Can acupuncture increase microcirculation in peripheral artery disease and diabetic foot syndrome? - a pilot study

Background

Globally, diabetes mellitus (DM) and peripheral artery disease (PAD) have an increasing incidence and a high prevalence and are both associated with high morbidity and complication rates, e.g., as chronic non-healing peripheral ulcers. Impaired macro- and microcirculation and peripheral neuropathy lead to an increased risk of foot ulcers and infections. These complications are difficult to treat, have a high risk of becoming chronic and often lead to lower limb amputation. The aim of this planned study was to investigate the potential effects of acupuncture on improving microcirculation in patients with Diabetic Foot Syndrome (DFS) and PAD.

Materials and methods

In 18 patients with chronic non-healing peripheral ulcers and diagnosed DM or PAD, data on 8 microcirculatory parameters were collected simultaneously on intact skin close to the wound margin. Microcirculation was assessed using an O2C device combining laser Doppler shift and white light spectroscopy (LEA Medizintechnik GmbH, Giessen, Germany). Unilateral and bilateral acupuncture was performed on the connecting line between acupuncture points Stomach 14 and Stomach 15.

Results

After unilateral acupuncture (ipsilateral to the wound side), a statistically significant improvement in 7 out of 8 microcirculatory parameters was demonstrated compared to baseline measurements before acupuncture. After bilateral acupuncture, there was an additional improvement and statistical significance in all parameters in both DFS and PAD patients.

Discussion

These results show an improvement in the microcirculation and peripheral blood flow at the edges of the wound. As impaired micro- and macrocirculation is considered to be a critical prognostic factor for the healing of a peripheral lesion, the intervention could have a positive impact on the healing of (chronic) peripheral wounds.

First experiences of ultrasound vector flow imaging at the femoropopliteal artery in peripheral arterial disease

Background: The femoropopliteal artery (FPA) plays a central role in diagnosing and treating peripheral arterial disease (PAD). FPA lesions are the most frequent cause of intermittent claudication, and no other artery of the lower extremities is recanalised more frequently. Generally, ultrasound is the primary imaging tool in PAD, particularly FPA. With the development of high-frame-rate ultrasound technology in addition to traditional ultrasound modes, vector flow imaging (VFI) has provided deeper haemodynamic insights when used in the carotid artery. Here, we report the use of VFI at the FPA level in routine PAD examinations. Patients and methods: In this single-centre prospective study, we evaluated consecutive patients with PAD using B-mode imaging, colour Doppler, pulsed wave Doppler (PW) and vector flow. Hemodynamic parameters at predefined locations at the carotid artery and FPA were compared. Results: Qualitatively adequate VFI at all sites was possible in 76% of the patients with PAD. With decreasing volume flow from the common carotid artery to the internal carotid artery and from the common femoral artery via the superficial femoral artery to the popliteal artery, the correlation between VFI- and PW-derived-volume flow was high at every site. Based on different techniques, the VFI-derived values were significantly lower than the PW-derived values. The mean wall shear stress was significantly lower at all femoropopliteal sites than at the carotid sites, whereas the oscillatory shear index at the femoral site was higher than that at the carotid sites rather than at the popliteal location. Conclusions: Our findings suggest that vector flow data acquisition in the FPA is feasible in most patients with PAD. Therefore, with knowledge of the method and its limitations, VFI provides haemodynamic information beyond traditional ultrasound techniques and is a promising new tool for flow analysis in PAD.

Comparison of Functional and Morphological Estimates of Vascular Age

BACKGROUND/AIM

Vascular age (VA) is an emerging metric in preventive cardiovascular (CV) medicine. VA can be derived from morphological parameters such as carotid intima-media thickness (CIMT), or functional parameters such as pulse wave analysis (PWA), which celebrates its 100th birthday. This study aimed to investigate whether the results of both approaches are comparable.

PATIENTS AND METHODS

On the occasion of the double 100th anniversary of PWA and the Mannheim Clinic, 100 volunteers underwent a) bilateral CIMT assessment using high-resolution ultrasound and b) oscillometric PWA at the brachial forearm site. The respective VAs were calculated using previously published equations.

RESULTS

Median age of the participants was 53.6 years (range=39.8-62.6 years), and 56% were female. Median CIMT was 632.5 μm (range=548.8-730.0 μm). Median PWA-derived VA was 55.3 years (36.5-70.5 years). Different values were obtained for CIMT-derived VA, depending on the reference cohort used as calculation basis, ranging from median 43.7 (26.2-59.5 years) to median 64.0 years (43.5-82.1 years). In 46% of the participants divergent VAs were found, that is, the calculated age was higher according to one method and lower according to the other. Correlation analysis revealed a strong dependence of VA (both PWA- and CIMT-derived) and chronological age, as well as an increase in CV risk factors and the detection of plaques with age.

CONCLUSION

Different approaches for estimating VA are not comparable and often produce contradictory results. The current methods and their validity must be critically assessed if they are not standardized.

