Massachusetts General Hospital Center for Shared Decision Making, Massachusetts General Hospital, Boston, MA
| | - Brenda Sirovich
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT
| | - Philip P Goodney
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, VT.
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Raffetto JD. Surgical spine stabilization and its association with iliac vein obstruction. J Vasc Surg Venous Lymphat Disord 2020; 8:412. [PMID: 32305115 DOI: 10.1016/j.jvsv.2019.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 09/07/2019] [Indexed: 10/24/2022]
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14
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Raffetto JD. Understanding venous thrombosis pathways to effect pharmacologic treatment and resolution of venous thrombosis without increasing bleeding risk. J Vasc Surg Venous Lymphat Disord 2020; 8:279. [PMID: 32067729 DOI: 10.1016/j.jvsv.2019.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 09/10/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Joseph D Raffetto
- Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston VA HCS, West Roxbury, Mass.
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15
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Anderson PB, Wanken ZJ, Perri JL, Columbo JA, Kang R, Spangler EL, Newhall K, Brooke BS, Dosluoglu H, Lee ES, Raffetto JD, Henke PK, Tang GL, Mureebe L, Kougias P, Johanning J, Arya S, Scali ST, Stone DH, Suckow BD, Orion K, Halpern V, O'Connell J, Inhat D, Nelson P, Tzeng E, Zhou W, Barry M, Sirovich B, Goodney PP. Patient information sources when facing repair of abdominal aortic aneurysm. J Vasc Surg 2020; 71:497-504. [PMID: 31353272 PMCID: PMC10767985 DOI: 10.1016/j.jvs.2019.04.460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/04/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Shared medical decision making is most important when there are competing options for repair such as in treatment of abdominal aortic aneurysm (AAA). We sought to understand the sources of patients' pre-existing knowledge about AAA to better inform treating physicians about patients' needs for preoperative counseling. METHODS We performed a multicenter survey of patients facing AAA repair at 20 Veterans Affairs hospitals across the United States as part of the Preferences for Open Versus Endovascular Repair of AAA study. A validated survey instrument was administered to examine the sources of information available and commonly used by patients to learn about their repair options. The survey was administered by study personnel before the patient had any interaction with the vascular surgeon because survey data were collected before the vascular clinic visit. RESULTS Preliminary analysis of data from 99 patients showed that our cohort was primarily male (99%) and elderly (mean age 73 years). Patients commonly had a history of hypertension (86%), prior myocardial infarction (32%), diabetes (32%), and were overweight (58%). Patients arrived at their surgeon's office appointment with limited information. A majority of patients (52%) reported that they had not talked to their primary care physician at all about their options for AAA repair, and one-half (50%) reported that their view of the different surgical options had not been influenced by anyone. Slightly less than one-half of patients reported that they did not receive any information about open surgical aneurysm repair and endovascular aortic aneurysm repair (41% and 37%, respectively). Few patients indicated using the internet as their main source of information about open surgical aneurysm repair and endovascular aortic aneurysm repair (10% and 11%, respectively). CONCLUSIONS Patients are commonly referred for AAA repair having little to no information regarding AAA pathology or repair options. Fewer than one in five patients searched the internet or had accessed other sources of information on their own. Most vascular surgeons should assume that patients will present to their first vascular surgery appointment with minimal understanding of the treatment options available to them.
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Affiliation(s)
- Peter B Anderson
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt; Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Zachary J Wanken
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | - Jennifer L Perri
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | - Jesse A Columbo
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | - Ravinder Kang
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | | | - Karina Newhall
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | | | | | | | | | | | | | | | | | | | | | | | - David H Stone
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | - Bjoern D Suckow
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | | | | | | | | | | | | | | | - Michael Barry
- Massachusetts General Hospital Center for Shared Decision Making, Boston, Mass
| | - Brenda Sirovich
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt
| | - Philip P Goodney
- Department of Surgery and VA Outcomes Group, White River Junction VA Medical Center, White River Junction, Vt.
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Gianesini S, Mosti G, Raffetto JD, Maietti E, Chi YW, Tangerini L, Menegatti E. Case-control evaluation of the impact of below 20 mmHg elastic compression stockings on lower limb volume serial variations in standardized flights. Phlebology 2019; 35:199-206. [PMID: 31488042 DOI: 10.1177/0268355519873527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Graduated compression stocking (GCS) use during flights demonstrated to positively impact leg oedema. Nevertheless, these data were collected in a single flight, mainly at the ankle, and using greater than 20 mmHg GCS. This investigation reports data from 16 flights in which the same passenger’s leg circumferences variation were assessed wearing non-graduated ankle-sock or a below-knee 15–20 mmHg GCS. Methods The limb was divided by the circumferences in eight sectors, every 4 cm, labelled from 1 to 8, starting from the ankle up. The assessment was done at the take-off and after a 4-h flight time, for a total of 16 flights. The subject used non-graduated ankle socks (elastic band at 4 cm from B-point) during the outgoing flight and below-knee GCS (15–20 mmHg) during the return flight. Interface pressure was assessed at the ankle point of minimum girth (B) and ascending proximally every 4 cm (B+cm) for the GCS, and at B and at the elastic band level (B + 4 cm) for the sock. Results GCS interface pressure was 13.3 ± 2.5 mmHg in B and 18.1 ± 2.4 mmHg in B + 4 cm. The sock interface pressure was 3.1 ± 0.7 mmHg in B and 8.1 ± 0.9 mmHg at the band level (B + 4 cm). Socks led to a significant total volume increase (117.3 ± 25.8 mL; 5.2% ±1.1%; P < 0.0001). GCS led to a non-significant total volume decrease (–3.1 ± 14.4 mL; –0.1 ± 0.6%; P = 0.3964) and did not allow for volume increase. The different sectors showed a heterogeneous volume variation, not following a precisely graduated or progressive compression profile. Conclusions Leg oedema following a 4-h flight is controlled by <20 mmHg GCS. Leg fluids, with and without GCS, are mobilized in a non-graduated profile from the ankle to the knee after prolonged sitting on a plane.
