Impact of atherosclerotic risk factors on the anatomical distribution of peripheral arterial disease

BACKGROUND

The aim of the study was to determine predictors of hemodynamically relevant atherosclerosis (HRA) in different segments of lower limb arteries in patients with peripheral arterial disease (PAD).

METHODS

In a retrospective case-control study 106 hospitalized consecutive patients with symptomatic PAD and 52 asymptomatic control subjects were studied. All patients underwent distal aortofemoral angiography. The arteries of the lower limbs were divided into three sections: in the aorto-iliac and femoro-popliteal segments HRA was defined as one or more stenosis of over 50%. In the crural segment it was considered if at least two arteries of one lower leg had occlusions/stenoses of over 50%.

RESULTS

In 106 patients, there were 132 cases of hemodynamically relevant lesions, and in 26 patients in two segments. We separately compared 23 cases with aorto-iliac, 82 with femoro-popliteal and 27 with crural manifestation to the 52 control subjects. Calculating age- and sex-adjusted odds ratios, we found that current smoking status and plasminogen levels were significantly associated with HRA in the aorto-iliac and femoro-popliteal segments, whereas in diabetes mellitus the association was found to be in the crural and femoro-popliteal segments. However, there was no such association for lipid profiles and fibrinogen.

CONCLUSIONS

We conclude that the anatomic distribution of HRA in patients with PAD is different according to the risk factor profile. The aorto-iliac and crural segments show specific risk profiles while the femoro-popliteal segment seems to be a transition zone. Smoking and high plasminogen levels may be related to atherosclerosis of proximal segments, diabetes to that of the distal segments.

Association between erythrocyte mean corpuscular volume and peripheral arterial disease in male subjects: a case control study

Elevated serum total homocysteine, an established risk factor for peripheral arterial disease, is influenced by the vitamin B12 and folate status. Since these vitamins are inversely correlated with erythrocyte mean corpuscular volume, an investigation of whether mean corpuscular volume is higher in patients with symptomatic peripheral arterial disease than in healthy subjects was performed. Furthermore, a determination of predictors of increased mean corpuscular volume levels in this population free of symptomatic coronary artery disease, cerebrovascular disease, and diabetes mellitus was carried out. From 469 consecutive patients with symptomatic peripheral arterial disease, 100 fulfilled study inclusion criteria. Peripheral arterial disease was confirmed by angiography. One hundred age-matched subjects without peripheral arterial disease as verified by ankle-brachial index measurements >0.9 served as control subjects. Patients with PAD displayed a significantly higher mean corpuscular volume level (94.5 fl) than control subjects (90.9 fl, p<0.001). Logistic regression analysis showed that current smoking status (p<0.001) and mean corpuscular volume (p=0.009), but not total homocysteine or lipid parameters discriminated case control status. In addition, logistic regression analysis revealed a relationship of mean corpuscular volume with smoking (p=0.001), gamma-glutamyltransferase (p<0.001), and total homocysteine (p=0.012). This model predicted mean corpuscular volume values with an accuracy of 83%. Elevated mean corpuscular volume is a predictor of symptomatic peripheral arterial disease in the sample studied. A deficiency of folate and/or vitamin B12 may be responsible for this observation, as indicated by the correlation of mean corpuscular volume with total homocysteine. Due to the additional association of mean corpuscular volume with smoking and gamma-glutamyltransferase, an unhealthy lifestyle with low vitamin intake may cause elevated mean corpuscular volume values in patients with PAD.

PTA versus Palmaz stent placement in femoropopliteal artery obstructions: a multicenter prospective randomized study

PURPOSE

To evaluate if stent placement is superior to percutaneous transluminal angioplasty (PTA) in the treatment of chronic symptoms in short femoropopliteal arterial lesions.

MATERIALS AND METHODS

One hundred fifty-four limbs in 141 patients who ranged in age from 39 to 87 years (mean age, 67 years) were randomized to PTA (n = 77) versus PTA followed by implantation of Palmaz stents (n = 77). Inclusion criteria were patients with intermittent claudication (n = 108, Society of Vascular Surgery/International Society of Cardiovascular Surgery [SVS-ISCVS] categories 1-3) or chronic critical limb ischemia (n = 46 with either ischemic rest pain [category 4] or minor tissue loss [category 5]), short stenosis or occlusion (lesion length < or = 5 cm), and at least one patent run-off vessel at angiography. Follow-up included clinical assessment, measurement of ankle/ brachial index (ABI), color duplex ultrasound, and/or angiography at 6 or 12 months. Angiographic follow-up between 12 and 36 months was available in 46 limbs (29.9%).