First experiences of local pulse wave velocity measurements in 4D-MRI in focally stented femoropopliteal arteries

Background: In peripheral arterial disease (PAD) the femoropopliteal (FP) artery is the most frequently recanalized lower limb artery. Stent-based interventions change the biomechanical properties of FP arteries. However, no clinical tool for functional imaging is established for quantitative measurements in vivo. Four-dimensional-flow magnetic resonance imaging enables a detailed evaluation of the hemodynamics of the central and - more challenging - the peripheral arteries. The present study aimed to determine the feasibility of assessing pulse wave velocities (PWV) as a marker of vessel stiffness in PAD patients with multiple spot stents and to compare the values with age-matched subjects and young-adult healthy subjects. Patients and methods: Contrast-free 4D-flow MRI was performed in seven PAD patients with focally stented FP arteries, five age-matched subjects after exclusion of PAD, and five young, healthy adults. PWV values were calculated from flow curves by using the foot-to-foot method. Results: Four-D-flow MRI sequences offering high spatial and temporal resolution enables quantification of flow velocity measurements and estimation of PWVs. Assessment of segmental PWV as a surrogate of vascular stiffness in focally stented femoral arteries is feasible. PWV values across all groups were 15.6±5.2 m/s, 13.3±4.1 m/s, and 9.9±2.2 m/s in PAD patients, senior-aged volunteers, and young-adult volunteers respectively. PWV values in PAD patients were similar with those in the senior-aged volunteers group (15.6±5.2 vs. 13.3 ±4.1 years, p=0.43). However, when compared to the young-adult volunteers, PAD patients had a statistically significantly higher mean local PWV (15.6±5.2 m/s vs. 9.9±2.2 m/s, p<0.05). Conclusions: Calculating segmental PWV in the femoral arteries is feasible in PAD patients with focally stented FP arteries. PWV values in PAD patients were similar to those in senior-aged volunteers, both of which were higher than in young-adult volunteers.

Aortitis - An Interdisciplinary Challenge

The term 'aortitis' comprises a heterogeneous spectrum of diseases, with varied etiology and clinical presentations, whose common characteristic is the inflammation of the aortic wall. Since aortitis can mimic almost all common cardiovascular disorders, its clinical recognition remains a challenge. Some cases of aortitis remain undetected for a long time and may be diagnosed after severe life-threatening complications have already arisen. The diagnosis of aortitis is based on the presence of homogeneous circumferential thickening of the aortic wall detected on aortic imaging, or typical histological features in combination with clinical findings and laboratory parameters. Management of aortitis is usually conservative (immunosuppressive drugs in noninfectious aortitis; antimicrobial drugs in infectious). However, if vascular complications such as aortic aneurysm, rupture, or steno-occlusive events appear, aortic surgery or endovascular therapy may be required. This review article summarizes the current knowledge regarding the etiology, clinical presentation, diagnosis, and treatment of inflammatory diseases of the aorta to promote better clinical management of these entities.

Provisional focal stenting of complex femoropopliteal lesions using the Multi-LOC multiple stent delivery system – 12-month results from the LOCOMOTIVE EXTENDED study

Summary: Background: This study aimed to evaluate a Multiple Stent Delivery System for provisional focal stenting of the femoropopliteal artery. Patient and methods: The LOCOMOTIVE EXTENDED study (Multi-LOC for flOw liMiting Outcomes after plain old balloon angioplasty and/or drug-coated balloon Treatment in the infrainguinal position with the objectIVE to implant multiple stent segments) is a prospective, single-arm, multicentre observational study. The Multi-LOC Multiple Stent Delivery System (B.Braun, Melsungen, Germany) was used for provisional focal stenting of the femoropopliteal artery. We enrolled 357 patients with 449 femoropopliteal lesions; all had flow-limiting dissections or recoil following angioplasty. Eligibility included Rutherford classification 2 to 5 with a de novo or non-stented restenotic femoropopliteal lesion undergoing plain balloon or drug-coated balloon angioplasty. The 6- and 12-month efficacy endpoints encompassed target lesion revascularisation and primary patency rates. Results: The mean patient age was 71 ± 10 years. The mean lesion length was 16.0 ± 9.7 cm; 44.5% were TASC II C/D lesions and 31.4% were chronic total occlusions. By operator choice, 45% of the patients underwent drug-coated balloon angioplasty. On average, 4.0 stents (each 13 mm long) were placed in each lesion, resulting in a scaffolding proportion of 56% of the total lesion length with a technical success rate of 98.3%. At 6 and 12 months, the freedom from clinically driven target lesion revascularisation was 95.5% and 88.7% and the primary patency rates were 88.7% and 82.3%, respectively. At 12 months, significant improvements were noted in Rutherford categories and ankle-brachial indices. In multiple regression analyses, both diabetes mellitus and no distal run-off vessel showed a trend toward worse TLR, while other factors such as DCB predilation or the lesion length were not predictive. Conclusions: The LOCOMOTIVE EXTENDED study demonstrated the safety and efficacy of the Multi-LOC stent system for focal provisional stenting of complex femoropopliteal lesions.

Lesion Revascularisation Subsequent to Femoropopliteal Spot Stenting Using the Multi-LOC Stent Delivery System

BACKGROUND/AIM

Restenosis and stent fractures are well-characterised treatment failures following femoropopliteal (FP) stent-based interventions. We aimed to determine patterns of restenosis and fracture rates following focal stenting of FP arteries.

PATIENTS AND METHODS

This retrospective study investigated angiographic patterns of restenosis and the occurrence of stent fractures following focal FP stenting with the multiple stent delivery system VascuFlex® Multi-LOC.