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Affiliation(s)
- Sergio Gianesini
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Giovanni Mosti
- Angiology Department, Clinica MD Barbantini, Lucca, Italy
| | - Joseph D Raffetto
- Harvard Medical School, VA Boston Healthcare System, Brigham and Women's Hospital, Boston, MA, USA
| | - Elisa Maietti
- Center for Clinical Epidemiology - Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Yung-Wei Chi
- Vascular Center, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Luca Tangerini
- Venous-Lymphatic World International Network Foundation, Italy
| | - Erica Menegatti
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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17
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Raffetto JD. Invited commentary. J Vasc Surg 2019; 69:1589-1590. [DOI: 10.1016/j.jvs.2018.06.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 06/01/2018] [Indexed: 11/24/2022]
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Gianesini S, Raffetto JD, Mosti G, Menegatti E, Sibilla MG, Tessari M, Zamboni P. Healthy Subjects’ Lower Limb Volume and Perceived Exertion After a Standardized Walk With and Without Graduated Compression. J Vasc Surg Venous Lymphat Disord 2018. [DOI: 10.1016/j.jvsv.2017.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Background Portal vein aneurysms are rare dilations in the portal venous system, for which the etiology and pathophysiological consequences are poorly understood. Method We reviewed the existing literature as well as present a unique anecdotal case of a patient presenting with a very large portal vein aneurysm that was successfully managed conservatively and non-operatively without anticoagulation, with close follow-up and routine surveillance. Result The rising prevalence of abdominal imaging in clinical practice has increased rates of portal vein aneurysm detection. While asymptomatic aneurysms less than 3 cm can be clinically observed, surgical intervention may be necessary in large asymptomatic aneurysms (>3 cm) with or without thrombus, or small aneurysms with evidence of evolving mural thrombus formation on imaging. Conclusion Portal vein aneurysms present a diagnostic challenge for any surgeon, and the goal for surgical therapy is based on repairing the portal vein aneurysm, and if portal hypertension is present decompressing via surgically constructed shunts.
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Affiliation(s)
- Sameer A Hirji
- 1 Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Faith C Robertson
- 1 Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sergio Casillas
- 2 Division of Vascular Surgery, Boston Medical Center, Boston, MA, USA
| | - James T McPhee
- 2 Division of Vascular Surgery, Boston Medical Center, Boston, MA, USA.,3 Division of Vascular Surgery, Veteran Affairs Boston Healthcare System, West Roxbury, MA, USA
| | - Naren Gupta
- 2 Division of Vascular Surgery, Boston Medical Center, Boston, MA, USA.,3 Division of Vascular Surgery, Veteran Affairs Boston Healthcare System, West Roxbury, MA, USA
| | - Michelle C Martin
- 2 Division of Vascular Surgery, Boston Medical Center, Boston, MA, USA.,3 Division of Vascular Surgery, Veteran Affairs Boston Healthcare System, West Roxbury, MA, USA
| | - Joseph D Raffetto
- 1 Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,3 Division of Vascular Surgery, Veteran Affairs Boston Healthcare System, West Roxbury, MA, USA
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21
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Bush R, Comerota A, Meissner M, Raffetto JD, Hahn SR, Freeman K. Recommendations for the medical management of chronic venous disease: The role of Micronized Purified Flavanoid Fraction (MPFF). Phlebology 2017; 32:3-19. [PMID: 28211296 DOI: 10.1177/0268355517692221] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Scope A systematic review of the clinical literature concerning medical management of chronic venous disease with the venoactive therapy Micronized Purified Flavonoid Fraction was conducted in addition to an investigation of the hemodynamics and mechanism of chronic venous disease. Methods The systematic review of the literature focused on the use of Micronized Purified Flavonoid Fraction (diosmin) which has recently become available in the US, in the management of chronic venous disease. The primary goal was to assess the level of evidence of the role of Micronized Purified Flavonoid Fraction in the healing of ulcers, and secondarily on the improvement of the symptoms of chronic venous disease such as edema. An initial search of Medline, Cochrane Database for Systematic Reviews and Google Scholar databases was conducted. The references of articles obtained in the primary search, including a Cochrane review of phlebotonics for venous insufficiency, were reviewed for additional studies. Studies were included if patients had a diagnosis of chronic venous disease documented with Doppler and Impedance Plethysmography. Studies excluded were those that had patients with arterial insufficiency (Ankle Brachial Index < .6), comorbidity of diabetes, obesity, rheumatological diseases, or if other causes of edema were present (congestive heart failure, renal, hepatic or lymphatic cause), or if the patient population had recent surgery or deep vein thrombosis, or had been using diuretics (in studies of edema). Other elements of the study design were to note specifically the type of compression therapy used in conjunction with Micronized Purified Flavonoid Fraction. Results The literature review yielded 250 abstracts, 65 of which met criteria for further review and 10 papers were selected for consideration in the systematic review. Conclusion In summary, the general level of evidence supports the recommendation that the use of medical therapy with Micronized Purified Flavonoid Fraction has beneficial outcomes without serious adverse events. In the United States, diosmiplex is the only available prescription formulation of Micronized Purified Flavonoid Fraction. It is derived from the rinds of oranges and is categorized as a medical food and not as a drug; and may be a particularly attractive therapy for many chronic venous disease patients because of its favorable safety profile. The Working Group for chronic venous disease concurs with previous guidance by the International European Society for Vascular Surgery in 2015 which recommended the use of Micronized Purified Flavonoid Fraction for the healing of venous ulcers, alone and adjunctive to compression therapy, and for the reduction in symptoms of chronic venous disease such as edema.