RESULTS

In the PTA group, initial technical success was achieved in 65 of 77 limbs (84%) versus 76 of 77 (99%) limbs in the stent group (chi2 value = 0.009). Overall, major complications occurred in 3.9% (n = 6); n = 4 in the PTA group compared to n = 2 in the stent group. There was no difference between groups of treatment: hemodynamic/clinical success at 1 and 2 years in the PTA group was 72% and 65% versus 77% and 65% in the stent group (Gehan P value = .26). The cumulative 1- and 2-year angiographic primary patency rates were 63% and 53%, respectively, for both groups. The secondary 1- and 2-year angiographic patency rates were 86% and 74% in the PTA group versus 79% and 73% in the stent group (P = .5).

CONCLUSION

After stent placement, the primary success rate was significantly higher than after PTA. However, 1-year angiographic and clinical/hemodynamic success was not improved.

Chronic administration of aluminum-fluoride or sodium-fluoride to rats in drinking water: alterations in neuronal and cerebrovascular integrity

This study describes alterations in the nervous system resulting from chronic administration of the fluoroaluminum complex (AlF3) or equivalent levels of fluoride (F) in the form of sodium-fluoride (NaF). Twenty seven adult male Long-Evans rats were administered one of three treatments for 52 weeks: the control group was administered double distilled deionized drinking water (ddw). The aluminum-treated group received ddw with 0.5 ppm AlF3 and the NaF group received ddw with 2.1 ppm NaF containing the equivalent amount of F as in the AlF3 ddw. Tissue aluminum (Al) levels of brain, liver and kidney were assessed with the Direct Current Plasma (DCP) technique and its distribution assessed with Morin histochemistry. Histological sections of brain were stained with hematoxylin & eosin (H&E), Cresyl violet, Bielschowsky silver stain, or immunohistochemically for beta-amyloid, amyloid A, and IgM. No differences were found between the body weights of rats in the different treatment groups although more rats died in the AlF3 group than in the control group. The Al levels in samples of brain and kidney were higher in both the AlF3 and NaF groups relative to controls. The effects of the two treatments on cerebrovascular and neuronal integrity were qualitatively and quantitatively different. These alterations were greater in animals in the AlF3 group than in the NaF group and greater in the NaF group than in controls.

[Laser versus rotation angioplasty in the recanalization of chronic femoropopliteal arterial occlusions]

Between June 1987 and July 1989 laser angioplasty, and between July 1989 and December 1991 rotation angioplasty was used as the method of choice for the recanalisation of chronic (minimal duration 3 months) arterial occlusions in the femoro-popliteal region. The technical success rate and final results following supplementary balloon dilatation were identical and there was no significant difference between the two groups (laser 87%, rotation 87.7%). For long occlusions (more than 150 mm), the success rate for rotation angioplasty was 60% and significantly higher than for laser angioplasty at 40%. Complication rates for rotation angioplasty were 24.3%, higher than laser angioplasty with 20.3%. This was due to the higher incidence of emboli of 12.1% compared with the laser technique of 7.3%. Cumulative patency rates after two years showed no significant difference (uncorrelated/correlated: laser 53.4%/67.8%; rotation 56.6%/67.5%). Using lytic and aspiration techniques, the higher incidence of embolisation during rotation angioplasty had no adverse effect on final outcome. If both methods are available, it is advisable to treat long occlusions by rotation angioplasty because of the high immediate success rate, whereas short occlusions are best dealt by laser angioplasty because of the lower incidence of embolisation.

[Automated percutaneous lumbar diskectomy (APLD): the early and late changes in the CT with a clinical correlation]

In 52 out of 162 patients treated, CT changes were measured at early and late stages and correlated with clinical findings. Reduction in height of discs was measured by digital radiography. During early stages 9.6% showed gas collections peripherally and 3.8% centrally. Early and late examination showed uniform reaction in the area of the prolapse: no changes (type I), return to normal findings (type II), diffuse reduction of a broadly based lesion (type III), reduction in focal changes based on a broad lesion (type IV). Early results: 94.3% type I, 3.8% type III, 1.9% type IV. Late results: 55.7% type I, 3.8% type II, 21.2% type III, 19.3% type IV. Maximal reduction of the height of the disc of 10% occurred in 32.6% of cases. There was no meaningful correlation between CT appearances and clinical status.

Laser angioplasty: results of a prospective, multicenter study at 3-year follow-up

A prospective multicenter trial was initiated to evaluate the efficacy and safety of laser angioplasty. Laser recanalization was performed in 338 patients with arteriosclerotic femoropopliteal artery occlusions (average length, 8.5 cm). Neodymium-yttrium-aluminum-garnet lasers were used in combination with sapphire probe catheters. The initial recanalization rate was 85%. Complications were observed in 14% of the patients. Emergency surgery was required in 1.5%. The cumulative long-term patency rate of the successfully recanalized arteries was 80%, 70%, 62%, and 57% at 6 months, 1 year, and 2 and 3 years, respectively. The patency rates were not affected by the length of the occlusion and the long-term medication (platelet inhibition vs anticoagulation), but patients with a normal runoff had significantly better patency rates than those with reduced runoff (63% vs 52%, P less than .01). The study has shown that laser-assisted angioplasty is safe and at least as effective as conventional angioplasty.