RESULTS

We identified 10 patients with 10 (of 129) FP lesions (mean length 11.7±4.6 cm) and a total of 51 (of 646) Multi-LOC stents that underwent clinically driven target lesion revascularizations (TLR) after 11.5±9.2 months, due to symptomatic recurrence of stenosis. None of the Multi-LOC stents had fractured. No isolated in-stent restenosis (>50%) was observed. Median diameter lumen loss was significantly more pronounced at the inter-stent segments (27.0%) compared to in-stent segments (7.8%, p=0.023).

CONCLUSION

No evidence of fracture or susceptibility to stent-related restenosis using Multi-LOC stents was observed. Focal FP stenting may be more effective when combined with strategies known to reduce restenosis in non-stented artery segments.

Outcomes of severe limb ischemia with tissue loss and impact of revascularization in haemodialysis patients with wound, ischemia, and foot infection (WIfI) stage 3 or 4

Summary. Background: With growing prevalence, end-stage renal disease (ESRD) as well as critical limb ischemia (CLI) are both conditions associated with high morbidity and mortality rates. Patients and methods: A retrospective single-centre study provided data of a German interdisciplinary vascular centre. Seventy-seven consecutive haemodialysis (HD) inpatients (median age, 73.6 years) with 91 threatened limbs with Wound, Ischemia, and foot Infection (WIfI) clinical stage 3 or 4 were evaluated for in-hospital treatment of peripheral arterial disease, limb salvage rates, major amputation (MA)-free and overall survival. Results: The 1-year MA-free limb salvage rate was 82 %. On multivariate analysis, a higher WIfI clinical stage (hazard ratio [HR], 7.54; p = 0.008) indicated a higher risk of MA, while at least one-vessel run-off to the foot after revascularization of any kind was associated with a lower risk of MA (HR, 0.17; p = 0.001). In the composite endpoint analysis, the 1-year MA-free overall survival rate was 65 %. Patients with limbs in WIfI clinical stage 4 versus stage 3 carried a more than two-fold increased hazard of death or MA (HR, 2.63; p = 0.028), while revascularization was associated with reduced risk (HR, 0.40; p = 0.021). One-year overall survival (78 %) was not associated with WIfI stage or revascularization but was worse in patients with previous symptomatic coronary artery disease (HR, 3.25; p = 0.039). During long-term follow-up over 12 years, MA-free survival probability was significantly lower in the WIfI stage 4 versus WIfI stage 3 group (HR, 1.58; p = 0.048) without significant differences in overall survival (HR, 1.10; p = 0.696). Conclusions: Lower-extremity CLI with tissue loss in HD patients is associated with high morbidity and mortality rates. WIfI clinical stage was predictive of 1-year MA-free survival, while revascularization significantly reduced MA risk but did not influence overall survival.

Prevalence of abdominal aortic aneurysm and associated lower extremity artery aneurysm in men hospitalized for suspected or known cardiopulmonary disease

BACKGROUND

AAA is a disease affecting predominantly male patients ≥65 years and its dreaded complications such as rupture led to population-based screening programs as preventive measure. Nonetheless, the supposed prevalence may have been overestimated, so that targeted screening of high risk populations may be more effective. This study was performed to evaluate the prevalence of abdominal aortic aneurysm (AAA) of an inpatient high-risk cohort and to estimate the co-prevalence of lower extremity arterial aneurysms.

METHODS

Participants: 566 male inpatients, ≥ 65 years of age, hospitalized for suspected or known cardiopulmonary disease. Primary and secondary outcome measures: Maximal infrarenal aortic diameters using abdominal ultrasound (leading edge to leading edge method). Upon detection of an AAA (diameter ≥ 30 mm), the lower extremity arteries were examined with regard to associated aneurysms.

RESULTS

In 40 of 566 patients (7.1%) AAAs were detectable. Fourteen patients (2.5%) had a first diagnosis of AAA, none of which was large (> 55 mm), the remaining 26 patients were either already diagnosed (14 patients, 2.5%) or previously repaired (12 patients, 2.1%). The three most common main diagnoses at discharge were acute coronary syndrome (43.3%), congestive heart failure (32.2%), and chronic obstructive pulmonary disease (12%). The cohort showed a distinct cardiovascular risk profile comprising arterial hypertension (82.9%), diabetes mellitus (44.4%), and a history of smoking (57.6%). In multivariate analysis, three-vessel coronary artery disease (Odds ratio (OR): 4.5, 95% confidence interval (CI): 2.3-8.9, p <  0.0001) and history of smoking (OR: 3.7, CI: 1.6-8.6, p <  0.01) were positively associated with AAA, while diabetes mellitus (OR: 0.5, CI: 0.2-0.9, p = 0.0295) showed a negative association with AAA. Among the subjects with AAA, we found two large iliac and two large popliteal aneurysms.

CONCLUSION

Ultrasound screening in male inpatients, hospitalized for suspected or known cardiopulmonary disease, revealed a high AAA prevalence in comparison to the present epidemiological screening programs. There was a moderate proportion of newly-screen detected AAA and additional screening of the lower extremity arteries yielded some associated aneurysms with indication for possible intervention.