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22
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Chen Y, Peng W, Raffetto JD, Khalil RA. Matrix Metalloproteinases in Remodeling of Lower Extremity Veins and Chronic Venous Disease. Prog Mol Biol Transl Sci 2017; 147:267-299. [PMID: 28413031 DOI: 10.1016/bs.pmbts.2017.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The veins of the lower extremity are equipped with efficient wall, contractile vascular smooth muscle (VSM), and competent valves in order to withstand the high venous hydrostatic pressure in the lower limb and allow unidirectional movement of deoxygenated blood toward the heart. The vein wall structure and function are in part regulated by matrix metalloproteinases (MMPs). MMPs are zinc-dependent endopeptidases that are secreted as inactive pro-MMPs by different cells in the venous wall including fibroblasts, VSM, and leukocytes. Pro-MMPs are activated by other MMPs, proteinases, and other endogenous and exogenous activators. MMPs degrade various extracellular matrix (ECM) proteins including collagen and elastin, and could affect other cellular processes including endothelium-mediated dilation, VSM cell migration, and proliferation as well as modulation of Ca2+ signaling and contraction in VSM. It is thought that increased lower limb venous hydrostatic pressure increases hypoxia-inducible factors and other MMP inducers such as extracellular matrix metalloproteinase inducer, leading to increased MMP expression/activity, ECM protein degradation, vein wall relaxation, and venous dilation. Vein wall inflammation and leukocyte infiltration cause additional increases in MMPs, and further vein wall dilation and valve degradation, that could lead to chronic venous disease and varicose veins (VVs). VVs are often presented as vein wall dilation and tortuosity, incompetent venous valves, and venous reflux. Different regions of VVs show different MMP levels and ECM proteins with atrophic regions showing high MMP levels/activity and little ECM compared to hypertrophic regions with little or inactive MMPs and abundant ECM. Treatment of VVs includes compression stockings, venotonics, sclerotherapy, or surgical removal. However, these approaches do not treat the cause of VVs, and other lines of treatment may be needed. Modulation of endogenous tissue inhibitors of metalloproteinases (TIMPs), and exogenous synthetic MMP inhibitors may provide new approaches in the management of VVs.
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Affiliation(s)
- Yunfei Chen
- Vascular Surgery Research Laboratories, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Wei Peng
- Vascular Surgery Research Laboratories, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Joseph D Raffetto
- Vascular Surgery Research Laboratories, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Raouf A Khalil
- Vascular Surgery Research Laboratories, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
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Raffetto JD, Calanni F, Mattana P, Khalil R. Sulodexide Promotes Venous Contraction in Rat Inferior Vena Cava. J Vasc Surg Venous Lymphat Disord 2017. [DOI: 10.1016/j.jvsv.2016.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Reslan OM, Sundick S, Razayat C, Brener BJ, Raffetto JD. Rupture of a True Profunda Femoris Artery Aneurysm: Two Case Reports and Review of the English Language Literature. Ann Vasc Surg 2016; 39:290.e1-290.e9. [PMID: 27890839 DOI: 10.1016/j.avsg.2016.07.071] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 06/30/2016] [Accepted: 07/05/2016] [Indexed: 11/18/2022]
Abstract
Profunda femoris artery aneurysms (PFAAs) are very rare and easily overlooked because they are located deeply within thigh muscle. PFAAs have a high rate of rupture in comparison with other peripheral arterial aneurysms, resulting in emergency surgical procedures with significant morbidity. PFAA is diagnosed with color arterial Doppler ultrasound, although computed tomography angiography remains the best imaging method to precisely define the exact site and length of arterial involvement. PFAAs should be treated surgically once diagnosed, even if they are asymptomatic due to the high incidence of complications. Currently, around 28 patients with PFAA rupture, including the 2 cases from this report, have been described in the English language literature. In this report, we describe the diagnosis and treatment of 2 true ruptured aneurysms of the profunda femoris artery with 2 different approaches, and will review the relevant literature.
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Affiliation(s)
- Ossama M Reslan
- Division of Vascular Surgery, Department of Surgery, Newark Beth Israel Medical Center, Newark, NJ; Division of Vascular Surgery, Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ.
| | - Scott Sundick
- Division of Vascular Surgery, Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ
| | - Combiz Razayat
- Division of Vascular Surgery, Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ
| | - Bruce J Brener
- Division of Vascular Surgery, Department of Surgery, Newark Beth Israel Medical Center, Newark, NJ; Division of Vascular Surgery, Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ
| | - Joseph D Raffetto
- Department of Surgery, VA Boston HCS, West Roxbury, MA; Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
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Raffetto JD. Invited commentary. J Vasc Surg 2016; 64:1458. [DOI: 10.1016/j.jvs.2016.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Ligi D, Mosti G, Croce L, Raffetto JD, Mannello F. Chronic venous disease – Part I: Inflammatory biomarkers in wound healing. Biochim Biophys Acta Mol Basis Dis 2016; 1862:1964-74. [DOI: 10.1016/j.bbadis.2016.07.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/20/2016] [Accepted: 07/26/2016] [Indexed: 01/12/2023]
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Yu NR, Eberhardt RT, Menzoian JO, Urick CL, Raffetto JD. Vertebral artery dissection following intravascular catheter placement: a case report and review of the literature. Vasc Med 2016; 9:199-203. [PMID: 15675185 DOI: 10.1191/1358863x04vm565cr] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Vertebral artery dissections (VAD) are known to occur as a result of mechanical manipulations of the cervical region, traumatic injury, iatrogenic injury and are also known to arise spontaneously. We report a case of vertebral artery dissection following vertebral artery cannulation during a central line placement and review the literature. The patient underwent intravascular catheter placement that subsequently demonstrated arterial blood. Duplex ultrasound and computed tomographic (CT) scan confirmed vertebral artery cannulation. The catheter was removed at the bedside with pressure, and a subsequent duplex ultrasound scan revealed a vertebral artery dissection. There were no neurological sequelae. The patient was successfully anticoagulated with warfarin but died from unrelated complications. This case report describes the rare iatrogenic event of VAD and reviews its etiology, diagnosis, complications, and management.