[The peripheral macroembolism as a complication of laser angioplasty of the arteries of the extremities--therapy using interventional radiologic measures]

From 1987 to 1989 in the Barmherzige Brüder Hospital in Linz/Austria 160 arteries of extremities were treated with laser-assisted balloon dilatation. During these interventions peripheral macroembolism occurred 8 times. The mean length of the recanalised segment was 8.7 cm and thus longer than average (6.5 cm). All 8 cases were successfully treated by aspiration or aspiration combined with local lysis. No adverse effects on long-term results were noted. In 4 cases an early occlusion of the recanalised segment was diagnosed within 48 hours after laser-assisted angioplasty, three times accompanied by embolism. These emboli, too, were removed by aspiration and lysis. To reduce the risk of embolisation strict rules of indication concerning the age of an occlusion have to be observed and mechanical trauma has to be minimised.

Percutaneous transluminal angioplasty of crural arteries

The authors dilated 103 stenosed crural arteries in 71 patients. Primary success was defined as traversing and reducing the lesion to a residual stenosis of less than 30%. This was achieved in 96% of cases. Complications included one vessel rupture and one occluding intimal flap, which were treated by the vascular surgeon with bypass and venous patch, respectively. One hematoma at the puncture site was treated surgically because of its size. With modern materials such as steerable guide wires and low-profile balloon catheters, dilation of crural arteries has become safe. Until now, the indications for percutaneous transluminal angioplasty (PTA) of crural arteries have been limited to Fontaine stages III and IV disease. The authors believe that the indications for PTA in Fontaine stage IIb disease are justified, especially if intervention improves outflow after a more proximal recanalizing procedure is performed.

[Femoropopliteal laser recanalization--a multicenter study]

Laser-assisted angioplasty was performed in four different hospital centers, following the same treatment protocol and using an Nd-YAG laser with a sapphire-probe catheter. The initial recanalization rate of 259 femoro-popliteal occlusions with a mean length of 7.5 cm was 84%. Dissections or perforations were observed in 10%. An emergency surgical intervention was required in 1.1%. The long-term patency rate of the successfully recanalized arteries was 74% after 2 years. The cumulative cure rate of all 259 patients was 62%.

[Neurogenic appendicopathy--long-term results following appendectomy]

The neurogenic appendicopathy is a disease which is caused by proliferation of nerve fibres and hyperplasia of endocrine cells in the submucosa of the appendix. It is to be diagnosed surely only histologically. 28 patients in which appendectomy specimens solely changes of neurogenic appendicopathy type were present have been traced. Following statements can be made: 1. The disease is curable in 96% by simple appendectomy. 2. Concerning this diagnosis about 60% of so-called "negative" appendectomies will find a reasonable explication. 3. At the same time a facultative precurser disease of appendiceal carcinoid tumor is removed.

[Diagnosis of changes in supra-aortic extracranial vessels with special reference to collateral branches--real time sonography, Doppler ultrasound, angiography]

High-resolution real-time sonography combined with continuous-wave Doppler for non-invasive screening of the supraaortal extracranial arteries was performed in 1133 patients during the last 13 months. The results of these techniques with regard to diagnosis of stenosis greater than or equal to 50%, complete occlusions and collateralization, are given and compared with 134 cerebral angiograms. The diagnostic information obtained can be used to differentiate between potentially surgically correctable lesions from those that require other medical therapy.

[Pharmacophlebography with dihydroergotamine]

Insufficient imaging of the deep venous system of the lower limb can be expected in phlebography varying in number with the kind of venous disease. Either too little contrast is achieved or even a pair of deep veins are missed. Studying the effects of dihydroergotamine a shift of blood flow from surface to depth could be proven. In consequence a second phlebography after administering dihydroergotamine led to a decisive contrast enhancement in 85.7% and to the imaging of the missing veins in 75%. A control study without application of a pharmacon did not show these results. Administering 0.5-1.0 mg of dihydroergotamine i.v. (providing no contraindication is present) can improve the diagnostic value of phlebography in problem cases.

[Documentation of hemodynamic parameters in collateral circulation]

By adding phase-differences of serial angiographies in contrasting colours, combination-images are produced, which show the functional way of perfusion without loosing significant morphologic details. Using this technique it is possible to document the direction of blood flow and other hemodynamic parameters and to estimate the average flow rate in a single picture. Finally own results in patients with obliterations and collaterals are given and discussed.