Real-world outcomes of endovascular treatment in a non-selected population with peripheral artery disease - prospective study with 2-year follow-up

Background: The study aimed to evaluate the outcomes of percutaneous transluminal angioplasty (PTA) in lower-extremity peripheral artery disease (PAD) patients. Patients and methods: A multi-centre, observational study was performed with 32 German and Austrian centres contributing data to the PTA registry. Data of 1,781 patients with lower-leg and pelvic PAD who were suitable for endovascular PTA treatment were contributed from participating centres. Data from 1,533 patients are reported here (1,055 male and 478 female). This study did not have exclusion criteria. Quality of life (QOL) questionnaire (EQ-5D) scores, Rutherford classification, mortality, patency rate and details of major adverse cardiovascular events were collected at 6-, 12-, 18-, and 24-month follow ups. Results: PTA with/without stenting achieved 90.3 %, 86.5 %, 82.7 %, and 71.9 % technical success (recanalisation achieving ≥ 70 % patency, no evidence of embolisation, recoiling or dissection) in iliac, femoral, popliteal, and below-the-knee arteries, respectively. Procedural/postprocedural complications occurred in 142 (9.3 %, 1 death) and 74 (4.8 %) patients. QOL, mobility, self-care, activity, and pain/discomfort scores improved (p < 0.01), anxiety/depression was insignificantly improved. During follow-up, 409 (26.7 %) patients were hospitalised for PAD, 281 (18.3 %) required reintervention, and 145 (9.5 %) died or needed amputation (n = 49; 3.2 %). Multivariate analysis demonstrated poorer outcomes in patients with comorbidities. Conclusions: PTA with/without stenting is effective, safe, and widely applicable, with few complications. It improves QOL, but not anxiety/depression.

Multiple Stent Delivery System "Multi-LOC": Focal self-expanding nitinol stenting of complex femoropopliteal lesions-A monocenter feasibility pilot study

Aims

The Multiple Stent Delivery System (VascuFlex® Multi-LOC) is a novel stent delivery system with six short stents (13 mm long each) mounted on one wire-guided catheter, designed for the treatment of femoropopliteal arteries. The aim of the present study is to evaluate the safety and the feasibility of the VascuFlex® “Multi-LOC” stent delivery system, which enables spot stenting without changing the delivery system.

Methods and results

After proof of concept in a porcine model and after European Conformity marking, first clinical experiences were gathered in 20 patients with severe intermittent claudication or critical limb ischemia. First-in-human data are presented. The study included 20 limbs that underwent femoropopliteal revascularization for claudication (n = 14) or critical limb ischemia (n = 6). “Multi-LOC” provisional spot stenting resulted in acute technical success in all lesions with resolution of flow-limiting dissection and elastic recoil after balloon dilatation of the femoropopliteal artery. There were no device-related complications. Follow-up examinations after 30 to 40 days revealed no major adverse events, and six months’ results were encouraging.

Conclusions

First clinical use of the novel Multiple Stent Delivery System (Multi-LOC) after balloon dilatation of the femoropopliteal artery was safe and feasible in this early study.

Ist der allgemein akzeptierte therapeutische Nutzen des Gehtrainings bei Patienten mit arterieller Verschlusskrankheit evidenzbasiert?

Bei der Bewertung von Gehtrainingsstudien bei Claudicatio intermittens sind grundsätzlich ebenso stringente biometrische und medizinische Kriterien anzulegen wie bei Arzneimittelstudien. Dies ist jedoch, wie am Beispiel einer aktuellen Übersichtsarbeit der Cochrane Collaboration zum Gehtraining gezeigt wird, anscheinend nicht immer der Fall. In den Review gingen zehn randomisierte, kontrollierte Studien aus den Jahren 1966-1977 mit insgesamt 258 Patienten ein. In den einzelnen Studien variierte das mit oder ohne Aufsicht ausgeführte Trainingsprogramm erheblich hinsichtlich Art, Intensität, Häufigkeit und Dauer, ebenso wie die Laufbandmethoden zur Bestimmung der Gehstrecke bzw. Gehzeit (Zielkriterium). Keine der analysierten Studien wies einen konfirmatorischen Ansatz auf, zudem zeigten alle unter Berücksichtigung der geltenden biometrischen und medizinischen Richtlinien eine Reihe weiterer methodischer Mängel. Unerwähnt bleibt im Abstract auch der wichtige Umstand, dass wegen fehlender Daten letztlich nur 53 Patienten aus drei Studien für die eigentliche Metaanalyse gepoolt werden konnten. Insgesamt erscheint der Cochrane-Review wenig geeignet, die allgemein anerkannte Wirksamkeit des Gehtrainings bei Claudicatio intermittens wissenschaftlich zu belegen. Gleichzeitig wird deutlich, dass auch Publikationen angesehener Institutionen wie der Cochrane Collaboration stets kritisch hinterfragt werden sollten. Andererseits darf die Umsetzung der aktuellen Prüfrichtlinien unter dem Aspekt der evidenzbasierten Medizin nicht dazu führen, dass akzeptierte, historische wissenschaftliche Untersuchungen retrospektiv diskreditiert werden und damit erfolgreiche Therapien in Frage gestellt werden müssen.