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Affiliation(s)
- Nicholas R Yu
- Vascular Surgery, Boston Medical Center, Boston VA Medical Center Boston, MA, USA
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Madenci AL, Ozaki CK, Gupta N, Raffetto JD, Belkin M, McPhee JT. Perioperative outcomes of elective inflow revascularization for lower extremity claudication in the American College of Surgeons National Surgical Quality Improvement Program database. Am J Surg 2016; 212:461-467.e2. [DOI: 10.1016/j.amjsurg.2015.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 08/27/2015] [Accepted: 10/29/2015] [Indexed: 10/22/2022]
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Abstract
Saccular aortic aneurysms are eccentrically shaped and are commonly thought to be the consequence of infection of the aorta. However, saccular-type aneurysms can be found independent of any clinical or subclinical infection and can be associated with a penetrating aortic ulcer. Moreover, penetrating aortic ulcers have been described in the thoracic aorta, but there is a paucity of any documentation of this clinical and pathologic entity occurring in the abdominal aorta. The authors describe 2 cases of symptomatic, penetrating atherosclerotic ulcers of the abdominal aorta causing saccular, noninfectious abdominal aortic aneurysms.
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Anwar MA, Vorkas PA, Li J, Adesina-Georgiadis KN, Reslan OM, Raffetto JD, Want EJ, Khalil RA, Holmes E, Davies AH. Prolonged Mechanical Circumferential Stretch Induces Metabolic Changes in Rat Inferior Vena Cava. Eur J Vasc Endovasc Surg 2016; 52:544-552. [PMID: 27523725 DOI: 10.1016/j.ejvs.2016.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 07/02/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE/BACKGROUND Circumferential stretch on the vein wall has been suggested as a potential etiological factor in the development of varicose veins. However, the influence of vein wall stretch on vein metabolism has not yet been explored. The aim of this study was to investigate the effect of short and prolonged mechanical stretch on vein wall metabolism. METHODS Circular segments of inferior vena cava from male Sprague-Dawley rats were exposed to normal 0.5-g (nonstretched) or high 2-g (stretched) tension for short (4 h) or prolonged (18 h) duration (five vein segments per group). Contraction response to phenylephrine (10-5 M) and KCl (96 mM) was elicited to observe the effect of circumferential stretch on vein function. The polar and organic metabolites in vein tissue were extracted using a bilayer extraction method. Aqueous and organic extracts were analyzed using nuclear magnetic resonance spectroscopy and ultra performance liquid chromatography coupled to mass spectrometry, respectively. Data acquired from both analytical platforms were analyzed using mathematical modeling. RESULTS Increased concentrations of valine (p = .02) and choline (p = .03) metabolites and triglyceride moieties (p = .03) were observed in veins stretched for 18 h compared with the nonstretched/18 h group. DISCUSSION Increased concentrations of branched chain amino acid valine and cell membrane constituent choline indicate increased muscle breakdown and increased metabolism of membrane phospholipids under stretch in an ex-vivo model. Increased intensities of triglyceride moieties in stretched vein segments for 18 h suggest that high pressure may induce an inflammatory response. CONCLUSION This study has shown that prolonged mechanical circumferential stretch (18 h) alters the metabolic profile of rat inferior vena cava.
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Affiliation(s)
- M A Anwar
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College, London, UK.
| | - P A Vorkas
- Section of Biomolecular Medicine, Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College, London, UK
| | - J Li
- Section of Biomolecular Medicine, Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College, London, UK
| | - K N Adesina-Georgiadis
- Section of Biomolecular Medicine, Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College, London, UK
| | - O M Reslan
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - J D Raffetto
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA; Vascular Surgery Division, VA Boston Healthcare System, West Roxbury, MA, USA; Harvard Medical School, Boston, MA, USA
| | - E J Want
- Section of Biomolecular Medicine, Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College, London, UK
| | - R A Khalil
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - E Holmes
- Section of Biomolecular Medicine, Computational and Systems Medicine, Department of Surgery and Cancer, Imperial College, London, UK
| | - A H Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College, London, UK
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Raffetto JD, Vasquez R, Goodwin DG, Menzoian JO. Mitogen-Activated Protein Kinase Pathway Regulates Cell Proliferation in Venous Ulcer Fibroblasts. Vasc Endovascular Surg 2016; 40:59-66. [PMID: 16456607 DOI: 10.1177/153857440604000108] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Venous ulcer fibroblasts have been demonstrated to have low growth rates in response to platelet-derived growth factor (PDGF). Mitogen-activated protein kinase (MAPK) is an important signal transduction mechanism that regulates growth, differentiation, and apoptosis in eukaryotic cells. PDGF binds PDGF receptors that activate a multitiered signaling cascade involving MAPK. We hypothesize that the growth regulation in venous ulcer fibroblasts is dependent on the MAPK extracellular signal-regulated kinase (ERK) pathway in the presence of PDGF. Fibroblasts (fb) were isolated from 8 patients with venous ulcers (w-fb) and the normal skin (n-fb) of the ipsilateral thigh via punch biopsies. Fb were plated at 1,500 cells/dish and treated with PDGF-AB (10 ng/mL) for 15 days. Growth rates were determined. Immunoblot analysis of MAPK ERK for n-fb and w-fb were analyzed. To determine if PDGF-stimulated w-fb and n-fb utilized the MAPK ERK pathway in a dependent manner, the upstream kinase MAPK kinase 1 (MEK 1) was inhibited by PD 98059. In addition, fb were treated with chronic venous ulcer wound fluid (WF) to study its effect on MAPK ERK. In the presence of PDGF, growth rates were substantially lower in w-fb than in n-fb, and MAPK was activated in 6/8 w-fb and in only 2/8 n-fb. Fibroblasts expressing MAPK had significantly reduced cell proliferation compared to fibroblasts not expressing MAPK (p = 0.023). PD 98059 significantly inhibited wfb and n-fb cell proliferation from basal level, which was reversible with addition of PDGF. In neonatal fibroblasts WF demonstrated inhibition of MAPK ERK over time and addition of PD98059 was not additive. This study suggests that the MAPK ERK pathway is important for cell proliferation in venous ulcer fibroblasts. In the presence of PDGF, fibroblasts with decreased growth rate express MAPK, and proliferation is further abrogated with addition of MEK 1 inhibitor, suggesting the importance of the MAPK ERK pathway regulating w-fb and nfb proliferation. Although the majority of w-fb activated the MAPK ERK pathway in the presence of PDGF, proliferation was significantly attenuated, indicating that other MAPK inhibitory pathways are competing. Venous ulcer wound fluid directly inhibits the MAPK ERK pathway, suggesting that the venous ulcer wound environment has negative trophic factors that effect fibroblasts proliferation and ulcer healing.
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Affiliation(s)
- Joseph D Raffetto
- Boston University School of Medicine, Boston VA Healthcare System, MA 02132, USA.
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Ligi D, Mosti G, Croce L, Raffetto JD, Mannello F. Chronic venous disease - Part II: Proteolytic biomarkers in wound healing. Biochim Biophys Acta Mol Basis Dis 2016; 1862:1900-8. [PMID: 27460704 DOI: 10.1016/j.bbadis.2016.07.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/04/2016] [Accepted: 07/22/2016] [Indexed: 12/14/2022]
Abstract
Venous leg ulcers (VLU) are characterized by sustained proteolytic microenvironment impairing the healing process. Wound fluid (WF) reflect the biomolecular activities occurring within the wound area; however, it is unclear if WF from different healing phases have different proteolytic profiles and how VLU microenvironment affects the wound healing mechanisms. We investigated the proteolytic network of WF from distinct VLU phases, and in WF- and LPS-stimulated THP-1 monocytes treated with glycosaminoglycan sulodexide, a well known therapeutic approach for VLU healing. WF were collected from patients with VLU during inflammatory (Infl) and granulating (Gran) phases. WF and THP-1 supernatants were analyzed for nine matrix metalloproteinases (MMP) and four tissue inhibitors of metalloproteinases (TIMP) by multiplex immunoassays. Our results demonstrated that: 1) WF from Infl VLU contained significantly increased concentrations of MMP-2, MMP-9, MMP-12, TIMP-1, and TIMP-2 compared to Gran WF; 2) WF from Gran VLU showed significantly increased levels of MMP-1, MMP-7, MMP-13, and TIMP-4 compared to Infl WF; 3) LPS- and WF-stimulation of THP-1 cells significantly increased the expression of several MMP compared to untreated cells; 4) Sulodexide treatment of both LPS- and WF-stimulated THP-1 significantly down-regulated the release of several MMPs. Our study provides evidence-based medicine during treatment of patients with VLU. WF from Infl and Gran VLU have different MMP and TIMP signatures, consistent with their clinical state. The modulation of proteolytic pathways in wound microenvironment by glycosaminoglycan sulodexide, provide insights for translating research into clinical practice during VLU therapy.
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Affiliation(s)
- Daniela Ligi
- Department of Biomolecular Sciences, Section of Clinical Biochemistry and Molecular Genetics, University "Carlo Bo", Urbino, Italy
| | - Giovanni Mosti
- Department of Angiology, Barbantini's Clinic, via del Calcio 2, 55100 Lucca, Italy
| | - Lidia Croce
- Department of Biomolecular Sciences, Section of Clinical Biochemistry and Molecular Genetics, University "Carlo Bo", Urbino, Italy
| | - Joseph D Raffetto
- Vascular Surgery Division, VA Boston Healthcare System, West Roxbury, MA, USA; Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Ferdinando Mannello
- Department of Biomolecular Sciences, Section of Clinical Biochemistry and Molecular Genetics, University "Carlo Bo", Urbino, Italy.
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Raffetto JD, Eberhardt RT, Dean SM, Ligi D, Mannello F. Pharmacologic treatment to improve venous leg ulcer healing. J Vasc Surg Venous Lymphat Disord 2016; 4:371-4. [DOI: 10.1016/j.jvsv.2015.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
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Abstract
Venous leg ulcer (VLU) is one of the most common lower extremity ulcerated wound, and is a significant healthcare problem with implications that affect social, economic, and the well-being of a patient. VLU can have debilitating related problems which require weekly medical care and may take months to years to heal. The pathophysiology of VLU is complex, and healing is delayed in many patients due to a persistent inflammatory condition. Patient genetic and environmental factors predispose individuals to chronic venous diseases including VLU. Changes in shear stress affecting the glycocalyx are likely initiating events, leading to activation of adhesion molecules on endothelial cells, and leukocyte activation with attachment and migration into vein wall, microcirculation, and in the interstitial space. Multiple chemokines, cytokines, growth factors, proteases and matrix metalloproteinases are produced. The pathology of VLU involves an imbalance of inflammation, inflammatory modulators, oxidative stress, and proteinase activity. Understanding the cellular and biochemical events that lead to the progression of VLU is critical. With further understanding of inflammatory pathways and potential mechanisms, certain biomarkers could be revealed and studied as both involvement in the pathophysiology of VLU but also as therapeutic targets for VLU healing.