First clinical experience with the Multi-LOC multiple stent delivery system for focal stenting in long femoro-popliteal lesions

Background: The purpose of this observational study is to report the six-month clinical outcomes with a new multiple stent delivery system in patients with femoro-popliteal lesions. Patients and methods: The LOCOMOTIVE study is an observational multicentre study with a primary endpoint target lesion revascularization (TLR) rate at six months. Femoro-popliteal lesions were prepared with uncoated and/or paclitaxel-coated peripheral balloon catheters. When flow limiting dissections, elastic recoil or recoil due to calcification required stenting, up to six short stents per delivery device, each 13 mm in length, were implanted. Sonographic follow-ups and clinical assessments were scheduled at six months. Results: For this first analysis, a total of 75 patients 72.9 ± 9.2 years of age were enrolled. The majority of the 176 individually treated lesions were in the superficial femoral artery (76.2 %, 134/176) whereas the rate of TASC C/D amounted to 51.1 % (90/176). The total lesion length was 14.5 ± 9.0 cm with reference vessel diameters of 5.6 ± 0.7 mm. Overall 47 ± 18 % of lesion lengths could be saved from stenting. At six months, the patency was 90.7 % (68/75) and all-cause TLR rates were 5.3 % (4/75) in the overall cohort. Conclusions: The first clinical experience at six months suggests that the MSDS strategy was safe and effective to treat femoro-popliteal lesions of considerable length (14.5 ± 9.0 cm). Almost half of the lesion length could be saved from stenting while patency was high and TLR rates were acceptably low.

Multiple stent delivery system Multi-LOC, a new technology for spot-stenting of the femoropopliteal artery - proof of concept study in a preclinical large animal model

BACKGROUND

A new stent system was studied in a porcine model to evaluate its feasibility for spot-stenting of the femoropopliteal artery.

MATERIALS AND METHODS

In a preliminary study in a single pig, handling and mechanical features of the novel multiple stent delivery system were tested. The Multi-LOC system demonstrated great feasibility regarding its pushability, trackability, and crossability. Excellent visibility of the individual stents allowed exact anatomically controlled implantation. In our main study, four to five short Multi-LOC stents (13 mm long) were implanted into the femoropopliteal arteries of six domestic pigs and long (60 to 100 mm) self-expandable nitinol stents were implanted into the same target vessel contralaterally to allow for intraindividual comparison. After four weeks survival under dual antiplatelet treatment, control angiography was performed. The animals were euthanized, stented vessels were explanted, and histologic sections were examined for the presence of neointimal formation.

RESULTS

Multi-LOC stents demonstrated no occlusion of the femoropopliteal axis (0 vs. 1 occlusion distal to a control stent), no stent fractures (0 out of 26 vs. 2 out of 6 control stents), and lower percentage diameter stenosis (0.564 ± 0.056 vs. 0.712 ± 0.089; p = 0.008) and length of stenosis (19.715 ± 5.225 vs. 39.397 ± 11.182; p = 0.007) compared to a standard control stent, which was similar in total length to the multiple stented artery segment. Histological examination confirmed myointimal hyperplasia underlying in-stent stenosis.

CONCLUSIONS

The multiple stent delivery system was studied in a porcine model, which demonstrated its feasibility. Preclinical experience revealed favourable results concerning stent fracture, restenosis, and patency of spot-stented femoropopliteal arteries.

PGE1 and Other Prostaglandins in the Treatment of Intermittent Claudication: A Meta-analysis

In intermittent claudication, pharmacologic drugs and invasive measures are indicated in patients who do not benefit from exercise training. To evaluate the therapeutic role of prostaglandins (PGs), especially of prostaglandin E1 (PGE1), for this indication, the author performed a meta-analysis of all published prospective, randomized, controlled clinical studies in which descriptive sample statistics of the pain-free walking distance (PFWD) and the maximum walking distance (MWD) were available. In total, 9 studies with PGE1 and 4 studies with other PGs (beraprost, iloprost, AS-013) that met these selection criteria could be analyzed. In patients treated with PGE1 (n=344), PFWD increased significantly (p<0.001) more (+107%) than in patients treated with other PGs (n=402; +42%) or placebo (n=470; +24%). Similar results were also found for the MWD. Side effects were significantly (p<0.001) fewer with PGE1 therapy than with other PGs (14.0% vs 30.8% of patients). In conclusion, PGE1 proved to be the most effective and best tolerated of the PGs evaluated.

Primary Self-EXPANDing Nitinol Stenting vs Balloon Angioplasty With Optional Bailout Stenting for the Treatment of Infrapopliteal Artery Disease in Patients With Severe Intermittent Claudication or Critical Limb Ischemia (EXPAND Study)

Purpose: To compare primary placement of a self-expanding nitinol stent to percutaneous transluminal angioplasty (PTA) with bailout stenting in infrapopliteal arteries of patients with severe intermittent claudication or critical limb ischemia (CLI). Methods: In the EXPAND trial ( ClinicalTrials.gov; identifier NCT00906022), 92 patients (mean age 72.9±9.5 years; 62 men) undergoing treatment for infrapopliteal stenosis in 11 European centers were randomized 1:1 to either self-expanding nitinol stenting with the Astron Pulsar/Pulsar-18 nitinol stent or PTA with bailout stenting. The primary endpoint was sustainable clinical improvement after 12 months, defined as a ≥1-category increase for Rutherford category 3 patients or a ≥2-category increase for CLI patients (Rutherford categories 4/5) compared with baseline. Furthermore, target lesion revascularization (TLR), mortality, and amputation were assessed after 12 months. Results: Sustained clinical improvement at 1 year was observed in 74.3% of the patients treated with primary stenting and in 68.6% of the patients treated with PTA and bailout stenting (p>0.05). Kaplan-Meier estimates of freedom from TLR (76.6% and 77.6%), mortality (7.4% vs 2.1%), and amputation [8.9% (major 6.7%) vs 13.2% (major 8.7%)] at 1 year were not significantly different. Conclusion: Primary self-expanding nitinol stenting did not show statistically different clinical outcomes compared to angioplasty with bailout stenting for infrapopliteal lesions.