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Affiliation(s)
- Joseph D Raffetto
- Boston VA Health Care System, Vascular Surgery, Boston, MA, USA
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Daniel VT, Gupta N, Raffetto JD, McPhee JT. Impact of coexisting aneurysms on open revascularization for aortoiliac occlusive disease. J Vasc Surg 2016; 63:944-8. [PMID: 26843353 DOI: 10.1016/j.jvs.2015.10.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 10/14/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE National data evaluating outcomes for occlusive abdominal aortic reconstructions are well described. The relative effect of operative indication as well as the presence of concomitant abdominal aortic aneurysm (AAA) on in-hospital mortality is not well defined. METHODS The Nationwide Inpatient Sample was queried to identify patients who underwent open aortic surgery (2003-2010). Indication for surgery was classified by International Classification of Diseases, Ninth Revision diagnostic codes to identify isolated occlusive indications as well as combined occlusive disease and AAA. Primary outcome was in-hospital mortality. Secondary outcomes were complications and discharge disposition. RESULTS Overall, 56,374 underwent aortic reconstruction, 48,591 for occlusive disease (86.2%) and 7783 for combined occlusive disease with AAA (13.8%). Intermittent claudication was the most common indication for intervention (60.9%), whereas 39.7% underwent intervention for critical limb ischemia (22.2% rest pain, 17.6% gangrene). Patients with intermittent claudication had more concomitant AAAs (17.3%) than did patients with critical limb ischemia (8.4%). The baseline characteristics for those with occlusive disease and combined occlusive with AAA disease were similar in terms of obesity (4.8% vs 4.2%; P = .27) and congestive heart failure (6.6% vs 6.3%; P = .65) but differed by age (62.2 years vs 68.4 years; P < .0001) and hypertension (65.4% vs 69.1%; P = .005). Patients with combined occlusive and AAA disease had higher mortality than those with occlusive disease alone (3.9% vs 2.7%; P = .01). On multivariable regression, factors associated with in-hospital mortality included gangrene with AAA compared with gangrene alone (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.6-4.7; P < .0002), age >65 years age (OR, 3.1; 95% CI, 2.4-4.1; P < .0001), renal failure (OR, 2.7; 95% CI, 1.9-3.8; P < .0001), and concurrent lower extremity revascularization (OR, 1.3; 95% CI, 1.1-1.7; P < .02). CONCLUSIONS Intermittent claudication or critical limb ischemia with concomitant AAA carries a higher mortality than intermittent claudication or critical limb ischemia alone, especially in older patients with gangrene requiring revascularization and renal insufficiency. Preoperative risk stratification strategies should focus on the indication for surgery as well as the presence of concomitant AAA.
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Affiliation(s)
- Vijaya T Daniel
- Department of Surgery, University of Massachusetts Medical School, Worcester, Mass.
| | - Naren Gupta
- Division of Vascular Surgery, VA Boston Healthcare System, West Roxbury, Mass; Department of Surgery, Harvard Medical School, Boston, Mass; Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Joseph D Raffetto
- Division of Vascular Surgery, VA Boston Healthcare System, West Roxbury, Mass; Department of Surgery, Harvard Medical School, Boston, Mass; Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, Mass
| | - James T McPhee
- Division of Vascular Surgery, VA Boston Healthcare System, West Roxbury, Mass; Department of Surgery, Boston University School of Medicine, Boston, Mass
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Abstract
Objectives Venous leg ulcers (VLU) are the most severe clinical sequelae of venous reflux and post thrombotic syndrome. There is a consensus that ablation of refluxing vein segments and treatment of significant venous obstruction can heal VLUs. However, there is wide disparity in the use and choice of adjunctive therapies for VLUs. The purpose of this study was to assess these practice patterns among members of the American Venous Forum. Methods The AVF Research Committee conducted an online survey of its own members, which consisted of 16 questions designed to determine the specialty of physicians, location of treatment, treatment practices and reimbursement for treatment of VLUs Results The survey was distributed to 667 practitioners and a response rate of 18.6% was achieved. A majority of respondents (49.5%) were vascular specialists and the remaining were podiatrists, dermatologists, primary care doctors and others. It was found that 85.5% were from within the USA, while physicians from 14 other countries also responded. Most of the physicians (45%) provided adjunctive therapy at a private office setting and 58% treated less than 5 VLU patients per week. All respondents used some form of compression therapy as the primary mode of treatment for VLU. Multilayer compression therapy was the most common form of adjunctive therapy used (58.8%) and over 90% of physicians started additional modalities (biologics, negative pressure, hyperbaric oxygen and others) when VLUs failed compression therapy, with a majority (65%) waiting less than three months to start them. Medicare was the most common source of reimbursement (52.4%). Conclusions Physicians from multiple specialties treat VLU. While most physicians use compression therapy, there is wide variation in the selection and point of initiation for additional therapies once compression fails. There is a need for high-quality data to help establish guidelines for adjunctive treatment of VLUs and to disseminate them to physicians across multiple specialties to ensure standardized high-quality treatment of patients with VLUs.
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Affiliation(s)
- Faisal Aziz
- 1 Vascular Surgery, Penn State Heart and Vascular Institute, Penn State Hershey College of Medicine, Hershey, PA, USA
| | - Joseph D Raffetto
- 2 Vascular Surgery, VA Boston HCS, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jose A Diaz
- 3 Vascular Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Daniel D Myers
- 3 Vascular Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Teresa L Carman
- 5 Vascular Medicine, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Brajesh K Lal
- 6 Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Reslan OM, Raffetto JD, Addis M, Sundick S. Congenital Absence of Inferior Vena Cava in a Young Patient with Iliofemoral Deep Venous Thrombosis Treated with Ultrasound-accelerated Catheter-directed Thrombolysis: Case Report and Review of the Literature. Ann Vasc Surg 2015; 29:1657.e9-15. [DOI: 10.1016/j.avsg.2015.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 04/20/2015] [Accepted: 05/20/2015] [Indexed: 11/27/2022]
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Raffetto JD, Eberhardt RT. Benefit of anticoagulation for the treatment of lower extremity superficial venous thrombosis. J Vasc Surg Venous Lymphat Disord 2015; 3:236-41. [DOI: 10.1016/j.jvsv.2014.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 11/18/2014] [Indexed: 11/16/2022]
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Abstract
Venous leg ulceration (VLU) is one of the most predominate medical disorders worldwide and in the western hemisphere it affects around 1.5% of the general population and up to 5% of the elderly population. Unfortunately, this trend will only increase given the growth of an aging population worldwide. Understanding its pathophysiology that begins with venous hemodynamic abnormalities and leads to inflammatory alterations with microcirculatory changes is critical to delivering effective curative therapy. As such, the main component to treatment is reversing the underlying venous hypertension and pro-inflammatory milieu using compression treatment along with various adjuvant therapies. Given its impact, a comprehensive multi-pronged approach to care, treatment and prevention is required to reverse the increasing trend that is observed worldwide.
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Affiliation(s)
- Yung-Wei Chi
- Department of Internal Medicine, Section of Cardiovascular Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Joseph D Raffetto
- Vascular Surgery Division, VA Boston Healthcare System, West Roxbury, MA, USA
- Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Raffetto JD, Mosti G, Santi M, Ligi D, Mannello F. Matrix Metalloproteinase Profiles in Chronic Venous Ulcer Wound Fluid of Inflammatory and Granulating Venous Leg Ulcers. J Vasc Surg Venous Lymphat Disord 2014; 3:119-20. [PMID: 26993699 DOI: 10.1016/j.jvsv.2014.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
| | - G Mosti
- Angiology Department, Lucca, Italy
| | - M Santi
- University "Carlo Bo" of Urbino, Urbino, Italy
| | - D Ligi
- University "Carlo Bo" of Urbino, Urbino, Italy
| | - F Mannello
- University "Carlo Bo" of Urbino, Urbino, Italy
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Affiliation(s)
- Robert T. Eberhardt
- From the Cardiovascular Medicine Center, Boston Medical Center, Boston, MA (R.T.E.); Boston University School of Medicine, Boston, MA (R.T.E.); Vascular Surgery, Boston VA Health Care System, Boston, MA (J.D.R.); and Harvard Medical School, Boston, MA (J.D.R.)
| | - Joseph D. Raffetto
- From the Cardiovascular Medicine Center, Boston Medical Center, Boston, MA (R.T.E.); Boston University School of Medicine, Boston, MA (R.T.E.); Vascular Surgery, Boston VA Health Care System, Boston, MA (J.D.R.); and Harvard Medical School, Boston, MA (J.D.R.)
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O'Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, Lurie F, Henke PK, Gloviczki ML, Eklöf BG, Stoughton J, Raju S, Shortell CK, Raffetto JD, Partsch H, Pounds LC, Cummings ME, Gillespie DL, McLafferty RB, Murad MH, Wakefield TW, Gloviczki P. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014; 60:3S-59S. [PMID: 24974070 DOI: 10.1016/j.jvs.2014.04.049] [Citation(s) in RCA: 361] [Impact Index Per Article: 36.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Mannello F, Ligi D, Canale M, Raffetto JD. Omics profiles in chronic venous ulcer wound fluid: innovative applications for translational medicine. Expert Rev Mol Diagn 2014; 14:737-62. [DOI: 10.1586/14737159.2014.927312] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Gupta N, Moreira C, White S, Mattera S, Raffetto JD, Bhatt DL, Gaziano JM, McPhee JT. PS126. Vascular Surgeons Can Improve the Cardiovascular Health of Patients With Clinical Atherosclerotic Cardiovascular Disease by Implementing an Intensive Lipid-Lowering Regimen and Providing Smoke Cessation Counseling. J Vasc Surg 2014. [DOI: 10.1016/j.jvs.2014.03.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Mannello F, Ligi D, Raffetto JD. Glycosaminoglycan sulodexide modulates inflammatory pathways in chronic venous disease. INT ANGIOL 2014; 33:236-242. [PMID: 24936532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Inflammation represents an important epiphenomenon in the etiopathogenesis of chronic venous disease, a worldwide debilitating condition affecting millions of subjects. The pathophysiology of chronic venous disease (CVD) is based on the hemodynamic abnormalities in conjunction to alterations in cellular and extracellular matrix biocompounds. The endothelial dysfunction results from early perturbation in the endothelium linked to glycocalyx injury and promoted by inflammatory cells and mediators (such as matrix metalloproteinases and interleukins), which lead to progressive dilation of the vein resulting in chronic venous insufficiency. Activated leukocytes during the inflammatory process release enzymes, free radicals, chemokines and inflammatory cytokines in the vessel microenvironment, which are responsible for the changes of the venous wall and venous valve, reflux and venous hypertension, and the development/progression of tissue destruction and skin changes. Sulodexide, a highly purified mixture of glycosaminoglycans composed by 80% fast moving heparin and 20% of dermatan sulphate, exhibits anti-thrombotic and profibrinolytic properties, restoring also the essential endothelial glycocalyx. Glycosaminoglycan sulodexide has been also characterized to reduce the release of inflammatory cytokines/chemokines and to inhibit the matrix metalloproteinases-related proteolytic cascades, counteracting endothelial dysfunctions. The pleiotropic effects of sulodexide set the basis for a very promising agent in treating the spectrum of CVD.