Lower extremity vasculitis in giant cell arteritis: important differential diagnosis in patients with lower limb claudication

Most patients with peripheral arterial disease suffer from arteriosclerosis, the prevalence of which increases with age. In some of these patients, however, the ischemic symptoms are not caused by stenotic arteriosclerosis, but by large vessel giant cell arteritis (LV-GCA), a disease also predominantly affecting patients of the older generation. Identifying large vessel vasculitis is a challenge for all physicians caring for patients with peripheral artery disease. The results of invasive treatment such as bypass surgery and angioplasty of inflammatory vascular lesions differ fundamentally from those of patients with atherosclerosis. Duplex ultrasound is a widely available diagnostic method for examining patients with lower limb claudication and pathological ankle-/toe- brachial index or pulse volume recording with or without exercise. Knowledge of characteristic sonographic findings suspicious about large vessel vasculitis is essential for a differential diagnosis of vasculitis versus atherosclerosis. In addition to clinical and laboratory findings, further imaging techniques, e.g. contrast-enhanced computed tomography, magnetic resonance imaging or a combination of positron emission tomography and computed tomography (PET-CT) can provide information on further vessel involvement and inflammatory activity. The present study focuses on diagnostic imaging of LV-GCA in patients presenting with claudication, illustrated by a series of cases.

Readmissions of patients with diabetes mellitus and foot ulcers after infra-popliteal bypass surgery - attacking the problem by an integrated case management model

Background: Patients with neuroischemic diabetic foot syndrome (DFS) may need arterial revascularization, minor amputations, débridements as well as meticulous wound care. Unfortunately, postoperative outpatient care is frequently inadequate. This is especially true for Germany, where the in- and outpatient sectors are funded and managed separately, with poor communication between the two. Thus, many patients may be readmitted to the hospital following successful treatment and discharge. In an attempt to overcome these problems, we looked at whether an integrated case management (CM) system for outpatient care according to in-hospital standards might improve patients care and avoid readmissions. In addition we analyzed the length of hospital stay (LOS) as well as hospital costs. Patients and methods: In this retrospective cohort study patients with DFS, bypass surgery and foot surgery after implementation of the CM (study group; n = 376) were compared with a matched historic control group (HCG; n = 190) including the flat rate revenues (G-DRG K01B). Following a standardized assessment, integrated trans-sectoral CM care was offered to 116 patients (CMP). Results: The proportion of patients who were readmitted to hospital was reduced in CMP compared to HCG (8.8 vs. 16.4 %; p < 0.01), with consequent reduction of case consolidations (9.7 % versus 17.8 %, p < 0.001). Although initially, the mean LOS was higher in the CMP patients, the reduction in readmissions meant that this integrated CM program improved the hospital’s economic situation. Conclusions: A hospital-based integrated CM system significantly reduces the hospital readmissions in patients with neuroischemic DFS following bypass surgery, with lower hospital costs.

Long-term outcomes after medical and interventional therapy of critical limb ischemia

BACKGROUND

Recommendations of clinical guidelines for the treatment of critical limb ischemia (CLI) are based on randomized controlled trials. Recent data from clinical practice are however lacking. Therefore a prospective observational study in patients with critical limb ischemia (CLI) in 3 hospitals with a specialized vascular medicine department was conducted to document the clinical course and outcome of patients with critical limb ischemia (CLI) in clinical practice.

METHODS

155 patients were stratified: 56 received endovascular intervention, 82 prostanoids and 17 antibiotic treatment. Patients with surgical revascularisation and primary amputation were excluded. All patients received structured wound treatment, analgesia and vascular risk factor treatment during hospital stay.

RESULTS

Age 72.0+/-12.7 years, hospitalisation 23.2+/-20.3 days. 56.1% had Diabetes, 9.7% multiresistant staphylococcus aureus infection. 40% patients had rest pain, 60% ischemic tissue loss. At discharge 40.0% had no ulcers, 48.4% ongoing trophic alterations, 10.3% received major amputation and 4.5% had stable necrosis. After 18 month rate of major amputation was 6.3% (prostanoids), 14.5% (endovascular treatment; p=n.s. vs. prostanoids) and 26.7% (antibiotics; p=0.0323 vs. prostanoids). Major amputations were not different in logistic regression analyses adjusting for baseline characteristics. Wound healing and mortality rate was not different between groups (26.8, 25.0 and 23.5%).

CONCLUSION

Structured therapy at specialized vascular centres in combination with interventional or conservative treatment is beneficial in patients with critical limb ischemia. Survival without amputation is higher than expected over 18 months.

[The vascular surgeon's role in interdisciplinary treatment of diabetic foot syndrome]

There are more than 6 million diabetes patients in Germany. Due to long-term neuropathic and angiopathic sequelae, the number of patients with "diabetic foot syndrome" has increased dramatically in recent years. Diabetic foot ulcers have become one of the most common pathologies in interdisciplinary wound care centers. Because of its complex pathogenesis, diabetic foot syndrome needs a multidisciplinary therapeutic approach. More than 150,000 diabetics per year develop foot ulcers that often heal slowly and progress into chronic wounds. Despite all efforts at prevention, early diagnosis, and adequate therapy, more than 20,000 diabetics suffer major limb amputation in Germany every year. Applying stringent standards of care in interdisciplinary wound care centers, the amputation rate in patients with diabetic foot syndrome can be reduced to less than 50%. This article describes the complexity of diabetic foot syndrome with respect to pathogenesis, diagnostics, and therapy from a vascular surgeon's point of view. The importance of an interdisciplinary approach is emphasized.

[Is the generally accepted therapeutic benefit of exercise training in patients with peripheral arterial occlusive disease evidence based? Analysis of the Cochrane review]

When assessing the quality of clinical trials in intermittent claudication, on principle the same strict biometric and medical standards need to be applied for studies on the effect of walking exercise as for conservative drug treatment studies. However, as demonstrated by a recent review of the Cochrane Collaboration, this is apparently not always the case. The review included ten randomized controlled studies published between 1966 and 1997 with a total of 258 patients. The exercise regimes varied considerably between studies with regard to mode, intensity, frequency, duration and supervision, just as the treadmill tests employed to measure walking distance and walking time, respectively (primary endpoint). None of these studies used a confirmatory approach, and they all have a number of further methodological flaws when taking current biometric and medical guidelines into account. Also unmentioned in the abstract remains the important fact that, owing to missing data, finally only 53 patients from three studies could be pooled for the actual meta-analysis. All in all, the Cochrane review under discussion here is hardly suitable to scientifically prove the generally accepted efficacy of walking exercise in intermittent claudication. At the same time, it becomes clear that even publications of well-reputed institutions such as the Cochrane Collaboration should always be critically scrutinized. On the other hand, applying modern guidance for investigation under the aspect of evidence based medicine must not lead to a retrospective discrimination of accepted historical scientific data and thereby call into question proven therapeutic strategies.

Cerebrovascular manifestations of Takayasu arteritis in Europe

OBJECTIVES

Takayasu arteritis is well known as a cause of stroke in Asia but has rarely been described in the Western world. Here we report the clinical and neuroimaging follow-up of a series of patients with Takayasu arteritis from Europe.

METHODS

Seventeen consecutive patients who fulfilled the diagnostic criteria for Takayasu arteritis of the American College of Rheumatology were evaluated on follow-up by standardized neurological examination, sonography and MRI.

RESULTS

At follow-up almost 20 yr after onset of symptoms, the subclavian artery and the common carotid artery were often affected. In addition, evidence of intracranial pathology was found in seven patients. In contrast to the severe vessel involvement, the neurological state was stable. Two patients had suffered from stroke before the diagnosis was made and therapy was initiated, and one patient had recurrent transient ischaemic attacks. Intermittent dizziness was associated with pathology of the vertebral and basilar arteries. However, clinical symptoms of subclavian steal syndrome were rare.

CONCLUSION

This case series shows that the clinical neurological course of Takayasu arteritis on treatment is benign in most cases despite the severe vascular involvement.

[The prevalence of hyperhomocysteinemia in thromboangiitis obliterans. Does homocysteine play a role pathogenetically?]

OBJECTIVE

As hyperhomocysteinaemia is known to be an important risk factor in the early onset of arteriosclerotic occlusive disease and leg-vein thrombosis, we investigated the prevalence of hyperhomocysteinaemia in patients with thromboangiitis obliterans (TAO), a condition predominantly affecting peripheral arteries and veins.

PATIENTS AND METHODS

Plasma homocysteine (HC), before and after administration of methionine (0.1 g/kg) as well as serum folic acid, vitamins B6 and B12 were measured in 15 patients with TAO (12 men, 3 women; mean age 33.3 years: group 1), in 15 non-smokers without peripheral vascular disease (group 2) and 15 smokers without peripheral vascular disease (group 3). At the time of the study, of those in group 1 seven were active smokers, seven were ex-smokers and one was a non-smoker.

RESULTS

Before methionine administration four patients (27%), none of the healthy non-smokers and one smoker without vascular disease (7%) had increased HC levels (> 13.9 nmol/ml). The difference between groups 1 and 2 was statistically significant (P < 0.05), but not that between groups 1 and 3 and between 2 and 3. 4 hours after methionine increased HC levels (> or = 31 nmol/ml) were measured in nine patients but in none of the healthy controls. The difference between patients and the two control groups without vascular disease was clearly significant (P = 0.0107). There was a difference in folic acid levels between the patients and the smokers without vascular disease: in eight patients (53%) the levels were in the lower third of normal, in six (40%) they were in the middle and in one (7%) in the upper third. Corresponding levels in group 3 were: four (27%), three (20%) and eight (53%).

CONCLUSION

Hyperhomocysteinaemia occurs frequently in patients with TAO. It may play an important and nicotine-independent role in its pathogenesis.