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Affiliation(s)
- F Mannello
- Department of Biomolecular Sciences, Section of Clinical Biochemistry and Cell Biology, University "Carlo Bo", Urbino, Italy -
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Raffetto JD, Mannello F. Pathophysiology of chronic venous disease. INT ANGIOL 2014; 33:212-221. [PMID: 24755829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Chronic venous disease (CVD) is a debilitating condition with a prevalence between 60-70%. The disease pathophysiology is complex and involves genetic susceptibility and environmental factors, with individuals developing visible telengiectasias, reticular veins, and varicose veins. Patient with significant lower extremity symptoms have pain, dermal irritation, swelling, skin changes, and are at risk of developing debilitating venous ulceration. The signature of CVD is an increase in venous pressure referred to as venous hypertension. The various symptoms presenting in CVD and the clinical signs that are observed indicate that there is inflammation, secondary to venous hypertension, and it leads to a number of inflammatory pathways that become activated. The endothelium and glycocalyx via specialized receptors are critical at sensing changes in shear stress, and expression of adhesion molecules allows the activation of leukocytes leading to endothelial attachment, diapedisis, and transmigration into the venous wall/valves resulting in venous wall injury and inflammatory cells in the interstitial tissues. There is a complex of cytokines, chemokines, growth factors, proteases and proteinases, produced by activated leukocytes, that are expressed and unbalanced resulting in an environment of persistent inflammation with the clinical changes that are commonly seen, consisting of varicose veins to more advanced presentations of skin changes and venous ulceration. The structural integrity of protein and the extracellular matrix is altered, enhancing the progressive events of CVD. Work focusing on metabolic changes, miRNA regulation, inflammatory modulation and the glycocalyx will further our knowledge in the pathophysiology of CVD, and provide answers critical to treatment and prevention.
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Affiliation(s)
- J D Raffetto
- Vascular Surgery Division, VA Boston Healthcare System, West Roxbury, MA, USA -
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Abstract
Chronic venous leg ulcers (VLU) affect around 1% of the adult population in the Western world. The impact of VLU is both social and economic, with significant expenditures on active venous ulcers to provide medical treatment and eventual healing. At the core of VLU is venous hypertension which affects the venous macrocirculation. The changes incurred in venous hemodynamics leads to microcirculatory changes affecting the postcapillary venule and surrounding tissues. Inflammation by leukocytes affecting the venous endothelium, promotes a complex cascade and activation of adhesion molecules expression, chemokines and cytokines released, altered growth factor responses, and activation of protease (e.g. tPA) and proteinase (e.g. MMPs) activity that causes dysregulation and compromise of tissue integrity with eventual dermal damage and ulcer development. A critical component to treating VLU is correcting the abnormal venous hemodynamics and compression therapy. Unfortunately, VLU recurrence ranges between 30–70%, and other modalities in therapy along with compression are required. The goal for adjuvant products is to restore the balance from an inflammatory chronic wound to that of a reparative wound that will promote provisional matrix and epithelialization. There are many products on the market that can be used as adjuvant to compression therapy, but it must be recognized that there is a paucity of clinical trials that have evaluated the clinical effectiveness of specific products with clearly defined end points, and most importantly a healed VLU with a low recurrence rate. This review will discuss the fundamentals of VLU inflammation, and evaluate the available literature that may have benefit in reducing inflammation and lead to effective VLU healing.
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Affiliation(s)
- Joseph D Raffetto
- Vascular Surgery Division, VA Boston Healthcare System, West Roxbury, MA, USA
- Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Raffetto JD. Invited commentary. J Vasc Surg 2013; 58:426. [PMID: 23890441 DOI: 10.1016/j.jvs.2012.12.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 12/17/2012] [Accepted: 12/22/2012] [Indexed: 10/26/2022]
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Mannello F, Medda V, Ligi D, Raffetto JD. Glycosaminoglycan Sulodexide Inhibition of MMP-9 Gelatinase Secretion and Activity: Possible Pharmacological Role Against Collagen Degradation in Vascular Chronic Diseases. Curr Vasc Pharmacol 2013; 11:354-65. [DOI: 10.2174/1570161111311030010] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 03/29/2012] [Accepted: 04/24/2012] [Indexed: 11/22/2022]
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Abstract
Chronic venous ulcers (CVUs) occur in approximately 1% of the general population. Risk factors for chronic venous disease (CVD) include heredity, age, female sex and obesity. Although not restricted to the elderly, the prevalence of CVD, especially leg ulcers, increases with age.1 CVD has a considerable impact on health-care resources. It has been estimated that venous ulcers cause the loss of approximately two million working days and incur treatment costs of approximately $3 billion per year in the USA.2 Overall, CVD has been estimated to account for 1–3% of the total health-care budgets in countries with developed health-care systems.1 The pathophysiology of dermal abnormalities in CVU is reflective of a complex interplay that involves sustained venous hypertension, inflammation, changes in microcirculation, cytokine and matrix metalloproteinase (MMP) activation, resulting in altered cellular function and delayed wound healing.3,4
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Affiliation(s)
- J D Raffetto
- Harvard Medical School, VA Boston Healthcare System, West Roxbury
- Brigham and Women's Hospital, Boston, MA, USA
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