The effects of tertatolol on lipid profile

Tertatolol is a noncardioselective beta-blocker without intrinsic sympathomimetic activity. In a preliminary 3-month open study, it was shown that T was devoid of any atherogenic effect since HDL-cholesterol (HDL-C) and apoprotein levels did not change for 3 months of therapy. To investigate the long-term effects of tertatolol on the lipid profile and its safety in hypertensive patients with peripheral arterial disease (PAD), a 9-month, randomized, double-blind, parallel group study was carried out in 40 patients. Tertatolol 5 mg once daily was compared with metoprolol 200 mg once daily. If BP was not controlled after 2 months, a vasodilatator agent, dihydralazine, was added at the lowest dose required to control BP (diastolic BP < 90 mm Hg). Lipoprotein fractions and apoproteins were assayed before (M0) and after 2, 6 and 9 months of therapy. At the same occasions, peripheral arterial disease (PAD) was evaluated on exercise tests carried out on a treadmill and on the regional blood flow measured in the ankle arteries by the Doppler technique. Four patients were not eligible for analysis. In the tertatolol group, 1 patient with a normal BP, and 2 patients who dropped out, 1 because of persistent nausea and 1 because of personal reasons. In the metoprolol group, 1 patient refused to take dihydralazine. In the 35 fully documented patients, BP control was achieved in both groups. The mean reductions in supine systolic/diastolic BP were 31.4/14.6 and 34.7/17.1 mm Hg in the tertatolol and metoprolol groups, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Antidromic activation of sensory afferent fibres in sympathetic nerves of the cat by stimulation of collaterals within the dorsal medulla oblongata

Action potentials were evoked in the white ramus of the third thoracic segment by electrical stimulation in the dorsal medulla oblongata. The following findings indicate that these potentials are due to antidromic activation of collaterals of afferent fibres in sympathetic nerves rather than to orthodromic synaptic activation of preganglionic sympathetic neurones via bulbospinal sympatho-excitatory pathways: (i) they had short latencies yielding intraspinal conduction velocities of 13-43 m/sec; (ii) they followed short trains of stimuli at frequencies up to 600 Hz; and (iii) they were abolished by cutting the dorsal roots of the same spinal segment.

Tonic descending inhibition of the spinal somato-sympathetic reflex from the lower brain stem

In chloralose-anaesthetized cats the spinal and supraspinal components of the somato-sympathetic reflex were evoked in the white ramus at T3 and/or L2 by stimulation of intercostal and spinal nerves. A reversible blockade of all ascending and descending spinal pathways was performed by cooling the spinal cord between the second and third cervical segment. Total blockade of conduction was produced at temperatures below 8.5 degrees C (281.5 K). The spinal blockade produced the following reversible effects. (1) Mean arterial pressure fell to 30-50 mm Hg (4.0-6.7 kpa) and the tonic background activity in the white ramus was reduced to 0-24% of control (mean 12.1 +/- 10.0%). (2) The amplitude of the early spinal reflex was increased from 100% to 111-316% (mean 200.9 +/- 49.5%, n = 49) at the thoracic level and to 125-342% (mean 181.4 +/- 74.4%, n = 7) at the lumbar level. The onset latency of the spinal reflex at T3 (range 8-21 msec) was shortened by 0.5-3.0 msec (mean 1.7 +/- 0.9 msec). (3) Supraspinal components were completely abolished. (4) Neither baroreceptor denervation nor midcollicular decerebration altered these effects. (5) The cold block induced increase of the amplitude of the spinal reflex was reduced by the alpha-adrenoceptor agonist clonidine; this effect was reversed by the alpha-adrenoceptor antagonist yohimbine. Selective cooling of the dorsolateral funiculus caused the same effects on the spinal and supraspinal reflexes as cold block of the whole spinal cord. From these findings it is concluded that in the anaesthetized cat the spinal component of the somato-sympathetic reflex is modulated by a descending tonic inhibition. This inhibition acts at both the thoracic and the lumbar level and its origin is in the medulla oblongata. This inhibition is, however, independent of baroreceptor inputs. The pathways descends in the dorsolateral funiculus. It is suggested that noradrenaline or adrenaline might be involved in the transmission of this inhibitory influence.

Bulbospinal projections to the intermediolateral cell column: a neuroanatomical study

The location of those neurones in the brain stem that project to the intermediolateral column (ILC) from which preganglionic sympathetic neurones have their origin was studied by the method of retrograde transport of horseradish peroxidase (HRP). In cats 30--50 nl of a 30% HRP solution was injected into the region of the ILC at T3 or L1 on one side. After a survival period of 72 h the lower brain stem from C1 to the inferior colliculi was sectioned and prepared for histological study under brightfield illumination. Neurones stained with exogenous HRP were found in three regions: (a) in the ipsilateral, dorsomedial part of the nucleus of the solitary tract (NTS) (43% of all labeled neurones), in the cranial part of the NTS, and also on the contralateral side (7%); (b) in the ventrolateral reticular formation beginning at the level of the obex up to 8 mm cranial to the obex (25% ipsilateral, 3% contralateral); and (c) in the ventral part of the raphe nuclei (postpyramidal and inferior central nucleus) from 2 to 9 mm cranial to the obex (22%).

Neurones within the "chemosensitive area" on the ventral surface of the brainstem which project to the intermediolateral column

With the method of retrograde transport of horseradish peroxidase it has been demonstrated that neurones within the "chemosensitive area" of the brainstem project to the thoracic intermediolateral column. The function of these neurones is discussed in regard to the regulation of blood pressure.